Little Big Med

On this episode, host Jason Woods speaks with Dr. TJ Doyle, medical director of the communicaton center at the University of Pittsburgh Medical Center (UPMC) and medical director for STAT-MD, a ground based consulting group for airlines. The discussions encompasses that frequency and types of in-flight medical emergencies (IME), what is in the medical kit on airplanes, what resources are available in-flight, and the legal ramifications for medical vounteers. The highlights: * Worldwide ~ 2.75 billion persons fly annually.* IME occur in roughly 1 per 604 US flights, or 24-130 IME per 1 million passengers. * 69% had EMS requested, 25% transported to hospital, 8.6% admitted, 0.3% died. * Aircrafts divert in about 4$ of IME* Airplane cabins are pressurized to between 5000 and 8000 ft altitude* Minimum equipment in the US (see graphic) * AED* Hemorrhage control* IV line* Gloves* Medications to treat “basic conditions”* Pain* Allergic reactions* Bronchoconstriction* Hypoglycemia* Dehydration* “Some” cardiac conditions* Equipment for initial assessment* Most common IME* Syncope or near 32.7%* GI 14.8%* Resp 10.1%* CV 7.0 %* Medical volunteer role* Individual airline policies may have different guidance* Not generally required to carry proof of medical license* Primary role is to gather info, provide assessment, and communicate with ground support. May need to admin medicines or perform procedures but direction of care is by ground medical. * Legal and ethical issues* US Aviation Medical Assistance Act* Protects passengers who provide medical assistance from liability except in cases of negligence or willful misconduct. * Medical volunteers who seek compensation for this service may jeopardize their protections under this law, though now lawsuit of such has been filed* Duty to respond * In US, Canada, England, Singapore, no legal duty* In Australia, many European countries, physicians are required to render assistance. * Other countries may have different protections or no protections at all Guests Thomas J. Doyle, Clinical Assistant Professor of Emergency Medicine, University of Pittsburgh Medical Center; Associate Medical Director, STAT MedEvac; Medical Director, Command Center, STAT-MD. References * Christian Martin-Gill, MD, MPH; Thomas J. Doyle, MD, MPH; Donald M. Yealy, MD. In-Flight Medical Emergencies: A Review. JAMA. 2018;320(24):2580-2590. doi:10.1001/jama.2018.19842* Peterson DC, Martin-Gill C, Guyette FX, et all. Outcomes of Medical Emergencies on Commercial Airline Flights. NEJM. 2013:368(22):2075-2083. doi:10.1056/NEJMoa1212052

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 2 of a 2 part discussion. The highlights: * Definition of trafficking* recruitment, harboring, transportation, provision, and/or obtaining of a person* By the use of force, fraud, and/or coercion* For purposes of labor and/or sexual exploitation* Numbers and general info* Overall labor trafficking is most common* Under age 18 “survival” sex considered victim of trafficking* US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.* On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked* There is no comprehensive trafficking screening tool in existence* The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking* Quotes from Makini’s published work that I loved* It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience. * We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve. Guests Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System Other Resources * HEAL Trafficking* Training for providers that Dr. Chisolm-Straker mentioned* Human trafficking hotline: * Phone: 1-888-373-7888 * SMS:233733 text HELP or INFO * Humantraffickinghotline.org* HumantraffickingED.com References 1.     Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52.  2.     Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7.  3.     Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33.  4.     Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1.  5.     Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D.

