MedMechanix

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

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

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

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

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

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

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. 

Imaging PDF: https://www.medmechanix.com/wp-content/uploads/2020/02/imagingdoc1.pdf

Our Website: https://www.MedMechanix.com

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. 

Resources for learning to read imaging:

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

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 ph<7.1
• -E  electrolytes  K>6.5
• -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.

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.

1. Terpenoids which are found the in glands of the cannabis flower that help influence the uptake of the other categories
2.  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.

LINKS:

PDF Pain Handout:
https://www.medmechanix.com/wp-content/uploads/2019/10/Pain-Medication-Basics-PDF.pdf

Episode Webpage:
https://www.medmechanix.com/mm01-choosing-pain-meds-opiates/Episode Page: 

Our Website:
https://www.MedMechanix.com