Core EM - Emergency Medicine Podcast

[https://coreem.net/content/uploads/2025/06/Capacity-Assessment.001.jpeg] https://coreem.net/podcast/episode-210-capacity-assessment/ We discuss capacity assessment, patient autonomy, safety, and documentation. Hosts: Anne Levine, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Capacity_Assessment.mp3 [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Capacity_Assessment.mp3] Download [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Capacity_Assessment.mp3] Leave a Comment [https://coreem.net/podcast/episode-210-capacity-assessment/#comments] SHOW NOTES THE IMPORTANCE OF CAPACITY ASSESSMENT * Arises frequently in the ED, even when not formally recognized * Carries both legal implications and ethical weight * Failure to appropriately assess capacity can result in: * Forced treatment without justification * Missed opportunities to respect autonomy * Increased risk of litigation and poor patient outcomes DEFINING CAPACITY * Capacity is: * Decision-specific: varies based on the medical choice at hand * Time-specific: can fluctuate due to medical conditions, intoxication, delirium * Distinct from competency, which is a legal determination * Relies on a patient’s ability to: * Understand relevant information * Appreciate the consequences * Reason through options * Communicate a clear choice REAL-WORLD ED EXAMPLES * Intoxicated patient with head trauma refusing CT * Unreliable neuro exam * Potentially time-sensitive intracranial injury * Elderly patient with sepsis refusing admission due to caregiving responsibilities * Balancing autonomy vs. beneficence * Patient with gangrenous diabetic foot refusing surgery * Demonstrates logic and consistency despite high-risk decision THE 4 PILLARS OF CAPACITY ASSESSMENT * Understanding * Can the patient explain: * Their condition * Recommended treatments * Risks and benefits * Alternatives and outcomes? * Sample prompts: * “What are the options for your situation?” * “What might happen if we do nothing?” * Appreciation * Does the patient grasp the personal relevance of the information? * Sample prompts: * “Why do you think we’re recommending this?” * “How do you think this condition could affect you?” * Reasoning * Can the patient logically explain their choice? * Must demonstrate a rational process, even if the outcome seems unwise * Sample prompts: * “What factors are you considering in making this decision?” * “What led you to this conclusion?” * Choice * Is the patient able to clearly communicate a decision? * Any modality acceptable: verbal, written, gestural * Sample prompts: * “We’ve discussed several options. What do you want to do?” * “Have you decided what option is best for you?” COMMON ED CHALLENGES & SOLUTIONS Time Pressure * Capacity assessments can be time-consuming * Yet, patients leaving AMA without proper evaluation are at higher risk: * ↑ 30-day mortality * ↑ 30-day readmission Communication Barriers * Language differences → use certified interpreters * Cognitive impairment or psych illness → clarify baseline status * Noisy ED environment → relocate to quiet space * Use simple language, avoid jargon Ethical Dilemmas * Providers may disagree with patient choices * Ensure decision-making process—not the choice itself—is being judged * Use tools like the Aid to Capacity Evaluation (ACE) * When uncertain, consult Psychiatry or Risk Management BEST PRACTICES IN DOCUMENTATION Clearly document: * The patient’s understanding, appreciation, reasoning, and choice * Information delivered: * Condition * Treatment recommendations * Alternatives and risks * Patient’s responses and logic * Witnesses to the conversation * Any discharge instructions, including: * Follow-up plans * Prescriptions provided * Return precautions Also document: * If patient refused treatment, document: * That risks and benefits were clearly explained * That refusal was voluntary * If treatment was administered despite objection: * Document rationale for presumed lack of capacity * Legal/ethical justification for action * Involvement of other services (e.g., Psychiatry, Risk) Read More [https://coreem.net/podcast/episode-210-capacity-assessment/]

