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Core EM - Emergency Medicine Podcast

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Core EM - Emergency Medicine Podcast

Episode 210: Capacity Assessment

Mon, 02 Jun 2025







We discuss capacity assessment, patient autonomy, safety, and documentation.


Hosts:

Anne Levine, MD

Brian Gilberti, MD









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Show Notes


The Importance of Capacity Assessment



  • Arises frequently in the ED, even when not formally recognized

  • Carries both legal implications and ethical weight

  • Failure to appropriately assess capacity can result in:

    • Forced treatment without justification

    • Missed opportunities to respect autonomy

    • Increased risk of litigation and poor patient outcomes




Defining Capacity



  • Capacity is:

    • Decision-specific: varies based on the medical choice at hand

    • Time-specific: can fluctuate due to medical conditions, intoxication, delirium



  • Distinct from competency, which is a legal determination

  • Relies on a patient’s ability to:

    • Understand relevant information

    • Appreciate the consequences

    • Reason through options

    • Communicate a clear choice




Real-World ED Examples



  • Intoxicated patient with head trauma refusing CT

    • Unreliable neuro exam

    • Potentially time-sensitive intracranial injury



  • Elderly patient with sepsis refusing admission due to caregiving responsibilities

    • Balancing autonomy vs. beneficence



  • Patient with gangrenous diabetic foot refusing surgery

    • Demonstrates logic and consistency despite high-risk decision




The 4 Pillars of Capacity Assessment



  • Understanding

    • Can the patient explain:

    • Their condition

    • Recommended treatments

    • Risks and benefits

    • Alternatives and outcomes?



  • Sample prompts:

Episode 209: Blast Crisis

Thu, 01 May 2025







We dive into the recognition and management of blast crisis.


Hosts:

Sadakat Chowdhury, MD

Brian Gilberti, MD









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Show Notes


Topic Overview



  • Blast crisis is an oncologic emergency, most commonly seen in chronic myeloid leukemia (CML).

  • Defined by:

    • >20% blasts in peripheral blood or bone marrow.

    • May include extramedullary blast proliferation.



  • Without treatment, median survival is only 3–6 months.


Pathophysiology & Associated Conditions



  • Usually occurs in CML, but also in:

    • Myeloproliferative neoplasms (MPNs)

    • Myelodysplastic syndromes (MDS)



  • Transition from chronic to blast phase often reflects disease progression or treatment resistance.


Risk Factors



  • 10% of CML patients progress to blast crisis.

  • Risk increased in:

    • Patients refractory to tyrosine kinase inhibitors (e.g., imatinib).

    • Those with Philadelphia chromosome abnormalities.

    • WBC >100,000, which increases risk for leukostasis.




Clinical Presentation



  • Symptoms often stem from pancytopenia and leukostasis:

    • Anemia: fatigue, malaise.

    • Functional neutropenia: high WBC count, but increased infection/sepsis risk.

    • Thrombocytopenia: bleeding, bruising.



  • Leukostasis/hyperviscosity effects by system:

    • Neurologic: confusion, visual changes, stroke-like symptoms.

    • Cardiopulmonary: ARDS, myocardial injury.

    • Others: priapism, limb ischemia, bowel infarction.



Episode 208: Geriatric Emergency Medicine

Tue, 15 Apr 2025







We explore the expanding field of Geriatric Emergency Medicine.


Hosts:

Ula Hwang, MD

Brian Gilberti, MD









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Show Notes



Key Topics Discussed



  • Importance and impact of geriatric emergency departments.

  • Optimizing care strategies for geriatric patients in ED settings.

  • Practical approaches for non-geriatric-specific EDs.


Challenges in Geriatric Emergency Care



  • Geriatric patients often present with:

    • Multiple chronic conditions

    • Polypharmacy

    • Functional decline (mobility issues, cognitive impairments, social isolation)




Adapting Clinical Approach



  • Core objective remains acute issue diagnosis and treatment.

  • Additional considerations for geriatric patients:

    • Review and caution with medications to prevent adverse reactions.

    • Address functional limitations and cognitive impairments.

    • Emphasize safe discharge and care transitions to prevent unnecessary hospitalization.




Identifying High-Risk Geriatric Patients



  • Screening tools:

    • Identification of Seniors at Risk (ISAR)

    • Frailty screens



  • Alignment with the “Age-Friendly Health Systems” initiative focusing on:

    • Mentation

    • Mobility

    • Medications

    • Patient preferences (what matters most)

    • Mistreatment (elder abuse awareness)



Episode 207: Smoke Inhalation Injury

Wed, 02 Apr 2025







We discuss the injuries sustained from smoke inhalation.


Hosts:

Sarah Fetterolf, MD

Brian Gilberti, MD









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Show Notes


Table of Contents


00:37 – Overview of Smoke Inhalation Injury


00:55 – Three Key Pathophysiologic Processes


01:41 – Physical Exam Findings to Watch For


02:12 – Airway Management and Early Intervention


03:23 – Carbon Monoxide Toxicity


04:24 – Workup and Initial Treatment of CO Poisoning


06:14 – Cyanide Toxicity


07:19 – Treatment Options for Cyanide Poisoning


09:12 – Take-Home Points and Clinical Pearls



Physiological Effects of Smoke Inhalation:



  • Thermal Injury:

    • Direct upper airway damage from heated air or steam.

    • Leads to swelling, inflammation, and possible airway obstruction.



  • Chemical Irritation:

    • Causes bronchospasm, mucus plugging, and inflammation in the lower airways.

    • Increases capillary permeability, potentially causing pulmonary edema.



  • Systemic Toxicity:

    • Primarily involves carbon monoxide and cyanide poisoning.




Episode 206: Acute Back Pain

Mon, 03 Mar 2025







We discuss the evaluation of and treatment options for acute back pain.


Hosts:

Benjamin Friedman, MD

Brian Gilberti, MD









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Show Notes


**Please fill out this quick survey to help us develop additional resources for our listeners: Core EM Survey**



Clinical Evaluation:



  • Primary Goal: Distinguish benign musculoskeletal pain from serious pathology.

  • Red Flags: Look for indicators of spinal infection, spinal bleed, or space-occupying lesions (e.g., tumors, large herniated discs).

  • Assessment: A thorough history and neurological exam (strength testing, gait) is essential.

  • Additional Tools: Use bedside ultrasound for post-void residual assessment in suspected cauda equina syndrome


Imaging Guidelines:



  • Routine Imaging: Generally not indicated for young, healthy patients without red flags.

  • ACEP Recommendations: Avoid lumbar X-rays in patients under 50 without risk factors, as they do not change management and may increase costs and ED time.

  • Advanced Imaging: Reserve MRI for patients with red flags, neurological deficits, or suspected cauda equina syndrome; CRP may be a part of your calculus when evaluating for infectious causes of back pain


Treatment Options:



  • Evidence-Based First-Line:

    • NSAIDs offer modest benefit.

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