Best EM podcasts?

[xaelia]

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FOAM education for your next ED shift. Your patients will be:

1) Viral URI
2) Ankle sprain
3) Abdominal pain - negative workup
4) Medication refill
5) Etoh, or meth
6) Abdominal pain - appy
7) Viral URI
8) GI bleed with critical anemia
9) SI
10) Flank pain - ureterolithiasis
11) Afib RVR - cardioversion and dc
12) Purple hair - why were they in the ED?
13) Distal radius/ulna fracture
14) Low risk chest pain
15) High risk chest pain
16) Dementia - I had chest pain?
17) Viral URI
18) Septic shock
19) Lymphedema
20) PNES

Not a list of patients I saw. Just a typical shift. Continuing education just isn’t that important for 99.99% of these patients. It’s good to stay relatively up to date, but for most community physicians it’s a waste of time to scour medical journals as much as it pains me to say that after rigorous prior education. Most of these are just pretty straight forward day after day.

Don't forget –

1) 8 month old with fever for one hour
2) too drunk for jail
3) unwitnessed fall, leg shortened/rotated
4) accidentally took one pill of my diazepam this morning instead of my enalapril
5) five weeks of fatigue normal labs with PCP
6) under-vaccinated child with a rash
7) took mystery drug two days ago and still feel jittery am I going to die
8) Triple-stack Lime scooter FOOSH

 

[JacobMcCandles]

Not a list of patients I saw. Just a typical shift. Continuing education just isn’t that important for 99.99% of these patients. It’s good to stay relatively up to date, but for most community physicians it’s a waste of time to scour medical journals as much as it pains me to say that after rigorous prior education. Most of these are just pretty straight forward day after day.

I think more time needs to be spent with residents (and attendings who are already out) on actually managing a department in an efficient way.

 

[RustedFox]

by grabthar's hammer!

I googled that, and it led me to the reference that you guys know that I don't.
LoL.

No shade thrown. I'm not a sci-fi type; but it makes me smile to see an in-joke shared between bros.

 

[RustedFox]

FOAM education for your next ED shift. Your patients will be:

1) Viral URI
2) Ankle sprain
3) Abdominal pain - negative workup
4) Medication refill
5) Etoh, or meth
6) Abdominal pain - appy
7) Viral URI
8) GI bleed with critical anemia
9) SI
10) Flank pain - ureterolithiasis
11) Afib RVR - cardioversion and dc
12) Purple hair - why were they in the ED?
13) Distal radius/ulna fracture
14) Low risk chest pain
15) High risk chest pain
16) Dementia - I had chest pain?
17) Viral URI
18) Septic shock
19) Lymphedema
20) PNES

Not a list of patients I saw. Just a typical shift. Continuing education just isn’t that important for 99.99% of these patients. It’s good to stay relatively up to date, but for most community physicians it’s a waste of time to scour medical journals as much as it pains me to say that after rigorous prior education. Most of these are just pretty straight forward day after day.

Remember when we did this in a thread?
"Post your boring, nonsense shifts" or something?

It was great.
" Jaime, pull that thread up."

 

[Rekt]

I think what's changed/changing is our awareness and appreciation of awake paralysis, nothing about the drugs.

Funny for this to come up in a discussion about EM podcasts, as I suspect the increased use of rocuronium had a lot to do with EM Rap saying "roc rocks and sux sucks".

I’ll bite and be the dummy. What’s the issue with roc? I’m a fairly new. I pretty much only use roc. Sedative varies some but usually ketamine. Rarely sux. Sometimes if I need them immediately down like some violent drugged out loser or something I’ll use six. With roc, the same time nurses are grabbing the RSI meds i have propofol pre hanging and usually have fentanyl infusion on the way. Is it just poor post intubation sedation? Seems like that’s just basic 101 post intubation management to me and has nothing to do with roc.

 

[GatorCHOMPions]

My partners are dinosaurs and do not use YEARS or attempt cardioversion of atrial fibrillation in the emergency department.

Been out of full time EM for a while now but last I checked YEARS has data but not considered full blown standard of care, unlike age adjusted d-dimer which has the stamp of approval from the AHA and ACEP.

