Episode 21: Ethics

In this episode we interview Dr. Alycia Valente. She is an emergency physician who also has a degree in bioethics.

There are 4 basic principles to bioethics. These principles are the framework that allows us to understand ethics as applied to our daily practice. The 4 principles are as follows:

  • Autonomy: this is the principle that patients are able to make their own decisions based on their own system of values and morals. This is the reason we have informed consent
  • Non-maleficence: this is the principle that as a physician we should do no harm. One way to approach this idea is to be a competent clinician and work within our skill set. In other words, we should be able to weigh the risks vs benefits of our decisions.
  • Beneficence: we have a duty to remove patient from harm. This is why we treat people without consent who have life threatening injuries, why we perform psychiatric holds, etc.
  • Justice: People are equal and qualify for equal treatment. This applies to treatment decisions and allocation of resources. We treat everyone regardless of insurance status and triage based on acuity of condition.
  • All other moral values, such as courage, trustworthiness, impartiality, etc. are all connected to the above 4 principles

The application of these 4 principles can help us approach the ethical dilemmas we face and help guide us to making appropriate decisions. Alycia also discusses that this helps us understand our “gut feeling” and will help us sleep better at night when we have difficult situations.

Check back soon for the CME quiz!

Download the episode here: Episode 21: Ethics
Difficulty downloading? Right click (Mac users ctrl-click) then choose “Save link as…”

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Episode 20: Sepsis Core Measures

In our experience, the CMS (Centers for Medicare & Medicaid Services) core measures for sepsis have been misunderstood. I have personally heard multiple comments on how we have to give large amounts to fluids to all septic patients to stay in compliance. I have personally seen patients that are fluid overloaded because of these misunderstandings. In addition, these misunderstands have lead to hospitals reporting failures to CMS when in fact they have been compliant. For these reasons we decided to discuss the CMS core measures for sepsis.

We presented this at the 1st Annual Native American and Rural Emergency Medicine Conference that was held in Flagstaff, AZ in May 2019. We included the slides for a more in depth summary. Feel free to distribute these slides, but remember they are under the creative commons license and you must reference us if you use the slides.

I recommend that you think of the sepsis core measures in three distinct categories: sepsis, severe sepsis, and septic shock. I will discuss these 3 categories separately.

Sepsis: the core measures defines sepsis as having 2 SIRS criteria and a source of infection. The SIRS criteria are:

  • Temp >38°C (100.4°F) or < 36°C (96.8°F)
  • Heart rate > 90
  • Respiratory rate > 20 or PaCO2 < 32mmhg
  • WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands

It is important to remember that the core measures do NOT apply to simple sepsis. Management of simple sepsis is based on your clinical judgement.

Severe Sepsis: the core measures define severe sepsis as sepsis with a lactic > 2 OR sepsis with evidence of end organ damage. Examples of end organ damage are as follows:

  • Systolic blood pressure < 90 mmHg or MAP < 65 mmHg
  • >40 mmHg decrease in SBP from baseline
  • Acute respiratory failure
  • Creatinine > 2.0
  • Urine output < 0.5 mL/kg/hour for 2 hours
  • Total bilirubin > 2 mg/dl
  • Platelet count < 100,000
  • INR > 1.5 or aPTT > 60 sec

It is important to remember that the end organ damage and SIRS criteria must be the result of the infection and not from a chronic condition or medication. For example, a patient on warfarin with an INR of 2 or a patient with chronic kidney disease with baseline creatinine of 3.0 cannot be used for evidence of end organ damage if documented as such by the provider.

Septic Shock: septic shock is defined as severe sepsis with a lactic acid >= 4.0 OR severe sepsis with persistent hypotension (SBP < 90 mmHg or MAP < 65 mmHg or >40 mmHg decrease in SBP from baseline). The core measures also state that if the provider states the patient has septic shock then the patient needs to meet the core measures for septic shock even if the patient doesn’t meet the above criteria.

Core Measures: patients with sepsis can be placed in one of the above 3 categories. It is important to remember that simple sepsis is not part of the core measures and therefore you can treat according to your clinical judgement. The core measures are as follows:

  • Severe Sepsis (the following needs to be completed within 3 hours)
    • Measure serum lactate
    • Obtain blood cultures prior to antibiotics
    • Administer broad spectrum antibitoics
  • Septic Shock (the following needs to be completed within 3 hours)
    • Complete the measures for severe sepsis
    • Resuscitate with 30 mL/kg crystalloid fluids
  • The following needs to be completed within 6 hours after presentation
    • Repeat lactate if initial lactate was > 2
    • Repeat volume status and tissue perfusion assessment if septic shock
    • Vasopressor administration if hypotension persists after fluids

I would like to point out a few things that are commonly misunderstood about the above core measures. The 30 mL/kg bolus is only when the patient has septic shock. I cannot stress this point enough. If the patient doesn’t have septic shock, you can use fluids according to your clinical judgement and the 30 mL/kg bolus is not required!

