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 579: Yersinia Pestis Jul 20, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Yersinia Pestis is the bacteria that caused the black plague. It was first discovered to be the cause of the bubonic plague in 1800s in China during the 3rd bubonic plague where 10-20 million people died
Causes 3 types of plague:
- Bubonic plague: characterized by severe swelling of lymph nodes called buboes, most commonly in the groin, also axillary and olecranon lymph nodes.
- Septicemic plague: characterized by severe sepsis, no lymphadenopathy. This strain famously causes disseminated intravascular coagulopathy (DIC) and can lead to limb necrosis and fingers turning black. Hence the name the Black Death.
- Pneumonic: most dangerous of the plagues and characterized by PNA on CXR with pronounced mediastinal lymphadenopathy
Fleas are the largest reservoir, although prairie dogs and squirrels have been known to carry the bacteria as well.
Yersinia Pestis creates a microfilm inside the stomach of fleas and renders them incapable of digesting your blood when they try to eat it and they vomit the bacteria into your blood.
Doxycycline and Ciprofloxacin are the mainstay of treatment.

References

Achtman M, Zurth K, Morelli G, Torrea G, Guiyoule A. Carniel E. Yersinia pestis, the cause of plague, is a recently emerged clone of Yersinia pseudotuberculosis. Proc Natl Acad Sci U S A. 1999. doi:10.1073/pnas.96.24.14043

Galimand M, Carniel E, Courvalin P. Resistance of Yersinia pestis to Antimicrobial Agents. Antimicrob Agents Chemother. 2006;50(10):3233 LP - 3236. doi:10.1128/AAC.00306-06

Sexton D, Stout J. Clinical Manifestations, Diagnosis, And Treatment Of Plague (Yersinia Pestis Infection). Waltham, MA: UpToDate; 2020.

Summarized by Mason Tuttle & Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 578: Brown-Sequard Syndrome Jul 14, 2020

Show notes

Author: Eric Miller, MD

Educational Pearls:

Brown-Sequard Syndrome is a neurological deficit that results from hemisection of the spinal cord
This is usually from traumatic injury (blunt or penetrating), but can rarely be seen with cancer, disc herniation, or infection
It presents with flaccid paralysis and loss of sensation to touch/vibration/position on the same side as the injury with loss of pain/temperature sensation on the opposite side of the injury. These deficits will be below the level of injury.

References

Roth, E., Park, T., Pang, T. et al. Traumatic cervical Brown-Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes. Spinal Cord 29, 582–589 (1991).

Wagner R, Jagoda A. Spinal cord syndromes. Emerg Med Clin North Am. 1997;15(3):699.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast 577: Immunotherapies Jul 13, 2020

Show notes

Contributor: Don Stader, MD

Educational Pearls:

Checkpoint inhibition normally helps our body detect abnormal cells and terminate it but cancerous cells often are able to avoid this countermeasure
Monoclonal antibodies that bind to checkpoint inhibitors can stop cancerous cells from turning off immunologic T cells and allows the immune system to continue to attack cancers.
These therapies carry risks of exacerbating autoimmune problems due to the ramped up immune response
Most often this autoimmune attack leads to skin and GI symptoms but can affect many other organ systems. In the emergency room this can present many different ways, but the mainstay of treatment is steroids to stop these exacerbations.
Chimeric Antigen Receptor (CAR) T-cell Therapy is another immunotherapy where antigens to a cancerous cell are re-introduced to spur a directed immune response
Cytokine release syndrome can occur in these patients and mimic other presentations such as septic shock, a result of tumor break down
This is treated with steroids and monoclonal antibodies that help thwart the cytokine release

References

Hay, KA. Cytokine release syndrome and neurotoxicity after CD19 chimeric antigen receptor-modified (CAR-) T cell therapy. Br J Haematol. 2018 Nov;183(3):364-374. doi: 10.1111/bjh.15644. Epub 2018 Nov 8.

Hryniewicki AT, Wang C, Shatsky RA, Coyne CJ. Management of Immune Checkpoint Inhibitor Toxicities: A Review and Clinical Guideline for Emergency Physicians. J Emerg Med. 2018;55(4):489-502. doi:10.1016/j.jemermed.2018.07.005

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

UnfilterED #9: Dr. Steven Bradley Jul 08, 2020

Show notes

Dr. Steven Bradley is an active duty U.S. Naval officer practicing as a Staff Anesthesiologist in Virginia where also resides on the Medical Ethics Committee for his hospital. He serves as the Anesthesiology Residency Simulation Coordinator there and enjoys the opportunity to teach residents drawing from his experiences as a student. He just recently started The Black Doctors Podcast where he strives to tell stories of Black physicians who overcame adversity to attain their goals so that young individuals in the minority can listen and learn.

