We need to talk about something: misinformation. 

Unfortunately, the world is full of it and we cannot seem to stop ourselves. The Internet was one of the greatest inventions brought forth to the modern world to allow for the rapid sharing of scientific information. We have bastardized it in time to now spread hate and grossly incorrect information. What was once a way to spread knowledge is now attacking science and what we have learned.

Most spread misinformation by mistake or without malicious intent to say the least. Some are scared, others are ignorant, and there are those who are simply lazy. The ones that are the most dangerous are those who know precisely what they mean to do and in their own divisive ways share such misinformation. They are sensationalists and radicalize an unwitting population into sharing false narratives under the guise of "truth" but without the very meaning of the word. 

We talk about "fake news" and "spinning" frequently along with other clever words and phrases, but what do they mean? Where did we go astray? Science was once respected as an art, a way to better the world. But so many mislead others away from this noble method by convincing them that they are only "theories" or play on emotions rather than what is proven. 

How do we combat and address such issues? Those who research and then post after vetting information is so infrequent that even media outlets fail to do it properly. How does this translate to us as individuals? Being skeptical is part of our existence and a means of survival, but are we applying this incorrectly? Are we killing ourselves because something does not fit an archaic worldview?

I mention all of this not to demean others, but as a legitimate concern. The numbers are growing and misinformation is worsening. I fear the death of science in its proper sense. We need to make the change. Educate and encourage others to remember that we are in a time where misinformation rapidly spreads but that we need to do our part to not contribute to such an issue.

​Above is an example of the WRAITEC system which has been used in even children at the elementary school levels to help teach them how to use basic philosophical and argumentative structure to address and develop an argument in an appropriate manner.  We should strongly consider this along with other resources such as ways to vent the information itself.  One favorite that is very easy to access and seems to be fairly reliable is Snopes.  Facebook has even helped with organizations like NewseumED to support sharing appropriately and escaping junk news with fun infographics.

Will you help? We see people rapidly like and share without reading or fully comprehending what it means. Maybe we can be the light. Let us spread this message.

Remember to look us up on Libsyn, share on Facebook, retweet on Twitter, and rate on iTunes to help spread the word on TOTAL EM.

Rule out criteria have many benefits, but they are not perfect.  Sometimes, they can miss an important disease process or problem.  Those who provide care to patients must use them wisely.  In this post, the discussion is aimed to help explain the purpose of rule out criteria as well as their pearls and pitfalls.

Imagine a 36 year old male friend was playing softball when he got hit in the head by a softball that was thrown at him.  He did not lose consciousness and he has been acting his usual self.  In fact, he remembers everything and wants to go back to the game.  He has no headache, no vomiting, no bruising, and no signs of broken bones to the head or face.  The coach says he needs to get checked out and goes to the closest emergency department (ED).  As the Canadian CT Head Rule graphic from The SGEM shows above, the patient described in the podcast would not have been caught by the criteria even though he was found later to have two important brain bleeds.  This does not mean though that all head injuries need an expensive CT that carries with it a risk of cancer from the radiation.  Rather, that patient was the exception to the rule.  

Rule out criteria are not meant to be perfect.  Rather, they are meant to help risk stratify patients.  As stated above, not everyone needs a head CT.  Most will be fine and no bleeding would be found even if such as CT was performed.  However, to expose someone to a head CT unnecessarily exposes them to radiation that in turn increases their risk for cancer.  By using rule out criteria and other clinical decision aids, those who provide care (including the ED provider) can help decide if a patient is in need of further testing.  

These tools are used in a number of conditions.  Some of the most common are for head injuries (there are ones both for children and for adults), neck injuries, blood clots in the legs and clots in the lungs, risk for sepsis, and risk for heart attacks.  Let us talk briefly about the last example, heart attacks.  Although rare, the clinician taking care of you may decide you still need to be in the hospital even if your HEART score is low for a potential heart attack.  The criteria itself may not score high enough if you have obvious EKG changes or high blood levels for a heart attack.  Thus, such criteria are only one piece of the puzzle.  

