Ask Me Anything with Steve Carroll, DO (@embasic)

Thanks Alex- I think all the new blogs and podcasts that are being created are a good thing for medical education. I don’t think we are re-inventing the wheel or diluting quality- we are putting the power of the internet to work for us as a platform to share our expertise across the world instantaneously. I don’t think there’s anything magic about anything in FOAMed- when you think about it it’s all about bandwidth. 15-20 years ago (in the dial-up days- if people remember that!) we just didn’t have the bandwidth to share all of this information quickly and easily. Today’s bandwidth and ubiquitous internet access has allowed us to talk take talks that used to be only seen by a few dozen or a few hundred people and make them available to thousands, tens of thousands, etc.

The other power of FOAMed at the internet is that it is really motivating to content producers to see their content being downloaded across the world. It’s really motivating to see that an episode that you put dozens of hours into is getting downloaded hundreds to thousands of times across the world- you can’t get that at your average lecture hall or conference. This encourages people who have something valuable to say to get out there and say it for a huge audience when they would probably be confined to a lecture hall in the past so I think we are adding to the quality, not diluting it.

That is a really interesting question- this is where I rely on my audience to give me feedback and help me move it into new directions. I have people email me to suggest show topics- that really helps me focus on what people want to hear about. The recent episode I published as a screencast on airway topics is probably something that you will see more of in the future. While I think most audience members listen to the audio portion, I do have a lot of requests to have visual presentations. It comes down to learner preference and I try to cater to that as much as possible.

My ultimate goal would be to have EM Basic be a comprehensive audio/visual resource covering most (if not all) core content topics in EM and make it a living and breathing resource that is updated as new information and our ways of thinking about EM evolve (and also correct mistakes/oversights!). I am already running into having to update the “evergreen” content. For example- my sepsis podcast could use an update to pretty much eliminate the use of CVP to determine volume responsiveness. Seth Treuger pointed out on twitter that I really didn’t mention AVRD and short QT as cardiac causes of syncope.

The limiting factor in all of this is time- if EM Basic was my full time job the possibilities are limitless. This is a common theme with FOAMed producers- while the monetary costs are relatively low to enter, the time costs can be significant. Unless you are lucky enough to have protected time from your employer to produce content, the amount of time becomes the limiting factor. That’s why I have opened up the podcast to other contributors and that has certainly help me publish more consistently.

I tell interns to go to the reliable resources like Life in the Fast Lane and sign up for the LITFL review. I think that provides an excellent overview of the latest and greatest FOAMed resources that has been evaluated for quality. I also advise them to join EMRA to get EM:RAP, EMA, and (I think?) EM Practice for “free” because I think these are extremely valuable resources. After that I tell them to wade into it- see what you like, follow links on the websites you like, and use email subscriptions and an RSS reader to collate what you like. I don’t think you need to “sell” FOAMed a lot- if you can get them to listen or read just one solid resource, they will be hooked

Wow- that’s a really interesting question- I have to say that I have actually started to enjoy interacting with “difficult” patients. While some patients certainly test my patience sometimes, I have found great satisfaction in being a problem solver for these difficult cases that the staff have problems dealing with. Being someone who is very interested in airway, surprisingly I have also found myself enjoying helping those patients avoid intubation through the use of non-invasive ventilation and high dose nitro for those with acute pulmonary edema. If you told me as an intern that I would like those cases later on, I would have said you were nuts!

I had to think about things that I don’t enjoy- when I started my residency I used to love scanning anyone and anything with the ultrasound- now not so much. Don’t get me wrong, I love using US to make critical decisions in critical patients (AAA? Good cardiac output? Blood in the belly?) but I think we are taking some applications a little too far. I don’t do the transvaginal US routinely when I am practicing without residents unless the patient is critically ill- I think patients are better served by having a formal US and the ED is better served by me seeing other patients while that patient is getting a US done elsewhere besides the ED.

I have to say that I have mild concerns about the rise of intubation without paralysis. The literature basis for RSI in the ED is strong and I feel that we may be treading into untested waters by forgoing paralysis in some ED intubations. I admit that I can’t recall the last patient whom I intubated without paralytics. I am not saying that awake (or sedation only) approaches are not a valuable tool to have in your armanterium- I just worry about us testing these limits without a decent literature basis and then seeing increased rates of aspiration and other complications. I am much more of a fan of using an awake technique, sighting the larynx (with either VL or DL) and then pushing paralytics. I think we forget that paralytics not only improve our view but also prevent vomiting and regurgitation.

