Denver Health's legendary emergency medicine residency

[Groove]

Speaking of big ballers, did anyone read that perimortem c-section with tandem thoracotomy case in Annals for December where they got both the mother and the kid back? Craziness. Talk about beating the 0.000000001% odds. I'd be curious to know whether both pt's survived to hospital discharge.

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[ShockIndex]

Speaking of big ballers, did anyone read that perimortem c-section with tandem thoracotomy case in Annals for December where they got both the mother and the kid back? Craziness. Talk about beating the 0.000000001% odds. I'd be curious to know whether both pt's survived to hospital discharge.

They did. Mother’s EF was back to 55% several months after discharge and the child was meeting milestones at 6-month follow-up.

I know the senior author, Kevin Ward, pretty well. He is extremely bright, both as a researcher and clinician. His decision making and procedural skills in that case challenges the notion that research faculty in the ivory towers struggle to perform. That was some real doctor **** in that case.

 

[BoardingDoc]

That case is freaking crazy. This line from the article though: "We empirically transfused 2 units of packed RBCs and administered calcium chloride to help prevent disseminated intravascular coagulation"
What? If anything, PRBCs could potentiate DIC, not prevent it. As to the CaCl, I have no idea what they're talking about.

 

[Apollyon]

As to the CaCl, I have no idea what they're talking about.

Maybe it's because calcium is Factor IV in the clotting cascade?

/biochem

 

[alpinism]

The citrate in blood products causes hypocalcemia which inhibits clotting.

I’ll usually give 2 grams calcium in any patient requiring massive transfusion.

Sometimes trauma is more than mindlessly following protocols.

 

[ShockIndex]

The citrate in blood products causes hypocalcemia which inhibits clotting.

I’ll usually give 2 grams calcium in any patient requiring massive transfusion.

Sometimes trauma is more than mindlessly following protocols.

I think the issue was the way it was written made it sound like the blood and Ca were given to prevent DIC in a patient without significant blood loss since this was not a trauma thoracotomy (she was opened in a medical code situation because external compressions were ineffective).

However, I suspect that real reason the blood was given was that they anticipated a massive transfusion situation in a patient with a couple of reasons for significant blood loss (ED thoracotomy and C-section).

Regardless, I’m not going to throw stones at the decision to start blood on someone who is splayed open from stem to stern - regardless if it wasn’t trauma related. As for the calcium, she can thank Kevin for strong bones and teeth in 30 years.

 

[thegenius]

I think the issue was the way it was written made it sound like the blood and Ca were given to prevent DIC in a patient without significant blood loss since this was not a trauma thoracotomy (she was opened in a medical code situation because external compressions were ineffective).

However, I suspect that real reason the blood was given was that they anticipated a massive transfusion situation in a patient with a couple of reasons for significant blood loss (ED thoracotomy and C-section).

Regardless, I’m not going to throw stones at the decision to start blood on someone who is splayed open from stem to stern - regardless if it wasn’t trauma related. As for the calcium, she can thank Kevin for strong bones and teeth in 30 years.

Do you think they made one big "L" shaped incision and did the thoracotomy and perimortem C-section at the same time? all with one swoop of the scalpel?

 

[ShockIndex]

Do you think they made one big "L" shaped incision and did the thoracotomy and perimortem C-section at the same time? all with one swoop of the scalpel?

The baby was delivered first by C-section (xyphoid to pubis). The mother got at least a round or two of CPR before the thoracotomy due to poor ETCO2 with compressions.

Like @alpinism suggested, this was an example of a doctor operating way, way outside of the ACLS protocols that, at times, limit physician’s perspective in these rare situations. Having said that, University of Michigan as been at the forefront of resuscitation science for a while (EC3, EROCA, ICECAPS, MCIRRC, etc.) despite today’s showing against OSU. #bias.

 

[doggydog]

The baby was delivered first by C-section (xyphoid to pubis). The mother got at least a round or two of CPR before the thoracotomy due to poor ETCO2 with compressions.

Like @alpinism suggested, this was an example of a doctor operating way, way outside of the ACLS protocols that, at times, limit physician’s perspective in these rare situations. Having said that, University of Michigan as been at the forefront of resuscitation science for a while (EC3, EROCA, ICECAPS, MCIRRC, etc.) despite today’s showing against OSU. #bias.

Which author are you?

 

[ShockIndex]

Which author are you?

I’m not an author. Those of us who know Ward or with ties to Michigan have heard about this case for a year. It also made local news and Twittersphere.

 

[thegenius]

That is The Case of the decade. Jeez.

 

[Groove]

Speaking of big ballers, did anyone read that perimortem c-section with tandem thoracotomy case in Annals for December where they got both the mother and the kid back? Craziness. Talk about beating the 0.000000001% odds. I'd be curious to know whether both pt's survived to hospital discharge.

As for the rest of December's issue, for anyone that doesn't have a subscription...you aren't missing much. The highlight was that single case. There were about #5 total articles on gender bias and "enhancing" gender diversity in EM. I stopped reading when I started suffering repeated attacks of yawning and eye rolling. Apparently EM is controlled by a "deep state" of discriminatory misogynists aimed at expelling all women from our field. Who knew?

