EM Quick Hits 68 Osteomyelitis, Tourniquet Technique, Pediatric Distal Radius Buckle Fractures, DSI RCT, AMS in ESRD & Dialysis, EM Leadership Spotlight #3

Interactive Transcript

Speaker A This is Emergency Medicine Cases EM Quick Hits podcast and I'm your host Dr. Anton Hellman. EM Cases is brought to you by Shremi, the Schwartz Reisman Emergency Medicine Institute. That's a non profit organization dedicated to improving EM care through high quality research and education. The opinions expressed on this podcast are intended for general information and educational purposes only and should not be used to diagnose, treat or prevent any medical condition, nor should they be used as a substitute for medical advice from a qualified practicing physician. Unless stated otherwise. The opinions expressed by the hosts or guests are made in their individual capacity, not on behalf of the Institute nor Medicine Cases. First, a word from our sponsor, Metrocade, the experts in Complex physician scheduling since 2012 I've been using Metricade's incredible scheduling system for a decade and it's been a game changer for me and my colleagues. Shift work comes with its challenges, but Metricade helps minimize the drawbacks by ensuring a fair distribution of shifts while integrating circadian friendly rhythm recovery time into its methodology. Less sleep deprivation means I can be a better EM doc on shift and still have energy for life outside the hospital. Check out metricade.com emcases to make your schedule fair and improve your sleep. This episode is brought to you by Easy Recess, the Resuscitation Assistant. This amazing app has drug dosing equipment, size calculation, treatment algorithms all in under three clicks, rapid access to life saving critical info in a user friendly interface. Try the app for free with the promo code emcases or visit easyresus.comemcases that's ezresus.com emcases it's an absolute pleasure to have Dr. Isaac Bogoch. He's an incredible speaker and some of you might remember him during the COVID pandemic because he was on television quite a lot. Dr. Bogoch, can you just give us a little bit of your background, your professional background?

Speaker B Sure. For starters, for those of you who obviously can't see us because this is a podcast, I'm sitting in this gorgeous studio and I'm impressed that Anton has this incredible teched out studio at his house. I'm Isaac Bogosh, I'm an infectious diseases physician. I'm based out of the Toronto General Hospital, the University of Toronto. I deal with general infectious diseases and then have a clinical interest and focus on tropical infectious diseases and HIV prevention. Spent a lot of time on the wards. Also spent a lot of time working in a lot of time in Africa and Asia and public health related initiatives that are associated with preventing or mitigating the Burden of emerging infectious diseases.

Speaker A Fantastic. So. So let's dive into our quick hit here on osteomyelitis. And I guess the first question is just why the heck should emergency doctors even care about osteomyelitis in the first place?

Speaker B Yeah, I mean, osteomyelitis is a pain in the ass for patients. And of course, we know it's a very significant infection that can cause tremendous morbidity. If it's untreated, it can lead to disfigurement. It could result in amputation. We know it can significantly impede mobility, patient autonomy. I mean, it's a huge problem for a lot of different reasons. The other. The other issue, of course, is if you have a smoldering infection, it can spread. It might not just be restricted to the bone. You can get spillover bacteremia or skin and soft tissue infections, and people can get acutely unwell as well. So morbidity, mortality, decreased autonomy, and it's a tough infection to have, but fortunately, not that hard to diagnose, not that hard to treat. We just have to know a few pearls.

Speaker A We're definitely going to get to those. I was amazed to read that the amputation rate for osteomyelitis is as high as 68%. Does that sound right? Right. To you? In your clinical practice, do you see lots of patients getting amputations like anything else?

Speaker B Osteomyelitis, it's an umbrella term with lots of different forms. And when we deal with, for example, foot infections in someone with, for example, diabetes, yeah, we do see lots of amputations associated with that. On the other hand, I think there's lots of cases of osteomyelitis that we see that we can diagnose rather quickly, treat rather effectively, and does not result in amputation. But certainly we know that diabetes is a massive global issue, and anyone practicing clinical medicine is going to see patients presenting with diabetic complications, including osteomyelitis. And many of those cases will sadly result in amputation.

Speaker A I want to talk about how to distinguish osteomyelitis from cellulitis and simple soft tissue infections. And this seems to come up all the time. You know, let's say a diabetic comes in with what looks like a cellulitis on their foot. Or maybe you're thinking, oh, maybe it's an abscess. You throw a pocus on there and see if it's an abscess. How do you distinguish between cellulitis and soft tissue infection? There's ulcer. With soft tissue infection, cellulitis and then there's osteomyelitis. So clinically, when would you suspect that we should go on to thinking, oh, this might be osteomyelitis, we need to work this out?

Speaker B Yeah, that's a great point. And you know, unfortunately, you know, we're not going to percuss our way out of all these, out of all these answers. And sometimes it does boil down to imaging. But you know, if someone has risk factors. So for example, there's an ulcer present, and the ulcer has been present for, you know, quote unquote, a long time. Well, what's a long time? You know, typically over a couple of weeks, or if the ulcer is present right over bone, or if there's, you know, exposed bone to state the obvious, these are big arrows pointing in the direction that, yeah, there might be osteomyelitis there. It doesn't always have to be, but you know, you're obviously gonna look for or consider that on the differential diagnosis. But you know, people have run of the mill cellulitis and you can use therapeutic trials. Even if it's in an area that's more prone to osteomyelitis, even if it's in a person with risk factors for osteomyelitis. Right. Five day course of an oral antibiotic usually tempers down the vast majority of cellulitides. And if they are doing well afterwards, there's no reason to suspect osteomyelitis in them. But I think there are those with those deep ulcers, those chronic ulcers, risk factors for osteomyelitis, that I think we at least thinking about that when they're presenting to medical care.

Speaker A Okay, let's talk a little bit more about the risk factors. So there's the obvious diabetes. Who else would kind of tweak you to thinking, oh, this could be osteomyelitis. What other risk factors are you looking for?

Speaker B It's really if you think about the risk factors for arterial disease and venous disease, so anything causing chronic ulceration, chronic venous stasis could be, you know, the list of causes of that is longer than your arm. Arterial insufficiency, again, risk factors for that is longer than your arm. But if you have chronic arterial or chronic venous insufficiency that can lead to ulceration, then those are both significant risk factors for osteomyelitis. The other thing to think about too is the pathophysiology of osteomyelitis. So how does the bacteria actually get to the bone and through ulceration, there's an obvious path, there's a direct inoculation. Right. You ulcerate the skin, it's on top of a bony prominence, you have an infection, it erodes through the cortisol cortex of the bone. You've got yourself some osteomyelitis, that's fine. But we also have to think about hematogenous spread as well. So you might have completely intact skin and no ulcer, but hematogenous spread that ends up in the bone. So people who inject drugs, I think that's another risk factor for osteomyelitis. You can have transient bacteremias and, you know, the spleen is a remarkable organ that can clear bacteremia rather quickly. But, but it's not perfect. And certainly we see a significant burden of osteomyelitis in those who are injecting drugs.

Speaker A Okay, so it's kind of the usual immunocompromised patient.

Speaker B Yeah.

Speaker A I want to talk a little bit about pain. So one of the things I read about suspecting osteomyelitis is persistent pain in your practice. How does pain play into the osteomyelitis thing? It's a bit of a tricky question because a lot of diabetics will have zero pain because their nerves are completely shot.

Speaker B Bingo. I don't think pain plays into it at all. It's never, I don't think it's going to be sensitive or specific. It's obviously going to direct you to a particular anatomic site. If someone says, my foot really, really, really hurts, sure, you're going to investigate that. And you know, arterial ulcerations or arterial insufficiency is very commonly associated with pain. And of course we definitely see osteomyelitis in the context of arterial insufficiency very frequently. But pain in and of itself, I don't think is sensitive or specific for this. And to your exact point, we know that those who have diabetes, especially long standing diabetes and poorly controlled diabetes, we know that there is significant neuropathy associated with that. And that's one of the risk factors for developing osteomyelitis. I mean, they might have a pebble in their shoe, they continue to walk on it, they don't feel this irritation against their skin, they develop an ulcer, they continue to put pressure on that area because their peripheral nerves just are not as functional. And those ulcers can get infected and they can sadly get deep and cause osteomyelitis and terrible skin and soft tissue infections as well.

