Emergency Medical Minute

Dr. Tsipis sits down with colleague Dr. Ricky Dhaliwal for some insightful conversation regarding the differences between academic and community settings as well as the various roles of advocacy in medicine. Time Stamps 00:23 Banter and introductions 2:41 upbringing in 1st generation immigrant Indian household 14:30 losing culture as 2nd gen immigrant 7:32 Balancing family and work with a two doc family 8:32 President of EMRA 10:42 Working in academia vs community 13:29 New job advice 15:55 Nick talks about being the product of your environment and needing to be challenged 20:42 Advocacy in medicine 25:49 Legislative advocacy 27:27 Advocacy for medicine in COVID 29:44 Who are the most influential figures in your career? 33:23 What is your teaching style 38:05 What does the future hold for you?

Contributor: Dave Rosenberg, MD Educational Pearls: The potential of vaccinations was first observed in the late 1600s when Jenner observed people who had cowpox never contracted smallpox, so he inoculated people with cowpox to see if it prevented smallpox, and… Years later, Louis Pasteur inoculated chickens with cholera after his assistant accidently created the first live attenuated vaccine by creating a weakened bacteria when he left the bacteria out while he went on vacation Pasteur observed that exposing chickens to full strength cholera after the exposure with the weakened bacteria led to minimal or no ill effects References Stewart AJ, Devlin PM. The history of the smallpox vaccine. J Infect. 2006 May;52(5):329-34. doi: 10.1016/j.jinf.2005.07.021. Epub 2005 Sep 19. PMID: 16176833. Hajj Hussein I, Chams N, Chams S, El Sayegh S, Badran R, Raad M, Gerges-Geagea A, Leone A, Jurjus A. Vaccines Through Centuries: Major Cornerstones of Global Health. Front Public Health. 2015 Nov 26;3:269. doi: 10.3389/fpubh.2015.00269. PMID: 26636066; PMCID: PMC4659912. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Chris Holmes, MD Educational Pearls: During a typical flu season positive rates of flu tests run around ~20% Surveillance data from Australia, South Africa, and Chile showed remarkably low rates of flu during their typical high season - only 51 total cases were reported This overlapped with COVID, meaning extensive social distancing and other measures likely have benefit with flu Editor's note: at 35 cases, we are over half way there! References https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a6.htm https://www.cdc.gov/flu/weekly/index.htm Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: John Winkler, MD Educational Pearls: Swimmers itch is due to a flatworm parasitic infection that causes an itchy rash after the worm burrows into the skin The flatworm is passed between bird and snail hosts The itch is due to the death of the parasite under the skin which leads to an extremely itchy reaction. The rash can be difficult to identify, often erythematous and macular but can develop papules and vesicles eventually scaling The treatment is diphenhydramine for milder cases and steroids for more severe cases. References Kolářová L, Horák P, Skírnisson K, Marečková H, Doenhoff M. Cercarial dermatitis, a neglected allergic disease. Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74. doi: 10.1007/s12016-012-8334-y. PMID: 22915284 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Nick Hatch, MD Educational Pearls: Kratom is derived from the evergreen tree sharing the same name, found in Southeast Asia Kratom is legal is most regions Adverse effects of this substance are increasing in prevalence as its use becomes more widespread At lower doses kratom has a stimulatory effect Higher doses of kratom can cause opioid-like and psychotropic effects Documented instances of more severe acute liver toxicity do exists References LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–. Kratom. 2020 Apr 3. PMID: 31643556. https://www.fda.gov/news-events/public-health-focus/fda-and-kratom Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Jared Scott, MD Educational Pearls: Lactate is a byproduct of anaerobic metabolism or tissue hypoperfusion Though typically associated with severe sepsis, hyperlactatemia can be caused by vigorous exercise, seizures, liver failure, asthma exacerbations, albuterol, metformin, antiretroviral drugs, and propofol Liver failure can lead to an inability to clear lactate, or convert it back to glucose byproducts, instead of an overproduction of lactate Always remember the other causes of elevated lactic acid besides sepsis but also remember sepsis! References: Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014 Dec 11;371(24):2309-19. doi: 10.1056/NEJMra1309483. PMID: 25494270. Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying Lactate in the Emergency Department. Ann Emerg Med. 2020 Feb;75(2):287-298. doi: 10.1016/j.annemergmed.2019.06.027. Epub 2019 Aug 29. Erratum in: Ann Emerg Med. 2020 Apr;75(4):557. PMID: 31474479. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Don Stader, MD Educational Pearls: Pain is ubiquitous in the emergency department but it is not the enemy - suffering is Nociception is the ability to feel noxious stimuli which usually causes a reaction, like pulling a limb away when you feel something painful. Nociception is really a brainstem reflex. Pain is nociception plus cognition, meaning we process the noxious stimuli in our frontal cortex but it is not necessarily suffering. Pain can be associated with euphoria, such as with distance running Suffering, unlike pain, is associated with emotional distress Nociception is a brainstem reflex, pain involves the brainstem and the frontal cortex, while suffering involves the brainstem, frontal cortex, and the limbic system attaching an emotional response Providers should educate patients' expectations on pain as a part of the physiologic process and emphasize the focus on alleviating suffering References Sneddon LU. Comparative Physiology of Nociception and Pain. Physiology (Bethesda). 2018 Jan 1;33(1):63-73. doi: 10.1152/physiol.00022.2017. PMID: 2921289 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Dr. Parisa Jamshidi, a Pediatric Emergency Physician, dives into the world of common respiratory illnesses in children. She highlights bronchiolitis and croup, detailing their symptoms and treatment options. The conversation also covers the diagnostic processes and management strategies for these conditions. Listeners learn how to distinguish various respiratory sounds like stridor and wheezing, along with the vital role of high flow nasal cannula therapy in pediatric care. A case review adds practical insight into handling croup effectively.

