Episode 82 – Emergency Radiology Controversies

EM Cases Episode 82 Emergency Radiology Controversies, pearls and pitfalls: Which patients with chest pain suspected of ACS require a CXR? What CXR findings do ED docs tend to miss? How should we workup solitary pulmonary nodules found on CXR or CT? Is the abdominal x-ray dead or are there still indications for it's use? Which x-ray views are preferred for detecting pneumoperitoneum? When should we consider ultrasound as a screening test instead of, or before, CT? What are the indications for contrast in abdominal and head CT? How should we manage the patient who has had a previous CT contrast reaction who really needs a CT with contrast? What is the truth about CT radiation for shared decision making? And much more...

Episode 75 Decision Making in EM – Cognitive Debiasing, Situational Awareness & Preferred Error

While knowledge acquisition is vital to developing your clinical skills as an EM provider, using that knowledge effectively for decision making in EM requires a whole other set of skills. In this EM Cases episode on Decision Making in EM Part 2 - Cognitive Debiasing, Situational Awareness & Preferred Error, we explore some of the concepts introduced in Episode 11 on Cognitive Decision Making like cognitive debiasing strategies, and some of the concepts introduced in Episode 62 Diagnostic Decision Making Part 1 like risk tolerance, with the goal of helping you gain insight into how we think and when to take action so you can ultimately take better care of your patients. Walter Himmel, Chris Hicks and David Dushenski answer questions such as: How do expert clinicians blend Type 1 and Type 2 thinking to make decisions? How do expert clinicians use their mistakes and reflect on their experience to improve their decision making skills? How can we mitigate the detrimental effects of affective bias, high decision density and decision fatigue that are so abundant in the ED? How can we use mental rehearsal to not only improve our procedural skills but also our team-based resuscitation skills? How can we improve our situational awareness to make our clinical assessments more robust? How can anticipatory guidance improve the care of your non-critical patients as well as the flow of a resuscitation? How can understanding the concept of preferred error help us make critical time-sensitive decisions? and many more important decision making in EM nuggets...

Episode 65 – IV Iron for Anemia in Emergency Medicine

For years we’ve been transfusing red cells in the ED to patients who don’t actually need them. A study looking at trends in transfusion practice in the ED found that about 1/3 of transfusions given were deemed totally inappropriate. As we explained in previous EM Cases episodes, there have been a whole slew of articles in the literature over the years that have shown that morbidity and mortality outcomes with lower hemoglobin thresholds, like 70g/L for transfusing ICU patients (TRICC trial), patients in septic shock (TRISS trial), and patients with GI bleeds are similar to outcomes with traditional higher hemoglobin thresholds of 90 or 100g/L. We’re simply transfusing blood way too much! The American Association of Blood Banks in conjunction with the American Board of Internal Medicine’s Choosing Wisely campaign, as one of its 5 statements on overuse of procedures, stated, “don’t transfuse iron deficiency without hemodynamic instability”. So, in this episode with the help of Transfusion specialist, researcher and co-author of the American Association of Blood Banks transfusion guidelines Dr. Jeannie Callum, Transfusion specialist and researcher Dr. Yulia Lin, and 'the walking encyclopedia of EM' Dr. Walter Himmel, we give you an understanding of why it’s important to avoid red cell transfusions in certain situations, why IV iron is sometimes a better option in a significant subset of anemic patients in the ED, and the practicalities of exactly how to administer IV iron.

Episode 62 Diagnostic Decision Making in Emergency Medicine

This is Part 1 of EM Cases' series on Diagnostic Decision Making with Walter Himmel, Chris Hicks and David Dushenski discussing the intersection of evidence-based medicine, cognitive bias and systems issues to effect our diagnostic decision making in Emergency Medicine. In this episode we first discuss 5 strategies to help you master evidence-based diagnostic decision making to minimize diagnostic error, avoid over-testing and improve patient care including: 1. The incorporation of patients' values and clinical expertise into evidence-based decisions 2. Critically appraising diagnostic studies 3. Understanding that diagnostic tests are not perfect 4. Using the concept of test threshold to guide work-ups 5. Understanding that the predictive value of a test depends on the prevalence of disease We then go on to review some of the factors that play into the clinician’s and patient’s risk tolerance in a given clinical encounter, how this plays into shared decision making and the need to adjust our risk tolerance in critical situations. Finally, we present some strategies to prevent over-testing while improving patient care, patient flow and ethical practice.

Episode 55: Fluids in Sepsis, Post-intubation Analgesia and Sedation

In this second part of the Weingart-Himmel Sessions on critical care pearls for the community ED on the EM Cases podcast, we discuss the many controversies and recent changes in fluid management in severe sepsis and septic shock. With the recently published ARISE trial, and some deviations from Early Goal Directed Therapy, we are changing the way we think about fluids in sepsis: the type of fluid, the volume of fluid, the rate of fluid administration, the timing of introducing vasopressors and the goals of fluid resuscitation. In the next section of the podcast we discuss the PAD mnemonic for post-intubation analgesia and sedation, the prevention of delirium, and medication choices to minimize time on the ventilator, and improve prognosis.

