Tara's kids...doing all the same things other kids do!!!
A while back now, I got an email from Weingart stating that he had received correspondence form a Canadian paramedic by the name of Tara Anema. Tara really wanted to get the word out about a particular pediatric patient population that she had seen mismanaged by all levels of emergency provider in all types of situations. Why all the hubbub about this particular group…well the condition is hemophilia and her own two sons are effected. After speaking to Tara I knew her passion and message was perfect for the show. I have also brought in our hemophilia expert from the University of Kentucky, Dr. Vlad Radulescu to answer all your burning questions about how we SHOULD be taking care of these children.
As a bonus this month, stay tuned to the end of the show when Dr. Marianne Gausche-Hill and I do a little update on Pediatric Readiness and be sure to check out her most recent publication below!!
Pediatric Syncope Part Deux...Still Fell Out
Apr 25, 2015
Buck Kyle MD...AKA pediatric cardiologist extraordinaire... is back to finish up part two of our in-depth look at pediatric syncope and the thirteen causes of sudden cardiac death. Never feel threatened by the patient with a chief complaint of DFO (done fell out) again! For the next hour we will cover the rest of the electrical, structural, and miscellaneous conditions that are responsible for V Tach/DFO, which may can ultimately to sudden cardiac death.
I was recently asked to discuss my best case ever with Anton Helman, MD of Emergency Medicine Cases and then to join Alex Koyfman, MD from EMDocs for a session of "Ask Me Anything." Both were so much fun and we covered a lot of interesting material. You have to check out these two sites they are fantastic!!! Thanks to both for the invites!!!
Click the links below:
Pediatric Syncope (DFO ~ Done Fell Out)
Feb 04, 2015
Welcome back to the show Dr. Buck Kyle! Dr. Kyle is a attending pediatric cardiologist at Texas Children’s Hospital and on this episode we will discuss what causes all those little kids to pass out before they come to your ER and then look so fantastic. Are they all OK to go home? Is there anyone in there that’s truly sick and if so how do we identify that subset? Sit back, hold on tight, and try not to DFO (done fell out) because it’s going to be fast, fun, and may leave you a little mareado….
The Five Canons of Levitan - Difficult Airway Part 3
Dec 02, 2014
Canon - a general law, rule, principle, or criterion by which something is judged
No one has changed the face of how we approach difficult airway more than Rich Levitan, MD. In this episode I review five of Rich's most important contributions to how we approach emergent intubations. These are techniques you can take to the department tomorrow to improve your view, increase your success, and save your patient's life!
Click here to follow Dr. Levitan on twitter.
Ear to sternal notch positioning will not only improve your view, but save your backside and possibly your patient's life!
Levitan's best bougie techniques (includes Shaka, Kiwi and Ducanto)!
It is hard to put into words or even imagine the concept of someone intentionally hurting a child, but it happens more frequently than we'd like to believe. In this episode, I had the privilege of discussing some of the cornerstone exam findings and history flags for occult abuse with Marci Donaruma-Kowh, MD a child abuse expert from the Baylor College of Medicine ~ Texas Children's Hospital. This episode will change the lens you view your pediatric patients through; even with those who have what appears to be the most mundane of injuries. Unfortunately, abuse is not always overt and Dr. Donaruma is an expert in identifying the subtleties of this diagnosis, nailing the perpetrator, and making sure they go away for a long-long time...
If you know of a child that is being abused call the police now. If you would like to refer a case and you are in the Houston area please click here: Children's Assessment Center.
Wow! We've made it to the end of three episodes on asthma. We've covered everything from diagnosis to treatment and everything in between. We now know how to best educate our patients to empower them to treat their disease at home and prevent recitivism!
Tune in this episode for the specifics on how to use a Peak Flow Meter, Bi-Pap, EtCO2 and of course how to set-up the ventilator in a way to maximize support and minimize chances of injury in your asthmatics.
Asthma Andrews Style - What's the best oral steroid you ask?
Jul 01, 2014
What's the best oral steroid to treat acute asthma exacerbations you may ask? Well, we're here to answer that for you. Please welcome Dr. Annie Andrews, MD, MSCR who has written all the articles you will find listed below on just that subject. In this podcast we will prove that dexamethasone is not only the most cost effective steroid to prescribe in asthma exacerbations, decreases recidivism, and has the best compliance rates, but it tastes great too!
