Emergency Medical Minute

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**Emergency Medical Minute**

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

Latest Episodes:

Podcast 614: Perichondritis Nov 17, 2020

Show notes

Contributor: Nick Tsipis, MD

Educational Pearls:

Perichondritis involves infection of not only the connective tissue of the ear but typically the cartilage as well
Symptoms include erythema, ear pain, and fevers
The most common bacterial cause is Pseudomonas.
Perichondritis often occurs after a wound or piercing, but trauma is not necessary for the infection to occur
Anti-pseudomonal coverage is essential with typically oral agents for milder disease and IV antibiotics for severe infections
Can have devastating outcomes if not treated aggressively and/or treated early due to poor blood supply to the cartilage of the ear

References

Prasad HK, Sreedharan S, Prasad HS, Meyyappan MH, Harsha KS. Perichondritis of the auricle and its management. J Laryngol Otol. 2007 Jun;121(6):530-4. doi: 10.1017/S0022215107005877. Epub 2007 Feb 26. PMID: 17319983.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Podcast 613: Spontaneous Bacterial Peritonitis Nov 16, 2020

Show notes

Contributor: Sam Killian, MD

Educational Pearls:

Spontaneous bacterial peritonitis (SBP) is an infection of peritoneal fluid that typically occurs in cirrhotic patients
Symptoms may include abdominal pain, fever, and/or altered mental status
Paracentesis is diagnostic test of choice.
Diagnostic criteria includes > 250 polymorphonuclear cells (PMNs) or a positive gram stain/culture
Treatment is typically a 3rd generation cephalosporin
·30-40% of SBP patients will go into renal failure and SBP associated with sepsis has an ~80% mortality

References

Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015 Jun;41(11):1116-31. doi: 10.1111/apt.13172. Epub 2015 Mar 26. PMID: 25819304.

MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus. 2018 Mar 1;10(3):e2253. doi: 10.7759/cureus.2253. PMID: 29721399; PMCID: PMC5929973.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Pharmacy Phriday #3: Drug Shortages in COVID Nov 13, 2020

Show notes

Contributor: Rachael Waterson, PharmD

Educational Pearls:

Drug shortages have been an ongoing issue since the 2000's. Improvement was being made; however, several factors have exacerbated the drug supply more recently.
According to the US Food and Drug Administration (FDA) Report there are 163 drugs currently on the drug shortage list. Of the 40 drugs critical to treating COVID-19, 18 are on this list.
In comparison, according to the American Society of Health-Systems Pharmacists (ASHP), the current drug shortages have limited 29 of the 40 drugs deemed critical to treating COVID-19 patients.
COVID-19 has had an impact on the supply and demand for pharmaceuticals and has exposed the vulnerability of the US drug supply chain. The demand for drugs that are specific to treating COVID-19 patients have increased, while supply has been impacted due to closed factories, shipping delays, trade limitations, and export bans. Supply has been further limited due to COVID-19 heavily affecting 2 of the 3 main drug manufacturer areas of the world, India and Italy.
In order to combat drug shortages, the US federal government developed a contract with a company to make generics in short supply during the pandemic. There is also current discussion about creating an "America First" program to increase domestic production of active pharmaceutical ingredients.
How pharmacists combat drug shortages:
- Re-assess the definition of need; need vs convenience of a medication.
- Look to see if there is another product, manufacturer, vial size, or drug concentration of that exact medication that can be substituted.
- Substitution of a similar drug if possible.
- Placing restrictions as to which patients can receive medications, who can prescribe medications and medication use dependent on location in the hospital.

References:

American Society of Health-System Pharmacists. (2020). Drug Shortages. ASHP. https://www.ashp.org/Drug-Shortages?loginreturnUrl=SSOCheckOnly.

FDA Drug Shortages. accessdata.fda.gov. (2020, October). https://www.accessdata.fda.gov/scripts/drugshortages/.

Summarized by Emily S Mack, MSBS, OMS III | Rachael Waterson, PharmD

UnfilterED #11: Dr. Ricky Dhaliwal Nov 11, 2020

Show notes

Dr. Tsipis sits down with colleague Dr. Ricky Dhaliwal for some insightful conversation regarding the differences between academic and community settings as well as the various roles of advocacy in medicine.

Time Stamps

00:23 Banter and introductions

2:41 upbringing in 1st generation immigrant Indian household

14:30 losing culture as 2nd gen immigrant

7:32 Balancing family and work with a two doc family

8:32 President of EMRA

10:42 Working in academia vs community

13:29 New job advice

15:55 Nick talks about being the product of your environment and needing to be challenged

20:42 Advocacy in medicine

25:49 Legislative advocacy

27:27 Advocacy for medicine in COVID

29:44 Who are the most influential figures in your career?

33:23 What is your teaching style

38:05 What does the future hold for you?

