Building resilience in emergency medicine

In this podcast I am joined by Rick McKnight PhD author of Victim, Survivor, Navigator and Curt Woolford MA E-RYT.  Rick, Curt, and I held a Workshop/Retreat for my Department last month with the goal of building resilience using mindfulness techniques.

The basic approach we took was to have all participants take a Maslach-Burnout Inventory and begin using a few apps (Mood Meter, Provider Resilience) before the retreat. The day of the retreat we started with a review of the groups Maslach-Burnout Inventory and then each individual opened the envelope with their results. It had a fairly powerful attention getting effect. We then moved to various small group sharing and transitioned to Mindful Resilience Training specifically focusing on individual based techniques (e.g. meditation, breathing exercises, etc). Finally, we created workshop like approach to identify best practices for Team Resilience. Four specific scenarios were discussed that typically result in interpersonal stress on teams in the Emergency Department (a few examples – an angry patient confronts a colleague, a difficult patient keeps calling for help, a colleague is not seeing enough patients or carrying an appropriate load, a rude consultant, a colleague appears to becoming distressed dealing with a violent patient). What should our response be? How would we want our colleagues to respond if it we were in distress, being attacked, treated rudely etc? This generated a lot of great discussion.

In the podcast we reviewed some of the important take home themes from the retreat. Social connectivity and a sense of not being alone in feelings of stress goes a long way to restoring a sense of balance and calm. Resilience is not about hardening you to be resistant to stress, resilience is about developing the attributes that make you and your team someone who thrives in stressful environments. Choosing to navigate the challenges and stress that EM has to offer leads to a much better outlook and a happier and enjoyable practice. Remaining a victim at worst or a survivor at best is not the path to a satisfying relationship with the practice of EM.

Finally we take a look at this brand new paper Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress.This papers develops the BTSF (Breath, self Talk, See (mental rehearsal), Focus with trigger word) mnemonic that is discussed at EMCrit and is specifically focused on high stakes performance. Somewhat different from our retreat topic, but still the same technique.

Just for fun – here are some of my favorite self talk, trigger word performance enhancing practices from the movies!

Inner Space – a fun favorite from way back when that has one of favorites “Zero Defects”

For the Love of the Game – the story of Billy Chapel – “Clear the Mechanism” dramatizes how weirdly personal a trigger word can be – and how effective. They say many of the great athletes had the ability to focus and eliminate distractions. This scene is perfect for EM physicians because I think on just about every shift I am trying to concentrate on something while being heckled (okay – distracted) by someone who thinks I need to do something else (get a phone call, hear about a case, read an ECG, get them food, the list goes on…).

Enjoy the podcast and leave your comments on how you build resilience personally and with your teams!!!

After the podcast, Rick, Curt and I headed out to our local Japanese BBQ and finished our meal with ‘smores – now that’s resilience building!


Can Social Media save Emergency Medicine?

Here’s a video cast of the talk I gave at the Association of Academic Chairs of Emergency Medicine Annual Retreat March 22, 2017. The purpose of the talk was to inform EM academic chairs about the social media in medicine movement. The theory of the talk is that our hero, your average EM physician, is in crisis. They are leaving patient care because they feel their autonomy threatened, they struggle to maintain mastery of the complexity of clinical practice, and they feel that they have lost a sense of purpose. Social Media is the found pilot of emergency medicine – building social capital, accelerating knowledge translation, and enabling personal learning networks. The net effect is to give EM physicians a restored sense of themselves. EM physicians engaged in social media feel empowered to defend their autonomy and have a stronger sense of purpose and mastery. I hope you enjoy the talk and would love to hear your feedback! I want to thank Ken Milne and K Kay Moody for taking time to speak to me about their ideas on social media – and more importanly for being social media pioneers that have made a difference. These and so many others are the found pilots of our specialty! #getonboard

Daniel Pink “Drive”

Robert Putnam “Bowline Alone”

O’Connor and Dornfield “The Moment You Can’t Ignore”

Social Media and Health Care Survey

Chung PJ, Chung J, Shah MN, Meltzer DO. How do residents learn? The development of practice styles in a residency program.Ambul Pediatr. 2003 Jul-Aug;3(4):166-72.

Diner BM, Carpenter CR, O’Connell T, Pang P, Brown MD, Seupaul RA, Celentano JJ, Mayer D; KT-CC Theme IIIa Members. Graduate medical education and knowledge translation: role models, information pipelines, and practice change thresholds. Acad Emerg Med. 2007 Nov;14(11):1008-14.

Acetaminophen and self poisoning: There is a role for a level drawn less than 4 hours.

In this podcast, Dr. Rita McKeever and I try to use some recent evidence to see if we can hasten the throughput of self-poisoning patients in the ED.