I would also like to state that the repeat volume status and tissue perfusion assessment has multiple specific points that need to be met. However, the core measures state that if the provider charts “after fluid bolus I reassessed the fluid status” it is sufficient to meet the measure.

Lastly, in our hospital many providers had patient encounters that failed the core measures because they just didn’t chart appropriate. Please chart what you did and the timing. Also, chart when there is a reason you are not following the core measures as this often will help you stay in compliance with the measures.

For specific details on the acceptable exclusions and ways to improve your charting, please see the included slides and listen to the episode!

Episode 20: Sepsis Core Measures

Presentation Slides

Episode 19: Lateral Canthotomy

In this episode we interview the ophthalmologist Dr. Shad Saunders. We discuss orbital compartment syndrome and the management of the condition in the Emergency Department–specifically performing the lateral canthotomy.

Orbital compartment syndrome is when the contents of the orbit are under pressure, typically due to a space occupying lesion such as hematoma. Since there is no room for expansion within the bony orbit, this can lead to elevated pressures that can cut off blood supply to the optic nerve, muscles, and eye. The symptoms of orbital compartment syndrome can include:

  • Periocular trauma
  • Proptosis
  • Decreased extra-ocular movements
  • Double vision
  • Decreased vision
  • Subconjunctival hemorrhage
  • Chemosis
  • Increased intraocular pressure
  • Pupil abnormalities
  • Afferent pupillary defect
  • Vision changes or loss

Orbital compartment syndrome is a clinical diagnosis in the Emergency Department and should be treated before further work-up is completed. Since this is a time sensitive condition and can lead to vision loss, a lateral canthotomy should be performed as soon as possible. You should not wait for imaging confirmation.

The lateral canthotomy is performed in the following way:

  • Clean the skin with betadine
  • Anesthetize the lateral canthal region with lidocaine with epinephrine
  • Make a 1 cm incision at the lateral canthus with a 15 blade scalpel or scissors
  • Using toothed forceps, grasp the lower lid and apply anterior traction to the lid
  • Locate the canthal tendon by “strumming” them with scissors
  • Once the canthal tendon fibers are located, cut them with the scissors
  • Continue strumming and cutting until you have completely released the inferior canthal tendon
  • Recheck pressure in the eye. If the pressure is still elevated, perform the same procedure on the superior canthal tendon

You can view our video of the procedure performed by Dr. Saunders himself on our YouTube channel!

If you are a physician, nurse practitioner, or physician assistant and going to claim CME credit, by downloading you acknowledge that you have read and understand the CME disclosures and information.

Download the episode here: Episode 19: Lateral Canthotomy
Difficulty downloading? Right click (Mac users ctrl-click) then choose “Save link as…”

Click here to take the Quiz for CME (***Physicians, NPs, and PAs only***)

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Episode 18: Recognizing Psychosis

In this episode we interview Dr. Craig Heacock. He discusses how to recognize psychosis in the Emergency Department.

Psychosis can be easy to recognize when the person is actively hallucinating and is agitated, however there are many types of psychosis that can be difficult to recognize.

Psychosis is a general term that describes losing touch of reality. Symptoms of psychosis can include paranoia, auditory hallucinations, command hallucinations, poverty of thought, ideas of reference, mind reading, delusions of grandeur, etc. It is important to remember that a person with psychosis may have one or many of these symptoms and each symptom can be of varying intensity.

When you have a patient in the Emergency Department and you suspect psychosis, the first to do is slow down and don’t rush the evaluation. To properly evaluate these patients you need to spend time with the patient and you need to obtain collateral history.

Collateral history from friends and family is a key component to evaluating any patient with mental health issues. Dr. Heacock describes collateral history “as the imaging of psychiatry.” Typically these patients lack insight into their condition and are suspicious. As such, the patient will often not be forthcoming during the interview. This leads to a lack of information, but collateral history can fill in these gaps.

