Predators

Posted on July 9, 2015 by Martin Huecker

Great discussion of the biases and conflicted interests of medical publication. Here is a fun little news story about one of the predatory journals, which we didn’t even get into. Looking forward to another conference dedicated to reading the literature.

I also meant to introduce everyone present to Belinda Yff, our medical librarian. Not only is she invaluable for assistance with literature search, but she completely caters to the Emergency Physician’s unrealistic expectations of rapid results. She completes and sends me literature searches in a matter of minutes to hours, and can borrow articles from other libraries when we do not have access.

I would strongly recommend everyone saving Belinda’s information and asking for her help with research interests and lecture preparation. Her email address is belinda.yff@louisville.edu.

FOAMed / Literature 7-8-15

Posted on July 8, 2015 by Martin Huecker

Here is the full powerpoint for FOAMed and the literature, to be continued in conference in the future.

Lit_FOAMed_2015

Readmissions

Posted on July 3, 2015 by Martin Huecker

A big topic for the inpatient docs but this video is hilarious for anyone.

Splinting

Posted on July 1, 2015 by Martin Huecker

Here is Dr Kennedy’s Lecture

Splinting in the Emergency Room

Procedural Sedation 7-1-15 – Dr Frick

Posted on July 1, 2015 by Martin Huecker

Here is the powerpoint, will post the tegrity file when available.

Procedural Sedation & Analgesia-1

My brain hurts

Posted on June 10, 2015 by Martin Huecker

Hey this is not a case but what goes through my own head on a difficult shift. There is a lot of information out there on cognitive load / error. Dr Croskerry is essentially the EM world expert on this subject. Take a look at this most recent article. Another great resource are a couple books, one short and sweet the other very in depth. Both are dirt cheap now on Amazon.

Meat Sweats

Posted on May 22, 2015 by Martin Huecker

I know I have had the postprandial coma, not sure about the meat sweats. I love the “localizes to bacon.” Not trying to be insensitive to anyone with weight problems, we have all been low on this GFCScale!

Maryland Pearl Tox Screen

Posted on February 7, 2015 by Martin Huecker

I hope everyone suscribes to the UMEM pearls.

Title: Drug Abuse Screens
Author: Kishan Kapadia
[Click to email author]

Performance Characteristics of Common Drug Abuse Screening Immunoassays
Drug/Class	Detection Interval (***)	Comments
Amphetamines	1-2 days (2-4 days)	Decongestants, ephedrine,l-methamphetamine, selegilene & bupropion metabolites may give False (+) results; MDA & MDMA are variably detected
Barbiturates	2-4 days	Phenobarbital may be detected for up to 4 weeks
Benzodiazepines	1-30 days	Benzos vary in reactivityand potency; False (+) results may be seen with oxaprozin
Cannabinoids	1-3 days (>1 month)	Screening assays detect inactive and active cannabinoids; Confirmatory assays detects inactive metabolite THCA (tetrahydrocannabinoic acid)
Cocaine	2 days (1 week)	Screening & confirmatory assays detect inactive metabolite BE (benzoylecgonine); False (+) results are unlikely
Opiates	1-2 days; 2-4 days (<1 week)	Semisynthetic opiates derived from morphine show variable cross-reactivity; Fully synthetic opioids (e.g., fentanyl, meperidine, methadone, propoxyphene, tramadol) have minimal cross reactivity; Quinolone may cross-react
Methadone	1-4 days	Doxylamine may cross-react
Phencyclidine	4-7 days (>1 month)	Dextromethorphan, diphenhydramine, ketamine, & venlafaxine may cross react
Propoxyphene	3-10 days	Duration of positivity depends on cross reactivity of metabolite norpropoxyphene

(***)Values are after typical use; values in parentheses are after heavy or prolonged use.

References

Adapted from Goldfrank’s Toxicologic Emergencies, 9th ed; Table 6-10.

Ketofol losing sexiness

Posted on February 5, 2015 by Martin Huecker

I rarely use ketofol at Jewish, but will let you guys use it at UL when you want. But this article gives a similar opinion to mine: Ketofol does not hold much benefit if any over Ketamine or Propofol.