I think if you attempt these awake approaches, you need to be ready for two things at the same time- to push paralytics at a moment’s notice AND being ready to cric at a moment’s notice (ala Reuben Strayer’s “double setup” http://emupdates.com/2012/1…)

I read just about everything produced by Life in the Fast Lane- the content they produce is relevant to just about any level of provider in EM. I am also a big fan of Reuben Strayer’s emupdates.com – he doesn’t publish on a regular basis but just about every time he publishes, it changes my practice or my way of thinking about something. I also like the Trauma Professional’s blog and Academic life in EM. ALiEM has exploded in the past year with the amount of content they are producing. For podcasts- SMACC, EmCrit, Ercast, Saint Emlyn’s, PHARM, and RAGE to name a very few- my full list of recommended blogs/podacasts is at- http://embasic.org/links/ -shameless self promotion but those are the ones that I think are the best and the ones that I keep up with

Catherine- that’s not really the focus of this- I am not an expert on Ebola- I would refer you to the CDC’s website http://www.cdc.gov/vhf/ebola/ for more information

1) Anything do with ketamine and head injury, seizure threshold (still out there), or there being a high incidence emergence reactions
2) Blankets for patients with fever (concern for a lot of nurses for some reason)
3) Protonix (pantoprazole) routinely before endoscopy (the SMART:EM deep dive on this should scare anyone away from this therapy before endoscopy- studies exist with increased mortality!)

So I laughed out loud at that because I loved the movie “Snakes on a plane”…but we are getting away from a serious discussion on EM topics so I would ask that we stay on that course- thanks!

Lol- how could I forget cricoid pressure- of course that’s a myth I want to see go away- there were just so many to pick from. And yes- cricoid pressure does kill kittens 🙂

Core content- hands down. Any time you say “critical care” people’s ears perk up and the downloads start. When you say “Otitis media” you can hear the crickets. We have some resources out there such as myself and Boring EM, among others but we need more. Nothing would make me happier than to have EM Basic be nothing but outside contributors (with myself as the executive producer) or for someone to “compete” with what I am trying to do- I encourage it!

Yes- absolutely. When I was in medical school I was not given the tools to do this. All it took was a few pointers from my seniors and my presentations dramatically improved. We can teach this in a structured way (I think it was Chad Kessler who published on this) and it works- so I totally agree- interacting with consultants would be high on my list to teach residents (and medical students) early in the game

Swami holding my feet to the fire- love it! One area that is vastly under-represented is process improvement in EM. This is so un-sexy but it leads to major improvements in care. I was thinking about this yesterday as I teamed up with a senior resident to improve our airway equipment and processes- we need more people who are excited in PI on the micro and macro level to get those “best practices” out there for everyone to use.

I have to say I am not a big admin type or one who deals with a lot of personnel issues. My main thoughts on retention is that people need to feel compensated sufficiently for their position and they need to feel that they make a valuable contribution. You don’t need to throw tons of money at people- they need enough to be competitive in your own local market and they need enough to pay the bills and live comfortably. After that they need responsibility and made to feel as if their input matters. Maybe they want to be a “master clinician” and want to improve themselves to be at the top of their game- maybe they want to work to improve things, maybe they want to teach the new providers how to do the job. Find what excites them and makes them want to get them up in the morning and give them the tools to do it.

Delayed Sequence Intubation (DSI) and the pre-ox paper by Weingart and Levitan has dramatically changed my practice for the better. I can’t stress how important it is to avoid desaturation during advanced airway management. Often what we need is just a few more seconds- if you get that with good pre-ox and apenic oxygenation then your difficult airways become much easier. Also- as we talked about before- Dr. Strayer’s Double setup lowers that threshold for the entire room to intervene with a cric. Even if you are by yourself- marking the neck, palpating the anatomy, and having a scalpel and 6.0 tube ready sends a powerful message about what the airway plan is should things go sideways. I see a positive change in the last few years where we are accepting the fact that surgical airways don’t represent a “failed” airway- they represent the final pathway in proper airway management. Just that concept alone I think will save lives. While VL has certainly given us more options, I think this change in thinking and psychology is much more valuable

I have no idea and I don’t think we should be doing that routinely. It’s hard to say “never draw basic labs”- everything has to be by gestalt. In the case of someone who swears they are taking their meds as prescribed I would be interested in a level on something like dilantin (phenytoin) if that is readily available but for others like keppra (levitreatacam sp?) those aren’t readily available. I don’t have a problem with discharging these patients without any labs (especially if you can’t “level” them) with followup with their PCP/neurologist.

Very good question- I will say that abdominal pain re-checks are something I was taught to do in residency but I admit that their yield (especially when doing a CT) is incredibly low. I would put the question back to you- have you found literature to suggest that the rate of complications is anything but negligible in these patients? I am not aware of any- maybe this is something we need to research better. I think abdominal pain rechecks are much more valuable in the pediatric population after a long discussion with the parents about avoiding CT plus or minus an ultrasounds. Anecdotally, I have found more than a few young kids with vague abdominal pain who have mesenteric adenines on their formal abdominal US. In that case it’s great- no radiation and if the kid is PO tolerant they go right home with PCP followup.

Pain control, pain control, and pain control. We do a poor job of managing pain in the waiting room and in the ED. If your institution doesn’t have it, you should empower your nurses with PRN pain medication schedules. I like the 1 + 1 method with dilaudid (hydromorphone)- asking the patient if they want more pain medication 15 minutes after the first dose is an incredibly effective method that has been validated to be effective without causing harm. We should also do a better job of post-intubation analgesia and sedation- especially with the rise of rocuronium. Don’t get me wrong- I love roc and I have now pretty much abandoned suxs in my practice. However, if you give roc and then don’t have a good plan for post-intubation analgesia and sedation, I will find you and I will kill you (insert Liam Nesson voice from the movie “Taken”)

In the waiting room- simple things like tetracaine for suspected corneal abrasions or eye pain are a God-send. I would love to see more intranasal ketamine for waiting room analgesia- it’s been tried and studied and found to be effective in a small pilot study.

You know- I don’t. It’s just not something that I was taught to do and I just don’t think it really has any value. I go by patient response- if they feel better, their wheezing is better, and they aren’t hypoxic then they can be safely discharged. I’m not one to say that this approach is wrong- I just don’t see it helping my decision making a lot in the ED. For example- in a patient who feels better but their FEV is the same or even a little worse I don’t see that changing my decision to admit versus discharge based solely on a number.

Me too! Awesome flick…

That is the million dollar question. I will admit that I had an easier time doing this in the last two years since I was living 2.5 hours away from my wife (and two dogs) and commuting back on the weekend and one weekday a week. That meant that it was easier to schedule my time for projects when I was away from my family. Fortunately, I am back in the same house and city as my wife (who is a peds chief resident 2 years behind me in training). I would say the overarching advice is this- don’t let your projects cut into your family time. Try to schedule those things around your family time or during time when you are both busy. I made it a rule that I would not use weekend time that I could otherwise spend with my wife on EM Basic or other projects. I would find time when she was on-call or otherwise busy with something else to do the podcast. I recall one blog post that talked about a study that showed with dual-physician couples that the biggest determinant of happiness was the percentage of time away from medicine spent together. I think that applies to non-physician couples as well- make sure that you maximize your time away from medicine with your family instead of doing things off on your own. Does that make sense?

I think the first things is setting a good example- be that person that is up to date and is motivated to expand the
ir own knowledge base on everything- not just the exciting stuff. The most motivating mentors for me were the ones that did that. If I was being taught by someone who was stuck in their ways, it didn’t motivate me to learn. As educators and mentors, I think its up to us to guide residents and students on the right path- show them the resources that we use and show them how to accomplish learning in a manageable way. Throwing Rosen’s/Tintinalli’s in front of them and saying “read until your eyes bleed” is just not the way to do it. You’ll get an unmotivated learner who is overwhelmed and just shuts down.

Ah yes- the M and M. I think our department does a good job of keeping it educational and away from finger-pointing but it’s hard for me to say exactly how we have done this. I think it takes good leadership form the top and a spelling out of the ground rules for each session. No matter how many times we have heard the same rules, they bear repeating. I also think having a representative from every involved service does more to help than hinder this. It is so easy to cast stones at someone who is not present but it’s hard to say it to their face- I think it keeps it more professional. During the actual session, it takes someone in a leadership role to bring people back to the systems and not focus on individual “mistakes”. In just about every M and M there is ALWAYS a systems issue to fix- have your leadership focus on that and steer it away from malignant name-calling and accusations. Does that help?

I have a few goals for the upcoming year- I have significant support from my program to expand the podcast and put out material more frequently. The small hiccup will be that I will be deploying to Afghanistan sometime in September for about 4-5 months. I should have internet access to continue the podcast but that will be a major hurdle. I would say that I would like to build up a reserve of episodes so that I can publish on a more regular schedule. To do that I need help! So if you know of any residents or attendings that want to help- please send them my way. I recently opened the door for MS-4s and above to publish episodes or scripts as long as they do it with the supervision of an attending. I have some ideas for airway studies focused on process such as equipment preparation and use of checklists that I would like to get through an IRB to start looking at those as well.

I look at the new sepsis studies as a confirmation that we know what we are doing. I think we now have more freedom to not put that central line in a patient who may meet the technical criteria for sepsis but is doing fine without pressers. I am not advocating letting our guard down on these patients- Rivers made that clear that we can’t do that. However, if we look to find these patients quickly and start aggressive ED resuscitation-ist led care then we don’t need a cookbook in everyone. I am not saying that we should totally thrown out protocols- Seth Treuger said it best- protocols are great for when you are busy or tired and you want to ensure a certain baseline of care. The earlier sepsis studies showed us we need to be aggressive- we responded by being aggressive and I think that is what those studies taught us the most. Now we are at the point where we can use our judgement as clinicians and not adhere to a rigid protocol and do unnecessary procedures when we think they aren’t needed.