Paucis Verbis: Ventilator settings for obstructive lung disease
Following up with last week's Paucis Verbis card on Ventilator Settings for Acute Lung Injury and ARDS, here is the card on Ventilator Settings for Obstructive Lung Disease. This is for patients who present with acute asthma or COPD exacerbation who require endotracheal intubation. What initial ventilator settings should you set for these patients? Go to ALiEM (PV) Cards for more resources. Thanks to Dr. Jenny Wilson for the card and Dr. Scott Weingart for the original stellar podcast from which this card was derived.
Paucis Verbis: Ventilator settings for acute lung injury and ARDS
A patient presents with severe multilobar pneumonia and refractory hypoxia requiring endotracheal intubation. The respiratory therapist connects your patient to the ventilator. "What settings would you like your patient on?" Back in 2010, Dr. Scott Weingart posted a great podcast on "Dominating the Vent". It's such a fantastic distillation of the practical aspect of ventilator setting management of all intubated patients except those with an acute asthma or COPD exacerbation, Dr. Jenny Wilson and I thought this would be a great Paucis Verbis card to have in your peripheral brain. Note: The tidal volume should be calculated based on Predicted [+]
Remembering Dr. Robert Buckman
For those who trained in Canada (especially Toronto), the name of Dr. Robert Buckman always brought a chuckle. He filled his lectures with his signature British wit and humour. Yet, the message was always loud and clear. Being an oncologist, he had great insight in communication with patients. He was the first to teach us medical students about communication and professionalism: Kindness, empathy, delivering bad news, what to say when you don’t know what to say. A decade later, out of the countless hours of lectures, his stood out. Truly a big loss to the medical educators community. [+]
Trick of the trade: Quieting the shaky EKG tracing
A patient with Parkinson’s disease presents with chest pain to your ED. Her tremors prevent you from getting a good quality EKG because of the movement artifact. How can you eliminate this artifact? (No cheating with rocuronium.) [+]
Paucis Verbis: Neutropenic fever in cancer patients
A 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are: Temperature 39 C BP 160/80 HR 60 RR 14 Oxygen saturation 99% on room air His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC. Is this patient "high" or "low" risk per the Multinational Association for Supportive Care in Cancer (MASCC)? Does this person require inpatient admission? What antibiotics would [+]
Trick of the Trade: Opioids for air hunger
A patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen: Oxygen by face mask Nebulized albuterol and atrovent Solumedrol Bipap Set up for possible intubation With the Bipap mask on, the patient’s subjective sense of dyspnea and “air hunger” seems to make it harder for him to tolerate the tight-fitting mask. [+]
Poll: YOU are on the residency selection committee. What would YOU do?
As an attending physician, you are friends with nurses and residents on social media. One day, you are browsing through your social media page. You came across a photo of a student – a candidate applying to your program in fact – scantily clad, inebriated, dancing in a rave. The comments followed agreed on how wild he/she had partied and drank that night. You are on the selection committee. Should this information be part of the assessment of the candidate? Please explain your decision in the comments section. [+]
Trick of the Trade: Needlestick hotline 888-448-4911
You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient’s venous blood. After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report [+]
Paucis Verbis: Does this DM leg ulcer have osteomyelitis?
We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it's the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you'll be surprised by what you find. Several questions come up with diabetic foot ulcers: Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer? Is there underlying osteomyelitis? How can I best diagnostically work this foot ulcer up for osteomyelitis? What is the Wagner grade of this ulcer? (I think it'd be Grade [+]
Trick of the Trade: Pediatric ear exam
Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about: Balloonimals iPhone app to grossly assess peak flow Candleflame iPhone app to grossly assess peak flow Eye Handbook iPhone app with pediatric fixation animation targets Casting/splinting your buddy bear What’s your trick on performing an otoscope exam of the ears? [+]