In this episode, the first of a three part series on asthma, we will cover the diagnostic and treatment strategies that will help you rapidly move patients through your ED. No, of course you don't need the patient's asthma classification, but you DO NEED to understand which patients need more treatment and when it's OK to stop. I will break that all down for you with the aid of the algorithm above. We'll talk in depth about who can go home safely and who should be in the Unit! Download the flow sheet from the link above, put it in your smart-phone so you have it for your next asthma encounter, and follow along. It's going to get musical..
Anyone Seen My Corn? Pediatric Foreign Bodies
Apr 09, 2014
THE DERMA-Q
How many times have you seen a square object inserted into a round hole.....of an ear canal??? It's quite a quandary and can be the source of frustration for both you and the patient. You may end up waiting two to three hours just to be able to sedate the little bugger because they have usually just choked down a cheese burger and fries (if your in Britain it may be bangers and mash, Australia a vegemite sandwich, Russia borscht, etc, etc) and then even after you have them sedated, you don't have the right tool to get the foreign body out because the right tool was never created… that is, until now! Thanks to Dr. David DeLemos from the Texas Children's Pediatric Emergency Medicine program, we now have the solution to the round (or square) object in the ear canal. Let me be the first to introduce you to the "Derma-Q." The Derma-Q is a contraption created from the plunger of a small syringe or a Q-tip, which has then been tipped (like a tribal dart) with a minute amount of Dermabond. The Derma-Q provides the perfect rescue technique to get those tough foreign bodies out of almost any orifice. Also making her debut this month on the PEM ED Podcast, my wife, Dr. Holly Sparks will risk life, limb, and my ear canal by getting a cheap piece of plastic jewelry out of my EAC for your viewing pleasure.
Rich Levitan's Yellowstone Advanced Airway Critical Care Course
Dr. Facilier begged the question..."Are you ready for Transformation Central?" Transformation? My ER runs just fine. What could I need to be ready for or transform my ER into??? Well, there's this little thing standing between you and poop in your underwear; most of us call them pediatric patients. What should scare you is that 30% of the hospitals in the US are not ready and by not ready I mean that they do not have the proper equipment or training necessary to take care of critically ill patients. So I say again, ask yourself, what is the most stressful patient whom you to take care? Is it the little old urosepsis patient that needs an art line, central line and intubation or the neonate that needs the same procedures. OK, the procedures are stressful, but what if you don't have the equipment to to do them. Do you know if your ER stocks a size 1 LMA? Now's the time to figure it out, not once the patient is staring you in the face (probably wide eyed). This month we are fortunate enough to be joined by the esteemed Dr. Marianne Gausche-Hill who is the creator and lead investigator on the Pediatric Readiness Project. We now know from a decade of research that 30% of hospitals in the US are missing the equipment needed to take care of these patients do you work at one of those????
Dr. Gauche Hill would like to thank: Dr. Kate Remick, The Federal EMS for Children Program Director Elizabeth Edgerton, National EMS for Children Data Analysis and Resource Center, American College of Emergency Physicians, American Academy of Pediatrics, the Emergency Nurses Association, State of California EMS Authority, and all the EMS for Children’s Coordinators in the US and its territories.
Now I've got your mind palatable to the fact that young thin kids can get cholecystitis too, lets figure out how to weed those kids out from the hundreds of gastroenteritis that you're still going to see each week. On this episode we'll explore which labs and rads get you to the place you want to be.... not just a disposition, but the correct disposition. Dr. Doug Fishman is back to get you on the right track to making the right diagnosis!
You may think that Miley Cyrus' on-stage theatrics was the most shocking thing to happen in 2013, but au contraire mon frère. Hold on tight, because the most outrageous thing you've heard between stanzas of "Auld Lang Syn" is that kid's are getting gallbladder disease. This is especially frequent in the good ole US of A where we have mid-morning cheese burgers for a snack. Shocking I know. In this episode Pediatric Gastroenterologist Dr. Doug Fishman, from the Texas Children's Hospital, is going to go through the In-N-Outs of pediatric cholecystitis. Not that In-N-Out is in anyway responsible for pediatric gallstones...they make a tasty burger....try the double-meat animal style...it's fantastic....
Thanks to Doug Fishman, MD. Director, Gastrointestinal Endoscopy
Texas Children's Hospital
Associate Professor of Pediatrics
Please visit his website devoted to education and treatment of Celiac Disease below
Park that Shoulder in Place - Shoulder Reductions & One Hip
Sep 28, 2013
How many times have you been involved in an adult or pediatric shoulder reduction that you just can't relocate. Very frustrating, but here's your solution: Dr. Jay Park has invented a method that allows you to reduce a shoulder without sedation (RNs love that) and without any pain to your patient (Press Ganey scores will rise faster than your salary). Listen up, this defines cool!