Episode 54: Preoxygenation and Delayed Sequence Intubation

Hot on the heels of Dr. Weingart's latest publication in the Annal of EM on Preoxygenation & Delayed Sequence Intubation, we have Dr. Weingart, perhaps the world's most influential critical care educator, and Dr. Walter Himmel, 'The Walking Encyclopedia of EM' discussing how the community ED doc can use preoxygenation, apneic oxygenation and delayed sequence intubation to help improve airway management knowledge and skills. Whether you work in a rural setting or a big urban community hospital, Dr. Himmel and Dr. Weingart explain how these concepts and skills are easily adaptable to your work environment. We introduce the Triple 15 Rule for preoxygenation as a memory aid that will help you the next time you're faced with a critically ill patient who's oxygen saturation isn't good enough on a non-rebreather.

Episode 51 Effective Patient Communication – Managing Difficult Patients

If you believe that coping with some of the people we deal with in emergency medicine is difficult or impossible, you’re not alone. We all feel this way from time to time. Managing difficult patients can be a challenge to the health care provider and to the entire ED. The hostile aggressive patient, the demanding patient, the know-it-all, the excessively anxious patient, and the incessant complainer, are some of the folks that we need to know how to manage effectively. If we fail to handle these patients appropriately, they may receive suboptimal care, grind patient flow to a halt, and delay care of other patients. If the staff has to deal with a multitude of these patients on a given shift, there’s a sort of swarm-based escalation in frustration and sometimes, unfortunately, a total breakdown of effective patient communication and care. But don't fret. In this one-of-a-kind podcast on effective patient communication and managing difficult patients, Dr. Walter Himmel, Dr. Jean-Pierre Champagne and RN Ann Shook take us through specific strategies, based on both the medical and non-medical literature, on how we can effectively manage these challenging patients. As a bonus, we address the difficult situation of breaking bad news with a simple mnemonic and discuss tips on how to deliver effective discharge instructions to help improve outcomes once your patient leave the ED.

Episode 49 Effective Patient Communication, Patient Centered Care and Patient Satisfaction

If you believe that coping with some of the people we deal with in emergency medicine is difficult or impossible, you’re not alone. We all feel this way from time to time. We all work in stressful environments where it may feel as though we have too little time for effective patient communication, patient centered care and patient satisfaction. You and your patients may often have mismatched views of what’s important. You may have a specific medical agenda and they might have a very different agenda. Then there’s the difficult patient – we all know who these people are – the hostile aggressive patient, the demanding patient, the know-it-all, the excessively anxious patient, and the incessant complainer, among others. If we don’t know how to handle these patients appropriately, they may receive suboptimal care, grind patient flow to a halt, and delay care of other patients. And of course, if the staff has to deal with a multitude of these patients on a given shift, there’s a sort of swarm-based escalation in frustration and sometimes, unfortunately, a total breakdown of effective care. These frustrations don’t only come out when we’re presented with multiple sequential difficult patients, but for some of us, the more we practice, the more we become desensitized to the needs of all of our patients and their families and, we run the risk of destroying the doctor-patient relationship, as well as making most of our patient interactions frustrating, unsatisfying, – even detrimental to our health and the outcomes of our patients. How you communicate in the ED can improve patient outcomes and enhance job satisfaction, yet there is little education on patient centered care for EM practitioners. After listening to this episode, it is my hope that what you learn from the literature and from expert opinion,and then apply to the way you communicate with your patients, will effectively make you a happier health care professional. Dr.Walter Himmel, Dr. Jean Pierre Champagne and RN Ann Shook guide us in this round table discussion on effective patient communication, patient centered care and patient satisfaction – this has evolved my practice into what I perceive as a higher level of personal satisfaction as well as patient care….I hope it will do the same for you.

Episode 47: Evidence Based Medicine from NYGH EMU Conference 2014

Dr. Walter Himmel (the 'walking encyclopedia of EM') gave a fantastic talk from North York General's Emergency Medicine Update Conference in Toronto, which have edited into a podcast with key commentary and summaries. Dr. Himmel eloquently shows us, through absolutely stunning personal cases, how evidence based medicine can be appropriately or inappropriately applied in real practice, resulting in major outcome differences for your patients. He elucidates the importance of clinical experience, patient values and ED resources in helping apply the medical literature to your practice. He reviews the essence of critical appraisal, the hierarchy of evidence and how to keep up with the emergency medicine literature. The famous NINDS thrombolysis for stroke trial is distilled down to a few key considerations and the NEJM transfusion for upper GI bleed trial from last year is dissected, analyzed and then applied to Dr. Himmel's personal cases, to help us understand exactly how to apply the literature to our daily practice. Blog post and written summary prepared by Keerat Grewal, edited by Anton Helman July 2014

Episode 37: Anticoagulants, PCCs and Platelets

In the second part of this epic 2-part authoritative episode, Anticoagulants, PCCs & Platelets, we have Dr. Walter Himmel (also known as 'The walking encyclopedia of EM') along with Dr. Katerina Pavenski (Head of Transfusion Medicine at St. Michael's Hospital) & Dr. Jeannie Callum (Head of Transfusion Medicine at Sunnybrook Hospital) who will discuss the latest on comparative efficacy and reversal of Warfarin vs Dabigatran vs Rivaroxiban vs Abixaban, the use of prothrombin complex concentrates (PCCs), the ins and outs of thrombocytopenia & platelet transfusions, ITP, TTP, anti-platelet associated intracranial bleeds, indications for Tranexamic Acid & more...

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