Tactical Medicine News Blog

Background: A series of tweets I sent out recently generated a visceral response from critical care clinicians the world over. I summarized my strategy of shock dose RSI as sedatives low and paralytics high (low dose ketamine, high dose rocuronium along with cardiovascular resuscitative strategies of push dose pressors and peripheral vasopressors). It seems that the visceral response and argument stems from EM’s desire to avoid peri-intubation arrest, and anesthesia’s equally strong desire to avoid awareness/suffering in the peri-intubation period.  Typically ketamine is dosed at 1 – 2mg/kg IV followed by a paralytic agent prior to RSI. I have written a blog post on how to manage hypotension prior to RSI in shock patients HERE, but I wanted to write a separate post on this topic as it is difficult to carry on a meaningful conversation with the character limitations of twitter.

I have been accused by many of my colleagues and friends as being hypomanic.  They always wonder how I get so much done.  Do I function on 4 – 5 hours of sleep?  Is it the fact that I am not married or don’t have kids?  Well those things definitely help, but I think it’s because I have a rigorous structure in my daily life, that allows me to get so much done.  Before we get into the post, I want to recommend two books to read that were recommended to me by my friend Scott Weingart: Getting Things Done by David Allen and Deep Work by Cal Newport.  There are some pretty extreme ideas in both of these books, but if you can get past that, you can find truth in each of their arguments.  These two books have changed the way I structure my daily life and have increased not only my productivity, but the quality of my productivity (i.e. Getting Things Done).

Background: With hundreds of journals, and thousands of publications in any given month it is near impossible to sift through all the current medical literature and hope that you find the most pertinent articles that could impact practice. One of the key mission statements of REBEL EM is cutting down the knowledge translation of research to clinical application (i.e. bench to bedside).  In the keeping up in EM series, we critically appraise and review some of the most relevant literature over the past year.

Friends, Concern regarding the Surviving Sepsis Campaign (SSC) guidelines dates back to their inception.  Guideline development was sponsored by Eli Lilly and Edwards Life Sciences as part of a commercial marketing campaign (1).  Throughout its history, the SSC has a track record of conflicts of interest, making strong recommendations based on weak evidence, and being poorly responsive to new evidence (2-6).

I was working a busy shift in the ED, like many of us do, and the next patient I was going to see was a 57 year old male with no real medical problems complaining of chest pain.  I remember thinking as I walked into the room this guy looks ashen and diaphoretic….he doesn’t look well.  He is a paramedic telling me how he has been having off and on chest pain for the past several months.  He just had a stress test two months ago that was “negative”.  Today he was working on his pool and developed the same chest discomfort as he had been having off and on the past several months, but today, the pain would just not go away.  In his mind, he thought this might be an ulcer and just needed some Pepcid to help. He got put on the monitor and an ECG was run… The patient involved in this case has given permission to share the story, and relevant images with the knowledge that this information will be used for the purposes of education.