Core EM - Emergency Medicine Podcast

Dr. Philip DiSalvo, an emergency physician and toxicologist, discusses the reliability and limitations of urine drug screens in emergency medicine. Topics include false positives/negatives, interference, and the need for additional testing methods. The impact of timing and drug detection duration is explored, along with the role of urine drug screens in ED management and psychiatry.

Discover the challenges and urgent decisions involved in managing precipitous vaginal breech deliveries. Learn about the different types of breech presentations and the associated risks that come with them. The hosts discuss essential techniques and safe maneuvers, like the Mauriceau and Pinard Maneuvers, to ensure both mother and baby's well-being. Valuable insights on collaboration with OBGYN and neonatal teams highlight the importance of teamwork in critical delivery situations. Tune in to gain practical knowledge for emergency scenarios.

The speech given by Dr. Goldfrank at the 2020 NYU / Bellevue Emergency Medicine Graduation Ceremony https://media.blubrry.com/coreem/content.blubrry.com/coreem/Goldfrank_Graduation_Speech_2020.mp3 Download Leave a Comment Tags: Graduation. Goldfrank Show Notes Graduation 2020 Lewis R. Goldfrank, MD June 17, 2020 WELCOME TO THE GRADUATES Congratulations to a wonderful group of physicians. It is a pleasure to recognize your great accomplishments in the presence of your friends, families, loved ones and the residents and faculty who have learned so much from and with you. I would first like to recognize those of you who are members of the Gold Humanism Honor Society. There are a remarkable number of awardees in our graduating class of 2020. CLASS OF 2020 Joe Bennett (R) Max Berger (R) Ashley Miller (R) Leigh Nesheiwat (S) Kristen Ng (R) Emily Unks (S) AND Arie Francis (R) Nisha Narayanan (S) FUTURE PGY-4 Elena Dimiceli (S) Kamini Doobay (S) Mark Iscoe (R) FUTURE PGY-3 Stasha O’Callaghan (S) Nicholus Warstadt (S) FUTURE PGY-1 Aaron Bola (S) Alison (Ali) Graebner (S) Aron Siegelson (S) Melissa Socarras (S) Sarah Spiegel (S) Thomas Sullivan (S) Christy Williams (S) GOLD HUMANISM CORE VALUES Integrity, Excellence, Compassion, Altruism, Respect, Empathy, Service These are the values you want as a doctor for yourself or a loved one, to have outstanding listening skills with patients to be at your side during a medical emergency, to have exceptional interest in service to the community, to have the highest standards of professionalism to integrate a humanistic approach in patient care. These values are what brought all of you to NYU-Bellevue and that you have honed throughout your training. The remainder of this talk shows how all of you have been successful and demonstrated these values some of you were elected to the Gold Humanism—all of you have achieved humanistic success. Your personal efforts in the face of uncertainty of the evolution of the pandemic, the inadequate supplies, the hospital and governmental problematic decisions are remarkable. In our country, the President did not mourn the loss of more than a 100,000 human beings and the needs of society. Nor did he provide the leadership and moral support that the country desperately needed to optimally handle this unprecedented crisis. You, in contrast, demonstrate unflappable commitment to address and overcome obstacles to care for your patients, assist your peers, educate and care for your families and friends, while also caring for yourselves. This is a tribute to your humanism. You created essential ways to help patients who were isolated from families and friends during the critical phases of COVID-19. You utilized new tools to communicate your sorrow, your compassion and love, to maintain essential humanistic traditions of medicine while you could not talk, touch or utilize other essential skills to the fullest extent of a physician. When you recognized that all your knowledge of the social determinants of medicine was playing out as COVID-19 assaulted the poorest in our country, the people of color, the people with essential jobs without personal protective equipment, the people crowded in apartments and subways and buses, you spoke up and acted with appreciation and understanding of these disparities. You recognized that our system of using medicine to correct the societal social institutionally entrenched disparities was inadequate. George Floyd’s  death, and that of Breonna Taylor and innumerable others document the racism in America that destroys a part of us each and every day and by extension reinforces and normalizes white privilege. The ever increasing body of video evidence of the horrors of systemic racism is indisputable. You recognized that the American system of criminalization of social determinants is unacceptable. You spoke up and demonstrated that you saw our blind spots on policing and race. You protested to demand change in America. Change for equity and justice must occur throughout our society. “Black Lives Matter” will only be realized when the social determinants are truly addressed through changes that impact every vulnerable person. We must recognize that person, institutional and societal failures will not be corrected by medicalizing or criminalizing of socially determined inequities. Racism is systemic. Today you are seeking to create essential changes in medicine that will only occur when all the workplaces and governmental sites across the country, are enriched to allow a full representation of all the voices of all the people. You are leaders in the response to COVID-19 and the fight against racism. You will not only be remembered for having been present, but particularly for how you have responded. Thank you for your courage, creativity, resiliency and ability to transition and advance under duress. It was a privilege to watch you demonstrate the importance of your core values and the impact that your training here at NYU/Bellevue has had on your ability to integrate them into your practice. You are truly individuals of immense potential, ideal for advancing our world. How you keep these values and grow them in the next developmental stage of your careers will be critical. Each of you will contribute according to your talent, resources and priorities whether in clinical practice, academics, advocacy or public health. Always in every encounter with patients and their families “Be the change that you wish to see in the world” Mahatma Ghandi. THANK YOU AND CONGRATULATIONS! Read More

