Rehearse on a sheet of newspaper: An acting coach critiques my SMACC keynote and tells me how I can do better

I thought there was nothing more excruciating than listening to myself in audiocasts, but then I was video-recorded at SMACCDub, and discovered that watching myself on video is even worse. So I sought the advice of a professional acting coach to improve my presenting mojo. I sent her the video of my presentation and she responded …

The Harms of Fasting

The following is adapted from my contribution to this discussion of how best to manage unfasted patients who require deep sedation to facilitate a painful procedure. I am responding mostly to Nicholas Chrimes, a thoughtful Australian anesthesiologist behind The Vortex Approach to airway management.  Because aspiration leading to clinically relevant morbidity is a rare event and is …

When RSI isn't the Right SI

Rapid sequence intubation, the simultaneous administration of a paralytic and induction agent immediately followed by laryngoscopy, provides the optimal view of the glottis and prevents emesis. RSI is the best strategy for most patients who require intubation, but not all. When you’ve decided to intubate, first maximally preoxygenate. If the patient will not cooperate with …

The Emergency Department Double Setup

  The double setup is an airway management strategy conventionally carried out in the operating room, in a stable or relatively stable patient who requires a definitive airway but is anticipated to be very difficult to intubate orally. An otolaryngologist or other surgeon fully prepares to perform a cricothyrotomy or tracheotomy–patient prepped, all equipment laid …

Hypertension and the Emergency Physician

  There are two kinds of hypertension encountered by emergency physicians: hypertensive emergencies, and hypertension. The term hypertensive urgency has minimal meaning, less than minimal utility, and should be abandoned. Patients with a hypertensive emergency are critically ill. They need to be in a resuscitation area on intravenous antihypertensive drips. The hypertensive emergencies are acute …

When the patient can’t breathe, and you can’t think: The emergency department life-threatening asthma flowsheet

Another case report demonstrates the utility of dissociative-dose ketamine in the deteriorating asthmatic. Life-threatening asthma is uncommon and difficult to study; we may never have better evidence and it’s time to add ketamine to the kitchen sink. This flowsheet incorporates ketamine into a stepwise approach to the severe asthmatic for the emergency clinician who may …

Dexmedetomidine has found its home in the ED: Pediatric painless procedures

Dexmedetomidine (trade name Precedex) is an alpha-2 receptor agonist, similar to clonidine. Whereas clonidine provides a robust decrease in blood pressure with mild sedation, dexmedetomidine provides robust sedation with a mild decrease in blood pressure. It does not depress airway reflexes or respiration. It has a variety of potential uses in the emergency department, including …