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

smaccdub-still

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 with these notes, which were so useful that I felt they were worth sharing.

 

Overall this is a strong talk, and you’re an engaging speaker. I enjoyed watching it. I have some thoughts on how you can fine-tune a few things, presented here in roughly chronological order.

One thing that stands out to me is that you tend to speak with your brows up, which makes your forehead get wrinkly and “hard.” This is a response to mild nervousness on your part which causes mild anxiety in your audience. If you can relax your forehead a bit, that would be great. To wean the habit, either get a gentle round of botox, or put a piece of scotch tape vertically on your forehead (from top of nose to hairline) while you rehearse the presentation. It will give you biofeedback when you wrinkle your brow. It will be distracting as hell, but it will help you gain awareness of the habit.

You tend to shift your weight a bit, which is probably not as distracting in person but on camera it’s too much movement; stillness would be better. This also comes from nerves–you don’t do it at all at 17:00, but you do it quite a bit around 2:20. When you’re comfortable, your body will reflect that state with increased stillness and more purposeful movements; you will shift your weight when you shift tone or subject, rather than doing it compulsively at unmotivated moments.  Again, biofeedback will help–my advice to young actors is to rehearse the talk while standing, wearing shoes, on a sheet of newspaper, so you can hear when your weight shifts. Wearing different shoes for your talks might help, too–the foam soles on those sneakers are going to make your entire stance more bouncy. Springy soles are good to help “lift” performers who tend to be overly rooted- but in your case that’s not a problem; harder soles would help ground you.

Weight shifting and tense forehead are very common reactions to the stress of presenting (other people nod their heads weirdly, or pace, or clear their throats, wring their hands, or any number of other tics). It will likely take months to wean these habits, don’t stress, you’re pretty good on these fronts already–working on them is just that last little bit of polish.

Around 12-13 mins in, when you talk about thrashing delirious people, you’ve really warmed into it–your delivery is smoother and more natural, and it feels like you’re speaking more in your own native turn of phrase to people you know, rather than giving a speech. That’s a sweet spot for you. You might be able to reverse-engineer this level of comfort; try to remember how you felt at that part of the presentation, dissect the reasons, and then recreate that feeling elsewhere in the presentation. Ideas for how to get that warmed up feeling at the top of the presentation:

– Give yourself a calm, private, focused atmosphere before starting the presentation. For instance, hide in a restroom far from the crowd, or duck into an empty room or stairwell, and rehearse the easiest, smoothest part of the script right before you start the presentation. This will help you tap into the emotional state of calm confidence. For rehearsal, try to create physical conditions that are as much like your performance as possible–stand up and look out at a large open space, focusing your gaze on at an imaginary audience, rather than looking down, looking into a corner, or letting your gaze turn inwards into memory land. Muscle memory works–harness it by rehearsing your stance and eyelines accurately (more on eyelines below).

Imagine a specific person in the audience and speak just to them. Pick a person who likes you, who’s interested in this subject and roughly as knowledgeable as the rest of the audience, and who you are NOT nervous about. Usually I find my nerves come from one or two specific imaginary or real people whom I catastrophize are peering at me from the audience and judging me. If I shift my imagined audience to just ONE person who I know is the perfect target for this talk, my tone will be right for the whole room. So never imagine “ladies and gentlemen,” instead imagine “talking to Greg” or whatever it takes. Who are you talking to? is question #1 for all acting, and public speaking is a form of acting. If the ideal target person is someone you’re close with and the talk is really important or intimidating, you could even go so far as to call them up and ask if you can deliver the talk to them privately as a form of intensive rehearsal.

– Alter the writing so the beginning of the presentation is more colloquial and less technical, which will help it sound more natural even if you feel a bit stressed.

– Add more jokes off the top. Jokes are great as you know, because they (a) engage the audience, (b) get the audience’s buy-in so they will cut you slack if you make errors or annoy them later, and (c) give you feedback – their laugh is authentic proof they like you and are listening, so you can relax.

