July brings new interns. They certainly have a lot on their plate, but seeing them work through their first shifts always reminds me that while they are learning how to practice medicine we depend on them to keep the patient flow moving – something most of them have never considered. Efficiency and flow management are skills that are learned. I’ll share my thoughts, even though I do not feel I am gifted in this area.
Continue readingAuthor: Jeffery Steele
Regional Wall Motion Abnormality
A 45 year-old man presents by EMS after a VF arrest. On arrival at the ED he has a pulse. An ECG shows an anterior STEMI. The cath lab is activated and the cardiologist is en route. While waiting for the cavalry to arrive, you ultrasound his heart and strike gold.
Continue readingA Tale of Two Clots
A thrombus in the heart is really the holy grail of point-of-care ultrasound. Here are two great examples.
Continue readingEye Can’t See!
A 23-year-old woman complains of painless vision loss in the left eye over the past two days. She has no past medical history. This one isn’t a diagnostic dilemma, but it does come with some nice imaging.
Why 0.14 units/kg/hr of insulin in DKA?
I recently reviewed the insulin dosing recommendation by the American Diabetes Association (and UpToDate) for the treatment of diabetic ketoacidosis. Both recommend either a 0.1 U/kg bolus followed by an infusion of 0.1 U/kg/hr or no bolus and 0.14 U/kg/hr. Where does such a bizarre number come from?
Which length dialysis catheter should I use?
Your patient needs emergent dialysis. To expedite the proceedings, you agree place the dialysis catheter. You look on the shelf, but there is more than one length of catheter. Which one do you grab? Do you know?
What type of shock is it?
For the sake of argument, let’s say that a patient has a pulmonary embolism. Their blood pressure is low, and they are toxic appearing. They get tPA and an ICU admission. Let’s also say, purely hypothetically, that one of their admission diagnoses was cardiogenic shock. Perhaps that’s a simple oversight. Perhaps, however, there is a knowledge gap. If these theoretical doctors have some confusion about the categories/causes of shock, other might as well. Do you know what type shock is caused by a pulmonary embolism?
Why do ‘bicarb amps’ come in such a weird concentration?
We have a handful of medicines that we administer by the “amp” (sodium bicarbonate, epinephrine, calcium chloride, and dextrose, for example). Clearly this is for simplicity as these are medications we use in emergent situations. That being the case, you may not spend much time thinking about the amount of medicine you are actually giving. Most have nice round numbers: D50 (50% dextrose), 10% calcium chloride, and although we don’t push this medicine by the “amp,” lidocaine comes in 1%, 2%, or 4%. But sodium bicarbonate comes as 8.4%. Weird. Why? Do you know?
Topical Anesthetics?
I saw some confusion recently as to which topical anesthetic to use for a laceration. In my experience the typical options are some stuff called EMLA and some other stuff called LET, but they are not interchangeable. Do you know the difference and which is indicated for what?
Dr. Gaskin, welcome to the club!
No reds. No whites. My man.
Searcy EM 