Speaker A All Right. I want to talk a little bit about the physical exam, and we'll get to the probe to bone test in a minute because that seems to be everyone's favorite topic when it comes to the. The physical exam for osteomyelitis. But what else are you looking for? You know, they talk about, like, bony tenderness, which I'm not sure exactly what that means. Like, again, to help distinguish between the soft tissue infection and osteomyelitis. Is there anything on physical exam that's going to help you here?

Speaker B Honestly, I think, like, listen, I am a huge fan of the physical exam. I prioritize it at bedside teaching. I love the physical examination, but this is one of those areas where you just got to be careful with the limitations of the physical exam. Right. Is there an ulcer present? That's helpful. Okay. Is the ulcer deep? And can you see bone? That's helpful. Is it perfect? Not at all. Purulence from an ulcer, that's not really going to help you. Right. You know, there's an infection, but the question is bone or not bone? That's. That's really what we're asking. And even to your point, too, probing to bone, that's not even a perfect test as well. That just means you can probe to bone. Okay, but we have to distinguish between osteomyelitis, meaning the bone itself, the cortex of the bone is infected, versus periostitis, which is the periosteum around the bone, which can be inflamed and infected. And those are two different clinical entities. Usually you can treat periostitis with a week or two of antibiotics and, of course, impeccable wound care. Osteomyelitis is going to require a longer duration of antibiotics. The bone itself, the cortex of the bone, is infected. And, you know, bone is alive and has a blood supply and has turnover, but it just takes a lot longer to treat that effectively.

Speaker A Fair enough. Let's talk about the probe to bone test a bit more and some of the test characteristics of it. Like, how good is it? Can we rely on it? I find that after I've done a probe to bone test, I'm still unsure whether it's positive or not. Any tricks about the probe to bone test? And what are the test characteristics? Like, what's the accuracy, the sensitivity, the specificity? Can we rely on it?

Speaker B No, you can't. It's helpful. It increases your pretest probability. And sometimes, and here's the issue, it's like when you're reading the papers on this, of which there is Scant evidence. There's like anything else, there's a wide range. So, you know, and I think you can go back to your clinical experience and recognize. I don't know if I'm supposed to be politically correct here, but like, sometimes you see just absolute horror shows of feet and, you know, you can see exposed bone and you're touching exposed bone and you're confident that when you're probing to bone, you know, you're basically, you know, you're up to your wrist in the ulcer and like you're touching bone. And other times, you know, there's like a small ulcer and you're using the little probe and you think you might be touching bone, but maybe you're not and you're not entirely sure if that's periosteum or bone and you're less certain. So like, I think we got to be very careful in any data here because we got to make sure we're truly comparing apples to apples and we might not be doing that. So there's going to be a lot of inter observer differences. I think at a very individual level, if you're confident that you're probing to bone, great. You've got a much higher likelihood of osteomyelitis. If you're not, hey, it's still on the differential. But ultimately, ultimately it's not like you're not going to image this foot or this limb. You're going to need imaging to really rule in or rule out osteomyelitis. And you know, I think you and I have worked in many parts of the world, including high, medium and low income countries. You know, in many places you still have access to X rays and imaging modalities and these are going to be extremely helpful in the diagnosis.

Speaker A All right, great. Before we get to imaging, we need to talk about lab tests and our favorite lab tests in the universe, CRP and then its cousin, ESR. It seems like some physicians order CRPs and ESRs, or one or the other on a kazillion emerge patients. And then some people hardly ever order them. There's always a controversy about CRP and ESR for osteomyelitis. What's the take home? Does everyone need an esr? Crp? I would think probably. And then how do you actually interpret it? So if The ESR is 25, does that help you? If it's 3, I'm assuming it does help you. If it's 140, I'm assuming it does help you. How do you interpret CRP and esr? Do you need them both? So many questions about CRP and esr, I don't even know where to start.

Speaker B Okay, let's start with the very fundamentals. I know we're in slightly different worlds in the internal medicine world, minus rheumatology. Most people aren't ordering ESRs and CRPs for the diagnosis of osteomyelitis. Most, in fact, I would say the pendulum is swinging away from them. And even the most cynical of cynical doctors are saying the only thing an ESR tells you is if the lab is open. I don't necessarily agree with this, and I think we order far more expensive tests that provide us with far less clinical information. And like anything else, this is a cheap, easy test to order with a pretty rapid turnaround time. And it can be helpful, but it's got to be contextualized appropriately. There's some data that shows that an ESR greater than 70 in the right clinical context has a high likelihood ratio, like a likelihood ratio of 11 for osteomyelitis. Like, that's pretty darn good for a test that is as basic and cheap as they come. Having said that, you're never gonna hinge any of your clinical decisions based on an ESR or a crp. The CRP is even less sensitive than the esr. So I think many clinicians are shying away from it. And if they are using it, they might be using it as a marker of inflammation, as an imperfect way of measuring, is this person getting better? Yes or no. But then the pushback to that is, okay, let's say your ESR was making up a number 100, and now you're, I don't know, three weeks into your osteomyelitis treatment, and now your ESR is, I don't know, 80. What are you going to do with that information? How does that change any of your management strategy? Like, it probably doesn't. You probably are still going to set the duration of antibiotics and, and look for meaningful clinical signs of recovery rather than follow an imperfect blood test. So, short story long, many people, at least in the internal medicine world, are not using ESR and crp. However, there is some data demonstrating that a pretty high ESR like greater than 70 in the right clinical context has a pretty decent likelihood ratio for osteomyelitis, but you would really be using other modalities to confirm it.

Speaker A Okay, so that's the rule in. I actually find it most useful to rule out and help risk, stratify, you know, who needs to be admitted and should I really worry about osteomyelitis. I mean, is there a good sensitivity? I mean, to me, if I have someone who I'm thinking maybe it could be osteomyelitis and their CRP and ESR are both like near zero. I'm like, oh, I'm not worried at all about this patient. They can follow up with someone and they can figure it out. From an emerge perspective, do you think, from a rule out perspective, is it useful?

Speaker B I think it can be, but again, I wouldn't rely on it completely. It absolutely can be a good rule out scenario. But. Okay, let's just come up with an imaginary scenario. Let's say someone has poorly controlled diabetes and they've got a foot ulcer that's been there for three plus weeks. And you know, you're not entirely sure if you can probe to bone. Is that ESR or CRP going to change anything that you're going to do? Is that going to decide whether or not you image that foot there? I would say it's not going to change anything. I'm still going to get imaging of the foot. Regardless of what the es, the esr, CRP could be unmeasurably high or it could be zero. I'm still going to get imaging of the foot. It's not going to change any of my management strategy.

Speaker A Fair enough. Any other lab tests we need to do? There's blood cultures and swabs and things.

Speaker B Yeah, yeah, exactly. I think these are semi controversial, which I don't know why they are because again, they're cheap. And again, just like the ESR and crp, it might help. Blood cultures are rarely positive in osteomyelitis. Definitely less than 30%. Usually less than 10% of the time. They'll be positive. And if they're positive, you probably have some other issues as well, like maybe contiguous skin and soft tissue infection with some, with some bacteremia associated with it. But again, it's an inexpensive test that has the potential to help guide therapy. We know that it's rarely positive, but sometimes it is. I think it's very reasonable to do. And here's the other controversial one is swab of the actual lesion. So let's say there's an an ulcer. We get it. You know, when you swab that, this might not be totally indicative of what the organism is in the bone. You might be culturing, you know, some organism that was on the inside of that person's shoe that is now contaminating an ulcer. You might be really picking up an Organism that's on the hospital emergency department floor, and the person was just walking around barefoot. So, like, is that the culprit organism causing the osteomyelitis? Maybe, maybe not. But again, you can contextualize that information. For example, let's say it grew mrsa. Okay? You'd probably cover MRSA if it grew mrsa. Let's say it grew some funky, weird organism that no one's ever heard of. Okay? That's probably not the target organism for the osteomyelitis, and you can safely ignore it. But, like, I think as a clinician, you can contextualize that data. And I like swabbing those ulcers because sometimes it does help guide clinical management. Not always, but sometimes it does.