On this episode, host Jason Woods speaks with Dr. Makini Chisolm-Straker, an ED physician in New York who is also a founder of HEAL Trafficking, an organization that works to fight human traffickingi n all forms. This is part 1 of a 2 part discussion. The highlights: * Definition of trafficking* recruitment, harboring, transportation, provision, and/or obtaining of a person* By the use of force, fraud, and/or coercion* For purposes of labor and/or sexual exploitation* Numbers and general info* Overall labor trafficking is most common* Under age 18 “survival” sex considered victim of trafficking* US reports 15-50k brought to US each year for trafficking, but tn 2014, US DOS reported 21,000 calls to its trafficking hotline, so it is likely far under-reported in the official numbers.* On a 2016 survey of victims of trafficking, 55% had seen an ED/UC while trafficked* There is no comprehensive trafficking screening tool in existence* The Greenbaum tool is only for use in english speaking patients ages 13-17 and evaluates for risk of sex trafficking* Quotes from Makini’s published work that I loved* It is important NOT to employ the Greenbaum Tool until the clinician has had a frank conversation about mandated reporting with the patient. Too often clinicians envision trafficking as a crime from which which victims must be rescued or saved. That is not our job. And it does not work. Victims that are unwillingly rescued often end up back in exploitation circumstances. Many young people in trafficking situations do not identify as victims and some feel a strong sense of agency: others expect to be criminalized by authority figures because that has been their experience. * We must apply the principles learned from because of IPV work. Survivors know more about their situation and needs than we do. Our rescue actions, intended with love, often have untoward unintended consequences for those we seek to serve. Guests Makini Chisolm-Straker MD, Assistant Professor of Emergendy Medicine, Mount Sinai Health System Other Resources * HEAL Trafficking* Training for providers that Dr. Chisolm-Straker mentioned* Human trafficking hotline: * Phone: 1-888-373-7888 * SMS:233733 text HELP or INFO * Humantraffickinghotline.org* HumantraffickingED.com References 1.     Greenbaum VJ, Livings MS, Lai BS et al. Evaluation of a Tool to Identify Child Sex Trafficking Victims in Multiple Healthcare Settings. Journal of Adolescent Health 2018;63(6):745–52.  2.     Greenbaum VJ, Dodd M, McCracken C. A Short Screening Tool to Identify Victims of Child Sex Trafficking in the Health Care Setting. Pediatric Emergency Care 2018;34(1):33–7.  3.     Chisolm Straker M, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson PN, Richardson LD. Health Care and Human Trafficking: We are Seeing the Unseen. Journal of Health Care for the Poor and Underserved 2016;27(3):1220–33.  4.     Shandro J, Chilsom-Straker M, Duber HC et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. YMEM 2016;68(4):501–1.  5.     Chisolm Straker M. Measured steps: evidence‐based anti‐trafficking efforts in the E.D. Acad Emerg Med 2018.

On this episode, host Jason Woods speaks with Dr. Tanya Davis, pediatric urologist and all around superstar, about common pediatric urology problems that present to the emergency department. The highlights: * Testicular torsion is an emergency, and ultrasound should be performed when this is suspected. If the symptoms are highly suggestive call urology even with a normal ultrasound* It is suggested that urology is contacted before performing any repair of a laceration that is more than superficial.* Pediatric patients that develop epididymitis in the absence of sexual activity should be referred to urology, as this is unusual and may indicate an anatomic abnormality.* Dr. Davis feels that any patient with complex urogenital anatomy, indwelling catheters, or a surgically created catheterizable tract should NOT have antibiotics started for UTI without contacting their primary urologist. Guests Tanya Davis MD, Clinical Instructor, Department of Urology, Children’s National Health System Pediatric Urologist, Mid-Atlantic Permanente Medical Group

First, apologies for the delay in this episode! We’ve got a 2-month-old at home and it turns out, those little amazing terrorists take a lot of time! On this episode, host Jason Woods speaks to Dr. Natalie Nokoff, a pediatric endocrinologist who works with transgender patients. The discussion centers on the health care needs of these patients, preferred language, safety, and how to approach the discussion of gender in our population. Important Links * Human Rights Campaign * National LGBT Health Education Center * GLAAD * World Professional Association for Transgender Health * Transgender Law Center References * Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet 2016; 388:401. * Turban J, Ferraiolo T, Martin A, Olezeski C. Ten Things Transgender and Gender Nonconforming Youth Want Their Doctors to Know. J Am Acad Child Adolesc Psychiatry 2017; 56:275. * Olson-Kennedy J and Forcier M. Management of transgender and gender-diverse children and adolescents. UpToDate. Last Update Nov 2018. Accessed Nov 2018. * Olson-Kennedy J and Forcier M. Gender development and clinical presentation of gender diversity in children and adolescents. Last Update Nov 2018. Accessed Nov 2018. Guests Natalie Nokoff MD, Assistant Professor of Pediatrics, Section of Endocrinology, Children’s Hospital Colorado and the University of Colorado  