Jay Park, MD
Contact Jay For Website Design: http://jayparkmd.com
Dr. Park is involved in numerous medical missions, if you would like to contact Dr. Park to see how you can get involved or make a donation email him at: jayparkmd@yahoo.com
Red eyes usually come in pairs and so do podcasts on the subject. In part two of the red eye disorders we discuss the non-threatening maladies that can turn into eye threatening disorders if missed. Sit back and relax and let dear ole' dad tell you one more time why it's going to be OK...If you listen to him. Otherwise you may get spanked. I'm serious he spanked me a lot for not listening. Call CPS; there's still a chance for me....
The Eyes Have It..... Or At Least The Red Eyes Do
Jul 08, 2013
Harold Andrew Sloas Jr, DO, CAPT, USN-R is a board certified ophthalmologist (and my dad). He had a competition with his son Harold Andrew Sloas III, DO, RDMS, FAAEM to see who could get get more letters behind their name. As it turns out none of those letters have any bearing on what we'll be talking about today.
You're in for a real treat because I got to sit down with dear ole' dad and talk about some red eye disorders. We explore all the threatening causes of the red eye on this podcast and move into the non-threatening red eye disorders on the next episode. You need to know something about both so you can distinguish between the two. Pull out your Kleenex and dry your eyes; you're going to need to see this.
I have had the opportunity to work with some truly amazing people in my life and Dr. Matt Bayes, sports medicine physician extraordinaire, is no exception. Dr. Bayes is the only person I have known to successfully ask about a “code red” and somehow avoid receiving one. Dr. Bayes now resides in St. Louis, Missouri (Bayes from The Lou) and has been part of the sports medicine team that delivers care to the St Louis Cardinals. On this episode Dr. Bayes takes me through the intricacies of diagnosing and managing a pediatric concussion from the ER perspective. Hold on to your head because you’re about to get knocked out....Smokey
José Álvarez-Sabín, MD; Antoni Turon; Manuel Lozano-Sánchez; José Vázquez, MD; Agustí Codina, MD Delayed Posttraumatic Hemorrhage "Spät-Apoplexie"Stroke. 1995;26:1531-1535doi: 10.1161/01.STR.26.9.1531
One of the most sphincter tightening overdoses to deal with in adults and pediatrics is the CCB overdose. In this podcast I cover all the treatments that work, don't work, and you would think should work to give you a recipe for success. Hold on to your insulin; it's not just for diabetics and critically ill patients anymore. Intralipids??? How the heck does that help??? Well you need to tune in to find out......
Our resident cardiologist Dr. Buck Kyle completes the second part of his lecture series on pediatric ECG reading. This time we get into the most common cardiac disease processes that occur in the pediatric population. What’s black and white and read all over??? OK, yes the newspaper, but ECGs are too....don’t steal my punch lines.....
Pediatric (and some adult) ECG Basics
Jan 08, 2013
The Squiggly Line Rule: The more squiggly lines in the outline/border lines of a state, the cooler/more fun it is to live in that state. In, for example, the state of California, the squiggly lines are found on the coastline adjacent to the pacific ocean ~ Urban Dictionary
It also happens to be true that if you are an electrocardiogramophile than the more abundant the squigglies, the more stimulating and salacious the ECG is to read (and you probably have eroticism issues). While it is also true that if you do not find electrocardiogram interruption to be lascivious than you probably find it to be frustrating (and you may have ECG performance issues). Either way, have I got a tonic for you. It cures all of the above (except the obvious sexual innuendo problems, you need to see a therapist for that soon).
In this episode, we start a two part series on the basics of pediatric ECG interruption with Dr. Buck Kyle, pediatric cardiologist and electrocardiogram aficionado. Sit back and relax as Dr. Kyle makes everything clear and really...see the therapist soon......
Penis Talk ~ With Your Hosts Sloas and Stroup
Dec 02, 2012
The finale in the Urology trilogy. In this episode Dr. Sean Stroup, CDR, USN, MC and I wrap-it-up with a series of "down-there" complaints (down-there does not imply that this episode is about Australians with grievances) with the most sensitive of subjects to any male patient, penile complaints, worries about the willie, persevering about the pee pee, jargon about the junk, etc. Hold on to your hats....
The Disclaimer hasn't changed: if you think jokes about "shrinkage" are funny than please listen to the podcast, but if you find those offensive then skip this episode and I wish you all the best in your attempt to make it through your career without encountering another penis...again....ever.