Speaker A All right, so crp, esr, blood cultures, wound swab, consider them all. They're not going to be total game changers. If the esr, which is better than the crp, is in the extremes, it might help you a little bit. It'll maybe shift your pretest probability a tiny bit. But it's not like a game changer. It really comes down to imaging. So let's talk about imaging. So we've got this whole menu of imaging to choose from for osteomyelitis. We've got the X ray, easy access. We're going to do an X ray on pretty much everyone. And we'll talk about X ray in a bit more in a minute. There's ultrasound, there's CT, and then there's Mr. Which in some places it's still very difficult to get an Mr. What should be our imaging approach to osteomyelitis?

Speaker B I'm a pragmatist. You get an X ray, right? And the X ray is not the most sensitive, but it's pretty specific. So, you know, if the X ray shows osteomyelitis, you got osteomyelitis and you're good to go. You can manage appropriately. The sensitivity, unfortunately, is pretty weak, and it can range anywhere from 30 to 60%, which, you know, obviously isn't. Isn't all that good, but the specificity is as high as 90%, and I think that's. That's pretty helpful.

Speaker A Great. And my understanding is that early in the course, your X ray is going to be normal and makes sense. Like it takes time for that cortical erosion to happen and the new bone formation to happen, and after the ischemia sets in and all of that. So I'm assuming, you know, the first couple of weeks, you're not going to see anything on The X ray. Like if the patient's only been sick for a week, your likelihood of seeing something on the X ray is pretty close to zero. It's more for the patients who have been sick for several weeks that you're likely to see something. Okay, so that's X ray. Let's talk about the whole middle group because we'll get to Mr. Which I'll give it away now, is the gold standard. And that's going to be what we want to go for, actually. But any role of ct. Like let's say you have, let's say the patient's been sick for 10 days, you have a normal X ray, your ESR, CRP are kind of in the middle. It doesn't really tell us. We have like a moderate pretest probability. We're not sure, maybe a low pretest probability, but we want to show that they don't have it. How useful is a CT that we can get a little bit easier than an Mr.

Speaker C In the ED?

Speaker B Yeah, I think CT is very helpful. And again, like you mentioned it, you know, if you can get an Mr. Of course get an Mr. If you work in a resource extravagant setting and you can access that in a timely manner, that's basically the gold standard imaging modality, at least from a pragmatic standpoint. It's got very high sensitivity, very high specificity. It's going to answer your question. And of course CTs right in the middle. CTs are pretty damn good. The sensitivity is like anywhere from like 65 to 85%. So that's not too bad. And the specificity is pretty high. It's up again, up to 90% specific. It's a good test.

Speaker A That's pretty good.

Speaker B Yeah. Yeah, it is.

Speaker A So I'm just trying to think from a pragmatic point of view in the emerge. You know, some places it might take days to get an mri. And so from a pragmatic point of view, if your X ray is negative, Connecticut is a great next step. If you don't have access to MRI, 100%.

Speaker B And we see this all the time. You know, I do a lot of general medicine and a lot of infectious diseases and we admit lots of people from the emergency department. And the EMERGE doc has, you know, said, you know what we're thinking about osteomyelitis, we've already got a CT scan and it's extremely helpful. Like it just sort of speeds up the decision making process. And a lot of the time we don't need an Mr. Because the CT has clinical imaging suggestive of osteomyelitis and, you know, it's appropriate clinical context. It's like, okay, that's great. I don't, I don't need an mister now. And you know, it shortens length of stay in hospital. It enables initiation of an appropriate course of therapy quicker. There's a lot of good reasons to do it. Having said that, if someone has early and easy access to mri, that's the best imaging modality, Highest sensitivity, high specificity. I'd go for that one.

Speaker A Okay, so the imaging gold standard is mri. Let's get into bugs. So what are the typical bugs? You'd mentioned MRSA before. Just quickly, what are the typical bugs? And then what antibiotics are we going to be thinking about? And then we can talk about IV versus po.

Speaker B It's staph and strep. That's basically it. It's staph and strep. And your staph can be MRSA or mssa. And you know, we know risk factors for mrsa. For example, homelessness or people are living in shelters or people who inject drugs. Like there, there's some obvious risk factors for mrsa, but there's some places and depending on where you're listening, where MRSA is just really prevalent, even in those without risk factors. So like anything else, you kind of have to know your local geography. But this is largely a gram positive infection. Yes, of course gram negatives can cause this. Yes, of course you have to consider gram negatives, especially in those who have open ulcers for prolonged periods of time. And I'm not just talking about gram negative contamination of the ulcer, but also gram negative osteomyelitis. But really, gram positive reign supreme. Sometimes we think about pseudomonas, but in all fairness, in North American settings, it's remarkably uncommon to have a Pseudomonas osteomyelitis. Yeah, of course it can happen. And of course, if it's isolated in an ulcer or in a tissue sample, for sure you're going to cover it. But in terms of empiric coverage for pseudomonas, you don't typically have empiric coverage for pseudomonas. So ultimately your empiric coverage is going to be broad, gram positive antimicrobials, and that may or may not include mrsa, depending on where you practice or the risk factors for the patient.

Speaker A You mentioned pseudomonas that it's distinctly uncommon in North America, but I remember reading an article like 15 years ago and I see a lot of emerge dogs doing this. And we see this all the Time in the emerge is the person's walking in an urban environment with their sneakers and a nail goes right through their shoe into their foot. And I read this article out of the US that said that all those patients are at risk for Pseudomonas and they should be put on ciprofloxacin. And you know, of course they could have osteomyelitis from that nail going into their foot. When do we actually need to worry about Pseudomonas?

Speaker B You know, that's a great, you know, Pseudomonas lives in warm, moist environments like sneakers. And yeah, sure, you can have direct inoculation of Pseudomonas right into your cortex, which would stink. But like, you know, there's recent Infectious Diseases Society of America guidelines on, on osteomyelitis treatment. And again, I'm a bit of a skeptic when it comes to guidelines because they're not all created equally. And you know, there's a lot of opinion based medicine thrown in there. But if you actually read these guidelines, these specific guidelines on osteomyelitis, they go through a lot of the data and they go through global data and they look at various scenarios. So sure, there are some scenarios where Pseudomonas inoculation is a factor, and that's one specific scenario where it might be a factor. But if you just zoom out and look at, for example, diabetic foot infections associated with osteomyelitis, remarkably few of them in North American settings are related to Pseudomonas. So if you have a run of the mill diabetic foot infection with osteomyelitis that you're treating, you don't actually need empiric pseudomonal coverage. However, if a swab shows up positive for Pseudomonas or there's other significant concerns for Pseudomonas, of course you can cover it empirically, but in general, it doesn't really need to be done the vast majority of the time.

Speaker A Okay, so empirically covering for Pseudomonas we don't really need to worry about, unless they do have the classic nail through.

Speaker B The shoe, or you've done a swab and you've isolated Pseudomonas in the past, or you look in their chart and you say, oh shit, this guy's had three positive swabs for Pseudomonas. Okay, you're covering for Pseudomonas then, but otherwise you don't really need empiric coverage.

Speaker A Okay, so it's really about gram positives again. Staph and strep and MRSA depending on where you are. If it's everywhere, you're gonna be covering for it empirically. So now we understand about the bugs. Then the obvious next question is, what antibiotics should we be putting these patients on empirically? And then I'll ask you about IV versus oral. And we were joking about this when we gave a talk together in Whistler about almost everything we talked about, from ticks to soft tissue infections to pneumonia was. It was like doxy was. And Isaac, you don't get paid by.

Speaker B Big doxy, big doxy pharmaceutical companies. Okay, yeah.

Speaker A No, in all seriousness, so how are you going to treat empirically? What antibiotic are you going to use?

Speaker B Yeah, again, line up 100 people. You're going to get about five or six different approaches. Things that we got to consider here. One thing that people listening might not be aware of. But in the world of ID and certainly in internal medicine, we're using oral way more than iv. And you're seeing a huge push away from intravenous towards oral antibiotics.