Although not all providers will discuss their use of rule out criteria in detail, they may mention the risk stratification portion.  This part is to help explain the risks and benefits of the tool being used.  They may discuss how the tool is not perfect and that some cases may be missed.  However, sometimes that miss rate is considered acceptable due to the risks of potential complications with the additional testing or inappropriate treatment.  Although we may want to get the testing for our own benefit (either the benefit of the patient or the provider), a serious discussion or at least consideration of the risks must be evaluated in detail.  The tests and treatments for blood clots for example can be life-threatening.  Smaller, less important clots in the lungs are less likely to have a negative impact compared to the treatment chosen.  

In conversation, a provider may mention odds ratios or percentages.  These numbers are meant to give an idea as to these risks.  Sometimes by going step by step with the different factors, a discussion can be had to make sure that the risk group is appropriate.  In general though, rule out criteria are meant to help reduce the need for unnecessary testing while still keeping patients safe and reducing their risk to a bad outcome such as death or disability.  The important thing to remember though is that no tool or provider is perfect and there is always a risk with any method to evaluating and treating patients.

If you are interested in more information about rule out criteria along with their pearls and pitfalls, consider seeing the podcast post under the Emergency Professionals side of the website.  This is also the same area to find the sources that were used to cover the information provided.  Remember to look us up on Libsyn, share on Facebook, retweet on Twitter, and rate on iTunes to help spread the word on TOTAL EM.  If you have any questions you can comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  ​Until then, continue to provide total care everywhere.

Anaphylaxis is an immediately life-threatening allergic reaction.  If left untreated, there is a real risk for death.  In this first ever Patient and Provider podcast and blog post we talk about what happens during anaphylaxis and how to receive the proper care to stay alive and get treated safely.  

If there is concern for anaphylaxis, rapid assessment is important.  In the United States, calling 911 is an important first step.  This allows for EMS (emergency medical services) via a local ambulance and/or fire service to come to help.  If there is suspicion for anaphylaxis, a commonly given medication is epinephrine.  This medication is usually given in the muscle but sometimes through an IV.  

Should this first step may not be possible, going to the emergency department (aka ER or ED) directly is also important.  EMS will take someone there for assessment, as well.  If epinephrine has not already been given or is not fully successful, additional epinephrine may be given at this time.  There are also other medications that may be attempted some of which include steroids, nebulizers, glucagon, and antihistamines.  Frequently, may of these medications are given whether it is an adult or a child who needs to be treated for anaphylaxis.  

It used to be common after treatment to keep someone for hours or even days to watch for a second reaction.  With new research, this is becoming less common.  It is also common to receive a prescription for an auto-injector such as an EpiPen (the most common).  Keep in mind there have been some cost issues as of late regarding EpiPens specifically which has led to a lot of controversy.  Either way, as a patient asking for a prescription if treated for anaphylaxis is very reasonable.  It is important to learn about how to use it properly.  An example is shown above with the graphic borrowed from this site.

If you are interested in more information about anaphylaxis, consider seeing the podcast post under the Emergency Professionals side of the website.  This is also the same area to find the sources that were used to cover the information provided.  Remember to look us up on Libsyn, share on Facebook, retweet on Twitter, and rate on iTunes to help spread the word on TOTAL EM.  If you have any questions you can comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  ​Until then, continue to provide total care everywhere.

This is our logo.  You may have noticed it from recent postings on Twitter and Facebook.  Thanks to Logan Featherston, a scribe at one of the departments I work in, he was able to help out and create a logo.  The logo was thought of in my head, but needed someone with actual artistic ability to be something that would look good, and Logan made it great.  

The logo is one of symbolism.  In the middle is a device known as an ultrasound probe.  Point Of Care UltraSound (POCUS) is a growing part of medicine, especially on the prehospital and emergency side.  Most are familiar with the stethoscope, but it is laid in a particular way.  It is meant to invoke the imagery of the Ouroboros.  For those of you not familiar, it is a serpent that is eating its own tail.  Part of the symbolism behind the Ouroboros is that there is a cyclical nature to medicine especially in the sense of constant recreation.  

Why invoke the Ouroboros?  It used to be that the stethoscope was the most advanced technology in medicine.  Although it is still beneficial, many tools have taken its place as being more advanced.  Many argue that ultrasound is replacing the stethoscope even in many of its applications.  Ultrasound can provide even more detailed exams of the heart and lungs than a stethoscope ever could.  Furthermore, even though they both use sounds, the ultrasound does it in a more advanced manner.  Yes, the stethoscope still very much has its place but it may not be too far in the future before ultrasound fully replaces the stethoscope.  