 

[Janders]

I’ll bite and be the dummy. What’s the issue with roc? I’m a fairly new. I pretty much only use roc. Sedative varies some but usually ketamine. Rarely sux. Sometimes if I need them immediately down like some violent drugged out loser or something I’ll use six. With roc, the same time nurses are grabbing the RSI meds i have propofol pre hanging and usually have fentanyl infusion on the way. Is it just poor post intubation sedation? Seems like that’s just basic 101 post intubation management to me and has nothing to do with roc.

A lot of people THINK they do a good job w/ post-intubation sedation, but in reality they don't... nurses taking a while to get the propofol, or more commonly you've clicked the epic orderset for propofol which starts low and only allows up-titration q10min and the nurse isn't aggressive with bolusing, and that fentanyl drip you ordered is "being made by pharmacy" which suddenly means it isn't up for 40min...

Especially with inexperienced, burnt out, or spread thin staffing it is easy to not sedate well, and after a big bolus of Roc that means awareness of paralysis.

 

[Rekt]

A lot of people THINK they do a good job w/ post-intubation sedation, but in reality they don't... nurses taking a while to get the propofol, or more commonly you've clicked the epic orderset for propofol which starts low and only allows up-titration q10min and the nurse isn't aggressive with bolusing, and that fentanyl drip you ordered is "being made by pharmacy" which suddenly means it isn't up for 40min...

Especially with inexperienced, burnt out, or spread thin staffing it is easy to not sedate well, and after a big bolus of Roc that means awareness of paralysis.

Yeah so not a roc issue. Bad doctor issue. Also going to be site/staff dependent. Depending on clinical context of the intubation I always have propofol hanging before pt even intubated and actively manage with nurses and just verbally increase titration beyond EMR limit timers. And also have no issue having people on prop/fent/versed especially if it’s poly od or something.

But I get what you’re saying. One of the docs at my shop tries to tube as much as possible but claps his hands after and walks away with prn versed ordered so we hear vent alarms for hours on end until they’re in icu

 

[Jabbed]

Maybe 70% of the patients that I intubate could be successfully intubated with toradol alone. I see paralytic awareness being more of a big deal for non-emergent situations since I doubt my GCS 5 IPH with stertorous respirations has any awareness of anything at all. Etomidate also puts people in comas for 10 minutes. Between that and a fentanyl bolus I’m comfortable waiting for the prop gtt which can get pulled/overrided from Pyxis in 2 minutes. Occasionally if they are super hypertensive afterwards I’ll bolus 1 mg/kg and have the RN max the gtt.

If I was committing crimes against humanity in doing this I feel like it would be reported when/if the patient is extubated.

Why use roc? So I can safely get lines, imaging, RN procedures after intubation. With sugammadex going off patent in January there’s really no reason to bother with sux anymore.

 

[TooMuchResearch]

Yeah so not a roc issue. Bad doctor issue. Also going to be site/staff dependent. Depending on clinical context of the intubation I always have propofol hanging before pt even intubated and actively manage with nurses and just verbally increase titration beyond EMR limit timers. And also have no issue having people on prop/fent/versed especially if it’s poly od or something.

But I get what you’re saying. One of the docs at my shop tries to tube as much as possible but claps his hands after and walks away with prn versed ordered so we hear vent alarms for hours on end until they’re in icu

That's terrible care wtf.

 

[WilcoWorld]

Yes - In a perfect world with good nurse staffing ratios, and docs who pay attention to post-intubation management, this would not be an issue.

Awake paralysis is not super common, so it might not have come to the awareness of folks like @Jabbed but it does happen in a significant minority of ED patients, and Roc markedly increases the risk.

The ED-AWARENESS Study: a prospective, observational cohort study of awareness with paralysis in mechanically ventilated patients admitted from the emergency department - PMC

Awareness with paralysis (AWP) is a devastating complication for mechanically ventilated patients and risks long-term psychological morbidity. Data from the emergency department (ED) demonstrate a high rate of longer-acting neuromuscular blocking ...

pmc.ncbi.nlm.nih.gov

Why should we care about it? Because the folks who it happens to say that it was the worst thing they have ever experienced.

I'm not saying to never use Roc, but if you don't have contraindications to Sux, please use it when you're tubing me.

 

[Janders]

I don’t think I’m a bad doctor, but I’ve worked enough single coverage, limited RN, no onsite pharmacy, multiple dying people at once clusters that I worry about my patients post intubation sedation but I HAVE to walk away.

Less of an issue at large, well resourced, especially tertiary / teaching shops.

I try to verbally instruct “just push all the prop you need and call for me” now. 🤷