Speaker A That's like a game changer.

Speaker B Absolutely. And again, the bacteria don't give a rat's ass how the antibiotic makes it to them. Right. If you have a functional gastrointestinal tract and a capable arterial system that can deliver it, you're going to absorb the antibiotic and deliver the antibiotic to all over the body, including the site. So IV versus po. There's. And again, forget osteomyelitis for a second. Look at any other area of infectious diseases. There are a growing number of, of clinical trials showing that oral antimicrobials are either equivalent or even superior to IV because there's fewer complications associated with oral rather than IV PICC line complications, bacterial super infections, et cetera, clots. And you're seeing a massive pendulum shift towards oral antibiotics. Having said that, listen, there's going to be situations where, you know, maybe someone's obtunded, maybe you're concerned about, I don't know, an organism that you can't cover very well with an oral organism. Maybe they were already put on an IV when you inherited the patient. And you're going to maintain that for a day or so until you figure out what oral antibiotic to put them on. But in general, the vast majority of patients can be treated with an oral antibiotic. And, you know, you're going to want an antibiotic that's going to cover gram positives and also have decent bone penetration. You're also going to think about tolerability of the antibiotic. You're going to think about drug interactions as well, and affordability and access as well. And I know many people practice in different environments, and I'm in Canada, so it's a lot different than the United States. So the cost of the drugs is also very different here. But in general, you know, doxycycline is an excellent antibiotic. It's. Well, yeah, it's well tolerated. It covers very good gram positive coverage, including mrsa, good bone penetration. And then the other one is Septra. Sometimes people call it Bactrim or TMP smx, depending on where you are. People call it different things. But also very well tolerated, good bone penetration, very effective against staph, including mrsa. Those are like good empiric choices for antibiotics. And again, I think the other thing too is you're not going at this alone. You've got a friendly neighborhood internist or a friendly neighborhood infectious diseases doc that you can pick up the phone and ask for advice along the way. But those are very reasonable choices. Sometimes people add other antibiotics if they're worried about polymicrobial infection. But in general, doxy or Septra will be a mainstay of OM treatment. I think we crap on the fluoroquinolones too much. And I think fluoroquinolones are fantastic. And you watch, I mean, currently we're in an era of shitting on these drugs because of the risk factors for Clostridium difficile, which are real, the risk factors for tendinopathy, which are real. But like, damn, these drugs are good, right? They, they, they penetrate bone beautifully. They're generally very well tolerated. They're pretty inexpensive. There are pretty, not, not that many drug interactions associated with them. And I think, you know, ahead of the published data and ahead of the podcasts, I think you're starting to see, at least in the niche of a niche of a world that I live in, the pendulum slightly swinging back towards favoring fluoroquinolone use. And they're great for osteomyelitis as well.

Speaker A Moxifloxacin.

Speaker B Moxifloxacin, great drug. One tablet once a day, well tolerated, penetrates bone, covers staph, not so much. MRSA covers strep, covers gram negatives, covers anaerobes. Like, this is a great. These are great drugs. These are great drugs. Of course, you got to be careful about C. Diff and other complications associated with them. But I think we, we crapped on them a little too hard and now people really are shying away from them. And I think they can be used with the appropriate caveats that we discussed.

Speaker A Okay, let's talk about timing and duration of antibiotics. So I'm assuming that once you've drawn your blood cultures and done a womb swab, you're good to go start your antibiotics. But there's usually no rush because most patients with osteomyelitis, it's kind of this slow.

Speaker B Yeah, yeah, two points. And I probably should have said this like 25 minutes ago at the beginning. You know, there's lots of different types of osteomyelitis, but one of the big forks in the road is this acute or is this chronic? And if this is acute, usually less than a few weeks old, you know, antibiotics are great, and antibiotics are going to work. And the duration of antibiotics is usually about six weeks. Okay. There's decent data showing that a little shorter. Eh, you know, there's. There's recurrences. There's also decent data showing that if you treat a little bit longer, it doesn't provide, you know, meaningful protection above and beyond, you know, six weeks. But that's for acute osteomyelitis. For chronic osteomyelitis, where you have bone destruction, and here's a great word, many people might not have heard it, but in a few years, sequestra, so dead bone that's just present and harboring bacteria that can sort of hide out. And, you know, your antibiotics can't penetrate all that. And sometimes you see these, you know, sacral ulcers that, you know, you can get elbow deep and to swab, and people think, oh, I'll just treat with six weeks of antibiotics and it's going to get better. It's not. It's not. If you have chronic osteomyelitis, the treatment is steel. Okay? That is the treatment. You need surgical debridement. And these are truly interdisciplinary treatment plans. Right? You need surgical debridement to get away that, scrape away that sequestra. And of course you do. Antibiotics plays a role. But antibiotics alone in chronic osteomyelitis is usually not going to be a successful approach. Sometimes people just stay on a chronic suppressive antimicrobial therapy. And any of these are people who are followed up in infectious diseases clinics. And the goal isn't to cure the osteomyelitis, it's just to keep it at bay, to keep it from progressing, knowing full well that it's still going to be there. Another approach is basically almost like a pill in pocket approach is, you know, for, again, for whatever reasons, surgery is not an option. And, you know, they have, let's say, an osteomyelitis of the great toe associated with a diabetic foot ulcer. Okay. It's also okay to do nothing. It's also okay to sit on your hands. You're making a conscious decision to do that, and you're doing that as part of shared decision making with the patient or their care providers. But occasionally there might be a superimposed skin or soft tissue infection. Occasionally you'll see some purulence or, you know, this skin and surrounding area gets big red hot, swollen, tender, and you see some purulence. And in those cases, you provide people with a course of antibiotics that they can fill ahead of time and they can self initiate that at home to sort of tamper down any skin or soft tissue infections that can be associated with this. No, you're not treating the osteomyelitis. No, everybody knows that. That's a conscious decision based on the extenuating circumstances. But you can still help people and keep them out of emergency departments, or reduce the frequency of emergency department visits, or reduce the frequency of clinic visits by enabling them to self initiate antibiotics at home for skin and soft tissue infections. We call it PIP pill in pocket. It works beautifully and we have a lot of people that are on that.

Speaker A It's so interesting to know what happens to these patients. You know, there's some educators in emergency medicine are like, well, we just want to know what to do in the emergency department. But I think the more we understand about what happens in the clinics and the hospital, the better decisions we can make in the emergency department.

Speaker B I think you can also make that decision in the emergency department too. For example, you can have the conversation with a patient and, you know, you might say, like, this is an obvious osteomyelitis. And whatever conversation you're having with the patient, you might discover that, you know what, surgery is not an option at this point, again, based on preference or what other circumstances. And like, you can prescribe a five day course of moxifloxacin or doxycycline or a beta lactam or something like that with four refills and say, you know what, fill this. Take five days now to tamper down that skin and soft tissue infection. Your osteomyelitis is still there. It's not getting treated. We all get that. But you're not really a candidate for surgery. And if it comes back and you get a flare up a month from now, hey, you got a bunch of refills, just go fill it. Obviously if you're sick, obviously if you're unwell, obviously if you're Febrile or in a terrible downward trajectory. Our doors are always open, you can always come back in. But here's a great little tool to help empower people and give them agency and autonomy over their care and help keep them out of emergency departments and urgent care clinics.

Speaker A Amazing. We're in the home stretch here. I'm going to ask one last question, which is disposition. So which patients need to be admitted? Which patients can go home?

Speaker B In general, if it's just osteomyelitis and you've made a diagnosis of osteomyelitis, like, again, it ain't hard to treat, right, you can put them on the right antibiotic and send them to a follow up clinic. Most people probably won't have to come in. Having said that, we know from everyone listening's experience that many people come in, right? There's disposition, there's logistics. It's rarely just an osteomyelitis, right? You know, someone needs better management of their diabetes. Someone has extraordinarily high glucose and they might have, you know, ketones. Like, there's a lot of reasons why people with osteomyelitis above and beyond the osteomyelitis itself are being admitted to hospital, either diabetes concerns or vascular concerns. You know, social and disposition concerns as well. But in general, you can make a diagnosis of osteomyelitis in the emergency department if it's as simple as that. You can put someone on an appropriate choice and duration of an oral antibiotic and you can send them to a follow up clinic. That can happen, you know, if people are septic or there's a superimposed skin and soft tissue infection where there's, you know, hemodynamic instability. Like these are obvious reasons why people would have to come into hospital.