This is part 2 of a discussion with Dr. Danielle Soranno, on specific renal issues in the ED. She discusses hyperkalemia, end-stage renal disease, and HUS among others. If you haven’t listened to Part 1 yet, got back an episode in the feed. Guests Danielle Soranno MD,  Assistant Professor, Pediatrics, Bioengineering & Medicine University of Colorado and Children’s Hospital Colorado

On this episode, host Jason Woods tries to tackle all things renal. This is part 1 of a discussion with Dr. Danielle Soranno, who gives an overview of how she approaches the kidney and what things we need to know in general. She talks about common renal issues in the emergency department and what information she wants to hear when called for a consult Part 2 will post later this week and digs into some specific illnesses such as HUS, hyperkalemia, and end-stage renal disease. Guests Danielle Soranno MD,  Assistant Professor, Pediatrics, Bioengineering & Medicine University of Colorado and Children’s Hospital Colorado Important Information * Fab Four – FABU * Function * Anatomy * Blood Pressure * Urine

On this episode, host Jason Woods speaks to Dr. Nader Shaikh about his recent paper on the development of a calculator (UTICalc) to estimate the probability of UTI in pediatric patients. The calculator itself is fantastic and easy to use (see link below) but the discussion centers on the methods behind the calculator. We dig into how these calculators are developed, how to determine if they are accurate/useful, and how to use them in clinical practice. Important Links * UTI Calculator link – UTICalc * AAP UTI Guidelines, 2016 Reaffirmation of 2011 Guidelines * AAP 2011 UTI Guidelines Update References * Shaikh N et al. “Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children”. JAMA Pediatr. 2018 Jun 1;172(6):550-556. doi: 10.1001/jamapediatrics.2018.0217. * Roberts  KB; Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management.  Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.  Pediatrics. 2011;128(3):595-610.Lavelle  JM, Blackstone  MM, Funari  MK,  et al.  Two-step process for ED UTI screening in febrile young children: reducing catheterization rates.  Pediatrics. 2016;138(1):e20153023. * Shaikh  N, Morone  NE, Bost  JE, Farrell  MH.  Prevalence of urinary tract infection in childhood: a meta-analysis.  Pediatr Infect Dis J. 2008;27(4):302-308. * Hoberman  A, Wald  ER, Reynolds  EA, Penchansky  L, Charron  M.  Pyuria and bacteriuria in urine specimens obtained by catheter from young children with fever.  J Pediatr. 1994;124(4):513-519. * Hoberman  A, Chao  HP, Keller  DM, Hickey  R, Davis  HW, Ellis  D.  Prevalence of urinary tract infection in febrile infants.  J Pediatr. 1993;123(1):17-23. Guests Nader Shaikh MD, Associate Professor, General Academic Pediatrics, Children’s Hospital of Pittsburgh  

On this episode, host Jason Woods speaks to Daniela Fellman and Alison Macklin, leaders from the Responsible Sex Education Institute, about a topic that can sometimes be difficult for patients, parents, and care providers…sex! Sexual and reproductive health education is hugely important and frequently politicized. Both interviewees are leading the way when it comes to education and outreach programs in the field of sex education. We talk about a variety of resources which are listed below, as well as get a sneak peek at two books which are being published soon. Important Links * Responsible Sex Education Institute * ICYC Instagram * ICYC – In Case You’re Curious * Making Sense of “It” by Alison Macklin (available for pre-order now!) Additional Resources * Glsen * Scarleteen * Healthy Teen Network * Advocates for Youth * Amaze Guests Alison Macklin – Vice President of Education and Innovation, Responsive Sex Education, Planned Parenthood of the Rocky Mountains Daniela Fellman – Program Manager of Texting Initiatives, Planned Parenthood of the Rocky Mountains  