[https://coreem.net/content/uploads/2025/04/Blast-Crisis.001.jpeg] https://coreem.net/podcast/episode-209-blast-crisis/ We dive into the recognition and management of blast crisis. Hosts: Sadakat Chowdhury, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blast_Crisis.mp3 [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blast_Crisis.mp3] Download [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blast_Crisis.mp3] 2 Comments [https://coreem.net/podcast/episode-209-blast-crisis/#comments] Tags: Hematology [https://coreem.net/tag/hematology/], Oncology [https://coreem.net/tag/oncology/] SHOW NOTES TOPIC OVERVIEW * Blast crisis is an oncologic emergency, most commonly seen in chronic myeloid leukemia (CML). * Defined by: * >20% blasts in peripheral blood or bone marrow. * May include extramedullary blast proliferation. * Without treatment, median survival is only 3–6 months. PATHOPHYSIOLOGY & ASSOCIATED CONDITIONS * Usually occurs in CML, but also in: * Myeloproliferative neoplasms (MPNs) * Myelodysplastic syndromes (MDS) * Transition from chronic to blast phase often reflects disease progression or treatment resistance. RISK FACTORS * 10% of CML patients progress to blast crisis. * Risk increased in: * Patients refractory to tyrosine kinase inhibitors (e.g., imatinib). * Those with Philadelphia chromosome abnormalities. * WBC >100,000, which increases risk for leukostasis. CLINICAL PRESENTATION * Symptoms often stem from pancytopenia and leukostasis: * Anemia: fatigue, malaise. * Functional neutropenia: high WBC count, but increased infection/sepsis risk. * Thrombocytopenia: bleeding, bruising. * Leukostasis/hyperviscosity effects by system: * Neurologic: confusion, visual changes, stroke-like symptoms. * Cardiopulmonary: ARDS, myocardial injury. * Others: priapism, limb ischemia, bowel infarction. * Rapid deterioration is common — early recognition is critical. DIAGNOSTIC WORKUP * CBC with differential: assess blast % and cytopenias. * Peripheral smear and manual diff: confirm immature blasts. * CMP: screen for tumor lysis syndrome: * Elevated potassium, phosphate, uric acid. * Low calcium. * LDH & uric acid: markers of high cell turnover. * Coagulation studies (PT, PTT): assess for DIC. * Definitive tests (done inpatient): bone marrow biopsy, flow cytometry. EMERGENCY DEPARTMENT MANAGEMENT * Resuscitation & ABCs: oxygen, IV fluids, vitals monitoring. * Avoid aggressive transfusions: * Risk of hyperviscosity with PRBCs and platelets. * Initiate broad-spectrum antibiotics early: * High suspicion for sepsis in functionally neutropenic patients. * Consider antifungals for prolonged febrile neutropenia. * Cytoreduction strategies: * Hydroxyurea to lower WBCs quickly. * Tyrosine kinase inhibitors (TKIs). * High-dose chemotherapy. * Early consultation with hematology/oncology is essential. * Mutation testing may guide targeted therapy. PROGNOSIS * Without treatment: median survival ~3 months. * With treatment: * Potential survival >1 year. * Best outcomes in patients who enter a second chronic phase and undergo allogeneic stem cell transplant. ETHICAL & LOGISTICAL CONSIDERATIONS * Treatment may involve aggressive interventions with serious side effects. * Important to assess: * Patient goals of care. * Capacity for informed consent. * Resource limitations: * Not all hospitals have oncology services. * Patients may require transfer over long distances. * Emphasize early, transparent discussions with patients and families. TOP 3 TAKE-HOME POINTS * Recognize early: Look for cytopenias, leukostasis, and rapid clinical decline. * Resuscitate appropriately: Start antibiotics; be cautious with transfusions. * Call for help: Early hematology/oncology involvement is essential for definitive care. Read More [https://coreem.net/podcast/episode-209-blast-crisis/]

[https://coreem.net/content/uploads/2025/04/Geriatric-Emergency-Medicine.001.jpeg] https://coreem.net/podcast/episode-208-geriatric-emergency-medicine/ We explore the expanding field of Geriatric Emergency Medicine. Hosts: Ula Hwang, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Geriatric_Emergency_Medicine.mp3 [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Geriatric_Emergency_Medicine.mp3] Download [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Geriatric_Emergency_Medicine.mp3] Leave a Comment [https://coreem.net/podcast/episode-208-geriatric-emergency-medicine/#comments] Tags: Geriatric [https://coreem.net/tag/geriatric/] SHOW NOTES KEY TOPICS DISCUSSED * Importance and impact of geriatric emergency departments. * Optimizing care strategies for geriatric patients in ED settings. * Practical approaches for non-geriatric-specific EDs. CHALLENGES IN GERIATRIC EMERGENCY CARE * Geriatric patients often present with: * Multiple chronic conditions * Polypharmacy * Functional decline (mobility issues, cognitive