Speaker A Fantastic. Thanks so much, Isaac. Dr. Bogosh, that was an amazing conversation. I can't believe this is actually the first time we've had you on the podcast. I really hope we can have you on the podcast many times again.

Speaker B Happy to chat anytime, Anton.

Speaker A And now a word from one of our sponsors, Echo Health. If you've ever guessed what you heard through a stethoscope, you're not alone. Detecting a new aortic regurgit murmur to help you pick up that acute aortic dissection with a regular stethoscope can be really hard in the noisy ed environment. Thank goodness for Echo Health. Echo combines a stethoscope you already know with enhanced audio and advanced AI to help you detect heart and lung conditions earlier and with more confidence. Echo's digital stethoscope amplifies heart and lung sounds up to 40 times and noise cancellation cuts out distractions. Unlock murmur and AFIB detection powered by Echo AI along with sound recording sharing and more for earlier diagnoses and seamless collaboration backed by 4 million heart sounds and eight FDA clearances for devices and AI algorithms, those who use Echo are two times more likely to detect heart disease. If you want to give your patients the highest quality care, I encourage you to join 600,000 healthcare professionals already using Echo. I trust Echo so much that I work with their team to create a special offer just for our listeners. Right now you can get $50 off plus a free customizable chest piece cover@echohealth.com emc. Your purchase is HSA and FSA eligible and may qualify for CME reimbursement. Plus, Echo guarantees you'll detect heart and lung conditions more confidently if you don't return it for a full refund. Go to echohealth.com emc for $50 off plus a free chess piece cover. That's ekohealth.com emc all right, we talked about prolonged tourniquet use with Dave Jerome in Quick hits episode number 62. This time Swami is going to talk about the indications for tourniquets and some practical tips on how to use them best.

Speaker D Tourniquets are life and limb saving devices. There are a few things as simple as placing a tourniquet that can do so much good for the patient. We have to be really adept at putting these on and it seems kind of intuitive, seems like it shouldn't be that difficult. But if you're not familiar with your device and you don't have a couple of tips in your head, you can do this wrong. So I just wanna review a couple of tips in tourniquet placement that I think are critically important and to use these devices to their best benefit. Number one is the optimal location of placing that tourniquet. If you know where the bleed is coming from, you want to put the tourniquet 2 to 3 inches above that area. That's about 5 to 6 centimeters for everybody on the metric system. And remember that when you place these, you don't want to place them over a joint that is going to harm your ability to provide compression. If you don't know where the exact source of bleeding is, and this happens all the time, both in the pre hospital setting and as well as in the emergency department, then place that tourniquet as high on the limb as you possibly can. That is the Best bet to controlling that bleed. Once you localize the bleed, you can always move that tourniquet or place a second tourniquet and then remove the first one. Tip number two is about tightening the tourniquet. Most of us work in places with windlass type devices. When you place that tourniquet, you don't want to be turning that windlass nine or ten times. You want to use the Velcro strap to tighten down that tourniquet as much as possible. And then you're going to turn the windlass maybe one or two times to complete that tightening. And you're going to do that until arterial bleeding stops. We often see people who put these on kind of loosely turn the windlass a bunch of times. You're never going to get proper compression. So tighten that velcro down first and then turn your windlass one to two times to provide that additional tightening. As soon as you have that tourniquet in place, make sure to note the exact time that it was put on. You want to know how long the patient has been without arterial flow and distal to that tourniquet. That's going to help to advise people on when to take that tourniquet down and allow some flow back to that limb so you don't have limb loss. Finally, and this is probably the most important tip with tourniquets should have let off with this, is that you have to place the tourniquet in order for it to be useful. For a long time we thought that tourniquets were going to lead to limb loss. We now know that's not true. So put the tourniquet on as soon as you see that arterial bleeding to get full control of the bleeding and stem the tide of hemorrhagic shock. All right, let's wrap this up. Place the tourniquet when you see arterial bleeding to get control of that hemorrhage, you want to place it 2 to 3 inches or about 5 to 6 centimeters above the exact source of bleeding. If you know where that exact source of bleeding is. If not, place it as high on the limb as possible. And when you're tightening it, tighten the Velcro strap first and then turn the windlass after you've tightened that Velcro strap. That's the best way to get control of bleeding.

Speaker C Hi, it's Andy Tagg here from don't forget the Bubbles. And I want to go through with a somewhat familiar case with you. A seven year old boy called Luke is brought into the emergency department. After falling, he's tripped, landed awkwardly on his outstrenched hand and is now cradling his wrist. There's no deformity, just a little bit of swelling over the distal radius. You get an X ray and there it is, a subtle cortical bulge. A classic buccal fracture. You pause hand on the plaster trolley, because that's what we've always done. But maybe this time you're going to remember the Force trial. A study from a galaxy not so far away, just the UK reminding us that sometimes less really is more. So let's take a step back. A buccal fracture is a compressive injury. It's not a breakthrough of the bone, it's a crumpling of the cortex. Think about that accordion section of a bendy straw. Push hard from both ends and it doesn't snap, it just concertinas. And that's what happens to a child's distal radius when they fall on an outstretched hand. The bone compresses and deforms, but the periosteum stays intact. These fractures are inherently stable, they have a negligible risk of displacement and almost always heal well with minimal intervention. And here's something surprising. Buccal fractures are probably the most common pediatric fracture we see in the emergency department and probably the most over treated as well. Historically we've treated these with a rigid back slab or a full cast orthoclinic follow up often repeat imaging. It felt safe, it felt responsible. But what if that wasn't actually necessary? What if the act of immobilising and following up was actually the thing adding cost, stress and risk? So let's take a look at the force trial, what it asked and what it found. The Force trial published in the Lancet was a pragmatic multi centre RCT run across 23 UK hospitals. It enrolled over 950 children aged 4 to 15 years old with distal radius buccal fractures. And it asked one simple is a soft bandage combined with a vice just as good as rigid immobilization? The primary outcome they looked at was pain at three days and secondary outcomes included functional recovery, complications, school days missed and parental satisfaction. What they found was pain, no significant difference, function actually better in the soft bandage group, satisfaction higher in that bandage group and complications and representations fewer in those that had the more conservative treatment. And all this without casts, without orthopaedic follow up, without repeat X rays. So the force trial is a compelling, well designed, pragmatic and practice changing trial. But like any study, it has its limits. For one diagnosis was based on the rolling clinician's interpretation of the x rays. That introduces real world variability, which is both a strength and a potential source of bias. It reflects everyday ED practice and yes, sometimes it means misclassification is possible. Second, follow up was pretty short. Pain and function were measured at three days, seven days, six weeks. And that's great for short term reassurance, but doesn't answer questions about rare later complications or how long children stayed off sport or full activities. And most importantly, children and parents weren't blinded. Understandably. Really, but still, if you know you're in a minimalist group, it may influence how you rate satisfaction or how much discomfort you report. So no, this trial doesn't mean we abandon caution, but it does mean we can be more deliberate in how we treat these stable injuries. It's an invitation to think, not to shortcut. Forced trial isn't really just about wrist injuries, though. It's about letting go of reflexive care and trusting the evidence. What we don't do matters just as much as what we do do. And here's another angle. Ortho follow up rarely changes management and buccal fractures, but it fills clinic spots, reinforces dependence on specialist review, and teaches families that escalation is the norm even when it's not needed. Minimalist care isn't lazy. It's intentional, thoughtful, and easier for everyone the child, the family, the system. This model saves money, reduces ED length of stay, frees up orthoclinics, and limits low value imaging. 1 Small decision scales across thousands of presentations a year, and that adds up. Of course, nuance matters. This approach applies to a very specific cohort of patients, those with true torus fractures of the distal radius. There's no angulation, no cortical breach. They're extra fascile and away from the growth plate. It requires confidence in pediatric X ray interpretation and a willingness to document your rationale clearly. And a safety net for rare but possible diagnostic misses. Remember, buccal fractures often show up only on one view, usually the lateral. So if you don't see it on the ap, go back and check again. And yes, many clinicians still use a Velcro splint, but not because it's better, because it helps families feel more secure. And that's okay too. Parents may come in expecting a plaster cast when they're told their child has got a break in the bone. And when they don't get it, they may feel like the injury isn't being taken seriously. So your words do matter. Try something like this. This is a stable bend in the bone Not a breakthrough. There's nothing to push back into place and nothing can shift. We know from large studies that kids actually do better when we don't over treat this type of injury. We're treating it with comfort and time, not plaster and appointments. And perhaps my favourite explanation, I tell parents it's like a dent in a pool noodle. Safe, springy and ready to bounce back. But don't forget that minimal care still includes pain care. Because minimalist care doesn't mean doing nothing. It means doing the right amount. Offered with confidence, explained with care and backed by evidence. The Force trial asks us to loosen our grip not just on the wrist, but on our assumptions. It shows that the absence of intervention can be powerful when it's evidence based and intentional. So the next time you see a buccal fracture, don't be tempted by the dark side. Use the light side of the force and do as little as possible.