Just like the stethoscope, other parts of medicine are being replaced by new pieces of technology.  However, like the cycle of the Ouroboros, some things return like a Phoenix.  Although ketamine was once popular and for a time fell out of favor, it is now in the spotlight again with even more research backing its use over time.  

When you look at our logo, remember that TOTAL EM is devoted to updating emergency medicine via FOAMED.  We want to provide the tools necessary to advance both emergency professionals and their patients in the knowledge that exists.  Just like the Ouroboros, we will work hard to look introspectively and improve ourselves with time.

Before we go too far into this topic, I want to make one thing very clear.  You know your medical history and the way your body feels better than anyone else.  With that said, if you feel like you need to go to a higher level of acuity setting  than recommended, we are not discouraging you from that.  This post is simply to help you understand what constitutes a complaint that an emergency department (ED) will be most concerned about and will try to address first.

As depicted in our first image, the NHS does an excellent job educating its population about what levels of care people should seek.  For those in the United States, you will notice some differences compared to our broken system.  Also remember that the Queen's English is used in this image and spelling will differ from that in the United States.  We will approach this in a step-wise manner.  

Self-care is exactly what it sounds like: take care of yourself at home.  A simple cough or sore throat can usually wait.  Times that it may need to see a higher level of care is when it becomes complicated or not taken care of well.  One that is not listed but very well should be is pregnancy testing.  Many places have pregnancy tests available for a dollar.  Why go to the ER and pay a $500 (approximate and may vary) bill for a pregnancy test?  We are basically doing the same urine test that you are doing at home.  We care more if there are risks of complications and it is immediately impacting your health.

NHS 111 does not have a USA equivalent in its exact form.  However, most insurance companies do have nursing lines and can be somewhat helpful.  They will often direct you to a higher level of care than maybe needed though depending on how well you give the nurse information.  If you are not sure what level of care is needed and you do not feel like there is immediate danger to life, limb, or sight this can be a safe way to manage care.

Pharmacists (chemists) are very beneficial in many cases.  Have uncomplicated heartburn, headache, or diarrhea?  Talk to them and see what over the counter medications are used.  Keep in mind all these symptoms can have more severe and life-threatening implications and some common sense is required to help differentiate what level of care is needed.  For example, is this headache extremely severe and you do not usually get headaches but it hit its peak in less than an hour?  Any loss of sensation and/or strength to a part of the body?  These are potentially concerning and need to be evaluated in the ED.  

GP (Doctor) is referring to primary care.  Chronic complaints are best seen in these settings.  Yes, your back has been hurting for a week after you decided to be a weekend warrior and move all the furniture in your house without help but waiting one more day for the appointment with primary care is the best choice.  They know you best and can take care of you in a better manner than we can in the ED.  Usually they can do it much more quickly than waiting half a day (give or take) to get an ED bed for relief.  

Walk-in clinics and urgent cares are two very different services.  In many cases, walk-in clinics can be used for short-term complaints that you would otherwise see primary care for, but either do not have time for or unable to reach primary care.  Urgent cares are meant to take care of issues that cannot wait for the next day but are NOT immediately threatening to life, limb, or sight.  Examples of these including lacerations (cuts) that need sutures (stitches) or possible broken bones but that do not appear to be dislocated or displaced (not in normal alignment).  

Finally, there is the ED.  Choking, severe and uncontrolled bleeding, eye injury with loss of vision, chest pains, loss of consciousness (blacking out), or new onset stroke symptoms are some of the most common examples of life, limb, and sight threatening issues that require immediate evaluation and treatment.  Reserving the use of an ED for such situations helps free up these professionals to take care of the most critically ill and injured.

Keep in mind that coming to the ED for a low acuity issue often leads to over-testing.  Our main concern is to figure out if you have something that is immediately threatening to life, limb, or sight.  If none of those apply and it is unlikely to lead to complications, it is usually most efficient to see another type of care depending on the situation.  

Another example of this layout is seen above from the Mayo Clinic Health System.  As you may notice, they include the need to call 911 when there are immediate life, limb, or eye threatening issues.  There is a more expanded list with this image and may even seem more conservative compared to the less litigious NHS system.  Either way, the choice is up to you.