impairments, social isolation) ADAPTING CLINICAL APPROACH * Core objective remains acute issue diagnosis and treatment. * Additional considerations for geriatric patients: * Review and caution with medications to prevent adverse reactions. * Address functional limitations and cognitive impairments. * Emphasize safe discharge and care transitions to prevent unnecessary hospitalization. IDENTIFYING HIGH-RISK GERIATRIC PATIENTS * Screening tools: * Identification of Seniors at Risk (ISAR) * Frailty screens * Alignment with the “Age-Friendly Health Systems” initiative focusing on: * Mentation * Mobility * Medications * Patient preferences (what matters most) * Mistreatment (elder abuse awareness) MINIMIZING HOSPITAL-RELATED HARMS * Involvement of multidisciplinary teams: * Social workers and care managers for care transitions * Geriatric-certified pharmacists for medication review * Coordination with outpatient services post-discharge IMPLEMENTING GERIATRIC CARE IN ALL EDS * Basic geriatric care achievable even in resource-limited or rural EDs. * Level 3 Geriatric ED Accreditation can be achieved through: * Improved care transitions * Staff education enhancements * Age-friendly environments (comfort, nutrition, hydration) FUTURE OF GERIATRIC EMERGENCY MEDICINE * Vision: Universal integration of geriatric-focused care. * Goals: * Enhanced patient experience * Improved care transitions * Alignment of treatments with patient goals * Broader enhancement of emergency care quality for all patient populations Read More [https://coreem.net/podcast/episode-208-geriatric-emergency-medicine/]

[https://coreem.net/content/uploads/2025/04/Smoke-Inhalation-Injury.001.jpeg] https://coreem.net/podcast/episode-207-smoke-inhalation-injury/ We discuss the injuries sustained from smoke inhalation. Hosts: Sarah Fetterolf, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3 [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3] Download [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3] Leave a Comment [https://coreem.net/podcast/episode-207-smoke-inhalation-injury/#comments] Tags: Environmental [https://coreem.net/tag/environmental/], Toxicology [https://coreem.net/tag/toxicology/] SHOW NOTES TABLE OF CONTENTS 00:37 – Overview of Smoke Inhalation Injury 00:55 – Three Key Pathophysiologic Processes 01:41 – Physical Exam Findings to Watch For 02:12 – Airway Management and Early Intervention 03:23 – Carbon Monoxide Toxicity 04:24 – Workup and Initial Treatment of CO Poisoning 06:14 – Cyanide Toxicity 07:19 – Treatment Options for Cyanide Poisoning 09:12 – Take-Home Points and Clinical Pearls ---------------------------------------- PHYSIOLOGICAL EFFECTS OF SMOKE INHALATION: * Thermal Injury: * Direct upper airway damage from heated air or steam. * Leads to swelling, inflammation, and possible airway obstruction. * Chemical Irritation: * Causes bronchospasm, mucus plugging, and inflammation in the lower airways. * Increases capillary permeability, potentially causing pulmonary edema. * Systemic Toxicity: * Primarily involves carbon monoxide and cyanide poisoning. CLINICAL SIGNS AND SYMPTOMS: * Physical Exam: * Facial burns, singed nasal hairs * Hoarseness, stridor (upper airway swelling) * Carbonaceous sputum (lower airway edema) * Systemic Symptoms: * Headache, dizziness, nausea * Syncope, seizures, altered mental status AIRWAY MANAGEMENT CONSIDERATIONS: * Not every patient requires immediate intubation. * Intubation should be performed early if airway compromise is suspected, as swelling can rapidly progress. * Close airway monitoring recommended for all patients. CARBON MONOXIDE POISONING: * Common cause of death post-smoke inhalation (50–75% of fire-related injuries). * Hemoglobin affinity 250 times greater for CO than oxygen, impairing tissue oxygenation. * Diagnosis: * Carboxyhemoglobin level via VBG (ensure proper lab ordering). * Pulse oximetry unreliable; falsely high readings. * Treatment: * Immediate high-flow oxygen administration. * Consider hyperbaric oxygen therapy for severe cases to reduce delayed neurocognitive sequelae. CYANIDE POISONING: * Blocks cytochrome oxidase in electron transport chain, halting aerobic ATP production. * Patients present critically ill; notable features include: * Elevated lactate levels (>8–10 mmol/L) * Arterialization of venous blood * Treatment: * First-line therapy: hydroxocobalamin (Cyanokit) binds cyanide forming vitamin B12 for renal excretion. * Alternative: Cyanide antidote kit (amyl nitrite, sodium nitrite, sodium thiosulfate); induces methemoglobinemia and requires monitoring. * Important note: hydroxocobalamin turns blood and urine bright red; draw labs beforehand. KEY TAKEAWAYS: * Assess for airway compromise and signs of inhalation injury early. * Maintain a high index of suspicion for CO and cyanide poisoning in smoke inhalation victims. * Immediate, aggressive oxygen therapy and early antidote administration can significantly impact outcomes. Read More [https://coreem.net/podcast/episode-207-smoke-inhalation-injury/]