Speaker A Thanks so much Andrew. Next up is Justin Morgenstern and he's going to give us his take on delayed sequence intubation, riffing off of the only DSI RCT from May 2023. And now a word from one of our sponsors, EasyResus, the resuscitation assistant. Easy Recess is thrilled to announce that they are now available for Institutional access. In addition to providing the app for all employees in your organization, this means access to exclusive features like printable protocols with calculated medication doses, customizable content to fit your local protocols and practices, access to Easy Recess on computers via the web based version, and much much more. To learn more, visit the institutional license section@easyreSS.com and as always you can download Easy Recess and use the promo code EM cases, that's emcase1word to get your 2month free trial on an individual subscription.

Speaker E Delayed sequence intubation. I mean it comes from Scott Weingart, so you would probably have to be living under a rock to not have heard of it by now. But just in case so we're all on the same page, DSI is essentially procedural sedation for the procedure of preoxygenation. It was designed for agitated patients who were not allowing you to pre oxygenate them. The people who are pulling off their oxygen masks panicking because of their 70% O2 sat. You give small doses of ketamine until they're calm and then you can preoxygenate them. That can be with a BVM, with a non rebreather, BiPAP, whatever you think is needed at that point and then only when you're comfortable that everything is ready for intubation. Do you proceed with paralysis and passing the tube? And this has become wildly popular, partly because Weingart is a celebrity, but also because you only really need to use it once to realize how incredibly effective it is. You take these patients who are wildly agitated, who you could never get their sats up, who, at least when I trained you, just tried to tube them as fast as possible while their sats were plummeting. And all of a sudden you have this chill patient and you can take your time, you can position them, you can prepare your equipment, and then you can proceed with that very reassuring oxygen saturation of 100%. Like, I'm a huge EBM guy. We're not supposed to tell you about antidotes, but man, do I have dozens of antidotes where this completely changed a resuscitation. But evidence based medicine, we had the first RCT of delayed sequenced intubation. Now, let's just say from the outside, this is not a perfect study. It's small, it's single centered, it's unblinded. But it is our first study of a technique that a lot of people are already using. So I think this is an important study. The study looked at all adult trauma patients presenting who required intubation and they just compared DSI to rsi. Direct laryngoscopy was used in both groups. The intubation was done by a second year anesthesia resident. In both groups and across all outcomes, DSI was clearly better. Their primary outcome was peri intubation hypoxia and it was Significantly lower with DSI. It was 8% versus 25%. First pass success was higher, 83% versus 69%. Really, everything looks better with DSI. Now, there are a number of reasons that you can critique this trial. I don't think that their outcome was perfect. I'm not sure why they defined hypoxia as 92% rather than 90%. I don't think that they adequately preoxygenated in this trial. And again, it's an unblinded single center trial. But I think the most interesting critique of this paper is that they used DSI on the wrong patients. DSI was designed for agitated patients. Here they used it on all comers. But most patients don't need dsi. Most patients preoxygenate just fine without ketamine. So if anything, they included a bunch of patients that didn't seem to need dsi, which would seem to bias against dsi. Perhaps the numbers look Even better if you just focus on the agitated patients. So what do you do with this paper? This puts us in one of the most interesting spots, scientifically speaking. You have to base your practice on the best available evidence. And this is the only rct. And it suggests a big benefit from DSI in all comers. But if you've ever listened to me before, you know that we have a false positive problem in medical research. We use a ridiculously lack P value as compared to other areas of science, and we consistently underestimate the effects of bias. So time and time again, we see the same pattern. We see positive results in small trials just like this one that are completely overturned when we have better, larger, designed trials. In general, I advised against changing practice based on just one study of this quality. What makes DSI interesting? And the question that Scott asks is, what's the real harm here? Let's imagine you build in a pause, and that pause can be any length that you like. So you push your ketamine and you just take five seconds to ask, is everything set up exactly how I want for this intubation? And if it is, you proceed. And so the result looks essentially indistinguishable from rsi. But if something is wrong, if the sats are too low, if the patient isn't positioned properly, then you fix that problem before pushing the paralytic, and that's dsi. Now, my concern about making this routine is that we can get a little loose with the what's the harm argument. It would only take a few bad laryngospasms or a case where you lose the IV during that delay period, or something else that I can't predict right now. So I don't think that this should become routine at this point. I think we want to see the bigger, the higher quality studies. Whether or not you think this should be routine. I do think this is a technique that everybody needs to know. At this point in emergency medicine, you will definitely encounter patients who are too agitated for proper preoxygenation. And because of that agitation, you can't position them properly. And if you're like most eds that still lay out your airway equipment across the patient's chest, well, then your equipment's a mess, too. In those patients, you barely need an RCT Ketamine to take control of that situation just makes everything dramatically safer. Just make sure that you're prepared to take the airway right away in case the patient deteriorates. Again, I think this is a really interesting topic. I'd love to hear Your thoughts and arguments in the comments section. Take care.

Speaker A Thanks so much Justin. Always great insights into controversial topics and DSI is no exception. Next up, we have Brit Long for his second quick hit on end stage renal disease and dialysis. In part one on Quick Hits, number 67, he talked about the scope of the problem, the history taking checklist, physical exam essentials, and in this part two, he guides us through the differential diagnosis of the dialysis patient who comes in altered.