Explore the ins and outs of hemoptysis, from its definition to critical management tips in the emergency department. Learn about the various sources of bleeding and how to differentiate between mild and massive cases. The hosts share essential strategies for patient stabilization, including lab tests and imaging. Discover recent research on nebulized tranexamic acid and effective positioning techniques. Finally, gain insights into admission criteria and the importance of monitoring hemodynamic stability.

Exploring recent updates in the workup and management of pneumonia, including considerations for sputum and blood cultures, testing for influenza, the role of Procal in determining antibiotic use, and updates in the treatment of community-acquired pneumonia.

Mukul Ramakrishnan, a resident physician at NYU Bellevue, shares vital insights into posterior circulation strokes. He discusses the nuances of diagnosis, emphasizing the common symptoms that can lead to missed cases. The importance of awareness around risk factors is highlighted, alongside the challenges of identifying these strokes, especially in younger patients. Mukul also explains the HINTS exam, detailing its effectiveness in stroke evaluation and the distinction between peripheral and central nystagmus, enhancing clinical practice in emergency medicine.

We discuss one of the most complex problems we face – Homelessness Hosts: Kelly Doran, MD Audrey Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Homelessness.mp3 Download One Comment Tags: Social Emergency Medicine Show Notes Special Thanks To: Dr. Kelly Doran, MD MHS Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue ___________________________ References: Doran, K.M.  Commentary: How Can Emergency Departments Help End Homelessness?  A Challenge to Social Emergency Medicine. Ann Emerg Med. 2019;74:S41-S44. Doran, K.M., Raven, M.C. Homelessness and Emergency Medicine: Where Do We Go From Here? Acad Emerg Med. 2018;25:598-600. Salhi, B.A., et al. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med. 2018;25:577-93. U.S. Department of Housing and Urban Development, Annual Homeless Assessment Report to Congress. Available at: https://www.hudexchange.info/resource/5783/2018-ahar-part-1-pit-estimates-of-homelessness-in-the-us/ U.S. Interagency Council on Homelessness. Home, Together Federal Strategic Plan to Prevent and End Homelessness. https://www.usich.gov/resources/uploads/asset_library/Home-Together-Federal-Strategic-Plan-to-Prevent-and-End-Homelessness.pdf Read More

Delve into the intricacies of blunt neck trauma, revealing its common causes like motor vehicle collisions and strangulation. The discussion emphasizes the critical nature of airway management and the structured assessment necessary to prevent complications. Explore the evaluation of vascular and laryngotracheal damage, as well as treatment strategies for blunt cerebrovascular injury. The conversation also highlights the importance of advanced imaging for detecting rare injuries and the need for teamwork among trauma specialists.

Explore the intricacies of ankle sprains, a prevalent injury especially among teens and athletes. Discover the critical role of the anterior talofibular ligament and the distinctions between lateral and medial sprains. Unpack the grading system that helps assess injury severity, along with essential examination techniques to differentiate sprains from fractures. Learn about effective rehabilitation strategies and the importance of tailored immobilization. Gain insights into recovery management and the risks of re-injury.