 

[deuist]

As for the rest of December's issue, for anyone that doesn't have a subscription...you aren't missing much. The highlight was that single case. There were about #5 total articles on gender bias and "enhancing" gender diversity in EM. I stopped reading when I started suffering repeated attacks of yawning and eye rolling. Apparently EM is controlled by a "deep state" of discriminatory misogynists aimed at expelling all women from our field. Who knew?

FEMINEM won't be happy until all articles and conferences are based upon women in emergency medicine. We're eventually going to forgo any semblance of research and clinical care in the hopes of increasing diversity numbers.

 

[BoardingDoc]

The citrate in blood products causes hypocalcemia which inhibits clotting.

I’ll usually give 2 grams calcium in any patient requiring massive transfusion.

Sometimes trauma is more than mindlessly following protocols.

Giving calcium was part of the massive transfusion protocol where I trained once you got past 2 units of PRBCs. If that's all they meant in the article, that makes sense, but was poorly written.

 

[thegenius]

Giving calcium was part of the massive transfusion protocol where I trained once you got past 2 units of PRBCs. If that's all they meant in the article, that makes sense, but was poorly written.

I think it was probably written to impress. And impressed i was with the overall effort. The last thing I would think about would be giving calcium to a patient in the resus bay who produced another active patients, and had a huge open belly and chest and I’m squeezing her heart

 

[ShockIndex]

Giving calcium was part of the massive transfusion protocol where I trained once you got past 2 units of PRBCs. If that's all they meant in the article, that makes sense, but was poorly written.

You probably know this, but it bears repeating since it’s being mentioned several times in the thread - the hypocalcemia that occurs in blood transfusions is typically transient and resolves when the infused citrate is metabolized by the liver and kidneys. The issue is that patients in profound shock or those pre-existing liver disease probably do not clear the citrate fast enough, and prolonged ionized hypocalcemia can (and does result). However, nobody really knows if prophylactic treatment or simply responding to monitored levels is the preferred approach.

That would be a pretty interesting research project if anyone is interested (prophylactic Ca administration vs. monitored administration in MTT patients).

 

[Fox800]

FEMINEM won't be happy until all articles and conferences are based upon women in emergency medicine. We're eventually going to forgo any semblance of research and clinical care in the hopes of increasing diversity numbers.

I opened up an issue of Common Sense (AAEM's rag) for the first time in a while. The first thing I see is the new president's address about....get ready for it..............................

Promoting diversity and overcoming biases.

Yeah, we get it. Caucasian male doctors are evil and there are too many of them.

 

[The Knife & Gun Club]

I opened up an issue of Common Sense (AAEM's rag) for the first time in a while. The first thing I see is the new president's address about....get ready for it..............................

Promoting diversity and overcoming biases.

Yeah, we get it. Caucasian male doctors are evil and there are too many of them.

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

I get it, we should strive to be good unbiased people...but there’s a way to promote it without being overtly and unnecessarily antagonistic.

 

[Dr Mantis Toboggan]

Sorry that happened to you. That’s brutal. Prejudice in all forms is bad in my opinion.

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

I get it, we should strive to be good unbiased people...but there’s a way to promote it without being overtly and unnecessarily antagonistic.

 

[TheSingularity]

That's reportable, and you should report it.

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

I get it, we should strive to be good unbiased people...but there’s a way to promote it without being overtly and unnecessarily antagonistic.

Sent from my Pixel 3 using SDN mobile

 

[ShockIndex]

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

I get it, we should strive to be good unbiased people...but there’s a way to promote it without being overtly and unnecessarily antagonistic.

Hmm, that is some racist, sexist BS. It needs to be reported to the ACGME. I completely understand if you want to wait until after the Match, but for the love of God do not rank that program. Any PD who feels that way has no business training doctors or taking care of patients.

 

[bky3c]

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

I get it, we should strive to be good unbiased people...but there’s a way to promote it without being overtly and unnecessarily antagonistic.

(Female here.) I really don't care who the future hypothetical EP who may someday save my life is as long as they're an excellent EP, and I can't imagine why anyone else would care, either. And I'd hate for anyone to think that I got into medical school or residency or a job in order to fill some feminist quota rather than because I was the best applicant for the spot. If you, as a white male, are going to be an excellent EP, then that's all they need to know.

 

[SamtheWise]

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

I get it, we should strive to be good unbiased people...but there’s a way to promote it without being overtly and unnecessarily antagonistic.

I understand that was probably distressing for you and would be for most people, but I would use care divulging such specific identifying information. A few years ago there was someone who divulged something specific and they were identified when a spiteful member of program leadership read it.

 

[Fox800]

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

I get it, we should strive to be good unbiased people...but there’s a way to promote it without being overtly and unnecessarily antagonistic.

This is an NRMP match violation. Report it.

 

[deuist]

I was just in an interview yesterday where the PD of a program asked me why I’m going into the field because “we don’t need more white men in EM.”

That's called employment discrimination and requires filing a claim with the Equal Employment Opportunity Commission and the NRMP.

 

[thegenius]

I would also strongly consider reporting it, hopefully it can be done anonymously. If not I would consider doing it March after the match, especially if it can't be done anonymously.

The only problem with this kind of thing is without actual proof, then it becomes "he said / she said" or rather..."he said he said" (you know what I mean) and it's just hard to prove.

But in today's social climate where you can't even whisper even anything remotely offending to any class of people, no matter how small, without getting railed publicly and privately, this shouldn't end up being a big problem. Don't just expect much to happen from it unless there is a long line of complaints about this PD.