"Amigo, the only thing in this world that gives orders is balls. Balls. You got that?" ~ Scarface 1983
Every man is attached to their nuts. In this episode CDR Sean Stroup, MD USN and I continue to discuss non painful ballular complaints. You make think your safe with a non-painful swollen scrotum, but oh contraire mon frere, you can lose a nut that way too. A guy just can't get a break....
The Disclaimer from the last episode still applies: if you think jokes about old man balls are funny then please proceed to listen to this podcast, but if you find those offensive then skip this episode and look into non-urologic career paths. However, if you do listen to this podcast then the ball you save could be your own....
Urological Complaints Part 1 - The Painful Scrotum
Sep 05, 2012
"Rub your balls, squeeze your balls so you don't get cancer" ~ Tom Green
Few things cause more pain for the patient and fear in the practitioner than scrotal discomfort in a child. I sat down with my good friend and pee-pee doctor CDR Sean Stroup, MD USN at the National Naval Medical Center in sunny, beautiful, oh how I miss it: San Diego, to discuss painful ballular complaints. Dr. Stroup is a fellowship trained urologist practicing on the west coast and sees a ton of children at the Naval Medical Center. Disclaimer: If you are offended by jokes about pee-pee, the scroti, or not wearing appropriate underwear than it is probably best to skip this episode. No testicles were injured or neutered in the production of this podcast.
I had the privilege to sit down with one of Canada’s finest, Dr. Amit Shah, and discuss his blinded randomized prospective study concerning one of my favorite procedural medications: Ketofol.
This is the evidence based follow-up to my last (more opinion based) podcast on “Sedation and Ketofol.” The chocolate in my peanut butter.......
Shah A, Mosdossy G, McLeod S, Lehnhar, Peddle M, Rieder M. A blinded randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425 33.e2. Epub 2010 Oct 13. PubMedPMID: 20947210
There are a lot of ways to sedate, but I would like to provide you with a philosophy and the methodology to put together the safest possible sedation package.
Please stay tuned for my next episode in which I get a chance to interview Dr. Amit Shah the lead author on the game-changing Ketofol article listed below.
Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded,randomized controlled trial to evaluate ketamine/propofol versus ketamine alonefor procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425-33.e2.Epub 2010 Oct 13. PubMed PMID: 20947210
Pediatric Airway - The Advanced Course
Apr 15, 2012
This is the second part of a two part series in pediatric airway management. Here we focus on how to use the "Airway Algorithm" that we have created and how to manage the more difficult airways we encounter in the emergency department. The "Airway Algorithm" is designed to be used in both adults and children.
Reference: The Difficult Airway Course: Emergency™ (http://www.theairwaysite.com) and from Walls RM and Murphy MF: Manual of Emergency Airway Management, 4th Edition, Philadelphia, Lippincott, Williams and Wilkins, 2012.
“Airway is the reason that many go into emergency medicine…”
- Jaime McCarthy MD, UT Health Sciences Center at Houston EM Director
One of the many things that we do better than anyone in the business is obtain the emergent airway. Unlike our colleagues in other disciplines, we do not have the luxury of planning our airway approach on the golf course the evening before; we meet patients on their worst day. Even though we would often prefer it, we do not have the option to reschedule our intubations.
Smashed, bloody, distorted, edematous, airways secondary to trauma, anaphylaxis and GI bleeds are the things that we deal with routinely with nary a complaint or even a hither for a better look than what were given. We often feel lucky to get any type of view that resembles normal laryngeal anatomy. Personally, if I knew that I would need to be intubated today, that my airway would be bloody and edematous, and there was only time for one person to take a shot at placing the tube, then I would pray to God that the last face I see before the Roc and Etomidate push me asunder is the familiar grill of one of my EM colleagues. Who better to bet all my chips on then someone who deals with the hardest airways on the face of the planet as part of their daily routine? The general EM provider can not only get that airway, but is so relaxed about it that they will casually check on the patient in the next bed before and after the intubation. That’s the confidence I’m looking for when it comes to the fast paced life and death world of emergency airway.
Whether it is pediatric or adult emergency medicine, the most important thing that we do as “emergentologists and resusitologists” is control the airway.
Developing a good rule to clinically clear the pediatric cervical spine would be difficult. Very few kids suffer injuries to that region of the body making it nearly impossible to create a well-powered decision instrument. Like with many other attempts in pediatrics you would most likely end up with a guideline that would be fairly sensitive, but horribly specific.