Speaker F Your next patient is a 63 year old male brought in by EMS for altered mental status from dialysis. His serum glucose is normal and on your initial assessment he's stable. There's no focal neurologic deficits and there's a bandage over his AV fistula on the left upper extremity. Changes in mental status are common in patients with end stage renal disease on dialysis and there's a wide differential here. Much of what we do isn't really any different than any other patient with altered mental status, but we do have to think about several other more specific issues. I like to divide the differential into structural versus metabolic conditions. History and exam are essential here. You need to look for focal deficits, any trauma, but one of the key tests is to check a serum glucose. Many patients with ESRD have diabetes and they're on insulin. If they're hypoglycemic, that's an easy fix. There are many other electrolyte issues that can cause altered mental status. Hypocalcemia, hyperkalemia. So make sure you send an extended electrolyte panel and get an ecg. Uremic encephalopathy is another metabolic issue. It's due to a buildup of toxins and an imbalance of neurotransmitters. The more severe the renal failure, the greater the risk of encephalopathy. We're most commonly going to see this in patients who miss dialysis and older patients tend to have more severe changes in mental status. Early on. Patients will have mood changes and irritability, some diffuse weakness, tremor and asterixis, but these will worsen as the encephalopathy progresses. Patients with severe disease will present with lethargy, hallucinations, seizures, paralysis, even coma. Treatment is going to be dialysis, but their mental status usually won't improve for a couple days even after being dialyzed. These patients can present with focal deficits and with that change in mental status, a head CT is definitely needed. Now I mentioned head ct. This is absolutely essential in these patients because they also have a high risk of Subdural hematoma, other bleeds and stroke. Subdural hematoma occurs 10 to 20 times more frequently in these patients because the bridging veins may rupture and there's also uremic platelet dysfunction and anticoagulation that you need to think about. A subdural hematoma might present with vocal deficit if it's unilateral, but it's usually a change in mental status. Also headache and nausea with vomiting. Once you've obtained the head CT and made the diagnosis, consult your neurosurgeon. These patients might need airway intervention, and if they're anticoagulated, reversal will be necessary. If you're concerned about increased icp, raise the head of the bed and administer hyperosmolar therapy, something like hypertonic saline. ESRD is also a major risk factor for ischemic stroke. Treat these patients the same as any other patient with suspected stroke. ESRD itself is not a contraindication to thrombolytics. Another metabolic cause of altered mental status is infection and sepsis. Patients with end stage renal disease are immunocompromised, and sepsis always has to be a consideration. Do a focused neurologic exam, but you need to look for a source of infection. Look at their feet, the back and the perineum. Get cultures and if you find a source, administer broad spectrum antibiotics. One cause of altered mental status that we learn about for boards is dialysis dysequilibrium syndrome. This is only seen in patients on hemodialysis, and overall it's pretty rare. This is more common in patients who are just starting dialysis. It usually presents with headache, vision changes, restlessness, nausea and vomiting. But in more severe cases, patients can have changes in mental status and seizures. Mild cases will improve with a reduction in the flow rate of the hemodialysis, and they're typically back to normal within an hour or two. If it's more of a severe presentation, dialysis needs to be stopped. And in the ed, if they're still altered, you can give them hypertonic saline. The other classic association is dialysis dementia. This is much less common with today's dialysis machines. If this occurs, it's going to be in a patient who has been on dialysis for at least two years, and it presents with progressive encephalopathy and dyspraxia with seizures. The next cause that we have to talk about is a toxidrome or a medication effect. Over half of our available medications are cleared through the kidneys. That means that patients with ESRD have an increased risk of drug induced neurologic disorders that can be because of adverse interactions with other medications. The Wrong Dose Many different reasons here. Several drugs that we commonly use in the ED have to be adjusted for these patients. First are antibiotics like penicillins, cephalosporins, fluoroquinolones and carbapenems. You also have to think about metoclopramide, nitrofurantoin, benzos, even opioids. And if you are going to give an opioid, fentanyl is probably the safest option compared to something like hydromorphone or morphine. Reduce the dose by 75% of your standard dosing. You can always administer more. If you're sending the patient home and they need an opioid, don't use tramadol. You also need to avoid NSAIDs and other things like trimethoprim sulfamethoxazole. They increase the risk of hyperkalemia. The final aspect about mental status is whether this occurred during the hemodialysis session. If it did, keep in mind that these patients are not usually monitored during the actual session. Check an ECG for atrial fibrillation or some other arrhythmia. If they're still altered after dialysis in the ed, you need to think about hypoglycemia and other electrolyte abnormalities, head bleed, stroke, also sepsis. In summary, there's a wide differential for altered mental status in the patient with esrd. You can divide it into structural versus metabolic conditions. Keep in mind the risk of subdural stroke, sepsis, uremic encephalopathy, electrolyte changes, and of course, hypoglycemia. Check a serum glucose, do a focused neurologic examination, look for a source of sepsis and get that head ct. Let's.

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Speaker G Thank you very much for being with us today. My name is Dr. Victoria Myers and I'm an emergency physician and trauma team leader at St. Michael's Hospital. And I am working on a series about EM leaders in Canada focusing on some of our fabulous female physician leaders across the country and across the continent. It's a pleasure today to talk to Dr. Lisa Thurgor who's going to talk to us about her journey in physician leadership. She is an emergency physician and medical toxicologist and has expertise that has led to some work with the cmpa. She is also the former program director of the University of Ottawa Emergency Medicine Residency Program. During her tenure, she won numerous awards for her resident advocacy work. And I actually know her from when I completed my medical school training in Ottawa when I was a wee medical student. And there I experienced the massive respect that the residents and faculty alike had for her leadership and her commitment to residency education. So, Dr. Thurgood, thank you so much for joining us and it's an honor to be with you.

Speaker H Thank you for the invitation, Victoria. I actually have fond, fond, fond memories of working with you as a medical student. And there's, there's actually nothing I love more than seeing the trajectory of people's careers as they progress through life. And so I absolutely love that our paths have crossed again. So thank you.

Speaker G I remember very distinctly actually being on shift with a different staff and we were taking handover from you and the emergency department was buzzing. It was a really hectic afternoon and there was an epistaxis in one corner and a ROSC that you had just achieved in another corner. And your comment during our handover was it's a great day to be an emergency physician and as a third year medical student having like a semblance of an idea of what was going on, but certainly not full grasp. I just loved your end of shift enthusiasm after what was probably a super hectic shift.

Speaker H That is amazing. That just gave me goosebumps thinking about it because that is the perfect day in emergency emergency medicine and I love that you remember that.

Speaker G So to start, I'd love to hear a bit about your journey as an emergency physician and your journey into leadership and how it sort of started and then where it evolved to.

Speaker H Yeah, so I mean, I think what has drawn me to leadership roles is essentially my desire to, to bring people together to make connections. I'm truly an extrovert inside and out. I am 1000% an extrovert and I love people and I have a genuine desire to cultivate connections and to communicate, to share ideas, to foster other relationships. So when I think about why I entered into leadership roles, I think that that is probably the main factor. I think that that's the common denominator. I would say that thoughts of my leadership journey probably started while I was in residency. And you could probably say that's early in my medical career because I was in residency. But that was because I loved my residency. I loved everything about my residency. I loved emergency medicine. I loved academic day. I loved my co residents. I will say that I respected and admired my program director at the time. And I'm sure that it was because of all of this that I wanted to give back to the specialty. I knew then that I wanted to be involved with. With EM education, and I knew that I wanted to be a PD one day. So you could say that that positive experience and along with the many mentors that I had led me to my role as a program director. And I mean, I was fortunate to have so many mentors in a ton of different areas. They always raised me up. They always tapped me on the shoulder when they thought I should go for something. They filled me with confidence. I was very fortunate. They gave me honest feedback. I'll just add that, you know, did I become a leader to become a leader? No, absolutely not. I became a leader because I wanted to give back to emergency medicine, to academic emergency medicine. And so the opportunity to become assistant program director at the University of Ottawa with two amazing other people at the time, the program director and the other assistant, that opportunity came up. And then I was fortunate enough five years later to have the opportunity to be the program director for another five years.

Speaker G And I think it really says something when you talk about how much you loved residency, because although I think we hope that this is the experience of every medical resident learner, it certainly isn't. People have varied experiences in residency and approach medical education and the idea of being a learner differently. But the love that you had for the experience you had sounds inspiring to try and create that experience for other people, to try and find sort of like individual things for each of the residents that you'd eventually lead that would allow them to love their experience too.

Speaker H Yeah, it's a good point. I hope it's inspiring. At the same time, you have to realize, as you said, it's not for everybody. You know, everyone feels it and sees it in different ways. But you're absolutely right.

Speaker G How did you approach your time as program director? You'd been assistant program director for a while. And then stepped into the role of program director. Did you approach it with a specific idea or ethos or how did that evolve for you?

Speaker H That is a great question, because I actually really struggled with this in the beginning. I followed in the footsteps of an amazing program director. So the program director before me, he was incredible. I would have also loved him as a program director. And when I started, when I took on the new role as pd, I wanted to be like him. I felt the resonance, and the staff wanted me to be like him because things were working. It was an amazing program. And so I was actually trying to copy his leadership style, for lack of a better phrase. And then after about six months, I sort of realized that I wasn't being my authentic self. I had to remind myself that I, too, have great ideas, that I could connect with residents in my own way, that I could develop curriculum in line with. With my educational beliefs. All the things. Right. And I. I quickly realized that what I was doing worked, that my style worked most of the time. Not all the time, but, you know, I realized that I was carving out my own leadership style and that the residents and the faculty were responding positively to it. So I wasn't messing it up yet. But it took a bit of time for me to realize that. I think that we often think we have big boots to fill when we walk into leadership roles, and we feel the pressure to be like the other leader if they were, you know, a success. But we have to remind ourselves that we were chosen for a reason. And. And many of those reasons are unique to us. They're unique to the individual. So, you know, we can't be afraid to do things our way. And I. I actually often give this advice to people who've asked my opinion when entering a new role, because I. I remember it vividly.