Podcast 612: Origin of Vaccines Nov 10, 2020

Show notes

Contributor: Dave Rosenberg, MD

Educational Pearls:

The potential of vaccinations was first observed in the late 1600s when Jenner observed people who had cowpox never contracted smallpox, so he inoculated people with cowpox to see if it prevented smallpox, and…
Years later, Louis Pasteur inoculated chickens with cholera after his assistant accidently created the first live attenuated vaccine by creating a weakened bacteria when he left the bacteria out while he went on vacation
Pasteur observed that exposing chickens to full strength cholera after the exposure with the weakened bacteria led to minimal or no ill effects

References

Stewart AJ, Devlin PM. The history of the smallpox vaccine. J Infect. 2006 May;52(5):329-34. doi: 10.1016/j.jinf.2005.07.021. Epub 2005 Sep 19. PMID: 16176833.

Hajj Hussein I, Chams N, Chams S, El Sayegh S, Badran R, Raad M, Gerges-Geagea A, Leone A, Jurjus A. Vaccines Through Centuries: Major Cornerstones of Global Health. Front Public Health. 2015 Nov 26;3:269. doi: 10.3389/fpubh.2015.00269. PMID: 26636066; PMCID: PMC4659912.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 611: Flu Season in the time of COVID Nov 09, 2020

Show notes

Contributor: Chris Holmes, MD

Educational Pearls:

During a typical flu season positive rates of flu tests run around ~20%
Surveillance data from Australia, South Africa, and Chile showed remarkably low rates of flu during their typical high season - only 51 total cases were reported
This overlapped with COVID, meaning extensive social distancing and other measures likely have benefit with flu

Editor's note: at 35 cases, we are over half way there!

References

https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a6.htm

https://www.cdc.gov/flu/weekly/index.htm

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 610: Swimmers Itch Nov 03, 2020

Show notes

Contributor: John Winkler, MD

Educational Pearls:

Swimmers itch is due to a flatworm parasitic infection that causes an itchy rash after the worm burrows into the skin
The flatworm is passed between bird and snail hosts
The itch is due to the death of the parasite under the skin which leads to an extremely itchy reaction.
The rash can be difficult to identify, often erythematous and macular but can develop papules and vesicles eventually scaling
The treatment is diphenhydramine for milder cases and steroids for more severe cases.

References

Kolářová L, Horák P, Skírnisson K, Marečková H, Doenhoff M. Cercarial dermatitis, a neglected allergic disease. Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74. doi: 10.1007/s12016-012-8334-y. PMID: 22915284

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 609: Kratom Nov 02, 2020

Show notes

Contributor: Nick Hatch, MD

Educational Pearls:

Kratom is derived from the evergreen tree sharing the same name, found in Southeast Asia
Kratom is legal is most regions
Adverse effects of this substance are increasing in prevalence as its use becomes more widespread
At lower doses kratom has a stimulatory effect
Higher doses of kratom can cause opioid-like and psychotropic effects
Documented instances of more severe acute liver toxicity do exists

References

LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–. Kratom. 2020 Apr 3. PMID: 31643556.

https://www.fda.gov/news-events/public-health-focus/fda-and-kratom

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 608: Another Elevated Lactate? Oct 27, 2020

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Lactate is a byproduct of anaerobic metabolism or tissue hypoperfusion
Though typically associated with severe sepsis, hyperlactatemia can be caused by vigorous exercise, seizures, liver failure, asthma exacerbations, albuterol, metformin, antiretroviral drugs, and propofol
Liver failure can lead to an inability to clear lactate, or convert it back to glucose byproducts, instead of an overproduction of lactate
Always remember the other causes of elevated lactic acid besides sepsis but also remember sepsis!

References:

Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014 Dec 11;371(24):2309-19. doi: 10.1056/NEJMra1309483. PMID: 25494270.

Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying Lactate in the Emergency Department. Ann Emerg Med. 2020 Feb;75(2):287-298. doi: 10.1016/j.annemergmed.2019.06.027. Epub 2019 Aug 29. Erratum in: Ann Emerg Med. 2020 Apr;75(4):557. PMID: 31474479.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 607: Is Pain the Enemy? Oct 26, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Pain is ubiquitous in the emergency department but it is not the enemy - suffering is
Nociception is the ability to feel noxious stimuli which usually causes a reaction, like pulling a limb away when you feel something painful. Nociception is really a brainstem reflex.
Pain is nociception plus cognition, meaning we process the noxious stimuli in our frontal cortex but it is not necessarily suffering.
Pain can be associated with euphoria, such as with distance running
Suffering, unlike pain, is associated with emotional distress
Nociception is a brainstem reflex, pain involves the brainstem and the frontal cortex, while suffering involves the brainstem, frontal cortex, and the limbic system attaching an emotional response
Providers should educate patients' expectations on pain as a part of the physiologic process and emphasize the focus on alleviating suffering

References

Sneddon LU. Comparative Physiology of Nociception and Pain. Physiology (Bethesda). 2018 Jan 1;33(1):63-73. doi: 10.1152/physiol.00022.2017. PMID: 2921289

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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