As you’re rehearsing, pay attention to any parts of the presentation that consistently make you nervous or uncomfortable. Spend extra time on them and rewrite those parts if necessary–try not to have any sections that you dread, even a little bit. If you find a specific part of the talk is particularly hard to memorize, it’s a clue that the writing is weaker – perhaps you’ve inadvertently created non-sequiturs or used awkward phrasing. Rewrite those parts until they flow smoothly and are easy to memorize. This is a classic playwrights’ rule of thumb: good writing is easy to memorize.

Around 19:00 (ketamine) and again around 22:00 (CT/LP) you get a bit…intense. Intense for you is kind of a relative term, as you’re pretty mellow/consistent, but in these sections your pace accelerates and your tonal range flattens. Can you identify why? Is it because you’ve spoken about K so much that you’re going a bit by rote? Are you worried about time? Identify and address the cause so the tone through this segment can be a little calmer and more gracefully shaped–the ketamine part feels a bit like a bullet train. Maybe add some more jokes.

Are you reading a prompter? Your eyeline to the prompter is too low; can you raise the physical location of the prompter so your eyes are higher when reading it? Eyeline is important and often overlooked. I think you’re doing this pretty well already, but it bears mentioning: be sure your eye contact includes the whole audience. Eye contact is the net you use to draw the audience in–make sure to cast it out wide enough to get them all. Look at both sides right out to the edges, the front row, the back row, and right up to balcony.

I think it’s best to make true eye contact with specific people for about 3 seconds each, but if that freaks you out, you can cheat by looking at the spaces between their heads, and you can have a few default gaze targets that are along the back of the room, about a foot above the heads of the people in the back row. Angling your gaze upwards in this way helps your words to travel “up and out” to the audience, which draws them in–the amateur opposite is to look only at the front couple of rows, which creates a low, downwards eyeline, shoots your ideas into the floor, and shuts the back of the audience out. When you look slightly upwards, we can see you and connect with you better.

Answer this question out loud: What color is your bedspread? Your eyes probably darted up and to the right–but sort of blindly–as you remembered the answer. We tend to “look at nothing” for a second when we’re concentrating–for instance, carefully delivering a memorized speech–and those glazed, spaced-out eyes are a hindrance to connecting with the audience. So, as my favorite acting teacher used to holler at us mid-monologue, keep your gaze in the room. Work on being able to really look at people during your talk, rather than, say, hyperfocusing on the exit sign or sweeping your eyes around blindly. You want to actually see the people. You can practice at home by sticking little faces cut from magazines all over the wall (or use sticky notes with little faces drawn on), and actually look at each face for a few seconds as you speak. Or just look at actual objects in the room: the doorknob, the teapot, the rice cooker. Make sure your eyes are alive enough to really notice what you’re looking at, which will ensure that your eyes–like your feet, in an ideal world–are moving deliberately and with purpose.

The goal here is to keep your eyes, and by extension your awareness, alive, present in this room at this moment–to keep your eyes receiving, not just sending. A talk needs to send a message OUT, yes, but great speakers are great because they are simultaneously taking the audience IN. In most normal conversations, you probably achieve this state of simultaneous broadcast-and-reception without really trying; but when the pressure of the speech hits, we tend to shut down our receiving capabilities and become little automaton radios spitting pre-programmed words at the audience, so the listener may feel talked-at and tune out to some extent. During a speech, your ideal state of being is present and aware enough that if someone sneezed, you’d hear them and be able to say gesundheit without skipping a beat. Achieving this kind of awareness is super-advanced and takes a lot of time and practice- but it is truly the tipping point from good to great. As a bonus, it will also help ease your forehead tension and improve your posture–we tend to raise our brows and push our faces forward when we’re emphatically projecting, as though our ideas are a unicorn horn we’re stabbing at the audience–but when we are empathetically listening without judgement, our foreheads relax and our eyes soften, which lets the audience relax and allows them to hear you better.

Your little microphone cord loop at the back of your neck keeps distracting me. Look in a mirror and tuck that shit in.

Your tiny smiles when you’re about to make, or have just completed, a joke are delightful. It’s always fun to see someone enjoying themselves. This is why we love Saturday Night Live the most when the actors break character and giggle.

