About Gus M. Garmel, MD, FACEP, FAAEM

Adjunct Professor of EM
Stanford University;
Inaugural Member/Distinguished Educator
CORD Academy for Scholarship in Education in EM

11 Tips to Improve Epistaxis Management in the Emergency Department

Managing epistaxis is often challenging, time-consuming, and takes practice. Even under the best circumstances, epistaxis often results in return visits for rebleeding and poor outcomes. Rarely should you do “nothing” for adults who present to the ED with or following epistaxis. If it produced enough blood to seek care (even without hemodynamic compromise), epistaxis frequently recurs even if currently resolved. This is a less true in pediatric patients. A careful and comprehensive evaluation is essential in both populations, whether epistaxis is ongoing.

The following 11 pearls with a bonus tip should help you avoid common pitfalls, improve outcomes, and increase both patient and physician satisfaction:

Wear proper protection during the procedure, including a face shield and gown. Nasal manipulation often causes patients to cough or sneeze, resulting in blood spray.
Prepare your equipment in advance. Work with your nurses or techs to develop a policy where it is placed at the bedside when the patient is roomed. A bright, focused light is essential, ideally as a headlamp so both hands are free. This way, no assistant is needed. Cordless headlamps are easier to use but should be charged after each use.
Although an elevated blood pressure or hypertension can worsen epistaxis, acute treatment is generally not required. Help your patient relax by establishing a calm presence, demonstrating confidence, and explaining your approach in advance. Done well, these actions are often sufficient to reduce their blood pressure.
Have your patient slowly but firmly blow their nose to remove any clots that have formed, which not only will reduce or prevent medications from absorbing but will also interfere with visualization. After this, have your patient hold firm pressure with a clip or clamp for at least 15 minutes while you gather your supplies. If available, spray a vasoconstrictor such as oxymetazoline into the affected nostril(s) prior to holding firm pressure.
Tight packing of your selected medications and your preferred method of their administration (e.g., cotton balls, pledgets, swabs) is crucial, as the vasoconstrictor/anesthetic won’t be well absorbed without direct contact and pressure. Tight packing also helps tamponade any bleeding. It may be necessary to pack both nasal cavities to achieve adequate tamponade because the septum is mobile.
Avoid touching the nasal septum when using the nasal speculum. This is likely the area of bleeding and can be sensitive. Carefully insert the tip along the inner edge of the ala, open the speculum, then pull out with gentle traction to provide optimal visualization with your high-intensity light.
If using silver nitrate to cauterize a friable area or visible vessel, ensure the field is dry and the site is anesthetized. Chemical burns are painful, and this area is sensitive. Using light pressure with a gentle rolling motion, cauterize an area slightly wider than the area of bleeding, limiting the number of repeat cautery attempts.
If using commercial nasal packing that is too large (they come in several sizes, although some EDs stock only the largest sizes), shorten and trim the tip at an angle. Apply a topical antibiotic ointment to the nasal tampon to aid with insertion; this serves both as an antibiotic and lubricant. In some situations, using a hemostatic agent with the nasal tampon or in the nasal cavity may prove helpful. Follow the contour and direction of the nasal passage to ease insertion and minimize pain. Some patients poorly tolerate the placement of nasal packing and/or the packing itself.
Add 1-3 ccs of water or saline using a syringe (no needle) to wet the packing following insertion. This allows the packing to expand and soften. Be prepared for a small amount of leaking, coughing, or spitting. If using an inflatable device for packing, be prepared to inflate the balloon to the optimal size with air or appropriate fluid (depending on the device).
Do not immediately discharge a patient after successful epistaxis management. Observe your patient for a post-procedure recheck to ensure the bleeding remains well-controlled, your patient is tolerating the packing or balloon, and the vital signs are stable. This can be 15–30 minutes (or longer) depending on the amount of blood loss, the findings, the procedure, and your patient’s comorbidities.
Know how and when to call for help. Call for help early in situations such as hemodynamic compromise due to blood loss, hypoxia or acute cardiopulmonary distress, post-surgical epistaxis, bleeding tumors (especially those that have been irradiated), patients with underlying bleeding disorders, an inability to control the bleeding, or other circumstances that make poor outcomes more likely.

Charting Bonus Tips: You can complete your patient’s discharge paperwork while waiting for the pre-procedure topical anesthetic/vasoconstrictor to take effect. During the post-procedure observation period, complete your chart and document your findings, the procedure, whether the patient tolerated the procedure, and any complications while observing your patient and awaiting the final set of vital signs before discharge.