On this episode, host Jason Woods speaks with Dr. Elaine Reno, an emergency medicine physician who is also a wilderness medicine expert, about high altitude illness in pediatrics. We focus on risk factors, identification of illness, and recommendations for initial treatment. Important points * Significant altitude illness is rare below 8000 feet * Pre-verbal children DO experience high altitude illness but can be more difficult to diagnose given the difficulty in communication. * Dr. Reno strongly prefers slow acclimatization for children, rather than prophylactic medication. Point of Care Resources * Wilderness Medical Society * Colorado Wilderness Medicine * Lake Louise Acute Mountain Sickness Score * Children’s Lake Louise Score Guests Elaine Reno MD – Assistant Professor of Emergency Medicine, University of Colorado School of Medicine, Department of Emergency Medicine, Section of Wilderness and Environmental Medicine  

On this episode, host Jason Woods speaks with Dr. Austin Larson, a specialist in pediatric inherited metabolic disorders (and also someone way smarter than I), about what do do with the crashing neonate if there are concerns for a metabolic disorder. We review the diagnostic approach, emergent treatment, and what resources are available to read/consult in this situation. Important points * Most children with known inherited metabolic disorder will have a letter with them, from their metabolic doc, about what to do if they show up to the with a new illness. If they do not, then the New England Consortium website is a great resource. * Most protocols recommend starting D10 fluids at 1.5 x maintenance is generally the recommendation, unless there is a reason why glucose/fluids will otherwise harm the patient. * Be careful with patients who are on a ketogenic diet as treatment for their seizures, as giving them glucose can cause refractory status epilepticus. In those patients, the preferred calorie support would be lipids. Point of Care Resources * New England Consortium for treatment protocols * Vademecum Metabolicum handbook in book form * App version of Vademecum Metabolicum – eVM Guests Austin Larson, MD – Assistant Professor of Pediatrics and Metabolic and Clinical Genetics, University of Colorado School of Medicine and Children’s Hospital Colorado

On this episode, host Jason Woods speaks with Dr. Austin Larson, a specialist in pediatric inherited metabolic disorders (and also someone way smarter than I), about what do do with the crashing neonate if there are concerns for a metabolic disorder. We review the diagnostic approach, emergent treatment, and what resources are available to read/consult in this situation. Important points * If an ill neonate presents and there is any concern for inherited metabolic disorder, starting D10 fluids at 1.5 x maintenance is generally the recommendation, unless there is a reason why glucose/fluids will otherwise harm the patient. * If there are concerns for inherited metabolic disorder, in addition to glucose, checking ketones (urine or serum, though serum preferred), ammonia, and lactate can be very helpful. * If the ammonia level is >200 micromols/L and rising, dialysis will likely be needed and you need to start making plans for this. * Neonates generally can not generate a significant ketosis, even if fasting or ill, without an inherited metabolic disorder. * Other labs to consider obtaining in an ill child with hypoglycemia or concern for metabolic disorder * Cortisol * Serum Amino Acids * Urine Organic Acids * Serum ketones * Free fatty acids * Growth Hormone * Insulin * Acylcarnitine profile Point of Care Resources * New England Consortium for treatment protocols * Vademecum Metabolicum handbook in book form * App version of Vademecum Metabolicum – eVM Guests Austin Larson, MD – Assistant Professor of Pediatrics and Metabolic and Clinical Genetics, University of Colorado School of Medicine and Children’s Hospital Colorado

On this episode we discuss the rates and risks of post-resuscitation hypotension after cardiac arrest. Host Jason Woods MD talks with Dr. Alexis Topjian, a critical care doc from Children’s Hospital of Philadelphia with special interests in neuro-critical care and post-arrest care, about her recent article on post arrest hypotension. This article was published in JAMA in 2018 (see references below) and evaluated outcomes based on presence of hypotension, and hypotensive burden, after out-of-hospital cardiac. Guests Alexis Topjian MD, Associate Professor of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia References * Topjian AA, Telford R, Holubkov R, et al. Association of Early Postresuscitation Hypotension With Survival to Discharge After Targeted Temperature Management for Pediatric Out-of-Hospital Cardiac Arrest. JAMA Pediatr. 2018;172(2):143–11. doi:10.1001/jamapediatrics.2017.4043. * Topjian AA, French B, Sutton RM, et al. Early Postresuscitation Hypotension Is Associated With Increased Mortality Following Pediatric Cardiac Arrest*. Critical Care Medicine. 2014;42(6):1518-1523. doi:10.1097/CCM.0000000000000216. * Bhanji F, Topjian AA, Nadkarni VM, et al. Survival Rates Following Pediatric In-Hospital Cardiac Arrests During Nights and Weekends. JAMA Pediatr. 2017;171(1):39–7. doi:10.1001/jamapediatrics.2016.2535. * Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children. N Engl J Med. 2017;376(4):318-329. doi:10.1056/NEJMoa1610493.  

