Ask Me Anything – ANDY SLOAS – PEM ED Podcast Host

Hello Everyone! We are excited to be doing an AMA with Dr. Andy Sloas from PEMEDpodcast! We will be getting started in just a few moments! Go ahead and start sending in your questions!

Greetings Andy! Buckle fractures – removable splint, ACE wrap, or plaster cast?

Plaster cast probably ends being a waste of plaster bc the fx is not going to hurt the kid in 2-3 days and they are going to tear through it on day 3. A removable splint makes the most sense to me bc as the pt starts to return to play they can just take it off. I usually tell the parents to take it off with baths/showers and when it stops hurting then deposit it in the cylindrical file. Ace wraps makes sense as reminder, but when they roll over in bed it wakes the kid up…which wakes the parents up…then you get a letter addressed to the hospital administrator.

1. Atropine w/ sux. Please stop this. It is just about as useless as leaches and blood letting. Lit would say atropine prob leads to arrhythmia, doesn’t protect from brady.
2. Trying to get perfect forearm reductions…Since when are we perfect?? It’s like hunting the great white buffalo. 2 bones in the same room still heal…at least the lit would say at 2yrs almost all bones look the same. Even complete bayonet heals!
3. NPO status for sedation. Even the AAP is on board with not waiting! Obviously ACEP put out their statement saying that we should just go ahead with the sedation and the Emergency Nurse’s Assoc endorsed it. Aspiration happens with excessive laryngeal manipulation, extubation and prolonged sedations.

Concussions – how much should EM own it? ie – start Zurich protocol in ED, or tell them to do nothing and f/u with PMD / neuro ?

So I have some strong opinions and a podcast on this subject. I disagree with those on the ACEP Peds subcommittee with me who think we should own it and here’s why: We don’t follow these guys up!! I think our job is to find the concussion and tell the kid you can’t go back to play until your cleared by your PCP, Sports med, neuro, etc. To successfully clear them back to play they need to progress through an exam like Zurich or SCAT2 and that takes time (days to weeks). Progression is dependent on passing the previous step..meaning once you get to the point your head doesn’t hurt and TV doesn’t make your eyes bleed then you do light thought stim like reading, then math, etc, ect and you have to be tested with some type of cognitive test like SCAT2 or the equivelent and be symptom free before it’s safe to get your bell rung again (if that’s ever safe). We see them for an hour..the PCP can follow that out. If you mess this up then second impact syndrome can kill them or turn them into a vegatable. So…I think we own the diagnosis of the DAI (diffuse axonal injury) and we own the warning of the badness that can happend, but then it should be on the PCP, neuro, sports MD to clear them back

Had A 24-year-old HIV positive female with likely PCP pneumonia signed out to me by junior faculty. Pt had been on a BiPAP for two hours,”I said is this one of those PCP pneumonia as who looks okay and then suddenly dies”… They said does not happen? Right at that point a nurse walked in told as the patient was coding. Found the patient in the V tach arrest and luckily got them back. Needed tons of preload and afterload support probably secondary to cytokine response. I would caution everyone to consider steroids in a patient with HIV and potential PCP that sick enough to be on BiPAP

1. ProCESS and Arise (I love the Austrians; great methodology)
2. Mac and Miller equal in kids: http://www.ncbi.nlm.nih.gov…
3. Scott’s new DSI piece in Annals (digital version is out)

1. Ketamine
2. Ketamine
3. More Ketamine, should have used more the 1st and 2nd time.

Seriously, I love the concentrated 100mg/ml, nothing tells a patient to shut the heck up and stop beating your RN’s head against the bed rail like a fully loaded syringe of Ketamine deliver right into leg through their pants, by you like a ninja. Quick stab and get out…

Great question, don’t get me wrong I give one big dose of ketamine and it’s a doozy… I don’t ever plan to give a second and third dose I want to completely’s snoknocker them the first time. Usually takes about 30 seconds to two minutes for them to get to the trancelike state and then I prepare the team for battle. We line them up and as they start to come out of the ketamine trance I start to titrate in benzo’s. It’s pretty rare that I needed to add in an antipsychotic to the mix, but I do remember one case of a bad PCP OD that really needed a little haldol to get through his trip. So I want to emphasize this is not the patient to give ketamine and walk away. It’s the patient to give ketamine get your IVs in and then stay with them or have a nurse stay with them because the moment they start waking up you really need to start titrating in the benzo’s. IF you don’t you’ll be back in the same boat as you were pre-Ketamine. The benzo for me is Valium, max somnolence at five minutes max clinical effect at 15 minutes very hard to get in trouble by stacking and find yourself intimating when you didn’t want to…