Additional recommended reading

Gottlieb M, Long B. Managing Epistaxis. Ann Emerg Med. 2023;81(2):234-240. doi:10.1016/j.annemergmed.2022.07.002. PMID 36117013

Updated March 23, 2023

By Gus M. Garmel, MD, FACEP, FAAEM|2023-03-23T23:41:34-07:00Mar 3, 2023|ENT|

career success and longevity in emergency medicine EM — Photo by Snapwire on Pexels.com

The practice of emergency medicine (EM) is consistently challenging. At any given moment during a shift, emergency physicians are responsible for making numerous decisions about multiple patients. Many of these decisions are time-sensitive, some a matter of life or death. Physical, intellectual, and spiritual fatigue can set in during or after a shift. Our consultants, clinic physicians, or hospital administrators rarely understand the roller coaster we ride. Out of necessity, those of us practicing EM look for ways to navigate the peaks and valleys that make up the natural rhythm of the emergency department.

I was recently celebrated for more than 30 years practicing EM in the same ED. Following this virtual luncheon, one of my talented new colleagues (David Cisewski, MD) asked me to share my secrets for longevity and career success. I figured others might be interested as well, so I crystalized 20 tips for emergency physicians (and perhaps all physicians) looking to achieve more joy, professional satisfaction, and wellness throughout their careers. I’ve separated them into 3 categories: Attention to Self, Mastery of Skills, and Finding Joy and Purpose.

Attention to Self

Change your attitude from “woe is me” to “WOW is me” (Pearls from the Practice of Life). Dr. Peter Rosen used to say “Nobody woke up this morning and decided to ruin your day. Don’t get angry at your patients… Happiness is your choice.”
Be positive whenever possible. Bring a positive attitude to the ED every shift. Start each day (or at least each shift) by asking yourself “Will I make war or peace with this day?”
Nurture your health. Focus on and improve your diet, exercise, sleep, and spiritual wellness. Avoid drugs, tobacco, alcohol, energy supplements, and soporifics. Protect your time off, and schedule time for activities such as reading or exercise. Make time to connect with family and friends, as social isolation and loneliness put your health at risk. Some people now refer to these as the “new smoking” (Together: The Healing Power of Human Connection in a Sometimes Lonely World, also Relationships #8).
Practice mindfulness. Some form of daily meditation, yoga, relaxation, or self-reflection such as journaling (which does not mean posting on social media) is beneficial. The proper use of and participation in the right social media groups and networks can provide support for some physicians. The positive effects from these activities can be present throughout your shifts, and often contribute to wellness and better sleep.
Know when you need help. When you need help, get it without feeling shame or guilt. Seeking help is a sign of strength, not weakness. This must be a cultural shift in EM (and the medical profession in general). The more normalized that seeking help becomes, the better for us, our patients, our colleagues, our friends, and our families. Despite being trained to act heroically, we are nevertheless human and need (and deserve) support.

Mastery of Skills

Work to improve your technical, communication, leadership, efficiency, delegation, charting, and relationship skills. Embrace beginner’s mind – there is always something new to learn. Commit to developing emotional intelligence (EQ), which is as critical to your success, longevity, and mental well-being as are the technical skills you learned in residency.
Learn continuously. Every patient, consultant, EM colleague, advanced practice provider, nurse, and staff member has something to offer. Learn from reading textbooks and the medical literature. Discover what leaders in our field or at your medical center think or believe. Attend lectures and conferences related to EM or other areas of interest (including non-medical topics) to develop your intellect. Grow your knowledge base. As a bonus, you will have more interesting things to discuss with others.
Relationships matter. Nurturing and cherishing them will help you feel satisfied during your career and throughout life. Foster and maintain healthy professional relationships. Get to know your co-workers in the ED. In addition, network with people outside of the ED (physicians and non-physicians). Always make sure to strengthen and prioritize relationships with your family and friends. Disengage from and avoid toxic relationships.
Show interest in others. Be curious about what’s important to them, their lives, their families, and their interests. This gives your mind and heart a needed break from all things EM. Plus, it is the right thing to do and the best way to live.
Develop good listening skills and show empathy. Understanding empathy (and being good at using it) will not only help you in your practice, but also with your relationships.
Connect with patients and their stories. See your patients as people with lives outside of the ED. Patients are not just the “abdominal or chest pain in room 10.” (A Piece of My Mind. Gomer, JAMA 2004 and The Name of the Dog, NEJM, 2018).

