Paucis Verbis: Influenza - To treat or not to treat?

It's coming.

Influenza season is almost upon us.

Influenza season typically peaks in the United States during the Jan-Feb months and can start as early as October. You can read about the 2011-12 seasonal flu data on the CDC website.

Should you give a patient with influenza an antiviral agent or just provide supportive therapy?

This Paucis Verbis card summaries the CDC's Advisory Committee on Immunization Practices (ACIP) recommendations for this upcoming 2011-12 influenza season. I also let patients with uncomplicated influenza who are going to be managed as outpatients know that a 5-day course of osteltamivir or zanamivir will cost them about $50-80. Often that sways them towards declining a prescription and "toughing out" an extra day of the flu.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Centers for Disease Control and Prevention. Infectious disease. Antiviral agents for the treatment and chemoprophylaxis of influenza. Ann Emerg Med. 2011 Sep;58(3):299-303; discussion 303-4.
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G-Advising: Using Google Hangout to advise medical students

Get an advisor.

Don't try to climb the mountain on your own.

This is key especially during medical school as you navigate through the mounds of reading, paperwork, options, and pitfalls. If you are interested in Emergency Medicine (EM) as a career, that means getting one or several great EM advisors. Don't rely on non-EM faculty to give you any insight into EM. Inevitably, I have found that they give incomplete or slightly skewed perspectives about the pros and cons of EM.

What if you don't have an established EM residency program or established EM faculty at your school?

Be proactive in finding an EM advisor. Sometimes that means looking outside of your school. That's what a medical student at the Philadelphia College of Osteopathic Medicine, soon-to-be Dr. Rick Pescatore did. We conducted a Google Hangout with the EM Interest Group where I got to field insightful questions about EM. I was at home and the students were in a classroom. Another student in the library actually linked into our Hangout partway through. The Hangout allows for up to 10 link-ins. The video and audio worked seemlessly!

Check out Rick's account of this cool approach to advising on his blog LittleWhiteCoats.

For those looking for e-Advisors in EM, I'm working with a team, lead by Dr. Megan Fix (Utah) and Dr. Rob Cooney (Conemaugh Health Systems), who are almost ready to launch the massive program in 1-2 months. Keep a lookout for it. There will be a list of available faculty, their academic affiliation, and their interests. You can select whomever you want.

This is just my first (of hopefully many) adventures in G-Advising using Google. Here is a video on Google Hangouts.

Trick of the Trade: Nasal cannula oxygenation during endotracheal intubation

Image from EP Monthly

You are managing a 300-pound patient with a long history of severe COPD, who now requires intubation because of a pneumonia and COPD exacerbation. You anticipate that the patient may be a difficult airway intubation and may desaturate quickly during laryngoscopy. While you are setting up to orotracheally intubate this patient, you preoxygenate this patient as best as you can with a non-rebreather mask.

What can you do to prolong the patient's time-to-desaturation so that you aren't as rushed to place the endotracheal tube?
Trick of the Trade:
Administer high flow (≥ 5L) oxygen by nasal cannula during the face-mask preoxygenation and  intubation.

A 2010 publication in the Journal of Clinical Anesthesia conducted a prospective randomized study looking at nasal cannula oxygen administration during endotracheal intubation. They found that such oxygen administration resulted in a much longer period before the patient desaturated to SpO2 < 95% (about 5 minutes WITH nasal cannula and 3.5 minutes WITHOUT it).

In a 2009 EP Monthly article, Dr. Richard Levitan (airway guru) advocates for high-flow nasal cannula administration (15L) during the intubation. Logistically, he recommends placing a nasal cannula under the face mask so that both are delivering oxygen while you are setting up for the intubation. For the intubation, the face mask is removed but the nasal cannula remains to continue delivering oxygen. In fact, Dr. Levitan recommends this for all patients (not just obese patients as in the above publication).

But wait, the patient is apneic, how would nasal cannula oxygen administration help? 
Interestingly, the alveoli are constantly consuming about 250 ml of oxygen per minute. In the setting of apnea, it is theorized that the dropping partial pressure of oxygen in the alveoli creates a pressure gradient such that there is a "mass movement" of gas from the trachea and pharynx into the alveoli.

Thanks to Dr. Kit Tainter of EM Guidelines fame for the tip! Great to meet you in person finally at ACEP.

Reference
Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010 May;22(3):164-8.
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Paucis Verbis: Ventilator settings for obstructive lung disease

Following up with last week's Paucis Verbis card on Ventilator Settings for Acute Lung Injury and ARDS, here is the card on Ventilator Settings for Obstructive Lung Disease. This is for patients who present with acute asthma or COPD exacerbation who require endotracheal intubation.

What initial ventilator settings should you 

set for these patients?

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Jenny Wilson for the card and Dr. Scott Weingart for the original stellar podcast from which this card was derived.

2011 ACEP Scientific Assembly - A live Twitter feed by EMRA

The 2011 American College of Emergency Physician (ACEP) Scientific Assembly is well under way in San Francisco. There is incredibly amazing weather this week. Catch a compiled live feed of the various Twitter accounts which mention the Scientific Assembly. If you are tweeting, be sure to use the #SA11 hashtag (a.k.a. bookmark). Thanks to Dr. Steven Horng from EMRA for organizing this.

http://www.emra.org/emra_involved.aspx?id=43594

Learn about who is tweeting from the meeting! 

