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31 01, 2018

Troubleshooting the Crashing Patient with a Tracheostomy


Patients presenting to the ED with respiratory distress and a tracheostomy can unnerve almost any provider, and management is often fraught with preventable errors.1,2 This recognition has led to the development of treatment algorithms from groups including the U.K. National Tracheostomy Safety Project to improve the safety and quality of care for patients with tracheostomies.3 Use the ABC-Ts mnemonic to help you perform a focused tracheostomy evaluation and troubleshoot in a stepwise, systematic manner while waiting for your ENT consultant to arrive.


17 01, 2018

ALiEM Cards: Keeping the Sepsis Definitions and Criteria Straight

sepsis definitionsIn 2015 the Centers for Medicare and Medicaid Services (CMS) adopted the Sepsis Bundle Project, which is a quality improvement project aimed at reducing sepsis mortality by increasing compliance with national guidelines. But the CMS definitions of sepsis, differ from those is prominent trials (ProCESS, ARISE, ProMISE), and have since diverged from the Surviving Sepsis Campaign definitions, which may be different from your hospital guidelines! Also what are the criteria for SIRS, SOFA, qSOFA?
The ALiEM Card on Sepsis Definitions will help you keep it all straight.
13 08, 2017

Team-Focused CPR: Bringing Pre-hospital Success to the ED


High-quality chest compressions and early defibrillation are the cornerstones of effective cardiac arrest care.1 When implemented correctly these two interventions enhance patient outcomes and improve overall survival.2 However, despite simplified advanced cardiac life support (ACLS) algorithms and extensive training of providers, cardiac arrest scenarios in the emergency department (ED) are still high-stress and mortality rates remain high.3,4 


21 07, 2017

ALiEM’s Greatest Hits for Interns: A Curated Collection of High-Yield Topics

greatest hits for interns

Congratulations, you’ve made it! On July 1, thousands of medical students across the country made the transition to becoming Emergency Medicine residents. It was a particularly competitive year for Emergency Medicine, with 99.7% of first-year spots filled despite a whopping 2,047 positions being offered in 2017 (up by 152 spots compared to last year).1 Now begins the most crucial 3 or 4 years of your medical training that will prepare you for the rest of your career in Emergency Medicine.


17 07, 2017

ED Charting and Coding: Critical Care Time


After a STEMI activation from the field on Monday morning, the cardiac catheterization team scoops the patient away shortly after the paramedics arrive in the Emergency Department (ED). “Well that was a smooth and seamless resuscitation. The patient was barely in the ED for more than 15 minutes,” you think to yourself. You diligently complete your critical care documentation, noting 20 minutes of critical care time, before seeing your next patient. A few weeks later the chart is bounced back and noted as an erroneous documentation of critical care time. The coding department notifies you that the case will be billed as a Level 3 visit (E/M code #99283). Why is that the case?


13 02, 2017

Trick of the Trade: Rapid Insertion of Orogastric Tube


We have all been in the situation: an intubated patient needs an orogastric (OG) tube and no one has been able to place it successfully. Unfortunately, we typically find out about this situation after several failed attempts, when the patient is bleeding and/or the anatomy is distorted. It may coil in the mouth or esophagus. Here I present a novel technique to rapidly place an OG tube within seconds.

23 11, 2016

PV Card: LVAD Complications


Patients with left ventricular assist devices (LVAD) often cause much anxiety amongst providers in the emergency department. This is understandable with all of the hardware, diminished or absent peripheral pulses at baseline, and potential for complications. To add to the already helpful reviews about LVADs at REBELEM and emDocs, this is a PV card set providing a methodical approach to troubleshooting LVAD complications, including a reproduction of an algorithm for managing the LVAD patient with altered mental status from EMCrit.1–3