The last in our current series on firearm violence looks at suicide prevention and the relation of firearms to suicide. Host Jason Woods MD talks with Dr. Emmy Betz, a researcher in suicide prevention, about what is currently know, strategies for harm reduction, and her efforts as the co-founder of the Colorado Coalition for Firearm Safety, which works to bring the medical community together with firearm owners, gun shops, and shooting ranges to improve safety. Guests Emmy Betz MD, MPH – Assistant Professor, Department of Emergency Medicine, University of Colorado School of Medicine. Resources  * National Suicide Prevention Lifeline – 1-800-273-8255 * Dr. Betz’s TED Talk * Colorado Firearm Safety Coalition * Giffords Law Center – access state by state listing of firearm laws * Joint program between the American Society for Suicide Prevention and the National Shooting Sports Foundation References * Betz ME, Kautzman M, Segal DL, et al. Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen. Psychiatry Research 2018;260:30–5. * Betz ME, Wintersteen M, emergency EBAO, 2016. Reducing suicide risk: challenges and opportunities in the emergency department. annemergmedcom * Pierpoint LA, Tung GJ, Brooks-Russell A, Brandspigel S, Betz M, Runyan CW. Gun retailers as storage partners for suicide prevention: what barriers need to be overcome? Inj Prev 2018;:injuryprev–2017–042700–5. * McCourt AD, Vernick JS, Betz ME, Brandspigel S, Runyan CW. Temporary Transfer of Firearms From the Home to Prevent Suicide. JAMA Intern Med 2017;177(1):96–6. * Wintemute GJ, Betz ME, Ranney ML. Yes, You Can: Physicians, Patients, and Firearms. Ann Intern Med 2016;165(3):205–10.

We continue our look at firearm and violent injury in the youth population by examing the issue outside of the United States. Host Jason Woods MD gathered Canadian physicians Carolyn Snider and Natasha Saunders, both researchers on violent injury (and specifically firearm-related injury), to discuss the scope of violent youth injury in Canada, ED-based intervention programs, risk factors, and the rising rates of injury due to air guns and BB guns. Guests Carolyn Snider MD, MPH – Associate Professor, Department of Emergency Medicine, University of Toronto, Staff Physician Winnipeg Health Sciences Center, founder of the Emergency Department Violent Injury Prevention program (EDVIP) Natasha Saunders MD – Assitant Professor Department of Pediatrics University of Toronto, Staff Physician Hospital for Sick Children, Adjunct Scientist Institute for Clinical Evaluative Sciences Resources National Network of Hospital-based Violence Intervention Programs – http://nnhvip.org/ * Saunders NR, Lee H, Macpherson A, Guan J, Guttmann A. Risk of firearm injuries among children and youth of immigrant families. CMAJ. 2017;189(12):E452-E458. * Snider CE, Ovens H, Drummond A, Kapur AK. CAEP Position Statement on Gun Control. Canadian Journal of Emergency Medicine. 2009;11(1):64-72 * Snider CE, Brownell M, Dufault B, Barrett N, Prior H, Cochrane C. A multilevel analysis of risk and protective factors for Canadian youth injured or killed by interpersonal violence. Inj Prev. July 2017:injuryprev–2016–042235–7 * Snider C, Woodward H, Mordoch E, et al. Development of an Emergency Department Violence Intervention Program for Youth: An Integrated Knowledge Translation Approach. Progress in Community Health Partnerships. 2016;10(2):285-291