Paucis Verbis: Ventilator settings for acute lung injury and ARDS

A patient presents with severe multilobar pneumonia and refractory hypoxia requiring endotracheal intubation. The respiratory therapist connects your patient to the ventilator.

"What settings would you like your patient on?"

(In reality, the respiratory therapist already has placed your patient on the appropriate initial ventilator settings already, but let's think this through ourselves.)

Back in 2010, Dr. Scott Weingart of EMCrit fame, posted a great podcast on "Dominating the Vent". It's such a fantastic distillation of the practical aspect of ventilator setting management of all intubated patients except those with an acute asthma or COPD exacerbation, Dr. Jenny Wilson and I thought this would be a great Paucis Verbis card to have in your peripheral brain.

Note: The tidal volume should be calculated based on Predicted Body Weight (PBW), which is based on patient gender and height. The calculation is at the bottom of the card. Using a patient's actual weight might yield a tidal volume that is way too high. The initial vent settings in the example box are for a patient with a PBW of 70 kg. That's basically a 5'9" man or 5'11" woman.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Jenny Wilson for the idea and writing this card, and Dr. Scott Weingart for a great podcast as always.

Reference
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000 May 4;342(18):1301-8. Pubmed
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Remembering Dr. Robert Buckman

For those who trained in Canada (especially Toronto), the name of Dr. Robert Buckman always brought a chuckle.

He filled his lectures with his signature British wit and humour. Yet, the message was always loud and clear. Being an oncologist, he had great insight in communication with patients.

He was the first to teach us medical students about communication and professionalism: Kindness, empathy, delivering bad news, what to say when you don't know what to say. A decade later, out of the countless hours of lectures, his stood out.

Truly a big loss to the medical educators community.

Dr. Buckman's website

References
Buckman R. Communications and emotions. BMJ. 2002 Sep 28;325(7366):672. BMJ website

Buckman R. Words that make a difference: enhancing the "how" in "how we say it". Support Cancer Ther. 2006 Jan 1;3(2):127. Free PDF

Buckman R, Tulsky JA, Rodin G. Empathic responses in clinical practice: intuition or tuition? CMAJ. 2011 Mar 22;183(5):569-71. Pubmed

Trick of the trade: Quieting the shaky EKG tracing

A patient with Parkinson's disease presents with chest pain to your ED. Her tremors prevent you from getting a good quality EKG because of the movement artifact.

How can you eliminate this artifact? (No cheating with rocuronium.)

Trick of the Trade
Have the patient sit on his/her hands.

Although I haven't tried this myself, this trick apparently works for people with upper extremity tremors and movement disorders. Has anyone used this trick? It's been referenced in: Burdick E350 Operating Manual. Milton, Wis: Siemens Burdick, Inc; 1990.

Thanks to Brooke, RN for this tip, and Alex for being a hand-sitting model!

Paucis Verbis: Neutropenic fever in cancer patients

A 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are:

• Temperature 39 C
• BP 160/80
• HR 60
• RR 14
• Oxygen saturation 99% on room air

His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC.

• Is this patient "high" or "low" risk per the Multinational Association for Supportive Care in Cancer (MASCC)? 
• Does this person require inpatient admission?
• What antibiotics would you start on this patient?

Answers:

• The patient's MASCC score is 5 (mild symptoms) + 5 (no hypotension) + 4 (no COPD) + 4 (solid tumor) + 3 (no dehydration) + 3 (outpatient) = 24 = LOW RISK
• The patient is HIGH RISK clinically because of the finding of pneumonia on CXR. Admit.
• Abx = Cefipime + Vancomycin

FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.

You can download this PV card:  [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Alissa and Hemal for suggesting the topic!

Reference
Friefeld AG et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis. 2011; 52(4):e56-93. Pubmed
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YouTube: Now you can edit your videos online!

Starting September 2011, YouTube now allows you to directly edit your video online. This is especially useful for those of us who upload iPhone or other mobile phone-based videos and don't want to go through the added step of DOWNloading our video, doing minor edits, and then before UPloading to YouTube.

http://www.youtube.com/editor

They really capture the primary features which you really need:

• Trimming the video (start and end)
• Rotating the video
• Manually changing the brightness and contrast

Trick of the Trade: Opioids for air hunger

A patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen:

• Oxygen by face mask
• Nebulized albuterol and atrovent
• Solumedrol
• Bipap
• Set up for possible intubation

With the Bipap mask on, the patient's subjective sense of dyspnea and "air hunger" seems to make it harder for him to tolerate the tight-fitting mask.

Trick of the Trade:
Use a small dose of IV fentanyl

A 2001 Cochrane review evaluated studies involving non-nebulized opioids to treat symptomatic breathlessness. The review found a small statistically significant improvement in subjective air hunger, although most studies were with small sample size numbers.


Reference
Jennings AL, Davies AN, Higgins JP, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev. 2001;(4):CD002066. Pubmed
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Poll: YOU are on the residency selection committee. What would YOU do?

As an attending physician, you are friends with nurses and residents on social media.

One day, you are browsing through your social media page. You came across a photo of a student - a candidate applying to your program in fact - scantily clad, inebriated, dancing in a rave. The comments followed agreed on how wild he/she had partied and drank that night.

You are on the selection committee. Should this information be part of the assessment of the candidate?

Please explain your decision in the comments section.