First let’s look at:

Can a serum acetaminophen concentration obtained less than 4 hours post-ingestion determine which patients do not require treatment with acetylcysteine? Mark C. Yarema, Jason P. Green, Marco L. A. Sivilotti, David W. Johnson, Alberto Nettel-Aguirre, Charlemaigne Victorino, Daniel A. Spyker & Barry H. Rumack

The short answer is NO! If you suspect acetaminophen overdose then you should properly identify a time or range for a 4 hr level and obtain the specimen at that time.

However – “Only very low to undetectable acetaminophen concentrations prior to 4 hours reliably excluded a subsequent concentration over the treatment line.” We can use this to our advantage for patients who we do NOT suspect to have an acetaminophen overdose!

In this UK study, none of the 136 patients who denied taking acetaminophen had a detectable level at 4 hours.

Dargan PI, Ladhani S, Jones AL Measuring plasma paracetamol concentrations in all patients with drug overdose or altered consciousness: Does it change outcome? Emergency Medicine Journal 2001;18:178-182.

In another UK study, less than 10% (13 of 155) of patients who denied taking acetaminophen had any detectable level and none required antidote.

Hartington, K., Hartley, J., & Clancy, M. (2002). Measuring plasma paracetamol concentrations in all patients with drug overdoses; development of a clinical decision rule and clinicians willingness to use it. Emergency Medicine Journal : EMJ, 19(5), 408–411.

So although you can lower the prior probability of acetaminophen poisoning when the patient denies ingestion, you cannot completely exclude the diagnosis without an acetaminophen level. However, you can save a few hours of ED time – here’s how:

When you do NOT suspect an acetaminophen overdose (prior probability is close to zero!) , an undetectable level before 4 hrs (at 2 hours and even as soon as 1 hour) post ingestion will reliably exclude acetaminophen toxicity (likelihood ratio of zero!). If you draw a < 4hr level and it shows detectable acetaminophen  – it must be repeated at 4 hours to determine if it needs treatment.

If you DO suspect an acetaminophen overdose, obtain only a 4 hour level to guide NAC therapy.

Hopefully this will help with a more rapid throughput of patients with self poisoning who need to be medically cleared for further psychiatric evaluation. Of course, this represents one opinion based on a review of the literature. A prospective trial would be needed to prove this conclusively.

Enjoy the Podcast!


Heroin overdoses and naloxone reversal: ok for discharge or mandatory observation?

In this podcast Dr. Rita McKeever and I review the recent article entitled Do heroin overdose patients require observation after receiving naloxone? from our toxicology friends at Washington University – Michael W. Willman, David B. Liss, Evan S. Schwarz & Michael E. Mullin.  They reviewed the literature to try and answer the following questions:

(1) What are the medical risks to a heroin user who refuses ambulance transport after naloxone?

(2) If the heroin user is treated in the emergency department with naloxone, how long must they be observed prior to discharge?

(3) How effective in heroin users is naloxone administered by first responders and bystanders? Are there risks associated with naloxone distribution programs?

We also take a look at Ed Boyer’s article Management of Opioid Analgesic Overdose and an important but older article entitled Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule.

The clinical prediction rule that may predict safe discharge is as follows:

1) can mobilize as usual; 2) have oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; 4) have a temperature of >35.0 degrees C and <37.5 degrees C; 5) have a heart rate >50 beats/min and <100 beats/min; and 6) have a Glasgow Coma Scale score of 15

We conclude that if the patient demonstrates all six features carefully applied WITH the caveat that there be no verbal or tactile stimulation prior to the evaluation, then the patient  is likely to be safe to discharge after reversal with naloxone. This concept has not been strictly tested in the literature, but the article in Clinical Toxicology supports this practice. And now on to the podcast … let us know what you think!

Receiver Operator Characteristic Curves explained!

Warning: statistics ahead!! Actually, this very short VODcast is designed to keep it simple and help you understand ROC curves, sensitivity, specificity, positive predictive value, negative predictive value, and prevalence. Here is the paper I use to discuss this:

Glasgow Coma Scale Motor Component (“Patient Does Not Follow Commands”) Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury.


Synthetic cannabinoids: how science manufactured a drug epidemic and how to treat it


In this vodcast I discuss endocannabinoids, phytocannabinoids, and synthetic cannabinoids. I review the cannabinoid receptor physiology and how it leads to the  chaotic clinical course seen in synthetic cannabinoid overdoses, such as the profound hypotension and bradycardia we call the K2 Krash. Hopefully at the end of the broadcast you will have a sufficient understanding of all things cannabinoids to treat this growing epidemic. Enjoy!