A special short episode just in time for Christmas. Here we review an article published in The BMJ entitled "Dispelling the nice or naughty myth: retrospective observational study of Santa Claus."

This article, while funny, was also touching.

As healthcare providers we are constantly surrounded by death, negativity and people at their worst. We sometimes focus on the medicine and forget the human aspect. Even worse, we are sometimes 'forced' into customer service roles, relegating ourselves to be servants of our patients. However, we must keep in mind that while it can be tough in the hospital, we are still taking care of mothers, brothers and children that are beloved by their families. So while you are working your long night shift on Christmas - or while you are away from your family taking care of someone else's, try to spread some Christmas joy and cheer, in the hospital.  

Best holiday wishes,

From the MCP

Sources: Park, J. J., Coumbe, B. G., Park, E. H., Tse, G., Subramanian, S. V., & Chen, J. T. (2016). Dispelling the nice or naughty myth: retrospective observational study of Santa Claus. Bmj, I6355. doi:10.1136/bmj.i6355

Guide to the in-hospital fanny pack:

The decision to have a fanny pack was a natural progression. It started in 4th year medical school when a resident gave me a bougie and told me "son, you should keep this in your pocket for your entire rotation". From that moment I felt something inside of me change, I felt more prepared. I wasn't a pro at intubation but I knew I had one of the three things any ER doctor needs to be ready for any situation:

1. Knowledge
2. Equipment
3. The Ability to act

Then I witnessed an intubation where the waveform capnography would not calibrate properly resulting in an unnecessary extubation and re-intubation. After that, I started carrying a colormetric CO2 detector in my pocket. I had a bougie, scalpel, end tidal and EMRA pocket guides - along with my badge and stethoscope. I was starting to get weighed down. Finally, on a trip to Mexico, I adopted the use of a portable pulse oximeter as all the residents there carried their own due to the lack of available monitors on every bed.

The pulse ox was the final straw. I bought a fanny pack. 

So what's the final list?

1. Everest fanny pack.
2. 10 Blade Scalpel + Bougie = Cric Kit
3. 12g Angiocath for Needle Decompression
4. 18g Spinal Needle for Pericardiocentesis
5. Tape Measure
6. Portable Pulse Ox
7. EMRA Antibiotic Guide'
8. PALS Pocket Card
9. MCP Rapid Response Checklist (IAD Checklist)
10. Manometer for Central Line Placement Confirmation
11. Lollipops
12. Sharpie
13. Badge and Stethoscope (they hang on the belt as decorations!)

My Fanny:

Hospitalist's Fanny:

Critical Care PA Fellow's Fanny:

Link to fanny pack:https://www.amazon.com/Everest-Signature-Waist-Pack-Standard/dp/B000A13NJO/ref=sr_1_1?ie=UTF8&qid=1481136819&sr=8-1&keywords=everest+fanny+pack

Link to Pulse Ox: https://www.amazon.com/Santamedical-Generation-SM-165-Fingertip-Saturation/dp/B00R59OTOC/ref=sr_1_3_a_it?ie=UTF8&qid=1481136846&sr=8-3&keywords=pulse+oximeter

Each video larnygoscope model has its subtle quirks and troubleshooting techniques. The following techniques are useful when intubating with the Glidescope AVL:

1. Consider a deliberately restricted laryngeal view to aid in tube placement. Do this by withdrawing the glidescope slightly. Verathon recommends that the glottic apperature should occupy the "upper 1/3 of the screen".
   
2. Use the 1-4 step approach as per the Verathon official recommendations: see Verathon Glidescope Technique Video 
   1. Look at the mouth to introduce glidescope midline.
   2. Look at the screen to "obtain the best glottic view".
   3. Look at the mouth to introduce the ET tube.
   4. Look at the screen to pass the tube through the chords.
3. Look at the patients mouth when initially inserting the ET tube into the mouth- not at the screen.
4. Practice using VL!
5. Try shifting the entire laryngoscope to the left to allow more room for insertion of the ET tube into the mouth. 
6. When trying to pass the ET tube through the chords, hold the ET tube by the end furthest from the patients mouth. This will give you a longer lever arm. There is also a small grip on the Glidescope rigid stylet for this purpose; this grip can also be used to 'pop the stylet' when needed. Simply flick your thumb up. 
7. Consider withdrawing the stylet 3-5 cm if having difficulty passing the tube through the chords. This will straighten the tip of the tube allowing it to follow the natural curve of the trachea. 