Try to wean out the phrase “you guys” (it comes up in the Q&A at 25:00), and replace with “you” or “you all”, etc.  “You guys” is gendered and lacks gravitas.

You also mentioned, and I agree, that in general your posture could use a bit of an adjustment. As a diagnostic, try this: stand up, open your arms wide into a T and then drop them back down. Your hands will probably end up in front of your thighs naturally (here is an exaggerated version). Now do it again, but this time slowly and deliberately lower your hands beside you, so your thumbs end up resting along the side-seams of your pants. As you lower your arms, try to initiate that final hand position long before you get there, and from your back rather than from your arms or chest–it should not feel like holding your arms back or puffing your chest out, it should feel more like you are pulling your shoulder blades gently together–that’s the posture you want.

You can do exercises to enhance this:  try things that open your arms wide against resistance, like bent dumbbell flies where you try to get hands higher than shoulders, to strengthen / tighten your trapezius and latissimus dorsi muscles, or do incline dumbbell flies with low weight, but relax your arms outwards and let gravity and the weights stretch your pecs and biceps. And try to place your head over your spine rather than out in front of your spine. You can also add in some pec stretches in doorways and against walls and on balls. Yoga would be a good challenge for you.

Improving your posture is a very long term thing- it would be hard and distracting and probably a bad idea to think about it during presentations so I suggest working on it during workouts and in your regular life- once you have it as a normal habit, it will happen automatically onstage. I spent YEARS fixing my posture in acting classes, singing classes, yoga, and even flute lessons, before it became second nature.

Strengths overall: You have strong content to offer, your voice is pleasant, well-articulated, comfortable and easy to listen to–you’re breathing well and using your vocal instrument in an easy, natural way. The talk is well-written, strikes a good balance between natural and formal, and it’s interesting, even to a non-clinician, which I think is saying a lot. It’s obviously a great talk, and you deliver it very well. Would love to see the next iteration of it.

Nicole Stamp is a toronto-based director, actor, and acting coach.

Opioid Misuse: Tools for the Emergency Provider


[pdf format]

Buprenorphine Patient Information / Discharge Instructions (c/o RM) [.rtf]

Buprenorphine Home Initiation Patient Handout

HelpCardHelpCardFrontHelpCard Back

 

 

 

 

 

HelpCard for printing with your printer

HelpCard for submitting to printing company

 

Pain & The Poppy: Emergency Care During An Addiction Epidemic

Slideset

Pain, Compassion, Addiction, Malingering

How to use opioids and how to not use opioids

Video + Slides (University of Toronto) (35 minutes + questions)

SMACC 2015 Audio (right click to download) (25 minutes)

SMACC 2015 Slideset

SMACC Podcast Page

EM Cases Discussion with Anton Helman and David Juurlink

 

opioid misuse flow

Opioid Discharge Instructions

You are being discharged with a prescription for an opioid pain medication. Opioids are powerful analgesics that can be very effective for pain but also have the potential to harm you.  You should only take opioid pain medications if you are still suffering with pain after you’ve optimized non-medication strategies (rest, position of comfort, ice, heat, etc) and non-opioid medications such as acetaminophen (Tylenol) and ibuprofen (Motrin).  Take opioid pain medications as prescribed; do not take more than prescribed or take the pills in a different way than prescribed.

Opioids often cause constipation, nausea, and itching. Opioids can also cause more dangerous problems such as feeling ill, excessive sleepiness, confusion, and falls. Older people and people with liver or kidney disease are more prone to these harms. You should not drive or perform dangerous work while using opioid pain medications.

If you take too much opioid pain medication, your breathing can slow or even stop, which can be fatal. This is how people die from an opioid overdose.

Opioids can cause acute physical dependence after only a few days, which means that if you take opioid pain medications for a few days and then stop, you might experience withdrawal symptoms such as muscle aches, pain, insomnia, feeling nauseated and ill, depressed, agitated, or anxious, and you might even crave more pills. If you take more opioid pills, these symptoms will be greatly relieved, however this is the beginning of a very dangerous cycle of dependence, which can lead to addiction. If it is possible that you are experiencing acute physical dependence, do not take more opioid pills and discuss the problem with your doctor.