Finding Joy and Purpose

Celebrate your successes (even small ones) and your good fortune. Consider changing how you “define” success if your current definition doesn’t make you happy.
Take one day at a time and, when possible, one moment at a time. Look forward to the future but immerse yourself in the present.
Take pride in your work, your training, and your skills. Don’t lose confidence when you make an error. Instead, assume responsibility for your errors and don’t blame others. There are no failures, only growth opportunities. Commit to learning from your mistakes and from the mistakes of others.
Work hard with intentionality and purpose.
Remind yourself of the privilege and honor to care for patients who neither choose you nor have a prior relationship with you. Patients and their families are often afraid or have problems that they simply can’t handle without help. Be humbled by their courage to seek help, and that they’ve placed their trust in and hopes with you.
Mentorship. Seek mentoring early from experienced, trusted faculty who will commit to your success with passion, integrity, and confidentiality. Mentors do not all need to be from your discipline, of the same gender, or of similar training, cultural, or socioeconomic backgrounds. It is reasonable to have more than one mentor supporting your growth. Throughout your career, keep in touch with mentors, and add new ones as necessary. When you are ready, take on the responsibility of serving as a mentor to “give back” to a colleague. (Mentoring in Emergency Medicine, Ch. 4, in Practical Teaching in Emergency Medicine, 2nd ed).
Look forward to each patient and each shift as an opportunity to “cure sometimes, treat often, and comfort always” (Hippocrates).
Express gratitude and offer sincere thanks. Think about thanking at least one person each hour. This doesn’t have to only be for major things; it can be for simple things and can be directed to anyone – patients, families, nurses, consultants, staff, colleagues, EMS personnel, and environmental services who clean up after us. Be sincere and specific with your gratitude. Even better, use people’s names as a show of respect.
Keep a happy folder on your computer and establish a happy “area” in your office or home that has patient cards, gifts, perhaps your diploma, any recognition or important mementos, family items, and inspiring photos, quotes, or books. These items will likely make you smile, so refer to them regularly or as often as needed. Honor the impact you’ve had on others.

I hope these pearls help readers enjoy long and productive careers. I recommend reviewing the modern version of the Hippocratic Oath from time to time to remind yourself of medicine’s greater purpose. I also suggest Viktor Frankl’s book Man’s Search for Meaning. Although somber at times, Frankl beautifully relays the significance of finding meaning during life’s most challenging experiences. Our work in EM and healthcare in general is demanding, difficult beyond description, yet remarkable. As such, it has the potential to transform us in meaningful and lasting ways. I wouldn’t trade my last 30+ years in EM for any other profession despite the exceptional focus and effort it requires. Only by challenging ourselves do we learn the depth and breadth of what’s in our hearts. I hope that everyone reading this is fortunate to feel similarly about their career choices and clinical practices.

Good luck with your careers!

(special thanks to Laura)

By Gus M. Garmel, MD, FACEP, FAAEM|2021-10-05T13:08:15-07:00Oct 13, 2021|Academic, Life, Wellness|

How I Work Smarter: Gus M. Garmel, MD, FACEP, FAAEM

gus garmel how i work smarter

One word that best describes how you work?

Compassionately

Current mobile device

iPhone

Computer

MacMini

What is something you are working on now?

Multiple projects, presently Microaggressions & Civility in the Workplace, Communication and Success in EM, and Coaching/Mentoring in EM.

How did you come up with this Idea/Project?

These are important topics; not a lot of information is available about these topics related specifically to EM despite the need.

What’s your office workspace setup like?

Standing wrap-around adjustable desk with good lighting, multiple computer monitors, and sufficient space to work so that I can keep needed materials close and accessible in my work area. I have few distractions in my workspace, which allows me to focus best on the work I am doing.

What’s your best time-saving tip in the office or home?

Limit distractions and work on one thing at a time, which reduces inefficiencies and errors that often occur with multitasking.

What’s your best time-saving tip regarding email management?

I have several tips, although I have found that turning off email notifications and checking email infrequently (or on YOUR schedule when time allows) are perhaps the best recommendations I can share (again, this relates to multitasking inefficiencies, limiting distractions, and error prevention).

What apps do you use to keep yourself organized?

Ical, Notes, and email all help me stay organized. I also use SUPER-STICKY Post-It notes. They come in a variety of colors if you purchase them in bulk, which some people use to help with organization through color-coding (I don’t use this strategy, but it is a good one).