For tip #3 I mention that you should be looking at the mouth while introducing the ET tube. During this, it is easier to slide the ET tube underneath the right sided flange that the glidescope has. This concept is illustrated in the Mgrath X blade below where this region is labeled as the "ET Contact Zone".

Thanks to all of our listeners around the world! New Zealand, Pakistan, India, Nepal, UK, Canada and Australia!

References: 

Bacon, E. R., Phelan, M. P., & Doyle, D. J. (2015). Tips and Troubleshooting for use of the GlideScope video Laryngoscope for emergency Endotracheal Intubation. The American Journal of Emergency Medicine, 33(9), 1273–1277. doi:10.1016/j.ajem.2015.05.003

GlideScope® Video Laryngoscopes Channel, ©2012 Verathon Inc. 0900-4018-00-86, Retrieved October 28, 2016, from https://www.youtube.com/watch?v=7jb2tbqQ6VQ

Carlson, J. N., & Brown, C. A. (2014). Does the use of video Laryngoscopy improve Intubation outcomes? Annals of Emergency Medicine, 64(2), 165–166. doi:10.1016/j.annemergmed.2014.01.032

Duggan, L. V., & Brindley, P. G. (2016). Deliberately restricted laryngeal view with GlideScope® video laryngoscope: Ramifications for airway research and teaching. Can J Anesth/J Can Anesth Canadian Journal of Anesthesia/Journal Canadien D'anesthésie, 63(9), 1102-1102. doi:10.1007/s12630-016-0681-3

Show notes at www.medicalcasespodcast.libsyn.com. 

Remember in medical school when you were taught to treat the patient and not the numbers? It sounded so good, right? So why are we so aggressive with treating fever in patients with sepsis? This episode reviews the article "Acetaminophen for Fever in Critically Ill Patients with Suspected Infection".

Bottom line: for septic patients with fever, you can use acetaminophen to treat symptoms but there is no mortality benefit.

Furthermore, if patients are persistently tachycardic despite adequate resuscitation and all other causes of tachycardia have been ruled out there is no harm in giving acetaminophen to control fever/ tachycardia. 

Background: acetaminophen is often used to control fever in patients with suspected infection in the ICU - there is little data to suggest that this is beneficial. 

Population: 700 ICU patients with fever (temp ≥38°C) and suspected source of infection

Design: Multi-center, prospective, parallel-group, blinded, randomized, controlled trial.

Intervention: 1 gm IV acetaminophen Q6H until  1) ICU discharge, 2) Resolution of fever, 3) Cessation of antimicrobial therapy OR 4) Death

Control: Placebo Q6H

Results: Primary Outcome - No difference in ICU free days to day 28. 

Secondary Outcome - No significant differences between the acetaminophen group and the placebo group with respect to mortality at day 28 or at day 90

It should be noted that acetaminophen WAS associated with a shorter ICU stay among survivors but a LONGER stay among non-survivors. 

Acetaminophen has a low chance of harming your patient but it is clear that there is no pressing medical indication (other than discomfort) to treat mild fever in sepsis.

Keep in mind that we are talking about fever in suspected infection. There are many other cases where temperature management of some sort IS indicated. This is often acheived through medications or external cooling.

Examples include:

1. Neuroleptic malignant syndrome 
2. Serotonin syndrome
3. Environmental exposure like heat exhaustion and heat stroke
4. Post cardiac arrest - 33℃ vs 36℃
5. Malignant hyperthermia
6. Anticholinergic toxidrome
7. Brain trauma.
8. Premies with Hypoxic-Ischemic Encephalopathy 

From the article - Young, Paul, Manoj Saxena, and Rinaldo Bellomo. "Acetaminophen for Fever in Critically Ill Patients with Suspected Infection." New England Journal of Medicine N Engl J Med 373.23 (2015): 2215-224. 