Lastly, once this painful episode is over, dispose of any unused pills–you can take them back to the pharmacy or flush them down the toilet. Leftover opioid pills can be extremely dangerous to children, and are a major source of recreational use, especially among adolescents and young adults.

 

Opioid Misuse Phraseology

My job is to manage your pain at the same time that I manage the potential for some pain medications to harm you.

I know you are in pain and I want to improve your pain, but I believe that opioids are not only the wrong treatment for your pain, but that opioids are the cause of your pain. I think pain medications are harming you, and if you could stop taking them, your pain and your life would improve. Can I offer you resources that will help you stop taking pain medications?

Prescription pain medications, even when used as directed, can cause patients to become dependent, and I’m concerned that the pills we prescribed for you in the past, even though you were using them appropriately, you may now be dependent on them. We can help you break free of that dependence.

My most important job as an emergency doctor is to make sure there’s no emergency, so I would like to do some tests to make sure there’s nothing dangerous happening to you, and also I want to relieve your pain. But you will not receive any opioids while you are here, because I think opioids could be harmful to you.

Here is your prescription. I am not entirely comfortable giving you this prescription because I am concerned that you are being harmed by these pain killers. When you decide that you want to stop using these drugs, and I hope you do, we can help you. Here is a list of resources available to help you stop.

 

opioid-alternatives

 

Opioid Misuse Spectrum

 

NIDA resource page – includes bup pathway, video, discharge instructions.

NYC DOH resource page – includes great patient bup info links

 

 

John Oliver’s stunningly comprehensive, dead on accurate, often hilarious take: (20 minutes)

Your new angiocath will not relieve tension pneumothorax

Conventional teaching for treatment of confirmed or suspected tension pneumothorax in an unstable patient is immediate chest decompression with a large bore angiocatheter [1]. New generation angiocaths feature blood control technology, which allows a flash of blood to rise into the hub but will not transmit that blood out the end, which increases safety and decreases messes. Half of the departments I work in now stock blood control angiocaths; since this device is more expensive than its predecessors, you can expect all american hospitals will soon move to them.

Notice the blood control valve, which adds length to the hub compared to the same catheter without this feature.

BC Valve

 

2016-04-21 06.47.58

 

The blood control valve prevents blood from flowing out the hub but also prevents any other fluid from flowing through the catheter, including air. So stabbing your pneumothorax patient with this device will not decompress the chest.

Fortunately the valve opens permanently when it is pushed down by IV tubing, or by attaching a syringe.

valve is closed

attach syringe

now valve is opened

 

So place the angiocath as usual, then take a syringe, pull out the plunger, and twist it firmly onto the hub, until you hear your rush of air.

There are all sorts of problems with using any needle or angiocath to decompress pneumothorax, especially if you use the usual anterior approach, and you are better off in most cases performing a finger thoracostomy or quickly placing a chest tube. But if you do use an angiocath, be mindful of blood control technology, because if you place a catheter thinking you’ve relieved tension but you haven’t, now you’ve made a real mess.

BC angiocath in package

 

[1] See chapter ten of the sixth edition of Roberts and Hedges.

[2] I’ve pictured the Becton Dickinson device but many angiocath manufacturers offer the same feature under a variety of names.

Avoid Alcohol Withdrawal Admissions

 

NAAW

 

Alcoholic patients are predisposed to many dangerous conditions and present an array of management challenges for emergency providers, however at many centers, some of these patients present with uncomplicated alcohol intoxication and end up admitted for alcohol withdrawal. This serves no one’s interests because alcohol withdrawal is a condition that generally does not benefit from inpatient management; detoxification proceeds over several days and the patient is discharged, unfortunately often to resume drinking, no better off than before.

Though some alcoholics present in advanced withdrawal, requiring aggressive management and an ICU or step-down bed, many (most?) patients admitted for alcohol withdrawal present to the ED intoxicated and develop withdrawal in the department. Admitting this group is at best pointless and usually avoidable. There’s a lot of literature and discussion around treating alcohol withdrawal, but very little on how to prevent it, which perhaps is part of the problem.

