Chest Pain: What is the Value of a Good History?
Every year there are 6 million visits to the Emergency Department (ED) for chest pain, and approximately 2 million hospital admissions each year.1 This is approximately about 10% of ED visits and 25% of hospital admissions with 85% of these admissions receiving a diagnosis of a non-ischemic etiology to their chest pain (CP).2 This over triage has enormous economic implications for the US health care system estimated at $8 billion in annual costs. [+]
Mythbuster: No Maximum Dose of Enoxaparin
Venous thromboembolism (VTE) is often treated with low molecular weight heparins (LMWH) such as enoxaparin. For patients with normal renal function, dosing is as follows: Enoxaparin: 1 mg/kg subcutaneously every 12 hours, or 1.5 mg/kg every 24 hours Dalteparin 200 IU/kg subcutaneously once daily Tinzaparin: 175 IU/kg subcutaneously once daily What about the obese patient? Is there a maximum dose for enoxaparin? [+]
Trick of the Trade: No pelvic bed? No problem
Often finding a pelvic examination bed for a female patient needing a speculum exam can be challenging. Without the elevated foot stirrups, the bed under the patient’s buttocks obstructs the pelvic speculum handle so that it can’t rotate completely into a 6 o’clock position. Some people place an upside-down bed pan to elevate the patient’s buttocks slightly in order to create more space for the speculum. Not only is the position uncomfortable for the patient, it seems a waste of a perfectly good bed pan. Fortunately there is an alternative approach. [+]
Ketofol: Is this the “Game Changer” of Procedural Sedation and Analgesia?
When talking about procedural sedation and analgesia, our goal is to minimize pain and anxiety, with the appropriate agent that matches the needs of our patient and the clinical scenario. So what are some qualities of this “ideal agent?” In a perfect world, it would have: Minimal adverse effects Rapid onset and offset of action Pharmocokinetic predictability across a spectrum of patients [+]
First ALiEM journal article: Trial of void for acute urinary retention
A patient may present to the ED after foley catheter placement for acute urinary retention (AUR) a few days ago and now requests catheter removal. Ideally this should be performed in the urologist’s office. However, occasionally patients cannot or do not follow up with the urologist in a timely manner and return to the ED expecting urethral catheter removal. A careful history and physical should be performed along with a consulting urologist. If the eventual decision is to remove the urethral catheter in the ED, what is important to know about a Trial of Void (TOV)? [+]
Patwari Academy videos: Respiratory failure and ventilators
Dr. Rahul Patwari reviews the basics of respiratory physiology, the pathophysiology behind respiratory failure, and ventilator management. What do all the ventilator settings mean? [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital [+]
Is it time to trash the stethoscope? The age of ultrasound
Is the physical exam a relic of the past, because our tools are relics of a prior era? It is important to do and teach a thorough physical exam. I cautioned against the overreliance on diagnostic testing in lieu of a physical exam, which can be initially burdensome and prolonged. But perhaps our difficulty with the physical exam is not the exam itself, but the tools that we have at our disposal to perform an exam, rather than the exam itself. [+]
What’s the Code Dose of tPA?
Suppose you have a patient in whom you highly suspect a pulmonary embolism (PE) that devolves into PEA arrest while awaiting a CT angiogram. Or, what about a patient with an ECG showing clear STEMI that loses pulses? [+]
Lytics for sub-massive PE: Ready for primetime?
There was recently a great study published in the American Journal of Cardiology (2012) by Sharifi et al1, questioning whether we should be considering tPA in patients other than those patients with massive pulmonary embolism (PE)? You know the big “Saddle Embolus” we all fear? Well it turns out this is only about 5% of all PEs. Should we be considering tPA in patients with sub-massive PEs? [+]
Trick of the Trade: Ambient noise and creative cognition
For many of us in academia and medical education, we accomplish a tremendous amount of work outside of the workplace. This can be in our home office, on the public transit system, or in the library. Interestingly, creative cognition occurs best with a moderate amount of ambient noise (not too much and not too little), according to a 2012 article from Journal of Consumer Research. [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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