If you ask my wife, not as well and she would like. She’s upstairs right now having a glass of wine and I’m still working, But not seeing any patients. That’s difficult for her to understand…
I am a Christian and I put God before everything else which tends to help me keep my priorities straight or at least he does. My wife and family comes second and my job third. I’ve proved that twice by quitting two jobs when they started to interfere with my home life. That’s a tough call and I wouldn’t ask everyone to do that… I really think the solution is being able to say the word “no” that helps me find balance. My balance comes by not checking my cell phone when my wife and kids are around and doing all my podcasting/Non-clinical duties once they are asleep. AMA is the exception because I love you guys. I also try to do something fun with my family every weekday that I am not on a shift (zoo, out to eat, etc)

Sorry, could we clarify EM approach?

Think the biggest thing EM needs to figure out in the next five years is how to keep a patient centered care environment with so much pressure placed on us by the hospital administrators to move patients rapidly and in great quantity to make as much money as possible. I find that unnerving. At the end of the day one cannot serve two masters and you may say I would never choose money over at patients well-being, but it is highly likely that sometime in the near future, if you haven’t already been asked to admit or discharge a patient based on their insurance or lack there of, that you will half to make that decision. I think in the next 5 to 10 years our system will move more towards that of the British or Australian’s and we will see a giant chasm between those that have”Real” insurance and those that have the government alternative. As that happens I believe will see lawsuits drop or significantly lower because there won’t be any money in it, But the most important thing will be to find a way to keep the quality of care as highest possible.

A great question and it really tough one to answer. The easiest way to accomplish that is probably to have everyone on faculty at a training center be of like mind and refuse to except inadequate histories and physicals. Making the resident go back and ask more questions as opposed to “doing it yourself” is a great way to teach them, but if most people on faculty blow off a mediocre or bad residents presentation to go obtain the data themselves(which is the easiest way) and that resident continues to stay mediocre. If it ends up being a knowledge ace problem with the resident then unfortunately that’s a much harder not to crack. Remediation rarely helps and it really becomes up to the resident to decide if they want to sink or swim, Because they really need to go out and read and get smarter. Ours is a life or death specialty not considering worst first is not acceptable and if that mentality cannot be achieved in the resident probably should not matriculate. Again easy to say and hard to do. However, in this day and age with all the podcasts and foam out there if the resident is of average intelligence and highly motivated they really should succeed and be able to develop that type of thought process

1. I intubate nearly exclusively fiber-optically through the LMA. 90% of OR cases in the world are done with the LMA, it’s the last thing in the difficult algo before you cut the neck (In my opinion it should be the first) and it is in my opinion the gold std for difficult airways…so why not start with what works best..
2. I don’t treat strep or OM with abx. NNH to great and NNT not worthwhile. Check out SMART EM on that. I also don’t test or really look for it, which makes it hard to find and easy to explain when the PCP is mad I didn’t treat it.
3. US and quant EtCO2 is how I run my codes. I don’t allow pulse checks, they are worthless, meaningless and potentially harmful.

Can you name a few things you wish us non-academic / rural sites that refer to tertiary centers- would do better?

Having been in a non-academic/rural site for the beginning of my career I wouldn’t ask you to do anything better, You do a job well that I couldn’t do mediocre on my best day. I get to practice in an ivory tower with every subspecialty known to man holding my hand when things go bad. You should get a medal for what you do; my job is easy. I would only ask you recognize patients that are really sick and get them to the tertiary center as quickly as possible so all my subspecialists can save the day

1. Breathing Not Properly, RedHot to determine if you should ever order a BNP. Hint – only to have an excuse to tPA a PE
2. All Kline’s stuff on PE, but particularly his Geshtalt study and PERC
3. All the tPA lit to include NINDs, ECAS3 and IST-3, then listen to a lecture by J. Hoffman and figure out if it’s a drug company sham or the real deal. I have a I “heart” J Hoffman bumper sticker.
4. AAP bronchioltis rec last year and then burn them. They will only inc intuabtions and admissions.

Thanks again for Dr. Sloas for being AMAZING and doing this AMA! What great and thoughtful answers! Be sure to check out http://www.pemed.org/ soon!! Take care everyone!

Great fun! Thanks for having me.