Tune in to hear Dr. Bradley discuss his experience as a minority in medicine and how systemic racism can manifest in various aspects of medicine.

Check out The Black Doctors Podcast on Apple Podcasts, Spotify, and all major streaming platforms.

Instagram: @theblackdoctorspodcast

Twitter: @StevenBradleyMD

Podcast 576: Status Epilepticus Drugs Jul 07, 2020

Show notes

Author: Charlene Gnisci Melton, PharmD

Educational Pearls:

Status Epilepticus is defined as continuous seizure activity for >5 minutes, or 2 or more seizures without full return to consciousness between events
Status epilepticus is a true neurologic emergency with significant morbidity and mortality
Aggressive, early treatment of status epilepticus is essential as GABA receptors will regress over time and make benzodiazepines less effective as time elapses
Go large with doses of benzodiazepines and repeat doses if necessary: In adults this means lorazepam 4 mg IV push or Midazolam 10 mg intramuscular if no IV access
Second line agents include:
- Levetiracetam (Keppra) 60 mg/kg up to 4500mg
- Valproic Acid (40 mg/kg up to 3000 mg)
- Keppra has an arguably better side effect profile and compatibility compared to other second-line agents
Third line agents include intubation and sedation with propofol, benzodiazepines, or even ketamine

Editor's note: from a time management perspective, call for your second-line treatment early to get it from pharmacy while you slam the benzodiazepines, then it will be arriving hopefully when you need it, and no harm if you don't. Oh, and don't forget a fingerstick glucose.

References

Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48

Walker, M.C. Pathophysiology of status epilepticus. Neuroscience Letters. 2018:667:84-91. https://doi.org/10.1016/j.neulet.2016.12.044

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Epidemic Meets Pandemic #4: The Patient Perspective Jul 06, 2020

Show notes

This limited series will investigate how the nation's opioid epidemic has been impacted by the COVID-19 pandemic. Over the course of this series, we will hear from a harm reductionist, an addiction medicine physician, a Denver Police narcotics sergeant and two people currently in recovery.

Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In the final episode of this series, we are fortunate enough to speak with Chris Espinoza and Ashley Parsons, two individuals currently in recovery. Chris and Ashley bravely share the origins of their substance use disorders, the challenges that COVID has presented during their recovery process as well as their current life goals and hopes for the future.

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock

Podcast 575: Light on the Sedation Jul 06, 2020

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Studies have shown that patients who are under deeper sedation in the ICU have worse outcomes.
Recent study compared lighter vs heavier sedation of patients in the emergency department receiving mechanical ventilation
Patients receiving lighter sedation in the ED were often continued in the ICU
Patients who had lighter sedation also tended to do better, meaning less days on the ventilator, less days in the ICU, and lower mortality supporting prior observations.
Though purely observational, interesting suggestion that lighter sedation starting in the emergency department could have significant impact on important clinical outcomes

References

Fuller BM, Roberts BW, Mohr NM, et al. The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients. Crit Care Med. 2019;47(11):1539‐1548. doi:10.1097/CCM.0000000000003928

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

Epidemic Meets Pandemic #3: The Law Enforcement Perspective Jul 01, 2020

Show notes

Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In this episode, we speak with Lex Jorge -- a Denver Police Narcotics Sergeant -- to gain insight into how drug trafficking has been impacted by COVID. We also discuss law enforcement's role in the recovery process and touch on social issues currently afflicting the country.

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock

Epidemic Meets Pandemic #2: The Addiction Medicine Perspective Jun 30, 2020

Show notes

Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In this episode, we talk to Dr. Steven Young -- board certified emergency physician and addiction medicine physician -- to discover how his clinic has had to adapt and overcome the challenges presented by COVID.

Resources:

https://www.cotreatment.com/

https://www.samhsa.gov/medication-assisted-treatment

https://www.ernaloxone.org/

https://cha.com/opioid-safety/coloradomat/

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock

Epidemic Meets Pandemic #1: The Harm Reductionist Perspective Jun 29, 2020

Show notes

Unfortunately, both the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In the first episode, we catch up with Lisa Raville -- executive director of the Harm Reduction Action Center in Denver -- to learn how COVID has impacted her facility's daily operations as well as the lives of her clients.

For more information about HRAC:

http://harmreductionactioncenter.org/

Get In touch with HRAC:

Email: HRAC.Denver@gmail.com

Facebook: @harmreductionactioncenter

Twitter: @HRAC_Denver

Instagram: @harmreductionactioncenter

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock