Contributor: John Winkler, MD Educational Pearls: Unstable ventricular tachycardia (VT) typically manifests with syncope, shortness of breath, diaphoresis and/or chest pain with hemodynamic instability Electrical cardioversion of unstable ventricular tachycardia is first line treatment Starting with a higher energy level (or just using the maximum) when performing cardioversion may set you up for better success as many providers feel the first shock has the highest likelihood of success References Dresen, W.F. Ferguson, J.D. Ventricular Arrhythmias. Cardiol Clin. 2018 Feb;36(1):129-139. doi: 10.1016/j.ccl.2017.08.007. Epub 2017 Oct 27. Goyal, A. et al. Synchronized Electrical Cardioversion.StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020-. 2020 Feb 13. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD 

Emergency Medical Minute

Podcast 568: Shock ‘em! 

Contributor: Aaron Lessen, MD Educational Pearls: Mechanical CPR (machine assisted compression devices) remains a hot topic of debate in emergency medicine Machine assisted CPR has been advocated to provide more consistent compressions in cardiac arrest and free up staff for other tasks. However, multiple studies have shown mechanical CPR provides no significant survival benefit yet increased rates of injury to the chest and abdomen from the devices. Unless a clear benefit can be found, mechanical CPR devices should not routinely replace traditional CPR in most situations For prolonged transport as well as resource-limited settings, these devices still may provide the only option for sustained resuscitations References Bonnes, J. et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med. 2016 Mar;67(3):349-360.e3. doi: 10.1016/j.annemergmed.2015.09.023. Epub 2015 Nov 19. Wang, P. Brooks, S. Mechanical Versus Manual Chest Compressions for Cardiac Arrest. Cochrane Database Syst Rev. 2018 Aug 20;8(8):CD007260. doi: 10.1002/14651858.CD007260.pub4. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD 

Podcast 567: Mechanical CPR….Not So Fast

"Go unafraid! And also know that you got to reach out to the right people and hold on to those people no matter what they look like, no matter what background they come from...Find people who are positive in your life who can help you. If I'm one of those people, reach out to me."   Russell J. Ledet hails from Lake Charles, Louisiana. After serving in the U.S. Navy, he attended Southern University and A&M College for his undergraduate degrees in biology and chemistry. Afterwards, he went on to complete his Ph.D. in molecular oncology at New York University. He is currently a second-year MD-MBA student at Tulane University School of Medicine and A.B. Freeman School of Business. He is the co-founder and president of 'The 15 White Coats', a non profit organization focused on helping people of color get into medical school and improving the cultural literacy of our learning spaces.    The 15 White Coats website: https://www.the15whitecoats.org/   Get in touch with Russell: E-Mail: Russell.ledet@gmail.com Twitter: @theguywithyes Instagram: @maleahandmahlinasbaba   

Selected Audio from 'UnfilterED #7: Russell J. Ledet, Ph.D.'

Russell J. Ledet hails from Lake Charles, Louisiana. After serving in the U.S. Navy, he attended Southern University and A&M College for his undergraduate degrees in biology and chemistry. Afterwards, he went on to complete his Ph.D. in molecular oncology at New York University. He is currently a second-year MD-MBA student at Tulane University School of Medicine and A.B. Freeman School of Business. He is the co-founder and president of 'The 15 White Coats', a non profit organization focused on helping people of color get into medical school and improving the cultural literacy of our learning spaces.    In this very special episode of UnfilterED, Russell speaks candidly about his childhood, the challenges that made him the man he is today and his plans for the future, including The 15 White Coats' goal to put an individual of color through medical school debt-free.    Time Stamps: 1:53 - Russell’s Introduction 6:50 How have you learned from your experiences and where you came from? 9:30 - Entrepreneurship at a young age 14:15 - Russell's Faith 16:20 - Joining the Navy 20:30 - Role Models 32:40 - Visiting the Whitney Plantation and the origin of The 15 White Coats 44:40 - The future of The 15 White Coats 53:00 - What is your take home message for a young person of color listening to this interview?   The 15 White Coats website: https://www.the15whitecoats.org/   Get in touch with Russell: E-Mail: Russell.ledet@gmail.com Twitter: @theguywithyes Instagram: @maleahandmahlinasbaba     Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/

UnfilterED #7: Russell J. Ledet, Ph.D.

Contributor: Jared Scott, MD Educational Pearls: Cholera has been responsible for 6 previous global pandemics and currently the world is in the seventh pandemic of cholera, ongoing since 1961. Cholera originated in the Ganges Delta of India and spread worldwide but largely is unseen in the US and other developed countries due to water sanitation Cholera is a bacterial illness that is water borne and causes severe diarrhea Estimates say that there are 1.3-4 million cases annually and up to 143,000 people die each year from Cholera. Treatment is largely supportive and can be done with oral rehydration therapy consisting of water, salt, and sugar. There are three oral vaccinations for Cholera but unfortunately are not widely available Cholera has been responsible for ushering in public health initiatives. Most famously when John Snow was able to isolate a single water source causing Cholera infections in London and by shutting it off eradicated the bacteria References “Cholera.” World Health Organization, World Health Organization, 17 Jan. 2019, https://www.who.int/news-room/fact-sheets/detail/cholera Clemens JD, Nair GB, Ahmed T, Qadri F, Holmgren J. Cholera. Lancet. 2017;390(10101):1539‐1549. doi:10.1016/S0140-6736(17)30559-7   Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD  

Podcast 566:  The Cholera Pandemic

Contributor: Nick Hatch, MD Educational Pearls: A cesarean scar ectopic pregnancy occurs when the pregnancy implants along the scar tissue deep in the myometrium from a prior cesarean surgery, felt to be precipitated by a small fissure or fistula residual in the scar Diagnosis can be challenging and ultrasound may not clearly show this type of ectopic pregnancy MRI has been successfully used for diagnosis as well Various treatment options exist including medical and surgical management but if left untreated, cesarean ectopic pregnancies are life threatening References Gonzalez N, Tulandi T. Cesarean Scar Pregnancy: A Systematic Review. J Minim Invasive Gynecol. 2017;24(5):731‐738. doi:10.1016/j.jmig.2017.02.020   Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD    

Podcast 565: Cesarean Scar Pregnancies

Host: Elizabeth Esty, MD. At this point, with so many of the studies we’ve digested exploring correlations, associations, observational studies and anecdotal reports and speculation, we could subtitle the show: what we don’t know about COVID. And so, today, we’ll look at what we don’t know about Vitamin D and COVID. There have been a number of studies and a fair amount of media coverage in recent weeks that look at a possible link between low Vitamin D levels and severity of COVID.  Vitamin D plays a role in both adaptive and innate immunity, which we discussed at some length in our episode on the BCG vaccine and COVID. Macrophages starved for Vitamin D can’t produce peroxide to kill microbes, and some of the toll-like receptors crucial to innate immunity that recognize pathogen molecules don't work right without Vitamin D. Finally, Vitamin D modulates the immune response, preventing release of too many cytokines. The potential for Vitamin D to play a role in preventing severe COVID-19 seems plausible, but what does the science say? Research By: Elizabeth Esty and Nathan Novotny. Sound Editing By: Nathan Novotny. References: [1] Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. 3, Overview of Vitamin D. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56061/ [2] Helming L, Böse J, Ehrchen J, et al. 1α,25-dihydroxyvitamin D3 is a potent suppressor of interferon γ–mediated macrophage activation. Blood. 2005;106(13):4351-4358. doi:10.1182/blood-2005-03-1029   [3] Parva NR, Tadepalli S, Singh P, et al. Prevalence of Vitamin D Deficiency and Associated Risk Factors in the US Population (2011-2012). Cureus. 10(6). doi:10.7759/cureus.2741 [4] Sizar O, Khare S, Goyal A, Bansal P, Givler A. Vitamin D Deficiency. In: StatPearls. StatPearls Publishing; 2020. Accessed May 21, 2020. http://www.ncbi.nlm.nih.gov/books/NBK532266/ [5] Ilie PC, Stefanescu S, Smith L. The role of vitamin D in the prevention of coronavirus disease 2019 infection and mortality. Aging Clin Exp Res. Published online May 6, 2020. doi:10.1007/s40520-020-01570-8 [6] Vitamin D and Inflammation – Potential Implications for Severity of Covid-19 – Irish Medical Journal. Accessed May 21, 2020. http://imj.ie/vitamin-d-and-inflammation-potential-implications-for-severity-of-covid-19/ [7] Raharusun P, Priambada S, Budiarti C, Agung E, Budi C. Patterns of COVID-19 Mortality and Vitamin D: An Indonesian Study. Social Science Research Network; 2020. doi:10.2139/ssrn.3585561 [8] The Center for Evidence Based Medicine. Vitamin D: A rapid review of the evidence for treatment or prevention in COVID-19. CEBM. Accessed May 21, 2020. https://www.cebm.net/covid-19/vitamin-d-a-rapid-review-of-the-evidence-for-treatment-or-prevention-in-covid-19/ [9] Hastie CE, Mackay DF, Ho F, et al. Vitamin D concentrations and COVID-19 infection in UK Biobank. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020;14(4):561-565. doi:10.1016/j.dsx.2020.04.050

COVID-19 Digest: The Possible Link Between Severe COVID-19 and Low Vitamin D Levels (Recorded 5/21/20)

Jordan sits down to discuss trauma with Dr. Kaysie Banton, the Trauma Services Medical Director at Level 1 Trauma Center Swedish Medical Center in Englewood, Colorado. In this laid back interview, Dr. Banton discusses how the COVID-19 has affected trauma volumes at Swedish. While trauma as an aggregate hasn’t decreased, the types of trauma for the time of year have shifted as well as the acuity of injuries that present. This episode focuses on how public opinion surrounding the pandemic has shifted the way patients seek care, how delays to seeking care changes her role as a trauma surgeon and what is being done at hospitals to emphasize the safety of patients amidst COVID. Jordan and Dr. Banton talk about how EMS can shift their interview and examinations with this type of behavior in mind. As people delay their care for fear of contracting COVID-19, traumatic injuries that might only require a day or two in the hospital are worsening while untreated and progress to stages that are unnecessary. Dr. Banton leaves medical practitioners with a call to action to educate the public about the benefits of seeking medical care as one normally would outside the pandemic to avoid the worsening of an injury.

On the Streets #5: Trauma during COVID-19

Contributor: Nick Tsipis, MD Educational Pearls: Recent randomized controlled trial compared early intervention (PCI/CABG) to medical management for those diagnosed with moderate to severe cardiac ischemia on stress testing Primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest Secondary outcome was death from cardiovascular causes or myocardial infarction. The study reported that patients who had more aggressive invasive procedures early on in treatment had a 2% increase in poor outcomes in the immediate period after intervention (6 months) but long term had a 2% decrease in poor outcomes. Overall the mortality was essentially identical between the two groups References 1) Maron, D.J., et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9;382(15):1395-1407. doi: 10.1056/NEJMoa1915922. Epub 2020 Mar 30.

Podcast 564:  Cardiac Ischemia Management Update

Contributor: Nick Hatch, MD Educational Pearls: An AC (acromioclavicular joint) separation in the shoulder is a common traumatic injury XRs can help rule out other injuries as well as help with grading the injury There are six different grades for AC separations: Grade I: is stretching of the AC ligament without disruption or displacement of the clavicle and recovers with time. Grade II:  is partial tearing of the AC ligament with some displacement but will also heal with time. Grade III: is a full separation with ligament rupture and may require surgery but is not always indicated. Surgery is more common in active patients. Grades IV, V, and VI are severe separations and all require surgery. Other ligament damage or tears, like a slap injury, can mimic an AC separation and often require surgery but should remain on the differential diagnosis when working up shoulder trauma. Setting expectations is key. Patients with a grade 1 or 2 separation should expect 6+ weeks of limited range of motion and up to 12 weeks until return to full function. Cosmetically there may be a persistent bump on the shoulder. References van Bergen CJA, van Bemmel AF, Alta TDW, van Noort A. New insights in the treatment of acromioclavicular separation. World J Orthop. 2017;8(12):861‐873. Published 2017 Dec 18. doi:10.5312/wjo.v8.i12.861   Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD 

Podcast 563:  DC ACs

Host: Elizabeth Esty, MD. Smoking is known to increase both susceptibility and severity of all manner of colds and pneumonias, so you’d think the world's 1.1 billion smokers would be at risk in this pandemic of what at first seemed to be a just a respiratory virus.  What’s more, tobacco smoking increases risk for COPD, diabetes and coronary disease, so it may increase risk for more severe COVID indirectly. So it’s remarkable that preliminary evidence suggests that smokers may be less likely to be harmed by COVID than non-smokers. A story that’s gotten a fair amount of attention in the media concerns reports from France that smoking may be protective against COVID. We took a closer look and found that similar reports are coming in from across the globe, including the US. We decided to take some time to look at papers and attempt to explain this relationship.  Research By: Elizabeth Esty, MD. Sound Editing By: Nathan Novotny. References: [1] Miyara M, Tubach F, Pourcher V, et al. Low incidence of daily active tobacco smoking in patients with symptomatic COVID-19. Qeios. April 2020. doi:10.32388/WPP19W.3 [2] Guan W, Ni Z, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020;382(18):1708-1720. doi:10.1056/NEJMoa2002032 [3] Chow N, Fleming-Dutra K, Gierke R, et al. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382-386. doi:10.15585/mmwr.mm6913e2 [4] Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. April 2020. doi:10.1001/jama.2020.6775 [5] Berlin I, Thomas D, Le Faou A-L, Cornuz J. COVID-19 and Smoking. Nicotine Tob Res. doi:10.1093/ntr/ntaa059 [6] Farsalinos K, Niaura R, Houezec JL, et al. Editorial: Nicotine and SARS-CoV-2: COVID-19 may be a disease of the nicotinic cholinergic system. Toxicology Reports. doi:10.1016/j.toxrep.2020.04.012   Photo Sourced From: https://www.henryford.com/blog/2020/04/smoking-and-vaping-increase-covid-risks

COVID-19 Digest: Could Cigarette Smoking Actually be Protective Against COVID?

Contributor: Nick Tsipis, MD Educational Pearls: Case series reported 5 cases of generally young and healthy patients with COVID-19 who presented to the ER with acute stroke Now several case series showing cardiovascular involvement or complications related to COVID-19 While these case series may shed light on the nature of COVID-19 complications, it's worth remembering that so far these cases represent a few unique instances and we need more studies and data to pronounce COVID-19 infected patients at higher risk of thromboembolic events like strokes and heart attacks References Oxley, T. et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. April 28, 2020. DOI: 10.1056/NEJMc2009787 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD 

Podcast 562:  COVID-19 Occlusions

Contributor: Don Stader, MD Educational Pearls: Buprenorphine has been shown to decrease morbidity and mortality in opioid use disorder Buprenorphine used in naloxone-induced withdrawals can displace naloxone at opioid receptors, leading to reduced withdrawal symptoms and lessen the chance of using after discharge Patients in acute withdrawal due to naloxone after an overdose should be given Buprenorphine. Data shows that withholding Buprenorphine leads to increased mortality rates of 5% within the following month, and 10% in the following year. References Herring, Andrew. “Emergency Department Medication-Assisted Treatment of Opioid Addiction.” Chcf.org, Aug. 2016, www.chcf.org/wp-content/uploads/2017/12/PDF-EDMATOpioidProtocols.pdf. D.H. Cisewski et al. Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. American Journal of Emergency Medicine 37 (2019) 143–150   Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD 

Podcast 561:  Give Bup

In the US, few people receive vaccination for tuberculosis (TB), a disease that hasn’t been a major killer here for many decades.  But while we in the US mostly experience TB as a relatively rare but real threat in its multidrug resistant form, particularly in pts with HIV--or in Victorian novels--TB still kills 2 million people a year. There is a vaccine for TB, a live attenuated vaccine called BCG for Bacille Calmette-Guerin. In fact it’s the most widely used vaccine on earth, and an estimated 4 billion people have received it since was first administered to a baby whose mother died of TB a few hours after giving birth in the summer of 1921.  This connection of this vaccine to COVID caught our attention when a friend suggested a few weeks ago that Russia and other parts of the world where BCG vaccination is routine might be shielded from the worst COVID outbreaks. In the intervening weeks, as Russia grapples with its own COVID epidemic, that possibilty seems less tenable, but it did lead us down an interesting research path. Host: Elizabeth Esty, MD Research By: Elizabeth Esty, MD Sound Editing By: Nate Novotny References: Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu GH. Correlation between Universal BCG Vaccination Policy and Reduced Morbidity and Mortality for COVID-19: An Epidemiological Study. Epidemiology; 2020. doi:10.1101/2020.03.24.20042937 Kleinnijenhuis J, Quintin J, Preijers F, et al. Bacille Calmette-Guerin induces NOD2-dependent nonspecific protection from reinfection via epigenetic reprogramming of monocytes. Proceedings of the National Academy of Sciences. 2012;109(43):17537-17542. doi:10.1073/pnas.1202870109 Arts RJW, Moorlag SJCFM, Novakovic B, et al. BCG Vaccination Protects against Experimental Viral Infection in Humans through the Induction of Cytokines Associated with Trained Immunity. Cell Host & Microbe. 2018;23(1):89-100.e5. doi:10.1016/j.chom.2017.12.010 Further Reading: https://www.who.int/news-room/commentaries/detail/bacille-calmette-gu%C3%A9rin-(bcg)-vaccination-and-covid-19 https://clinicaltrials.gov/ct2/show/NCT04328441 https://www.mpg.de/14491738/0219-mpin-116799-modified-tuberculosis-vaccine-as-a-therapy-for-cancer-of-the-bladder

COVID-19 Digest: Bacille Calmette-Guérin (BCG) Vaccine for Treating COVID-19

Contributor: Don Stader, MD Educational Pearls: COVID-19 commonly appears as a bilateral patchy infiltrate on chest radiograph, but this is a non-specific finding  Sensitivities range from 17-70% for COVID-19 Many other viral pneumonias such as RSV and influenza can have similar findings Point-of-care ultrasound (POCUS) demonstrates B-lines, water-fall sign, or hepatization of the lung, but these are also non-specific Computerized tomography (CT)  appears to be one of the more sensitive tests for detecting COVID-19, demonstrating ground-glass opacities - often before or without the patient having symptoms However, routine use of CT for diagnosis COVID-19 is strongly discouraged by many medical societies and the CDC Imaging may not be necessary in most patients presenting with suspected COVID-19 for multiple reasons: Diagnosis is often clinical suspicion, with or without confirmatory PCR testing (if available) Imaging does little to change the management in the majority of patients with COVID-19 Obtaining imaging exposes additional healthcare workers Cleaning protocols for units (especially CT) can be extensive and require significant downtime of the machine, thereby leading to delays in care References Farkas, Josh. “COVID-19.” EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs. Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China.  February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Podcast 560: Imaging in a COVID world

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

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Emergency Medical Minute

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