How do you stay up to date with resources?

Staying current and updated (medical and non-medical) is challenging and takes time. I have a few key websites bookmarked, and still get some materials through the mail on paper. I schedule time for keeping up. Some aggregated links direct me to articles of interest, and I receive TOCs directly from society journals (EM and non-EM). I make a conscious effort to keep up, and spend very little (or no) time on Facebook, Twitter, and other social media platforms.

What’s your best time-saving tip in the ED?

Always think DISPOSITION (every patient needs one). I teach that if you don’t have a good idea about a patient’s disposition, you should ask more targeted questions and do a better physical examination before leaving the room. I recommend planning for test results that can only be normal, abnormal, or indeterminate. Imagine what you would do for (and with) each patient if the test results are all negative (or normal). Have a plan for indeterminate results, for positive findings, or what to do if there is a worsening in the clinical course (including persisting pain, dizziness, vomiting, shortness of breath, etc.). I also think and teach to consider what information is necessary before it is appropriate to call a consultant that I or the patient needs anyway. Often consultants appreciate hearing about a patient “early” even before all the results return (especially if it is near the end of their day while they are still in the hospital).

ED charting: Macros or no macros?

Macros, but only after I see the patient and with attention to modifying the EMR as necessary. I am meticulous about adding detail and removing anything that is incorrect from the Macro. I never use Macros in my free-text HPI.

Advice

What’s the best advice you’ve ever received about work, life, or being efficient?
FOCUS – that’s key. Make every minute (or moment) count. Whenever possible, try to “finish” one task before starting another, which keeps your “to do” list as short as possible and prevents errors and inefficiencies related to multitasking or task switching.
What advice would you give other doctors who want to get started, or who are just starting out?

My best and most frequent advice to all physicians (especially new physicians) is to work hard (and smart), be a team player at all times, show compassion and demonstrate empathy as often as possible (always is best), and strive to improve your communication and professionalism skills. Clinical knowledge is expected. Your efficiency will improve with experience and with practice. Be kind to as many people as you can as often as you can. These are important strategies for professional success, patient satisfaction, and personal wellness.

Is there anything else you’d like to add that might be interesting to readers?

Enjoy your career in EM, which will be challenging yet extremely rewarding. Strive to achieve Joy and Meaning in Medicine by working with purpose. Use people’s names frequently and correctly (patients, staff, consultants, colleagues), and express genuine interest in them as people and professionals. Learning something personal about your patients and colleagues (in and outside of EM) is a sign of respect. Expressing gratitude and saying “thank you” with sincerity are always beneficial.

Who would you love for us to track down to answer these same questions?

Anyone who has demonstrated consistent long-term success in EM, and is able to share his or her successes, failures, and strategies in a clear manner.

Read other How I Work Smarter posts, sharing efficiency tips and life advice.

By Gus M. Garmel, MD, FACEP, FAAEM|2021-07-31T07:24:53-07:00Jul 14, 2021|How I Work Smarter, Medical Education|

10 Tips to Improve Patient Satisfaction in the Emergency Department

Exceptional communication is essential when providing care to patients in the ED. This is especially true given that we don’t have a preexisting relationship with our patients. They have never seen us before, have little or no information about us, and didn’t choose us. They are typically anxious, uncomfortable, and would probably rather be somewhere else. Exceptional communication allows patients to gain trust in us, in our skills, and in our recommendations. Strong communication skills not only allow physician and non-physician staff to gather relevant information and share important findings, but also help improve healthcare outcomes, reduce misunderstandings, and minimize litigation. Below are 10 pearls, divided into 4 habits, to help you get the most out of the clinical encounter and improve your patient’s care experience.
(more…)

By Gus M. Garmel, MD, FACEP, FAAEM|2018-04-25T16:00:02-07:00Mar 29, 2018|Administrative|

10 Tips to Minimize Error at ED Sign-Out Rounds

Patient handoff at sign-out rounds is a high-risk period for clinical oversights and errors. The key to minimize this is to have a clear strategy. This means being precise yet concise, methodical, and forward-thinking in your presentation to the oncoming clinician and team. There are various tools like I-PASS¹ to frame your script, but the following are 10 additional key tips to consider.

(more…)

By Gus M. Garmel, MD, FACEP, FAAEM|2019-02-19T18:38:16-08:00Nov 24, 2017|Medical Education|