The topic of this lecture is how to approach a Rapid Response in the hospital. The website has a PDF version of the RAPID RESPONSE CHECKLIST that you can download/print/laminate. There are three sections:

1. Information
2. Actions
3. Differential Dx

While the topic is short, the general theme is one that I will continue to expound upon throughout the podcast: you need to be prepared to perform during variant or labile situations in the hospital. A systematic approach is one of keys to being ready.

Caveats to the list: You don't need to check of every item of the checklist but it can be useful to go back to basics if the situation becomes chaotic. Furthermore, no specific order is implied in the checklist. The information gathering and actions can often be done in tandem. The action section may have lab tests not available at your hospital but the general concepts apply. 

This episode was inspired by a lecture entitled "Chaos" given by one of our best senior residents. You may notice thematic similarities to Emcrit Podcast 118 - "EMCrit Book Club - On Combat by Dave Grossman"; I recommend listening to that episode as well. 

PDF LINK IS BELOW

Episode #2

A knowledge pearl episode with a short case seen during intern year of residency. These three clinical entities all share a common theme; they develop quickly and need definitive management within minutes. 

Fentanyl rigid chest syndrome: chest wall/abdominal/masseter rigidity following the administration of fentanyl. More commonly seen with doses >4mcg/kg but can be with ANY dose. 

Risk factors: higher doses, fast push rate, extremities of age, critical illness and use of medications that alter dopamine levels.

Treatment:

1. Double check your mask seal.
2. Recognize what is going on.
3. Give naloxone.
4. If still unable to ventilate- paralyze with Succinylcholine. 

Succinylcholine masseter muscle rigidity (MMR): whereas mild masseter rigidity and jaw stiffness is common up to a minute after giving succinylcholine, MMR presents with severe prolonged jaw stiffness after giving sux. Some of these patients will progress to outright malignant hyperthermia (MH) and management should proceed accordingly. 

Risk factors: inadequate dosing of sux (<1mg/kg), children, myotonia congenita, duchenne muscular dystrophy. 

Treatment:

1. Double check your ventilations
2. Recognize what is going on.
3. Consider propofol for further sedation.
4. Administer a non-depolarizing agent such as rocuronium or vecuronium.
5. Expectant management for MH - monitor vitals, EtCO2 (>55 mmHg is bad), urine, cpk, abg.
6. Give dantrolene 2.5mg/kg if MH. 

Ketamine Induced Laryngospasm: laryngospasm seen after giving ketamine. Results in difficult ventilation. Can often be managed with CPAP or positive pressure ventilation using a BVM. 

Risk factors: children <3 mo, pts with active URTI or asthma, larger doses, rapid push rate. 

Treatment:

1. Double check your mask seal
2. Recognize what is going on/ call for help.
3. Give 100% FiO2 through tight mask sealed BVM with positive pressure or CPAP.
4. Attempt pressure at "Larson's Point" (may or may not work).
5. Consider propofol for further sedation
6. Give succinylcholine (4 mg/kg IM or 1.5 mg/kg IV) for paralysis - this is very rarely needed for isolated ketamine induced laryngospasm. Use Broselow tape to determine dosages in children. 

Motivated by the podcast greats in the EM world; the very first episode of MCP. 

What inspired this podcast was a month long elective ER/ICU rotation during my second year of residency. In preparation for rounding and doing H/P's in Spanish I wanted to improve my medical vocabulary. I listened to a lot of medical podcasts in Spanish. What I wanted at that time was a podcast with variety, excitement and that fit my interests of EM/IM/critical care. There was nothing that fit that description perfectly - that is what this podcast will intend to be. While I did learn Spanish, episodes will be in English. 

The goal of the podcast is to provide interesting and clinically useful medical pearls, management strategies and case presentations to med students, EM/IM residents and foreign medical graduates. 

I suspect that the podcast will evolve as time goes on. 

Initially, lectures will be one of 4 types: 1) Knowledge Pearls (KP), 2) Clinical Pearls (CP), 3) Cases, 4) Board Review (BR)

Disclaimer: This is educational material much like any lecture that you would hear. Use your own judgement and know that every clinician including myself can be flawed in their teachings. Medicine changes, research changes and so should your opinions as time goes on.