Ask Me Anything – Haney Mallemat, MD

thanks Jeff….looking forward to this

I would for a few reasons….1) CPAP and BPAP increase aspiration risk, so now you take someone who is oxygenating badly and increase their risk of an aspiration event

I think you have to find that teachable moment….I used to think that residents wanted mini-didactic lectures during a shift….but that’s not the case. I’ve learned you have to find key moments to drop the knowledge relevant to a case…something small, but can be expanded upon if the learner wants to hear it…..but not everyone is ready to “get their learn on” at a moments notice….that’s the challenge of teaching on shift

Ketamine is a wonder drug and will eventually be found to all disease. I think that is a reasonable approach….sometimes starting at a lower dose and titrating up is best, but when someone is so agitated like that might not be possible

I think everyone is familiar with the negatives…..those being that FOAMed seems to cater to the high-end people who discuss the “art” of medicine….but as it evolves I think it will trickle down and people will start to find a niche within FOAMed for the basic learners…..this has already happened with some great podcasts like EMBasic and FOAMcast…..there is a much bigger audience in the med student/resident/fellows than the people who started FOAMed

1. Ketamine being bad for someone with intracranial disease 2. Radiologists/cardiologists are the “best” at bedside ultrasound/echo 3. Kayexalate for hyperK (not for us, but for our consultants)

Yes….apneic oxygenation everytime, more patients ramped up /HOB elevated, lower doses of sedatives for RSI, have your push dose pressors drawn and ready to go before RSI begins

I think it’s a great option for the right patient….for example, if you need to preoxygenate someone who isn’t letting you….I’d rather paralyze with good sats than bad

I don’t know if we “need” fellowships per se, but I think being fellowship trained is the way we will fight our way into units already dominated Intensivists. There is a real shortage of Intensivists in this country and who better to do this that EM docs who do critical care each and every day.

Exactly….that’s why I like it….also reduces risk of aspiration, even post-intubation

No, we don’t use a 2-hour…we have a CP protocol here that we follow

I think it would….the data is still being gathered…..but as long as you have good “hands” on the other end of the computer to do procedures….a lot of critical care in the ICU is cognitive decision making so doing it from afar seems like an option. However good critical care does require us to be able to gather critical data whether that’s an ultrasound or just our hands on the patient….so telemedicine might work for part of the time, but don’t think it can completely replace an Intensivist 24h/day

I’ve really changed to mostly ketamine and I can’t think of a situation where I’d prefer etomidate over that…..unless an allergy to ketamine (and I’ve never seen that)…what about you Swami?

I liked Process because it reinforces what we knew for a long time be aggressive with the care you deliver

Intraosseous?

Nice….I’ll +1 that 😉

ah….great question. Yes, just consider it. If you do that you’ll be waaay better off. This is a tricky diagnosis and I’ll I can say is make it part of your AMS algorithm so you never miss it

No….haven’t tried it but I really want to….looks very promising….how about you?

I think finding mentors early on is super-important. I have been so lucky to have found mentors who I can run things by…..and mentors don’t always have to be local, look around and you’ll find them. I also think you have to be ready to work hard when you first start out….maybe take a project or two that aren’t exactly in your vision but show people you are reliable and do good work. Be a nice person too…people hate to work with jerks.

Definitely will try.

I’ve seen a lot of good “upstairs care downstairs” in the past few years so I think EM is doing great managing critically ill people…..I think a few things are good post-intubation analgesia (fentanyl, morphine, etc.), elevating the head of the bed post-intubation, try to do your lines as cleanly as possible (even arterial lines)

personally, not yet

That’s a good question….hmmmm….this might be controversial to some, but I think you still need a fellowship if you plan on starting a fellowship, especially in competitive academic centers. These days people are finishing RDMS requirements before graduation from residency…so we’ll see what the future brings. Furthermore, people are learning ultrasound in medical school, so it’l be interesting to see if there are fellowships in 15-20 years or if it will be so prevalent that even pathologists know how to do ultrasound…..although they’d be too late to help 😡

not sure…..I haven’t heard good prospective data or guidelines on it

I don’t use CVP for resus anymore….ultrasound, lactate, even end-tidal CO2 can be used to assess for response to increasing cardiac output…CVP is fraught with so many problems….just type in Marik and CVP into google and happy reading 😉

I think the evidence is getting very good that this is reasonable

I don’t see pediatric patients so I cannot say….how about on your end?

I think finding mentorship early is a good piece of advice….don’t wait until you get the first job and then decide. Also, I wished I started writing publications earlier

nice, thanks.

It really depends where you go for a job. I don’t think you need a masters to do research and I know plenty of great researchers who did not. If research will be “your thing” then maybe the extra would be helpful…..honestly I don’t have a good answer for your question, sorry

interesting

I like it!

Yes…I think the ones who are undifferentiated but sick where you are just supporting the physiology but haven’t found the diagnosis yet are the hardest…..mostly because I want to find out what’s wrong, and then they go to the ICU…..these are people I want to continue caring for but there’s an ED filled with people to see

I usually start low for everyone and stand by the machine while titrating up. People find it “unnatural” and will often not want to try if you start of big. So I let them control the mask (no elastic band initially) and start very low while they self-apply…..I then increase until comfortable and then apply the bands to their head….my success has been better with this approach. Only downside is you have to be right there with the patient the entire time…and it sometime takes 15-20 minutes to set them up

I haven’t tried, but I want to in the future

Thank you! Great questions and I appreciate it. All the best

I think we will have to become facile in some in patient care and this is already apparent in us staffing some observational units….not exactly why we chose EM but this is part of the evolution.

Rob Rogers has a great Teaching course that runs during the fall. Here you can get mentorship and learn tools to be a cutting edge educator. ACEP also has a Teaching fellowship. I’d also advise learning how to navigate #FOAMed in there because this is really the medium of education and faculty development for this generation….it has certainly helped me out immensely