Ever worry about knowing when to stop the code? Today we discuss medical futility and the components that help you to recognize it. We also go through tips about talking to families, filling out the death certificate and who goes to autopsy. Episode Website Statistics about ROSC LITFL: Cessation of CPR When do you stop resuscitation Ethics of Calling Codes: how long is long enough Filling out Death Certificate Practice Cause of Legal Death Fact Sheet

MedMechanix

MM12: When CPR becomes DNR

Knowing when to admit your patient can get tricky, today we will increase your admission acumen! In this episode, we discuss 6 specific categories that can be used to help admit patients you are on the fence about. We discuss factors involved in how admission in determined and cover a few examples. Intended for medical providers in all specialties. Check out the episode shownotes Check out our website: MedMechanix.com Look through our Recommended Resources

MM11: When to Admit

Walk down the 4 pathways that lead to vomiting,  learn to organize types of nausea, how vomiting reflex and nausea threshold works, and explore how to choose between antiemetics.  The PDF Handout Website: medmechanix.com The Ginger Study Recommended Resources

MM10: All the Nausea Pathways

Join us for an exploration of why COVID medical data was so confusing and tools that you can use to interpret medical testing and data. With guest Dr. Natalie Alexander, we cover the politicization of medical data,  understanding what is behind medical testing, not mistaking treatment for prevention, the hierarchy of studies and more!   MedMechanix.com Youtube Bias Video Rambo Method Recommended safe sources: Skeptics guide to EM Journal Club REBEL Cast Podcast 

MM9: Do Umbrellas cause the Rain?

Join us for a basic guide to over the counter medications for providers. We will cover cough, runny nose, allergies, acid reflux, pain, antifungals. We also go over guidelines on how to choose the right combination cold and flu medications.  Today's PDF Handout: https://www.medmechanix.com/wp-content/uploads/2020/07/otc.pdf Our website: https://www.medmechanix.com Dextromethorphan study link: https://jamanetwork.com/journals/jamapediatrics/fullarticle/571638 Steroid Potency Article: https://www.verywellhealth.com/steroids-topical-steroid-strengths-1068832 

MM8: OTC Med Guide

Dissect the anatomy of complete blood count (CBC)! Explore how to better interpret the components of cbc, which are most important and how to use them in clinical practice. We discuss the differential, left shift, bandemia, RBC morphology, hemolysis and more! LINKS: Our CBC PDF: https://www.medmechanix.com/wp-content/uploads/2020/05/CBC_PDF.pdf Website: https://www.MedMechanix.com

MM7: Anatomy of a CBC

Check out the second episode in unzipping the confusion of imaging studies where we explore contrast. How contrast works, the types of contrast, when to use contrast and when not to are just some of the topics discussed in this episode. We also tackle contrast allergies and contrast nephropathy with a bonus on incidental findings. Find more links, shownotes, and the PDF on MedMechanix.com

MM6: Imaging Unzipped Contrast

The first of two episodes dedicated to unzip the basics of ordering medical imaging. This episode focuses on differentiating the 4 main imaging modalities, with a brief introduction on why Imaging is so dang hard and we wrap up with a quick quiz to help empower you to better understand medical imaging.  PDF handout for this episode   Here is that PDF handout for this episode. Xray Typically best for seeing bones and air     (ex acute abd series looking for free air) AIR is black, tissue/bone is white Gold Standard: orthopedic, screening initial cxr Air in places we don’t want - KUB air under diaphragm (upright CXR) means perforated bowel or air in soft tissue with nec fasc When air is not where it should be: lungs full of air, CXR shows white patch could be PNA or fluid or tumor Air patterns : KUB  bowel gas patterns (only for infants) SBO Pro: Old as dirt (invented in 1895!), low cost, relatively low radiation Limitations: miss early dz (like PNA, they say it takes at least 1-2 days to show, so if you are suspicious despite normal CXR then get CT), anything that is radiolucent including things like wood fb won’t show, misses lots of stuff in soft tissue - very limited use Types: don’t xray the cervical neck anymore or the skull, fluoroscopy for caths, myelograms, swallow study, barium enemas KUB (kidneys Ureters Bladder) looking for kidney stones. Many ppl use it for “constipation” - like reading tea leaves. Radio-opaque (objects that do show up) or Radiolucent (objects that do NOT) No: plastic (requires CT or US) Sometimes: wood (US best, then CT) Yes: Metal, glass, stone CT or CAT scan Typically best for most things, go to for bone, tumors, internal organs, bleeding Pro: higher resolution than MRI (therefore the highest) & easier to get Limitations: 1 CT = 200 CXR (given children are more sensitve to radiation, only do CT on child if ABSOLUTELY necessary, this does increase their risk of cancer later in life) Don’t do more than 6 in 6 month period for same complaint, but can do more than one per day depending on risks involved. Types: all kinds depending on kinds of contrast and where we put it Ex. angiogram (CT PE or CT abd looking for mesenteric ischemia) Ex. PET special contrast used by oncologists to look for spread of cancer Gold Standard: CT cervical spine, bowel problems (appendicitis), CT head for skull fracture, tumor/cancer Ultrasound Typically best for real time imaging, for body cavities, moving tissue, fluid/inflammation Pro:  NO radiation at all, cost, gives real time imaging Limitations: very user dependent, body habitus & bowel gas Types: bedside (cellulitis vs abscess), doppler, OB/GYN, IR, echo (heart), kidneys Gold Standard: fetal imaging, ovaries/testicles, gallbladders, sports injuries, thyroid, dopplers, and echo to determine heart squeeze (aka CHF or not) When to order: superifical or moving MRI Typically best for soft tissue like cartilage, m connective tissue, swelling, any neuro dx Pro: the most indetail pictures we have Limitations: NO METAL (rips out of body) some pacers are ok and all joint replacements but stimulators and other medical devices are not, pt gets claustrophobic & just scary put in a small tube that makes a loud banging noise, you have to stay still for 30-60 minutes, PRICE, this is the most expensive test Types: any body part,  MRV (venous), MRA (arterial) Gold Standard for all strokes or other neuro dx. spine tissue, neuro, joints, muscle Know that you are NOT going to get an MRI in the ER Unless you have cauda equina Resources for learning to read imaging: entire website with practice cases reading CXRs 7 minute Youtube video on CXR that does it BETTER THAN ME another Youtube video on CXR many 5 minute videos understanding each type of Ultrasound CT & MRIs should be left to professional radiologists to interpret, however I can point you toward some excellent youtube videos to get an idea of how each works. how CT work - quick and dirty! how MRI works - long winded and very detailed but easy to follow want something shorter? MRI physics in 5 minutes What do you think? Helpful or not? Do you have better resources? Please let me know! I am always happy to redo things to make it more helpful for you. 