Lets say we abstracted and validated a pediatric c-spine rule that was 95% sensitive and 50% specific. With a disease that occurs at an incidence of less than 0.1% (1/1000), by employing a decision instrument that is 95% sensitive you would reduce your patient's risk of missed injury to say 0.005% (1/20,000) . Sounds great right? Hold on though; there's more. If that same rule is 50% specific (which most peds clinical rules are) 50% of the kids you applied your rule to will have false positives. Therefore 500 of every 1000 patients you employ your decision instrument for would actually be subjected to further workup and needless radiation.
Does any of that sound familiar? It's nearly identical to the use of D-Dimer in very low risk adults (probably better stated as no risk). If you take a low to medium pre-test probability of disease (Wells Score of low-mod = 2-16% risk) and apply a D dimer (sensitivity > 95%) that comes back as a negative result (you now have reduced your 16% chance of having disease to less than 1% because 16% reduced 95% is 0.8%). Well done! You are done with the work-up and you have excluded disease. If you apply the D-Dimer to a very low risk population (1-1000 to 1/10,000 depending on who you read) then you may further reduce your risk (I'm not sure how much lower you need to go to fell comfortable 1/1000 is pretty low), but just like in the example above, you will have subjected twice as many patients to needless CTA of their chests because your D-Dimer specificity was so poor (about the same 50% as above).
Sorry, that's a lot of stats, but here's the take-home message. Your pediatric patient doesn't need a decision instrument as much as they need a good doctor. Any injury with extremely low prevelence will most likely end up below the test threshold of creating and validating a decision instrument that you can rely on. It is hard to get objective data in pre-verbal children, but it is easy to play with them, earn their trust and make a good clinical decision. NEXUS gets you to 8 years of age, but then it's up to you to make a decision based on experience.
If you downloaded the fist version of this (no intro music), delete it and re-downlad. The audio is much better on the second version.
Practitioners have a love-hate relationship with this procedure. Whether you embrace it or react to its’ necessity in the same manner you would when finding out you've just been cut-out out of your wealthiest relative’s will, the words “lumbar puncture” invoke emotion. I would like to thank Dr. David Delemos for inventing this simple recipe for success. It is one of my favorite procedures and hopefully after hearing this podcast it will be one of yours as well.
In this episode we complete our discussion on “Fever Without a Source” in the 2-3 month old population and also cover the 3-month plus age group. Again Dr. Andrea Cruz a subspecialist in emergency medicine and infectious disease at The Texas Children’s Hospital gives us some further insight into when and how to work these kids up.
Full disclosure: The author on two of the articles below is LCDR Sherry Rudinsky who is an old navy friend of mine. We were interns together and then attended the same Naval Flight School class. Dr. Carstairs is also an aquantaince; she was a resident when I was a Navy Surgical Intern. I was stationed at the Naval Medical Center San Diego when they were collecting their data, but I had no part in this study. They are simply dang good reads so check them out.
Reardon JM, Carstairs KL, Rudinsky SL, Simon LV, Riffenburgh RH, Tanen DA. Urinalysis is not reliable to detect a urinary tract infection in febrile infants presenting to the ED. Am J Emerg Med. 2009 Oct;27(8):930-2. PubMed PMID: 19857409.
Rudinsky SL, Carstairs KL, Reardon JM, Simon LV, Riffenburgh RH, Tanen DA. Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era. Acad Emerg Med. 2009 Jul;16(7):585-90. Epub 2009 Jun 15. PubMed PMID: 19538500.\
Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine. Ann Emerg Med. 2007 Jun;49(6):772-7. Epub 2007 Mar 6. PubMed PMID: 17337092.
Have you seen a bunch of snot-nose kids with fever recently? Do you want to put a needle in their back? Better yet, do you not want to put a needle in their back, but feel really guilty about it?
I sat down with Texas Children’s very own Dr. Andrea Cruz who is triple boarded in pediatrics, pediatric emergency medicine and pediatric infectious disease to talk about fever without a source in neonates/infants and who really needs that LP.
There are so many pearls here that I am going to break this into 2 podcasts. Enjoy part one now and don’t forget to check out the link to my “fever without a source” algorithm link below.
Undifferentiated Hypotension and the Modified RUSH Exam
Sep 05, 2011
This is my simplistic take on hypotension (ie. shock) in pediatric patients. All you need is an ultrasound, fluids and a basic understanding of the physiology.
Welcome to PEM ED Podcast. Pediatric Emergency Medicine; an Educational and Directional Podcast for the general emergency medicine provider. I hope you find this podcast informative and practice changing. Please click on the link below and enjoy.
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