The first step is to identify patients at risk for withdrawal. The most obvious risk factor is a history of alcohol withdrawal, especially prior admission for alcohol withdrawal; ideally these patients would be flagged at triage. Anyone who drinks every day is at risk, though. Most at-risk patients arrive to the ED drunk, but if a daily drinker presents not drunk (i.e. comes with some other concern) or is in early withdrawal, promptly dose librium and reassess.

Intoxicated alcoholics at risk for withdrawal should be reassessed frequently for alertness. Once the sobering alcoholic is alert he is at risk for withdrawal and the most pressing concern is whether he can be safely discharged. If yes, discharge.*  If he cannot be discharged for whatever reason (requires sutures, psychiatry, social work, an xray, etc.), dose librium and reassess (and re-dose) every hour or two, until he can be discharged or needs to be admitted for some other reason.

Librium dosing. I see librium dosed at 25 or 50 mg, which works as part of a taper in mild withdrawal, but is often inadequate in the severe alcoholic whose last drink was 8 hours ago. You can succeed with small doses if you’re able to keep a very close eye and redose frequently as needed, but in most busy ED’s, you’re better off with a bigger dose, which will give you more time to circle back to reassess. For patients at risk to withdraw but without signs/symptoms, I use 100 mg. If early withdrawal has already developed, I write for 200 mg, yes that’s eight tabs, thank your nurse for making sure you meant it. 200 mg is outside the guidelines, but oral chlordiazepoxide is very safe; I have used this dose on hundreds of patients without running into trouble with respiratory depression or excessive somnolence.

Caveat 1: Many alcoholics suffer with a host of comorbid medical, psychiatric, and substance problems beyond alcohol dependence. If these problems can be even partially addressed in a sustainable way during an inpatient stay, that admission is of benefit, even if the patient goes right back to drinking. My impression is that severe alcoholism so completely dominates the patient’s function that their accompanying problems cannot be meaningfully addressed unless and until the patient stops drinking. I am aware of no way to move severe alcoholics to sobriety other than high-intensity case management; if your hospital can set this up during an inpatient stay, by all means, admit.

*Caveat 2: An at-risk inebriate who sobers in the ED and is discharged must of course be able to acquire alcohol to avoid withdrawal. Though alcoholics are astonishingly capable of accomplishing this regardless of circumstance, it may not be safe to discharge a brittle alcoholic at the cusp of withdrawal at 4am. Have an honest conversation with him, if he won’t be able to get booze for a few hours, dose librium and observe for a few hours.

 

help me help you

 

 

Thanks to Lewis Nelson and Anand Swaminathan for their insights. 

Face Mask Capnography

Guest post by Terrance McGovern

End-tidal capnography is frequently used in the ED for monitoring patients at risk for hypoventilation.  Some departments stock the luxury oral/nasal sampling devices, but many of us have to make due with a nasal-only apparatus or fashion our own using a nasal cannula; these will not capture CO2 exhaled from the mouth. You can easily use a conventional face mask to build a capnometer that will continuously sample nasal and oral exhaled breaths, and provide supplemental oxygen. 

Screenshot 2015-12-28 06.14.12

Screenshot 2015-12-28 06.14.20

 

If you use a non-rebreather mask with both exhalation valves activated, you must keep the reservoir insufflated with oxygen. To deactivate the exhalation valves, peel off the rubber gasket pictured most prominently in step 4.

If you provide high-flow oxygen, this will dilute the exhaled CO2 and the ETCO2 number will be artificially low, but the waveform is intact–if the wave amplitude is too small, change the monitor scale from max of 50 (default on most monitors) to max of 20.

Thanks to Brendan Milliner for his assistance/face.

 

addendum: similar setup described by an obscure author in the air medical journal.

The Causes of Cardiac Arrest

It has been repeatedly demonstrated that the use of drugs empirically does not work in cardiac arrest. Despite this, ACLS often feels like an algorithmic march down a menu of pharmaceuticals, one drug after the next, hold compressions, ok still asystole, have we tried bicarb? Until everyone has had enough and the patient is pronounced.