Imaging Unzipped - Ordering Options

Today we go over common clinical post op complications with emphasis on clinical highlights for the non-surgeon providers. We cover general complications after any surgery and then we get into some specifics to watch for with certain surgical procedures including eye surgery, heart transplants and gastric bypass. PostOp PDF For more information: post op complications  or from the surgeons' mouth: common complications

MM4: PostOp Complications (for nonsurgeons)

 Unzipping the ins & outs of dialysis labs, the types of dialysis, indications for emergent dialysis, treating resistant hypertension and so much more! PDF Dialysis Handout  Visit our website: MedMechanix.com Hemodialysis (HD) What it is: Dialysis machine filters the blood and excess fluid for about 4hrs typically three days a week What you should ask: What kind of port are they dialyzing through? Is it a catheter usually located around the collar bones or do they have an AV fistula?  What is their schedule for dialysis, since hemodialysis is 3 days a week, which days (MWF or TTHSat). Do you still make urine? Pros/Cons: requires trained staff & site visit to complete, lots of fluid & diet restrictions, lots of heart strain, lower life expectancy, harder to travel Peritoneal Dialysis (PD) What it is: do this two ways, filtration nightly thru the patient’s own peritoneum, pt flushes dialysate fluid into their abdomen, lets it sit overnight and osmotically absorb the excess toxins, then pump out the fluid in the morning OR you can do it 5 times a day while awake without machine What you should ask: What did your dialysate fluid look like? (Cloudy is bad, clear yellow serous fluid= okay), Did you bring your machine with you? Pro/Con: not for morbidly obese, complex abd surgeries or noncompliant pt, longer life expectancy, more frequent sessions, better for travel, more patient responsibility Expected Labs:  Elevated BUN & Cr Hyperkalemia Hypoalbuminemia Elevated slight trop Anemia Hypocalcemia  Hyperphosphatemia HTN, nephrology article What sequelae do we need to know?  Fluid overload Hyperkalemia Thrombosed fistula Bleeding fistula SBP Chest Pain during or right after Hypotension after - esp if took lots of fluid off quickly Bleeding - with uremia How bad is it when a patient misses dialysis? All depends on how many toxins the patient has floating around in the blood. The three we are most likely to notice:  excess fluid, which can build up especially in third spaces and the lungs potassium, which can build up and cause cardiac arrhythmias BUN, also known as “uremia” this can cause salty skin and AMS A build up of any of these usually means admission and emergent dialysis. In most patients this takes 2-3 weeks without dialysis to build up to any symptomatic level.  When does a patient get put on dialysis?  No hard and fast rule Typical guidelines-  GFR less 15-12, significant symptoms which can be earlier than 12 if have other comorbidities, repeated need for emergent dialysis Indications for emergent dialysis -A  acidosis ph6.5 -I   Intoxication or Ingestion  (alcohols & toxic drugs like lithium) -O  overload, fluid   think extreme pulm edema -U  uremia (encephalopathy or pericarditis, etc) What are new onset kidney failure symptoms?: Weakness/fatigue Muscle cramping XS or minimal urine output Foamy urine Leg or orbital edema N/V Chest pain Itching About kidney transplants: lasts about 15 years  Average wait time for a transplant is 5 years Cellcept & tacrolimus r immune suppressing drugs to prevent rejection transplant surgeons don’t see their patients after the first year or two CKD & Dialysis Statistics if you are interested.  As promised: the Dialysis PDF handout. 

