Stimulus – Learn Tools to Crush It in Your Medical Career

Do you work in medicine and love patient care but feel like parts of the job don’t measure up? Stimulus equips you with tools, mindset shifts, and strategies they didn’t teach you in training—so you can practice medicine like a boss, flourish in your career, and not let it crush your soul. Emergency physician and executive coach Rob Orman, MD, goes in-depth with thought leaders on how to avoid burnout, improve communication, lead without drama, and stay calm amidst the storm. Don’t just suck it up, think differently.

Latest Episodes:

Cellulitis Jan 29, 2018

Show notes

Recorded at Essentials of Emergency Medicine 2017, Greg Moran, MD reviews current thinking on cellulitis diagnosis and management. Greg is a professor of emergency medicine at Olive View-UCLA medical center who, in addition to emergency medicine, is fellowship trained in infectious disease and has over 100 publications in journals including: New England Journal of Medicine, British Medical journal, JAMA, Lancet, and Annals of Emergency Medicine. Greg is a thought leader in the field of emergency infectious disease and a super nice guy. In this segment, Greg covers: a common cellulitis mimic; admit vs discharge of patients with cellulitis; what bugs cause cellulitis and, taking that into account, what antibiotic should I use- double coverage, single coverage?

The great cellulitis mimic: Stasis Dermatitis

Similar in appearance to cellulitis
Often bilateral (where cellulitis is usually unilateral)
Risk factors include venous stasis, lymphedema
Fluid goes into the interstitial space -> into the dermis -> and then causes superficial redness and irritation

Treatment

Many recommendations out there, many of them consensus, opinion or based on weak data
Elevation
Compression if the patient can tolerate it
Wet dressings if there is crusting and exudative eczema
Topical steroids (medium to high potency) such as triamcinolone, fluocinonide, fluticasone ointments
If you think there could be infection at play, consider a short course of oral antibiotics (also consider topical if there’s a break in the skin or part of the leg is looking particularly red and angry)

Admit or go home?

Inpatient mortality for cellulite is low (somewhere in the low single digits percent)
No validated decision instruments regarding admission or discharge
2014 study Predictors of Failure of Empiric Outpatient Antibiotic Therapy in Emergency Department Patients With Uncomplicated Cellulitis found that fever, chronic leg ulcers, edema, lymphedema, cellulitis at a wound site or recurrent in the same area were risk factors for outpatient treatment failure
Does this mean that patients with these risk factors need mandatory admission? It doesn’t, but it gives an inkling of who might do poorly or at least fail outpatient antibiotics
Bottom line: no clear consensus on who can be discharged but low inpatient mortality suggests we may be over-admitting
A nice review of the admit or discharge cellulitis question can be found here

Single or double antibiotic coverage

Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis. JAMA May 2017 PMID:28535235

500 patients with cellulitis
Treated cephalexin alone or cephalexin plus TMP/Sulfa
No significant difference in outcome

Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 2013 PMID:23457080

150 patients with cellulitis
Treated cephalexin alone or cephalexin plus TMP/Sulfa
No significant difference in outcome

Bottom line: In uncomplicated cellulitis without abscess or significant co-morbidities, current evidence suggests no advantage of adding TMP/Sulfa to cephalexin

Check out Essentials of Emergency Medicine. Well, I guess if you're against fun education and hate puppies, then disregard that recommendation. References

Weng, Qing Yu, et al. "Costs and consequences associated with misdiagnosed lower extremity cellulitis." Jama dermatology 153.2 (2017): 141-146. PMID:27806170
Weiss, Stefan C., et al. "A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis." Journal of drugs in dermatology: JDD 4.3 (2005): 339-345. PMID:15898290
Talan, David A., et al. "Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection." Western Journal of Emergency Medicine 16.1 (2015): 89. PMID:25671016
Peterson, Daniel, et al. "Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis." Academic Emergency Medicine21.5 (2014): 526-531. PMID:24842503
Khachatryan, Alexandra, et al. "Skin and Skin Structure Infections in the Emergency Department: Who Gets Admitted?." Academic Emergency Medicine 21 (2014): S50. Abstract from 2014 SAEM
Carratala, J., et al. "Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis." European Journal of Clinical Microbiology and Infectious Diseases 22.3 (2003): 151-157. PMID:12649712
Pallin, Daniel J., et al. "Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial." Clinical infectious diseases 56.12 (2013): 1754-1762. PMID:23457080
Moran, Gregory J., et al. "Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial." Jama 317.20 (2017): 2088-2096. PMID:28535235
Original Kings of County Analysis of Admit or Discharge Cellulitis

Performance Coach Jason Brooks Jan 22, 2018

Show notes

Jason Brooks PhD is a performance coach helping health care providers, athletes, and other high level performers live better, work better, and be better. In this episode Jason gives his strategies and tactics on myriad topics including: three techniques for stress inoculation, improving test taking, the unseen costs of hiding ignorance, and what habits are common among high level performers.

Episode Contents

A look back at ERCast episode one on Rectal Foreign Bodies
Jason's work with physicians through Phenomenal Docs
You can't stop the waves but you can learn to surf - Jon Kabat Zinn
Who consults a performance coach? Those who are stuck and want to become unstuck. Those who are excelling and want to excel at an even higher level. These forces can exist simultaneously in the same person
What's easier to accomplish? Moving from a perception of low-level performance or getting to a higher level of excellence?
Answering the question, "Why is this happening to me?"
Start with Why by Simon Sinek Book TED Talk
Having an internal yardstick to gauge how decisions align with your values
Making time for periodic reflection
The importance of adversity
It's not what we do that causes burnout, it's losing sight of why we do it
Common habits of top performers that transcend a particular career
Humility is a common attribute in high level and respected performers driven to be the best I can be, but I don't have all the answers
Expectations of a master physician to learners: make me better by contributing to my knowledge base, and I expect you let me know if you think I'm making a mistake
Shedding the fear of exposing ignorance. What is the real cost of not exposing ignorance? Leaving knowledge on the table
Three techniques for stress inoculation
Practice through visualization
Breathing techniques to trigger parasympathetic response and mitigate sympathetic fight/flight/flee
Using a trigger word to de-escalate stress (mine is "level down")
Improving test taking performance
How an Olympic archer recalibrates after missing a shot
Connect with Jason: Facebook, Twitter, email doctorjbro at gmail dot com

Should I give bicarbonate in DKA? Jan 15, 2018

Show notes

Should I give bicarbonate to DKA patients with severe acidemia? I've certainly been admonished for NOT doing it. The reason for withholding bicarb has been that I've heard that it doesn't help and may actually be a bad idea. I can't say the action (or inaction) was based on a deep understanding.

How could bicarb in DKA be a bad idea if even the American Diabetes Association (ADA) recommends we give a bicarb to DKA patients with pH under 6.9? The argument in favor of giving bicarb is that the more acidemic the patient, the higher the risk of circulatory collapse and cardiac arrest. Even though there is no evidence of benefit, the ADA gives a very specific set of steps to take in the low pH patient..

Because severe acidosis may lead to numerous adverse vascular effects, it is recommended that adult patients with a pH less than 6.9 should receive bicarbonate. Specially 100 mmol sodium bicarbonate, two ampules, in 400 mL sterile water with 20 mEq KCL admitted at a rate of 200ml/hr for 2 hours until the venous pH is over 7. If the ph isn’t over 7 at that point, they say repeat the bicarb infusion every 2 hours until the ph is over 7.0

With that sort of exact guidance, you'd think there would be evidence to back it up, but here is the sentence that precedes the above recommendation.

No prospective randomized studies concerning the use of bicarbonate in DKA with pH values

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