Favorite Peter Rosen quote: "Nobody woke up this AM and decided to ruin your day. Don't get angry at your patients. Don't get frustrated. Happiness is YOUR choice."
RIP Dr. Rosen, the father of EM.
Study hard, & you will know 50% of what you need to know in emergency medicine by the end of intern year; 75% by the end of 2nd year; & 90% by the end of residency. You will spend the rest of your career trying to learn the last 10%. Never stop studying hard!
@UMEmergencyMed
Take note: pub'd online Oct 11 2022, ACC now is formally endorsing deWinter T waves, as well as modified Sgarbossa criteria for LBBB + pacemakers as "STEMI equivalents" and need for immediate angiography. At last!
#foamed
Here's a chart worth remembering...authors looked at NEW ECG findings in PE (segmental up to saddle). Nice demonstration of the MYTH of sinus tach and S1Q3T3 in PE. Note-24% of patients had no new changes on the ECG
@EM_RESUS
Classic.
But
anyone have better data on utility of S1Q3T3 in PE diagnosis? (these are small n)
⬅️ no diff in the likelihood of PE vs not in those whom PE was suspected
⬅️ no difference in likelihood of massive vs non-massive PE
The biggest reason we MISS a diagnosis is because we MAKE a diagnosis. i.e. the diagnosis of a benign condition does not rule out the presence of a deadly condition. Always rule out the worst diagnoses first.
@UMEmergencyMed
#EMConf
#FOAMed
A 79-year-old male is brought into the ED by EMS with palpitations and lightheadedness while doing light yardwork. The following prehospital ECG was obtained. How would you manage this rhythm?
When bystanders witness cardiac arrest, they are LESS likely to initiate CPR vs UNwitnessed arrest! because during first 1-2 min, CA pts have agonal respirations & so laypeople assume pt still has pulse (Brinkoff, Resus 2018); we need to do more to educate the public
#FOAMed
Best pearl the residents taught me last night: Staph aureus UTI is due to endocarditis (bacteremia) until proven otherwise. Huh? I must have slept through that lecture! Thanks to residents Hannah Goldberg and Sarah Mahonski
@UMEmergencyMed
Yet another STEMI with a "normal" computer read. 100% D2 occlusion. "Normal" triage computer interpretations cannot be used to eliminate immediate ECG review by physicians!
The triage ECG does not need immediate physician review if the machine calls it normal....RIGHT??? 😱 Cath showed 100% LAD. This life saved because Dr. Arjun J.V. doesn't rely on machine interpretations!
#FOAMed
@UMEmergencyMed
@UMEMresidency
All lectures should be thought of as acts of persuasion, not simply conveyance of information. Raw information can be obtained from books. Your job is to tell the audience what’s important, tell them why, and CONVINCE them to DO something different with that information.
And by the way...why would you say "lowly paramedic"?? You all seriously are the heroes of acute care. I do EM because EMS would be too difficult!!
Seriously, thanks for all you folks do. You deserve far more credit.
Even as a lowly paramedic, I love
@amalmattu
Whiteboard teaching notes. Everyone involved in EM, be that in-hospital or prehospital should check them out.
#FOAMed
#Foamems
#IrishEMS
A med student I met this past week had never heard of Encyclopedia Britannica. 😱 I think I leaked some TN. Told him that when I was growing up, the internet was called "books" and Google was called "a library." Maybe time to retire soon...thankful the ECG hasn't changed much.
Kudos to ESC for finally incorporating ECG criteria for LBBB, pacers, and aVR into STEMI-cath criteria; hopefully AHA/ACC will follow; also finally got rid of "new LBBB = cath;" see attached
#FOAMed
@UMEmergencyMed
In reality ALL of my ECG lectures can be distilled down to 2 takehome points: (1) You don't need to be a cardiologist to be GREAT at reading ECGs, (2) no matter how good you are, if you improve your ECG skills, you'll save more lives! Isn't that why we are in EM?