MM3: Dialysis Unzipped

 Welcome to part 2 of Choosing pain meds. To learn about choosing opiate pain medications, how to pick IV or PO pain meds, or why pain can be so dang hard to treat, check out last week's episode. There are two different pain pathways (for this talk):  the neurotransmitter substance P and its friends who are released in response to tissue damage.  stretching nociceptors that represents the discomfort, inflammation or more specifically stretching of our visceral organs.   These pathways are different kinds of painful stimuli in the brain & are hard to express. Thus descriptive pain categories like : throbbing, cramping, achy, bloating, pulling, sharp, stabbing, burning, shooting and so many more. In school we learn “textbooks patterns” of pain (like crampy episodic RUQ pain = gallbladder) but these patterns are imperfect == atypical presentations of diseases To discuss specific agents refer to the PDF Pain Chart BONUS: Marijuana Info More & more patients will be looking to us --the medical professionals-- for information and opinions. It is important to educate ourselves with facts, regardless of opinions. To start there are two different chemical compound categories. Terpenoids which are found the in glands of the cannabis flower that help influence the uptake of the other categories  Phytocannabinoids: THC & CBD. Both of these compounds have benefits and serious SE but neither of them are currently regulated. THC: found in 1964, effects include: increased appetite & muscle relaxation, decreased nausea/vomiting & pain/inflammation  SE: dizziness, somnolence, dry mouth, anxiety, psychosis, cyclical vomiting CBD: found in the 1940s with same structure as THC but in a different structure, has no addiction potential (can't bind to the receptor), studies found significant positive use in: epilepsy, anxiety, huntingtons disease, ALS, MS, arthritis. It also stops conversion of THC into metabolite that causes psychosis. Right now, CBD is legal to sell anywhere and is what most of my patients are asking about.   My concern with prescribing CBD: The FDA does not regulate quality of brands, so you don't know what your patients are getting. To learn more about the topic, I go to Harvard’s answer page. I took their continuing medEd class for $200 and I found it politics and opinion-free. To learn about choosing opiate pain medications, check out last week's episode. Or if you would like handier notes for on-shift or in-clinic reference: PDF Pain Chart Do you have questions? feedback? topic suggestions? Leave me a comment below and I'll get back to you. 

MM2: Choosing Pain Meds - Non Opiates

   Our first episode! Part 1 of the ins and outs of choosing pain medications. Today we choose between narcotic pain meds for your patients: not a secret anymore! We discuss deciding between IV and PO and which opiate to use, how it works, the side effects and clinical problems associated. Purpose of pain = warning the body something is wrong. Pain is unmeasurable & surrounded by fear culture. Choosing pain meds based on route.  IV: faster onset (only about 5 mins) & lasts 4-6hrs & only available in hospital setting IM: variable absorption & good if no IV access PO: slower onset (takes about 30 mins to digest) & lasts about 6-8hrs & can prescribe for home Opiates: bind to 3 main receptors to block pain signals  Mu- analgesia, physical dependence, euphoria, resp depression, mast cell degranulation Kappa- analgesia, very little dependence, diuresis, dysphoria Delta- analgesia, sedation, generally unknown Opiates are equivalent in their analgesia effects. So how we choose between them? Side effects-- its all about the side effects.  See the attached PDF Pain Chart for individual agents.  4 effects of opiates you need to know: Constipation- opiates decrease gut peristalsis which can lead to bursting the intestines! Write for stool softeners Sensitization- chronic blockage of pain receptors lead to increasing the amount of pain receptors present on cells which amplifies even the smallest signal. These patients really  do feel more pain and are less able to handle pain. Addiction- two models of thinking: disease model vs psychological. Either way, prevent addiction as much as possible by not giving refills and only prescribing low # of pills for home. Withdraw-  As for withdraw, typical opiate withdraw syndrome consists of: sweating, vague abdominal pain, diarrhea.  Withdraw is not fatal.  Pseudoallergies- Most ‘allergies’ to opiates are side effects and not real IgE mediated allergies.  If you want to know more here is a really good article on the topic. For a rotation or clinic friendly reference as promised: PDF Pain Chart Or if you'd like to learn about alternative pain medications, check out next week's episode Choosing Pain Meds- Non Opiates Do you have any questions or feedback? Do you think I missed something? Let me know in the comments section below! 

MM1: Choosing Pain Meds - Opiates

A medical education podcast intended for medical professionals to learn the hows & whys behind patient care beyond the answer on the test. If you want to more visit our website: Medmechanix.com

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