There are three things you can do to benefit your patient in cardiac arrest. The first is good chest compressions, which serves mostly to buy time. The second is shocking shockable rhythms, and the third is identifying and treating the cause of cardiac arrest. The use of a vasopressor in the right dose probably offers some benefit; unfortunately we can’t figure out what the right dose is and epinephrine 1 mg every few minutes is almost certainly way too much.

Which drug is next keeps you busy and is the focus of how ACLS is taught, which is why it’s so dangerous: it feels right but not only does not benefit the patient, which drug is next distracts you from the most important task in cardiac arrest, which is figuring out why the patient in front of you just died, so you can offer a treatment to address it.

Causes of CA

Dysrhythmia is a central cause of cardiac arrest; as soon as a cardiac monitor is available, check a rhythm and if shockable, shock immediately. If you’re not sure if the rhythm is shockable, shock. The harm caused by an unindicated shock is trivial compared to the harm of untreated pulseless vtach or vfib.

Acute coronary syndrome is a hugely important cause of cardiac arrest, but causes cardiac arrest predominantly by dysrhythmia, which you will fix by checking the rhythm early and often. ACS can also cause cardiac arrest by pump failure, these patients may benefit from emergent reperfusion and would ideally be in a cath lab, if we knew that acute coronary artery occlusion was the problem. If you think ACS is the cause of arrest, cath lab is not an option, and the patient seems salvageable, give a thrombolytic. The data is equivocal in this context but I think the majority of resuscitationists would offer it for hearts too good to die.

Any sufficiently severe insult to airway or breathing can cause cardiac arrest, fortunately they are all treated at once with 100% FiO2 through an endotracheal tube. If the cause of cardiac arrest is unlikely to be primarily A or B, intubation can be deferred in favor of a supraglottic device; however, if A or B is the problem, all efforts should be directed at establishing oxygenation, usually via endotracheal intubation. Diverting your finite cognitive powers to ACLS drugs in respiratory arrest is particularly poor care.

There are three common, crucially important obstructive causes of cardiac arrest. Pericardial tamponade and tension pneumothorax are easily excluded and should be explicitly excluded in every case of undifferentiated arrest. Massive pulmonary embolism is amenable to reperfusion therapy, usually with intravenous thrombolysis–consider risk factors, exam signs, and ultrasound the legs and RV when the context fits.

Hyperkalemia is common, immediately lethal, and readily treatable. Calcium should be given to most arrested patients with kidney disease, and hyperK is a great reason to push for point of care electrolytes testing in your shop. Hypokalemia is much less common but also easily treated and a particular consideration in malnourished patients. Likewise hypoglycemia–fingerstick testing is routine if POC blood gas not available, and empiric use of D50 is reasonable in diabetics or liver patients.

Hemorrhage is of course most relevant in trauma, which may be occult, but the peritoneum is easily sonographed and uncrossmatched blood remains one of our best therapies. Ahemorrhagic hypovolemia is even more treatable though an uncommon cause of arrest in developed countries.

There are several key antidotes to important toxins, intralipid is a rising arrest therapy to consider if a cardiotropic medication is suspected; bicarb, digibind, and hydroxocobalamin may also restore circulation in the poisoned patient.

Hyperthermia is hopefully easily identified; treatment can be tricky but should involve some form of icewater in most cases. Hypothermia is an important cause and effect of cardiac arrest and determining which can sometimes be a challenge.

Anaphylaxis as a cause of cardiac arrest will be treated by airway management and the epinephrine you’re giving anyway. Once the patient has arrested from sepsis or an aortic or intracranial catastrophe, it is unlikely that you will be able to meaningfully reverse the process.

Though excellent, step-by-step algorithms exist, it can be difficult to remember this differential while managing an arrested patient as well as your team of providers which, when large enough, invariably obstructs rather than augments care. However, once you’re used to taking care of pulseless patients, the differential can be streamlined.