#foamed
Is it just me or does every talk given by
@amalmattu
make you freak out about every EKG you have ever looked at prior to his talk!! Great information at
#EEM2018
. Look for new upright T waves in V1. May be herald sign for LAD disease.
@EssentialsofEM
Which vessel? --> pulmonary artery! This was a massive PE. Tough case, but 2 takehome pearls: (1) PE can produce STE, esp. V1, aVR, and III (right side leads), and (2) it is very uncommon for STEMIs/OMIs to produce new right axis; STE + new RAD=PE until proven otherwise
#FOAMed
Heartfelt condolences to the EM community of Chicago on the loss of one of their emergency physicians as well as a pharmacist and police officer this afternoon to gun violence in ED shooting.
Quick correction about the drawing: the T-wave has to be taller than the ENTIRE QRS complex, not just the R-wave; so I would actually not be worried about the T-wave in the drawing; if you can fit the ENTIRE QRS under the T-wave, that's when you worry about ischemia (or hyperK)
That's such an important point: NTG gtt in cardiogenic pulmonary edema shouldn't be focused on BP control. It's used for acute preload and afterload reduction. We should stop focusing on BP. Follow the patient's clinical status, and run that NTG up to 400mcg/min if possible
Saw this in grocery store, was the Hershey's Kisses cereal that caught my eye; is there any doubt why we are seeing younger and younger patients w/ acute atherosclerotic (heart & brain) disease than ever before? Will continue to get worse. What's the youngest STEMI you've seen?
HyperK until proven otherwise. Massive PE can also produce large S in Lead I + STE in V1-2 & aVR (with CP) but Ts look too peaked and QRS too wide. This is a bizarre. “Bizarre” in emergency med = HyperK until proven otherwise.
Full set of lectures from our Univ of Maryland Emerg Med Cardiology Symposium focused on cardiac arrest are now
#foamed
on YouTube at ; feel free to share with anyone you think would be interested in cardiac arrest care
Another reminder that ECG computer interpretations cannot be trusted and should not be used at triage to decide how quickly the ECG should be viewed by the physician. Unbelievable miss by the computer! This patient had 100% LAD & 90% RCA.
#FOAMed
@UMEmergencyMed
Nice work! Reciprocal ST depression (here in aVL and V2) often precedes the STE, but is frequently ignored by the computer. Never rely on the computer!
Monday shift: final shift with superstar Shannon Petukhov after working with her the past 6 years (as student and resident); passed her “final exam” for me (but still needs to work on her drawing skills); good luck in practice!
@UMEmergencyMed
#WhiteBoardTeaching
#FOAMed
What's your opinion: 60 yo W w/DM, htn presents with 2 hours of facial droop, slurring speech, and hemiparesis; mild CP also, ECG shows anterior STEMI with reciprocal changes; dry CT head neg; HR 80, BP 150/90; what would you do first? no contraindications to tPA;
#FOAMed
This week a fun case on sent from Tasmania by Dr. Darren Briggs: 72yo M presenting with near-syncope, had a 30-second run of this while on monitor, how would you treat? Answer tomorrow.
Jessica, don't over-blow this! Here's my response based on what I said:
1. Kids unlikely to have ACS, but young people CAN have ACS; 2. unexplained fatigue--check an ECG; 3. negative biomarkers don't obviate the importance of doing hx and scrutinizing ECG; 4. scrutinize the ECG!
Sitting here in
@amalmattu
atypical ACS lecture having chest pain myself thinking about all the ACS I may have missed....
Kids can have ACS.
Unexplained fatigue in women? Possible ACS.
Biomarker negative ACS exists.
50% of missed ACS = EKG misreads
😱
#ACEP19
Current issue of Emergency Med Clinics focused on Crit Care in the ED. Awesome issue by EM-CC experts John Greenwood (UPenn) and Tsuyoshi Mitarai (Stanford). Must read...this will save lives! Authors include
@critcareguys
@CriticalCareNow
@MiscSusan