For quick procedures where you want muscle relaxation (joint reductions or cardioversion), I use propofol. For painful procedures and trauma patients (traction pins, intubating marginal BP patients, chest tubes) I prefer ketamine.

Propofol with the K does NOT seem to decrease emergence reactions. Though Midazolam does so do give 1-2mg midazolam with your ketamine.

My main issue is anecdotally that the ketofol duration of sedation is noticeably shorter than ketamine. I believe this is due to a lower ketamine dose. And we all know that once the dissociative threshold of ketamine is reached, higher doses simply lengthen the duration of effect. You can’t get “more dissociated” just like you can’t be “very unique.”

I don’t even want to mention etomidate here, as I see only one indication for etomidate (as of 2015 where we are on the brink of taking the head injury stigma away from ketamine).

Article is worth a read.

Stress Test

Posted on February 3, 2015 by Martin Huecker

Another one from Mattu’s Feb review. This article compares psychological stress to physical stress to detect effects on perfusion of the heart. Interestingly mental stress causes ischemia where physical stress does not seem to.

There has always been an intuitive relationship between psychological stress and myocardial ischemia. Bernard Lown, a famous cardiologist, said in EVERY MI patient he had he would find a recent large social stressor in the patient. Of course plenty of hindsight bias occurs here.

Either way, if nothing else with this article remember that emotional stress causing chest pain COUNTS AS exertional ischemic symptoms. The fight with the boyfriend or girlfriend does not allow for blaming the pain on “anxiety.” And perhaps the real stress test in our Chest Pain Center is the 20 hours of sleep deprivation coupled with exposure to yelling, retching and dying that our patients must undergo to make it upstairs for a nice quiet little stroll on the treadmill.

Death of CK-MB?

Posted on February 3, 2015 by Martin Huecker

Hey guys here is a relevant (albeit 7 years old) article supporting my abandonment of the CK-MB. I had heard Mattu talk about this on some podcasts but this article (along with some newer ones) is the evidence to support that practice. At Jewish I do not obtain a CKMB though when I want a total CK I now have to remember up front. On the POC machines at Jewish the Trop alone seems to error far less than when CKs are running with it. Still watch out for the Trop false positives.

Also I would plug Dr Mattu’s new ECG site. Now he charges a small fee (can pay weekly or monthly but I did the $27/year). Still video based (I prefer to just read a blog with pics) but top notch quality. There is a weekly case and a monthly lit review. The above article is in his Feb review. Might make a one month subscription part of the ECG month. ECGs of course are learned over years and decades, not in a month long elective.

Sedation and Hypoventilation

Posted on January 7, 2015 by Martin Huecker

Here is a nice little article specific to hypoventilation associated with propofol use. The concepts are applicable to all sedations and everyone should read this, quick read and will save you some BVMing or an intubation or a death someday.

Ultrasound IVs

Posted on January 2, 2015 by Martin Huecker

We are pretty spoiled at UL with our nurses being the best in the hospital, and being savvy with ultrasound-guided IVs. But when you leave UL to moonlight or graduate and start a new job, don’t expect your nurses to be able to place USN IVs. At Jewish the docs do them all. Nurses in places other than UL are quick to call IV therapy, very quick.

Here is a nice article, one of the simplest but

How do they do it?

Posted on December 12, 2014 by Martin Huecker

Really cool article with commentary attempting to investigate how experienced docs walk into a room and smell the diagnosis and dispo in a few seconds. Looks like most of the “reasoning” is done before even seeing the patient. Read the RN notes!

As a resident I made a comment about Dr Mallory’s knowing the unteachable. I think this diagnostic skill is learnable but maybe not teachable. It can be called intuition. Pattern recognition. Etc.

DSI

Posted on December 2, 2014 by Martin Huecker

DSI works. Weingart’s original article was descriptive. Now he follows with a prospective observational study. I actually haven’t read the whole article yet because like a good book, I just don’t want it to be over. Everyone needs to read this.

Also we all need to quit being slackers on room9er. Lets try to get a few more posts in before the holidays hit us.

Room9er ["Room Niner"]:

The sickest patients, who receive world-class care in the trauma/critical care bay of University of Louisville Department of Emergency Medicine

Author Archives: Martin Huecker