Another important thing to remember when evaluating a mental health patient is to keep yourself safe. Pay attention to your internal “danger meter” and if you feel like the situation is unsafe you need to leave the room immediately and call for help.

When you have identified psychosis (or other serious mental health issues) it is often beneficial to discuss the case with the patient’s psychiatrist or other mental health provider. They will often have insights on the patient’s situation and ways they can help.

Lastly, remember that marijuana use can potentiate psychosis. Discuss the need for marijuana cessation in these patients.

If you are a physician, nurse practitioner, or physician assistant and going to claim CME credit, by downloading you acknowledge that you have read and understand the CME disclosures and information.

Download the episode here: Episode 18: Recognizing Psychosis

Difficulty downloading? Right click (Mac users ctrl-click) then choose “Save link as…”

Click here to take the Quiz for CME (***Physicians, NPs, and PAs only***)

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Episode 17: Ketamine Revisited

This episode was originally published on February 12, 2019.

In this episode we interview Dr. Craig Heacock, our guest psychiatrist. We review using ketamine in the Emergency Department for depressed and suicidal patients.

The dose for ketamine for this indication is 0.5 mg/kg over infused 30-40 minutes.

Dr. Heacock recommends that you attempt to keep the room quiet. He even recommends eye shades and music if possible.

The patients that seem to have the best results are those with significant depressive symptoms. Dr. Heacock calls this “Black Bear Depression.” This is the depressed patient that has no energy, that has no desire to do anything, that wants to sleep all the time, that has no motivation to leave the house, that has difficulty finding the energy to go to work, etc.

Although the effect of ketamine in these patients can be profound, it is often in small ways. Examples of the benefits can be things such as having a desire to go to work, being able to walk the dog, the patient starts going to the gym, etc.

You should avoid ketamine in those patients that have a primary psychotic disorder. You can consider ketamine if they have had a drug related psychosis in the past and no recent drug use. Dr. Heacock uses ketaine in patients with PTSD, but he admits that this can be difficult in the Emergency Department because the hectic environment may trigger fear and anxiety in these patients.

If you are a physician, nurse practitioner, or physician assistant and going to claim CME credit, by downloading you acknowledge that you have read and understand the CME disclosures and information.

Download the episode here: Episode 17: Ketamine Revisited

Difficulty downloading? Right click (Mac users ctrl-click) then choose “Save link as…”

Click here to take the Quiz for CME (***Physicians, NPs, and PAs only***)

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Episode 16: Bradycardia (Complete Heart Block)

In this episode Dr. Julie Vieth and I discuss management options of complete heart block.

We start with a case where EMS responded to a call for an altered mental status. Glucose was normal, but when they checked vital signs they realized the patient was bradycardic. Patient was put on an external pacer and had improvement of symptoms.
Next we discuss a case where Dr. Vieth was called to the ICU to place a temporary transvenous pacer. She discusses the method she used to place the catheter, float the wire, and pace the patient.

Lessons learned from these cases are as follows:

  • Does the patient require airway management
  • Consider differential diagnosis (not diagnostic):
    • Myocardial infarct/ischemia
    • Myocarditis
    • Medications (beta blockers, calcium channel blockers, digoxin, amiodarone, organophosphates, clonidine, etc)
    • Hyperkalemia
    • Hypothermia
    • Increased ICP
  • Consider trial of medications such as:
    • Atropine: 0.5 mg IV repeated every 5 minutes up to 3 mg
    • If you need vasopressors, consider one of the following:
      • Dopamine: 3 mcg/kg/min, titrate up to 20 mcg/kg/min
      • Dobutamine if heart failure: 5 mcg/kg/min titrate up to 20 mcg/kg/min
      • Epinephrine: 2 mcg/min, titrate up to 10 mcg/min
    • Glucagon if on beta blockers
  • When you are changing the connection from the EMS device to your device in the Emergency Department, make sure you have the second device set up BEFORE you disconnect the patient!
  • Temporary transvenous pacing
  • The preferred site is the right IJ, if this is not available use the left subclavian.
  • Transfer to the appropriate care early and quickly!

If you are a physician, nurse practitioner, or physician assistant and going to claim CME credit, by downloading you acknowledge that you have read and understand the CME disclosures and information.