Causes Highlighted

You’re not going to forget to look for and shock shockable rhythms or intubate. Hyperthermia and hypothermia announce themselves, anaphylaxis will be treated with your supportive therapies and the last three causes are more or less irreversible once the patient is dead. This just leaves eight causes which are treated with six therapies. Six is the perfect number of items for a mnemonic.

Bling

If you’ve ever been to Antwerp you know it is gloomy as hell, and you would never, ever carry bling through gloomy Antwerp. Needle, calcium, blood/fluid, thrombolytic, glucose and antidote are the six things to remind yourself to consider in the arrested patient. It’s the Hs and Ts, evolved for our post-ACLS age.

Lastly, if you are able to put arrested patients on bypass/ECMO, you are playing a different game than the rest of us and that game has a different set of rules. Come up with your own mnemonic that includes Antwerp.

Pain, Compassion, Addiction, Malingering: How To Use Opioids (and how to not use opioids)

Lecture is 35 minutes, then questions for 20 minutes. On Vimeo.

 

Opioids are extraordinary agents that have been used for millennia for the relief of pain and suffering; however, the history of opioids is also one of abuse and addiction. In the US, we are in the midst of a devastating iatrogenic chapter in this history, a prescription opioid epidemic that kills 15,000 Americans per year by overdose and destroys hundreds of thousands of lives and families.

In this presentation we will consider the magnitude and consequences of the current epidemic; describe how clinical organizations and clinicians were appropriated by the pharmaceutical industry so that Americans–5% of the world’s population–consume more prescription opioids than the rest of the world combined; and discuss strategies for managing patients who present to emergency departments with acute or chronic pain complaints that account for our competing mandates to palliate and protect.

These strategies center on an assessment of the likelihood that using opioids will deliver benefit or cause harm. For patients at low risk to be harmed by opioids, utilize aggressive multimodal analgesia, including opioids as needed to control acute pain, and prescribe optimal outpatient non-opioid analgesia with a small number of breakthrough opioids if indicated. For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment. The goals of optimal opioid stewardship are to provide effective symptom relief while preventing de novo cases of addiction, to control the supply of opioids in the community, and to protect existing addicts from further harm while promoting recovery.

For slides, the HELPCard treatment referral business card, and phraseology to use when managing patients at risk for opioid misuse, go to emupdates.com/help

A Better Central Line Technique: Wire Through Catheter

Most of us were taught to place central lines using the wire through needle Seldinger technique, but using the introduction catheter instead of the needle makes successful wire insertion more likely and facilitates venous confirmation. A 7 minute screencast.

on vimeo

operating room video of wire through catheter technique. recommend viewing at 2x speed.

Update 1 Lee 2015 compares wire through needle and wire through catheter and shows that wire through needle is (slightly) better. The operators were anesthesiologists very experienced in central line insertion, which may account for their results. In the less controlled ED environment, with providers who don’t place a lot of lines (especially learners), the tendency of the needle to move before the wire can be transmitted may be more important. Also they did not confirm venous location in this study, which should be done whenever feasible and is greatly facilitated by the wire through catheter technique. Still, I’m aware of no data comparing the two techniques other than this (which appeared a few weeks after I posted the video), so though my success rate is definitely higher since I switched to wire through catheter, your mileage may vary.

Update 2  There are two advantages of the wire through needle (conventional approach): the needle is functionally slightly longer than the catheter, and the needle doesn’t kink. Neither of these advantages make a difference at the IJ site, and where I work almost all lines are IJ, so I didn’t mention this in the video. Based on feedback, I am surprised (and pleased) at how many non-IJ lines are being placed out there. If there is a lot of flesh in between the skin and the vein, for example at the femoral site in an obese person, the catheter can kink. This can be managed by keeping the pannus out of the way and keeping the skin taut throughout the procedure (flabby groin tissue can interfere with wire advancement as well, regardless of which technique you use to transmit the wire), but this requires an extra set of hands. At the subclavian site, the problem is not flesh but distance–sometimes you enter the vein relatively far away from where you enter the skin, and in this case the couple of millimeter difference between the wire and the catheter can be relevant. You can overcome this problem, in cases where you have to hub the catheter to get into the vein, by applying gentle continuous forward pressure on the hub until the wire is in the vein.