Remember, emergency medicine is all about risk stratification.  In the grand scheme of things when it comes to the ill and injured, we in the ED are more concerned about diagnosing and treating a new onset major heart attack than the uncomplicated strep throat you have had for three days that has not changed.  

Ultimately, it is up to you the patient to help with ED overcrowding.  Every person who inappropriately uses the ED is risking the lives of those that are needing care.  ED overcrowding has become a public health crisis.  Patients die from this problem and it can be easily prevented when patients use resources correctly.  

Thank you for reading this post.  There are sure to be questions and as mentioned multiple times, this is not a perfect list.  Patients do need to understand that overcrowding is a serious issue but we recognize that serious issues can be hidden in simple complaints.  Just remember to please use the ED appropriately and do not rely on it to fill other roles such as primary care.

For my first educational post under the "For the Public" section, the topic of physician assistant (PA) seemed to be an important one.  This site is run by a PA who practices emergency medicine.  Answering the question "What is a PA?" comes up rather frequently.  Although there are many resources to help answer this question, there is quite honestly no easy answer which fully encompasses the role.  

The American Academy of Physician Assistants (AAPA) defines a PA as a nationally certified and state-licensed medical professional.  PAs practice medicine as a team with physicians and other providers both in the United States and internationally.  In the United States, PAs are allowed to practice and prescribe in all 50 states, Washington D.C., most U.S. territories, and the military.  

PAs, like other advanced medical professionals such as physicians and nurse practitioners, are able to take medical histories and perform physicals, order and interpret tests, diagnose and treat illnesses, counsel on preventative care, assist in surgery, write prescriptions (including controlled substances in most locations), and perform rounds both in hospitals and nursing homes.  

Duties vary due to state laws, practice setting, level of experience, and specialty.  In emergency medicine (EM), PAs work in a variety of settings.  It ranges from the main section of the emergency department (ED), fast tracks, urgent cares, pre-hospital field, education, administration, and other settings.  No matter the setting, there is at least some form of collaboration between the PA and a physician.  This can vary widely by the scope of practice.

According to the Society of Emergency Medicine Physician Assistants (SEMPA), scope of practice is based on four main parameters.  The first parameter as discussed above is state law and regulation.  Interestingly, federally employed PAs may be excluded from state laws and may only follow the federal employer regulations depending on the situation.  Facility policy is the second parameter and can greatly effect how the PA practices based on the site.  A third major parameter includes education, experience, and expertise of the PA.  Some correlate this to how physicians and other providers evolve over time as most aspects in medicine have parameters change based on the same factors.  The final main parameter is determination of the collaborating physician(s) about what tasks are delegated.  In many cases, this falls in line with the other parameters but there are exceptions.

Depending on where a PA treats a patient (such as main ED versus fast track), what the PA does on a daily basis can vary.  A PA in a critical care or main ED setting could be regularly performing advanced procedures such as intubation (putting a tube in someone's throat to help them breathe on a machine) and thoracostomy tube insertion (placing a tube in a person's chest).  In a fast track, the patient is more likely to suture (stitch) lacerations or drain an abscess.  No matter the environment, PAs have to be highly intelligent and fast thinking as any patient can present to any of the EM clinical settings.  An example would be recognizing a major heart attack in someone who came to the ED and was placed in fast track for a cough with mild chest pain.  Failure to recognize this potential could lead to death or serious complications in this patient.  However, the PA must be able to further differentiate clinically in order to avoid working up every patient with a cough and mild chest pain for a possible heart attack.

PAs are trained rigorously in advanced programs.  In most cases, PAs have previous medical backgrounds including nursing and paramedicine.  With the current programs, PAs complete a master's type program.  These programs usually last approximately three academic years but most programs are full time and last approximately 27 months.  Training is very similar to medical schools and in some cases the students share a classroom.   After the period of classroom training, PAs will complete more than 2,000 hours (equivalent to a year of full-time practice) in a number of settings including EM.  

After their extensive training, PAs must complete a national certification exam.  Once passed successfully, PAs may then apply for state licenses.  To maintain certification, the current process is completing 100 hours of continuing education every two (2) years and a re-certification exam every 10 years.  

It is not easy to summarize what a PA is and there are always more questions.  Did we answer all your questions?  If there is something else you would like to explain, please post it in the comments.