Download the episode here: Episode 16: Bradycardia
Difficulty downloading? Right click (Mac users ctrl-click) then choose “Save link as…”

Click here to take the Quiz for CME (***Physicians, NPs, and PAs only***)

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Episode 1: Shoulder Dystocia

If your emergency department is in an area like mine (or even more remote), you do not have an in-house obstetrician. At night, the on-call obstetrician is at least 20 minutes away, if not longer. To make matters worse, it still takes at least 5-10 minutes to come from clinic during the day. This means our emergency physicians deliver more babies each year than those at larger centers. Sometimes those babies just won’t wait.

This month we talk about a case I had earlier this year: a precipitous delivery in the Emergency Department. This case was complicated by a shoulder dystocia. We talk about what I did in the case, my thought process at the time, what I would do differently, and then discuss the current recommendations for shoulder dystocia.

Shoulder dystocia is fairly common and occurs in 1-2% of the delivers. If this is not recognized quickly and if the shoulder is not delivered, this can lead to brachial plexus injuries, hypoxia, and even death. There is a mnemonic that can help you remember the steps to take to allow you to successfully deliver the baby. This mnemonic is HELPERR:

H: Call for Help
E: Evaluate for Episiotomy
L: Legs (McRoberts maneuver)
P: Pressure in the suprapubic region
E: Enter the vagina (rotational maneuvers)
R: Remove the posterior arm
R: Roll the patient to hands and knees.

The first step is to call for help. This is important as you will need additional staff to help you with these maneuvers and to help in ressusitative maneuvers if required.

Once you have called for help, you can evaluate the need for episiotomy. The main reason for the episiotomy is to allow to you more easily place fingers into the vaginal vault for maneuvering the fetus.

The first maneuver that you should try is the McRoberts Maneuver. This is hyperflexion of the hips and abduction of the legs. This rotates the pelvis and helps the pubic symphysis slide over the anterior shoulder. It can also cause the posterior shoulder to drop into the sacrum which also allows the anterior shoulder to be more easily delivered. The success rate varies in the literature from 40-90%.

The next step is to apply suprapubic pressure with the patient in the McRoberts position. This is NOT fundal pressure. This is applied by applying pressure to the posterior aspect of the anterior shoulder of the fetus. This is an attempt to reduce the shoulder-to-shoulder width and to rotate the shoulders to an oblique orientation allowing delivery of the anterior shoulder. This can be done either with a continuous pressure or by a rocking pressure.

If these maneuvers have not delivered the anterior shoulder, the next is rotational maneuvers. The first is Rubin’s maneuver. This is performed by placing a finger into the vaginal vault and applying pressure on the back of the anterior shoulder. This attempts to reduce the shoulder-to-shoulder distance and to rotate the shoulders into an oblique position allowing delivery of the anterior shoulder.

The next step if the shoulder dystocia has not been relieved is the Wood’s Corkscrew Maneuver. You apply pressure to the posterior aspect of the anterior shoulder with one finger and with the other hand you apply pressure to the anterior aspect of the posterior shoulder. This will create a rotational force that will add more rotation to help deliver the shoulder. This can be done to perform 180 degrees of roatation within the vaginal vault. You can also perform a reverse corkscrew maneuver to rotate the baby in the opposite direction.

If these rotational maneuver fails, you can also attempt to deliver the posterior arm. This is done by tracing the posterior arm from the shoulder, down the humerus, and locating the forearm. Once the forearm is located you swipe the forearm across the chest and then out of the vagina. This will cause the posterior shoulder to deliver which will in turn allow the anterior shoulder to deliver. If you cannot find the forearm, you can apply pressure to the antecubital fossa causing the elbow to flex which will bring the forearm into reach.

If these maneuvers fail you can rotate the mother into a hands and knees position and attempt to deliver the baby.

One maneuver that is not taught frequently in the United States is axillary traction. This is performed by inserting the index or middle finger of both hands into the vaginal vault and hooking them under each axilla. This allows you to deliver either the anterior or posterior shoulder. If this fails you can perform the rotational maneuvers as above but this time with more outward traction. Take care to not apply too much traction as it can cause a humeral fracture.

The last resort that can be made is to fracture the clavicle. This reduces the shoulder-to-shoulder distance allowing for delivery of the baby. This often increases the risk of brachial plexus injuries and vascular injuries, therefore this should only be used as a last resort.

If all of the above maneuvers fail, the last step is the Zavanelli maneuver. This is performed by pushing the head back into the mother until a c-section can be performed. This is a difficult option in the small hospital as there may not be an obstetrician nearby.

Click here to download this months episode: Shoulder Dystocia.
Difficulty downloading? Right click (Mac users ctrl-click) then choose “Save link as…”

CME no longer available for this episode.

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.