Contributor: Aaron Lessen, MD Educational Pearls: The use of oxygen is controversial when treating patients with certain conditions, like MI's, stokes, or ARDS because adverse outcomes have been demonstrated with using high oxygen concentrations. The Oxygen ICU trial looked at using higher and lower oxygen levels in treating intubated ARDS patients and found that mortality was improved when less oxygen was given allowing oxygen saturations to sit around 95% versus using high oxygen levels to obtain 100% blood oxygen saturation. The LOCO trial tested using even lower oxygen concentrations allowing patients to have oxygen saturations around 88% compared to more oxygen with saturation goals of 96%. They found a 15% increase in mortality in the lower saturation group and had some incidences of mesenteric ischemia leading to a premature termination of the trial due to the detrimental outcomes. This means a blood oxygen saturation rate of around 94% is probably a safe bet for patients to reduce episodes of hypoxia but limit over oxygenation injuries, especially in patients requiring longer term oxygen therapy. References 1) Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, Morelli A, Antonelli M, Singer M. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1583-1589. doi: 10.1001/jama.2016.11993. PMID: 27706466. 2) Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome. N Engl J Med. 2020 Mar 12;382(11):999-1008. doi: 10.1056/NEJMoa1916431. PMID: 32160661. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Peter Bakes, MD Educational Pearls: Classically presents with the 6Ps: Pain, pallor, paresthesia, pulseless, poikilothermia (cold), and paralysis Acute limb ischemia occurs by embolic or thrombotic causes Thrombotic causes are now more common due to aging populations and advancements in vascular surgery like stents which can be a nidus for thrombosis. Sudden onset of pain without prior symptoms is more typical of embolic causes Preceding symptoms leading to acute ischemia are more often from thrombosis Diagnosis can be clinical based on absent pulses, ultrasound or CT angiogram Definitive treatment includes thrombectomy, stenting, or bypass surgery to restore the blood flow to the distal limb References McNally MM, Univers J. Acute Limb Ischemia. Surg Clin North Am. 2018 Oct;98(5):1081-1096. doi: 10.1016/j.suc.2018.05.002. PMID: 30243449. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD