education

Penis Talk ~ With Your Hosts Sloas and Stroup

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 The finale in the Urology trilogy.  In this episode Dr. Sean Stroup, CDR, USN, MC and I wrap-it-up with a series of "down-there" complaints (down-there does not imply that this episode is about Australians with grievances) with the most sensitive of subjects to any male patient, penile complaints, worries about the willie, persevering about the pee pee, jargon about the junk, etc.  Hold on to your hats....

The Disclaimer hasn't changed: if you think jokes about "shrinkage" are funny than please listen to the podcast, but if you find those offensive then skip this episode and I wish you all the best in your attempt to make it through your career without encountering another penis...again....ever.

iTunes Link

Podcast 12 - Penis Talk ~ With Your Hosts Sloas and Stroup

Urology Part 2 ~ The Painless Scroti

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"Amigo, the only thing in this world that gives orders is balls. Balls. You got that?" ~  Scarface 1983

Every man is attached to their nuts.  In this episode CDR Sean Stroup, MD USN and I continue to discuss non painful ballular complaints.  You make think your safe with a non-painful swollen scrotum, but oh contraire mon frere, you can lose a nut that way too.  A guy just can't get a break....

The Disclaimer from the last episode still applies: if you think jokes about old man balls are funny then please proceed to listen to this podcast, but if you find those offensive then skip this episode and look into non-urologic career paths.  However, if you do listen to this podcast then the ball you save could be your own....

iTunes Link

Podcast 11 - Urology Part 2 ~ The Painless Scroti

Urological Complaints Part 1 - The Painful Scrotum

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"Rub your balls, squeeze your balls so you don't get cancer"  ~  Tom Green

Few things cause more pain for the patient and fear in the practitioner than scrotal discomfort in a child.  I sat down with my good friend and pee-pee doctor CDR Sean Stroup, MD USN at the National Naval Medical Center in sunny, beautiful, oh how I miss it: San Diego, to discuss painful ballular complaints.  Dr. Stroup is a fellowship trained urologist practicing on the west coast and sees a ton of children at the Naval Medical Center.  Disclaimer:  If you are offended by jokes about pee-pee, the scroti, or not wearing appropriate underwear than it is probably best to skip this episode.  No testicles were injured or neutered in the production of this podcast. 

iTunes Link

Podcast 10 - Urological Complaints Part 1: The Painful Scrotum

Ketofol & Shah

I had the privilege to sit down with one of Canada’s finest, Dr. Amit Shah, and discuss his blinded randomized prospective study concerning one of my favorite procedural medications: Ketofol.

This is the evidence based follow-up to my last (more opinion based) podcast on “Sedation and Ketofol.”  The chocolate in my peanut butter.......

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Shah A, Mosdossy G, McLeod S, Lehnhar, Peddle M, Rieder M. A blinded randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425 33.e2. Epub 2010 Oct 13. PubMedPMID: 20947210

iTunes Link

Podcast 9 - Ketofol and Shah

Sedation and Ketofol

There are a lot of ways to sedate, but I would like to provide you with a philosophy and the methodology to put together the safest possible sedation package. 

Please stay tuned for my next episode in which I get a chance to interview Dr. Amit Shah the lead author on the game-changing Ketofol article listed below.

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Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded,randomized controlled trial to evaluate ketamine/propofol versus ketamine alonefor procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425-33.e2.Epub 2010 Oct 13. PubMed PMID: 20947210

Sedation Show Notes

iTunes Link

Podcast 8 - Sedation and Ketofol

Pediatric Airway - The Advanced Course

This is the second part of a two part series in pediatric airway management.  Here we focus on how to use the "Airway Algorithm" that we have created and how to manage the more difficult airways we encounter in the emergency department.  The "Airway Algorithm" is designed to be used in both adults and children. 

 Mac Friendly Airway Algorithm

iTunes Link

Reference: The Difficult Airway Course: Emergency™ (http://www.theairwaysite.com) and from Walls RM and Murphy MF: Manual of Emergency Airway Management, 4th Edition, Philadelphia, Lippincott, Williams and Wilkins, 2012.

Podcast 7 - Pediatric Airway The Advanced Course

Clearing The Pediatric C-spine

Developing a good rule to clinically clear the pediatric cervical spine would be difficult.  Very few kids suffer injuries to that region of the body making it nearly impossible to create a well-powered decision instrument.  Like with many other attempts in pediatrics you would most likely end up with a guideline that would be fairly sensitive, but horribly specific. 

 

Lets say we abstracted and validated a pediatric c-spine rule that was 95% sensitive and 50% specific.  With a disease that occurs at an incidence of less than 0.1% (1/1000), by employing a decision instrument that is 95% sensitive you would reduce your patient's risk of missed injury to say 0.005% (1/20,000) .  Sounds great right?  Hold on though; there's more.  If that same rule is 50% specific (which most peds clinical rules are) 50% of the kids you applied your rule to will have false positives.  Therefore 500 of every 1000 patients you employ your decision instrument for would actually be subjected to further workup and needless radiation.

 

Does any of that sound familiar?  It's nearly identical to the use of D-Dimer in very low risk adults (probably better stated as no risk).  If you take a low to medium pre-test probability of disease (Wells Score of low-mod = 2-16% risk) and apply a D dimer (sensitivity > 95%) that comes back as a negative result (you now have reduced your 16% chance of having disease to less than 1% because 16% reduced 95% is 0.8%).  Well done!  You are done with the work-up and you have excluded disease.  If you apply the D-Dimer to a very low risk population (1-1000 to 1/10,000 depending on who you read) then you may further reduce your risk (I'm not sure how much lower you need to go to fell comfortable 1/1000 is pretty low), but just like in the example above, you will have subjected twice as many patients to needless CTA of their chests because your D-Dimer specificity was so poor (about the same 50% as above).  

 

Sorry, that's a lot of stats, but here's the take-home message. Your pediatric patient doesn't need a decision instrument as much as they need a good doctor.  Any injury with extremely low prevelence will most likely end up below the test threshold of creating and validating a decision instrument that you can rely on.  It is hard to get objective data in pre-verbal children, but it is easy to play with them, earn their trust and make a good clinical decision.  NEXUS gets you to 8 years of age, but then it's up to you to make a decision based on experience. 

 iTunes Link

 

 Podcast 5 - AVI Format (Larger Video Version)

 

Podcast 5 - Pediatric C Spine Clearance

An Easy LP Technique

If you downloaded the fist version of this (no intro music), delete it and re-downlad.  The audio is much better on the second version.

Practitioners have a love-hate relationship with this procedure.  Whether you embrace it or react to its’ necessity in the same manner you would when finding out you've just been cut-out out of your wealthiest relative’s will, the words “lumbar puncture” invoke emotion.  I would like to thank Dr. David Delemos for inventing this simple recipe for success. It is one of my favorite procedures and hopefully after hearing this podcast it will be one of yours as well.  

Check out the PDA friendly companion file below.

iTunes Link

Pediatric LP Show Notes

Podcast 4 - The Pediatric LP

Fever of Unknown Source - Part 2

In this episode we complete our discussion on “Fever Without a Source” in the 2-3 month old population and also cover the 3-month plus age group.  Again Dr. Andrea Cruz a subspecialist in emergency medicine and infectious disease at The Texas Children’s Hospital gives us some further insight into when and how to work these kids up.

Full disclosure: The author on two of the articles below is LCDR Sherry Rudinsky who is an old navy friend of mine.  We were interns together and then attended the same Naval Flight School class.  Dr. Carstairs is also an aquantaince; she was a resident when I was a Navy Surgical Intern.  I was stationed at the Naval Medical Center San Diego when they were collecting their data, but I had no part in this study.  They are simply dang good reads so check them out.

iTunes Link

Fever Algorithm

Fever Part 2 - MP3 Version

References:

Reardon JM, Carstairs KL, Rudinsky SL, Simon LV, Riffenburgh RH, Tanen DA. Urinalysis is not reliable to detect a urinary tract infection in febrile infants presenting to the ED. Am J Emerg Med. 2009 Oct;27(8):930-2. PubMed PMID: 19857409.

Rudinsky SL, Carstairs KL, Reardon JM, Simon LV, Riffenburgh RH, Tanen DA. Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era. Acad Emerg Med. 2009 Jul;16(7):585-90. Epub 2009 Jun 15. PubMed PMID: 19538500.\

Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine. Ann Emerg Med. 2007 Jun;49(6):772-7. Epub 2007 Mar 6. PubMed PMID: 17337092.

Podcast 3 - Fever of Unknown Source Part Two

Fever of Unknown Source - Part 1

Just in time for the winter season.....

Have you seen a bunch of snot-nose kids with fever recently?  Do you want to put a needle in their back?  Better yet, do you not want to put a needle in their back, but feel really guilty about it?

I sat down with Texas Children’s very own Dr. Andrea Cruz who is triple boarded in pediatrics, pediatric emergency medicine and pediatric infectious disease to talk about fever without a source in neonates/infants and who really needs that LP.

There are so many pearls here that I am going to break  this into 2 podcasts.  Enjoy part one now and don’t forget to check out the link to my “fever without a source” algorithm link below.   

iTunes Link

Undifferentiated Hypotension and the Modified RUSH Exam

This is my simplistic take on hypotension (ie. shock) in pediatric patients.  All you need is an ultrasound, fluids and a basic understanding of the physiology.  

 iTunes Link

 Undifferentiated Hypotension Slide

 RUSH Slide

 References

 

 

Podcast 1 - Und Hypotension & Mod RUSH

Introductions are in order....

Welcome to PEM ED Podcast.  Pediatric Emergency Medicine; an Educational and Directional Podcast for the general emergency medicine provider.  I hope you find this podcast informative and practice changing.  Please click on the link below and enjoy.

iTunes Link

Podcast 0 - Introductions are in order...