Speaker G And I suppose this is the reason why leadership positions have turnover, too. Intentional turnover. There's terms because we want new people, new ideas, fresh leadership leadership styles to fill the role. But I think it's a good reminder for everyone that even when you're filling or following a respected leader that you respect and admire, you can take maybe tips or traits from them. But ultimately, you have to forge your own path with your own style.

Speaker H Yeah, so true. Take the tips, but remember that you were chosen for a reason, for this role.

Speaker G Totally. What were some unexpected challenges you faced while being program director?

Speaker H I mean, besides realizing that? I ended up thinking about the residents continuously. I thought about them, you know, in the evenings. I thought about them on the weekends, outside of academic days. On vacation, all the things they, they sort of became part of my life. And you know, as a pd, you become invested in their happiness and their success. So. So it's a normal thing. I was thinking about their success constantly that that's not necessarily a challenge, but it is something that I didn't realize would happen until I did take on the role. So that was something unexpected. But in terms of a challenge per se, I would say that I didn't anticipate as many conflicting priorities between all the things in a residency program, right? The functioning emergency department, the residency program, other parts of the resident's life. So all of the things at the hospital, at the university, all kinds of conflicting priorities, which I didn't really appreciate until I took on the role, that was a challenge. I just sort of assumed that everybody's priorities would line up, but they don't always. The needs of an ac, you know, of a resident academically, aren't always the same as the needs of an emergency department, which aren't always the same as the needs of a post grad program. So essentially I had to learn to advocate for them within these constraints, which is doable, but it just takes a different skill set and it was a challenge.

Speaker G And sort of speaking similarly to this, I'm curious about how you approached a balance of supporting residents while also holding them to educational and professional standards when maybe they weren't meeting them or struggling academically. This sort of balance of helping a resident who may need extra support academically while still holding their respect and having a relationship with them aside from that.

Speaker H I mean, that's every program director's struggle for sure, but it is so important to think about that's probably the number one priority. These, these two roles are essentially the job of a program director. And, and the PD has to do both of them well. They have to support the resident as well as hold them to academic and professional standards. So as a preface to this question, Victoria, it really does need to be acknowledged that there is a tension between the world of patient care and the medical training system that really has not adapted well over many decades, as well as the recognition that that work, life balance and well being are very, very important. And unfortunately, many lapses in professionalism or academic standing are a result of this tension. So the first step, I think in my mind was always to realize that often the reason that a resident isn't or wasn't meeting the educational or the professional standards was because of something that resolved, required support. Right? There was usually an underlying issue that required support or advocacy. So that was sort of the biggest piece was just remembering that these. These lapses in. In professionalism or academic standing are happening on purpose. There's usually an underlying reason. The other piece of it is transparency. Right. There has to. To be open dialogue, there has to be mutual trust between the resident and the program director. There has to be continuous constructive feedback and coaching. That happens. And the bottom line is, is that we just need to be building a culture of. Of mutual respect for this to happen. And that is sort of how I approach. Approached the balance of supporting residents, but also being there to make sure they're meeting the standards.

Speaker G I think that makes sense, and I'll just summarize for our listeners. So it sounds like the first step is always to have a mutually respected relationship between the staff and the PD and the resident. And often the reason for not meeting medical and professional standards is because there's some underlying issue that the program can sometimes really help support residents. And the second, and I think really important in our medical education culture today is to be transparent and honest and to have feedback and dialogue flow back and forth about expectations about sort of the. The standards that we expect, and also to give feedback and coaching and to help residents sort of achieve their higher goals, which helps bridge this sort of. That. What can sometimes be a tension, I think, between supporting residents, but also holding them to a standard educationally and professionally to help them be the best emergency physicians they can be. And then I think for our final question, I'm curious about what you think about the medical education landscape right now and whether it's changing and advice you might have for the next generation of program directors.

Speaker H I think absolutely, it's changing, Victoria. We can't ignore so many things. Like the first thing that pops to mind is the development of AI technology. Right. Both for clinical care, but also for education. That's an obvious one. It deserves its own podcast, probably, for sure. The medical education landscape is. It's becoming more resident focused, which is a good thing. Right. We're tailoring programs and curriculums to individual needs of residents, which is incredible. But it does mean that residency education has a different face and everyone needs to be on board with this, including PDs, including staff physicians, including hospital leads. So that's. That's a bit of a change. We. We've realized that one size doesn't fit all, and. And that's probably a good thing. But. But in that sense, yes, the landscape is changing.

Speaker A Yeah.

Speaker G There's new technology, new ways that we're going to educate and Also new ways which we're going to individualize our programs, which I'm sure will go through some growing pains as we figure out how to properly individualize programs and how to individually train the best emergency physicians as we sort of take on this new road.

Speaker H Absolutely right.

Speaker G All right. That is sort of all the questions I have for you. We've been able to sort of talk about your journey into being program director, different challenges you face, how you sort of balanced building incredible mutual respect with the residents and also training and holding residents to exceptionally high standards, which is excellent. And then also how the medical education landscape is changing and how residency and education is changing. So thank you so much, Dr. Thurgor, for being with us today. Do you have any final thoughts or final words and otherwise we can wrap up?

Speaker H My biggest takeaways are that there are leadership positions out there, so look for them. If you don't happen to find them, they will find you. So don't be afraid to say yes. Also lead with your own style, so don't feel you have to repeat or mirror your predecessor's style. Remember, you were chosen for a reason. And if you are a pd, remember your biggest job is to be an advocate for your residents. And those are my takeaways.

Speaker G Wonderful. Thank you so much, Dr. Thurgor.

Speaker H Thanks so much for having me. Victoria.

Speaker A Thanks so much Dr. Thurgor and Dr. Myers, some great food for thought about leadership for trainees in em especially. Now there was quite a bit mentioned about coaching feedback and AI. Which reminds me that EM Cases is currently planning on releasing its first custom designed coaching app in the new year, which I'm really, really excited about. So EM Cases was founded on the learning principle of spaced repetition multimodal learning with its podcast show notes, videos, quizzes and push emails. And the idea is that you can listen to a podcast and then read the show notes a few days later, maybe watch a video of a quick hit, let's say maybe do a quiz and then the just for nuggets emails and the Q and A pearls of the week. You get the push emails and with the speed based repetition and then seeing some cases in the emergency department, that knowledge will just sink in and stay there that you can use on your next shift. So what we're planning with the app is you can sign up for the EM Cases coaching app, you can input your knowledge gaps or you can say that you just want to learn everything in emergency medicine. Then you put your schedule in there with specific times set aside for learning and the app generates a personalized learning program for you. Then once you take in the podcast, summaries, videos, quizzes, etc. AI can give you feedback to help guide your learning further. So if you're starting your EM residency for example, you can map out your learning through the entire residency and EM cases will feed you the material, give you the reminders and feedback all along the way. And if you're a staff emergency physician you can simply input which areas you want to brush up on and the app will serve them up in one convenient place and coach you along the way as well. It's like my dream come true for the ultimate in learning tools. I'm really psyched for this. I'll be making more announcement closer to the release date but I thought I'd just whet your appetite now. Thank you so much to our Quick Hit thank you so much to our Quick Hit contributors Justin, Anand, Britt, Andrew, Victoria and Lisa. Until next time, take it easy.

EM Quick Hits 68 Osteomyelitis, Tourniquet Technique, Pediatric Distal Radius Buckle Fractures, DSI RCT, AMS in ESRD &#038; Dialysis, EM Leadership Spotlight #3

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EM Quick Hits 68 Osteomyelitis, Tourniquet Technique, Pediatric Distal Radius Buckle Fractures, DSI RCT, AMS in ESRD & Dialysis, EM Leadership Spotlight #3