[https://coreem.net/content/uploads/2025/03/Acute-Back-Pain.001.jpeg] https://coreem.net/podcast/episode-206-acute-back-pain/ We discuss the evaluation of and treatment options for acute back pain. Hosts: Benjamin Friedman, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Back_Pain.mp3 [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Back_Pain.mp3] Download [https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Back_Pain.mp3] Leave a Comment [https://coreem.net/podcast/episode-206-acute-back-pain/#comments] Tags: Musculoskeletal [https://coreem.net/tag/musculoskeletal/], Orthopaedics [https://coreem.net/tag/orthopaedics/] SHOW NOTES **PLEASE FILL OUT THIS QUICK SURVEY TO HELP US DEVELOP ADDITIONAL RESOURCES FOR OUR LISTENERS: CORE EM SURVEY [https://docs.google.com/forms/d/e/1FAIpQLSfoZwHn4xAZish_ldczUbtNRkUbAUzD9_1YuzBwGL7SPE0ymA/viewform?usp=header]** ---------------------------------------- CLINICAL EVALUATION: * Primary Goal: Distinguish benign musculoskeletal pain from serious pathology. * Red Flags: Look for indicators of spinal infection, spinal bleed, or space-occupying lesions (e.g., tumors, large herniated discs). * Assessment: A thorough history and neurological exam (strength testing, gait) is essential. * Additional Tools: Use bedside ultrasound for post-void residual assessment in suspected cauda equina syndrome IMAGING GUIDELINES: * Routine Imaging: Generally not indicated for young, healthy patients without red flags. * ACEP Recommendations: Avoid lumbar X-rays in patients under 50 without risk factors, as they do not change management and may increase costs and ED time. * Advanced Imaging: Reserve MRI for patients with red flags, neurological deficits, or suspected cauda equina syndrome; CRP may be a part of your calculus when evaluating for infectious causes of back pain TREATMENT OPTIONS: * Evidence-Based First-Line: * NSAIDs offer modest benefit. * Skeletal muscle relaxants can be used but require caution due to side effects. * Ineffective Therapies: * Acetaminophen shows no benefit for back pain. * Steroids are not recommended for non-radicular pain, with only limited benefit in sciatica. * Topical treatments, lidocaine patches, and opioids are not supported by evidence and may pose additional risks. ALTERNATIVE AND EXPERIMENTAL INTERVENTIONS: * Nerve Blocks: Current evidence is limited; more research is needed on trigger point injections and erector spinae plane blocks. * Severe Pain Management: * A single opioid dose (preferably codeine or oral morphine) may be considered to facilitate discharge when necessary. * Use diazepam sparingly for immediate mobilization. * Onsite physical therapy in the ED can be beneficial when available. * Preventing Chronic Pain: * Research Focus: Ongoing studies are evaluating whether duloxetine (Cymbalta) can prevent the transition from acute to chronic back pain. * Non-Pharmacologic Measures: Consider spinal mobilization, physical therapy, acupuncture, and cognitive behavioral therapy (CBT) as adjuncts in management. TAKE-HOME POINTS: * Most acute back pain is benign, but watch for red flags like IV drug use, anticoagulation, or neurological symptoms (e.g., weakness, bladder dysfunction) that may indicate serious conditions like spinal infections, bleeds, or cord compression. * Avoid unnecessary lumbar X-rays in young, healthy patients without red flags—MRI is preferred only for those with risk factors, neurological deficits, or suspected cauda equina syndrome. *  Use NSAIDs and skeletal muscle relaxants for acute musculoskeletal back pain, as they offer modest benefits. Avoid opioids, acetaminophen, and steroids for non-radicular pain, as they lack evidence. * For severe, uncontrolled pain, consider a single opioid dose (e.g., codeine) or diazepam sparingly * Encourage patients to engage in non-pharmacologic therapies like yoga, massage, or cognitive behavioral therapy to aid recovery and prevent chronic pain. Read More [https://coreem.net/podcast/episode-206-acute-back-pain/]