An overview of Vaping Associated Lung Injury (VALI) Hosts: Audrey Bree Tse, MD Larissa Laskowski, DO Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Vaping_Associated_Lung_Injury.mp3 Download 2 Comments Tags: Pulmonary, Toxicology Show Notes Why this matters As of Oct 15, vaping has been associated with acute lung injury in over 1400 people 33 deaths have been confirmed in 24 states 70+% of those with VALI are young men A large number of patients are requiring ICU/ intubation/ ECMO 4 main ingredients in solvent +/- Flavor additives +/- Nicotine or THC (Tetrahydrocannabinol) Propylene Glycol (PG) Vegetable Glycerin (VG) CDC definition of VALI (Vaping Associated Lung Injury) Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset AND Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT AND Absence of pulmonary infection on initial work-up.  No evidence in the medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process). *Dabbing allows the user to ingest a high concentration of THC.  Butane Hash Oil (BHO), an oil or wax-like substance extracted from the marijuana plant, is placed on a “nail” attached to a specialized glass bong called a “rig.” A blow torch is used to heat the wax, which produces a vapor that can then be inhaled to supposedly produce an instantaneous effect. Pathophysiology At present, no single compound or ingredient has emerged as the cause, and there may be more than one cause The only common thread among the cases is that ALL patients reported using e-cig or vaping products Leading potential toxins: Vaping products containing THC concentrates: most cases are linked to THC concentrates that were either purchased on the street or from other informal sources (meaning not from a dispensary) Vitamin E acetate: nutritional supplement safe when ingested or applied to the skin (but likely not when inhaled) has been found in nearly all product samples of NY state cases of suspected VALI vitamin E acetate is NOT an approved additive at least by NYS Medical Marijuana program Other potential toxins: IT CANNOT BE UNDERSTATED that a small percentage of persons w/ VALI have reported exclusive use of nicotine-containing vape products, such as JUUL; as such, we must consider the potential toxicity of standard e-liquid or vape juice Flavor additives, that exists as chemical aldehydes: irritating and potentially damaging to lung tissue PG/VG: shown not only to break down to formaldehyde which is a known carcinogen, but also to produce lipoid pneumonia in rat lungs Some devices are easily manipulated to increase the capacity to produce vapor; increasing these settings may impact heating temperature, metabolic breakdown, and release of microscopic metal particles Lungs are multifunctional, including serving as an immune organ: lungs cleave proteins of all of the bacteria, viruses and other pathogens we are exposed to and inhale daily human studies on those that are chronic e-cig users or vapers have revealed that these products are shifting the balance of proteases and antiproteases in our lungs such that the proteases are destroying native lung tissue similar to how traditional cigarettes cause COPD Many potential reactions: NEJM article in references: details four radiographic phenotypes essentially reflecting different pathologic changes Long-term Effects Long term effects are unknown (some pts have required home oxygen on discharge) Risk for recurrence or relapse, especially if repeat exposure Presentation 95% of pts have had pulmonary sxs (cough, cp, dyspnea) 77% of pts have had GI sxs (abd pain, n/v/d) 85% of pts w/ constitutional sxs (f/c, weight loss) 57% w/ hypoxia (O2 < 95%) Unfortunately auscultation has been unreliable and poorly sensitive Workup There is no specific test or marker for dx, so VALI is still considered a dx of exclusion Labs: CBC ESR/CRP (93% w/ elevated ESR) LFTs (50% w/ transaminitis) ABG: hypoxia Imaging: CXR: typically shows bilateral infiltrates, although not always and there have even been some cases w/ unremarkable chest XR (so high degree of clinical suspicion in any person p/w hypoxia) CT: ground glass opacities, typically bilaterally  Management Dispo: 96% of cases required hospitalization Any pt w/ hypoxia, respiratory distress, or comorbidities Outpatient only if: no hypoxia or respiratory distress, reliable followup within 48h and good social support (keep in mind that some patients w/ mild symptoms of first presentation deteriorated rapidly within 48h) Empiric treatments for pneumonia inc abx, antivirals Steroids (methylpred 60mg q6h, based on how index cases in Illinois were managed) Case reports have documented improvement Mechanism: blunting of inflammatory response Aggressive supportive care Special Thanks To: Dr. Larissa Laskowski, DO Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue New York City Poison Control Center References: Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.  https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html Carlos WG, Crotty Alexander LE, Gross JE, Dela Cruz CS, Keller JM, Pasnick SP, Jamil S.  Vaping-associated Pulmonary Illness (VAPI). Public Health Information Series. Am J Respir Crit Care Med Vol. 200, 13-15, 2019.  www.atsjournals.org/doi/pdf/10.1164/rccm.2007P13 Henry TS, Kanne JP, Kilgerman SJ.  Images of Vaping-Associated Lung Disease — Correspondence.  N Engl J Med. 2019 Oct 10; 381;15.   Layden JE, Ghana I, Pray I, Kimball A, Layer M, Tenforde M, Navon L, Hoots B, Salvatore PP, Elderbrook M, Haupt T, Kanne J, Patel MT, Saathaff-Huber L, King BA, Schier JG, Mikosz CA, Meiman J.  Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report.  N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print].  https://www.ncbi.nlm.nih.gov/pubmed/31491072?dopt=AbstractPlus Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. MMWR Morb Mortal Wkly Rep 2019;68:919–927. DOI: http://dx.doi.org/10.15585/mmwr.mm6841e3external icon. https://www.health.ny.gov/press/releases/2019/2019-09-05_vaping.htm Read More