MEdIC Series | The Case of Breaking Bad News Badly

DNR canstockphoto4969800Code status. Do not resuscitate. Allow natural death… These can be some of the most daunting concepts for new learners to explain to patients, but they can also be the most critical. Depending on the circumstances, discussing these topics may be difficult for the most advanced clinicians.  This month’s ALiEM MEdIC series case considers how we might help a learner through a bad experience with end-of-life care discussions. Please join us in discussing the case this month, we would love your thoughts and advice.


P.S. Eve Purdy, Brent Thoma, Sarah Luckett-Gatopoulos and I would also like to invite you all to register for the ALiEM MEdIC pre-conference workshop at SMACC.  Come out and be part of a LIVE version of the ALiEM MEdIC case development and release for a special SMACC version of the case series!

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of Breaking Bad News Badly

by Dr. Stephen Singh (@SSingh_MD)

“I’m not sure that went so well…” William said to Sally. William was a first-year off-service resident rotating through emergency medicine. Sally, a third-year emergency medicine resident, was reviewing the case with him.

“I think…. I think the patient and his wife are upset with me…” William continued. The patient was Mr. Theodore Smith, a 78-year-old gentleman with stage four prostate cancer with metastases to the bones. He had come to the emergency department in a pain crisis, and a decision had been made to admit him to hospital to optimize his pain control.

“Why do you think that?” probed Sally, a budding medical educator. She had encouraged William to discuss the patient’s end-of-life goals, using the hospital’s ‘Code Status’ form as a prompt to open the discussion. She had even asked William if he was comfortable with the discussion, and he had stated he felt very confident, as he had just finished is in-patient internal medicine rotation.

“Like you asked, I was trying to get them to complete the code status form, to make it easier for the admitting team. But it sounds like no one had discussed this before with them,” William explained.

“How did you bring it up?”

“I asked them if they wanted everything done if something bad happened,” William explained. “They seemed confused, so I went through the checklist on the sheet, and that seemed to confuse them more. They wanted to know what this had to do with alleviating his pain, and why I was asking them these questions. Mr. Smith started to cry, and his wife asked me why I had to put him through more suffering. They then demanded to speak with the ‘real doctor.'”

Sally understood as she had had a similar experience when she was a first-year resident. Though able to empathize with William, she reflected that she was not well equipped to help sort this out now that there was clearly an issue between William and his patient. Not wanting to complicate the situation for the busy Senior Medical Resident, she and William come to you as the supervising staff emergency medicine physician and explain the situation.

Key Questions

  1. How should questions about a patient’s ‘code status’ be brought up?
  2. Who is responsible for helping to determine a patient’s goals of care?
  3. How can one “repair” the physician-patient relationship after a code status or goals of care discussion goes awry?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Dr. Ashley Shreves, an Assistant Professor of Emergency Medicine & Geriatrics and Palliative Medicine, Mt. Sinai in New York City.
  • Dr. Susan Shaw, Critical care & Anesthesia physician in Saskatoon. She teaches at the University of Saskatchewan, working to improve the system in Saskatchewan, Canada.

On January 29, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of Breaking Bad News Badly. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on January 29, 2015.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.


Image from CanStockPhoto

Author information

Teresa Chan, MD

ALiEM Associate Editor

Emergency Physician, Hamilton

Assistant Professor, McMaster University

Ontario, Canada
+ Teresa Chan

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PV Card: Testicular Ultrasound for Torsion and Epididymitis

Testicular Torsion sm“Time is testicle.” Every minute drags by while you are awaiting your ultrasonographer to arrive to scan your patient to rule out testicular torsion. Why not take a quick look yourself? What are you looking for? This is an excellent PV card by Drs. Matthew Dawson and Mike Stone on the topic of testicular ultrasound, giving the basics about testicular torsion and acute epididymitis.

PV Card: Testicular Ultrasound

Testicular Ultrasound 1

Testicular Ultrasound 2

You can download this PV card:  [MS Word] [PDF]

Author information

Scott Kobner

Medical student

New York University School of Medicine

ALiEM-EMRA Social Media and Digital Scholarship Fellow


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Must-Know EM Pharmacotherapy Articles of 2014

canstockphoto23105821There is so much literature to sift through each year, it becomes nearly impossible to stay abreast of it. Here is a quick summary of the 6 must-know Emergency Medicine pharmacotherapy articles from 2014, in my humble opinion.



1. High-Dose Droperidol and Risk of QT Prolongation2. Dexmedetomidine As Adjunct Therapy for EtOH Withdrawal - RCT3. A Simpler Dosing Regimen for Digoxin-Specific Antibody Fragments4. Treatment for Calcium-Channel Blocker Overdose: A Systematic Review5. Bactrim + ACE-Inhibitor (or ARB) + Older Adult = Increased Sudden Death6. Is That IV Antibiotic Before ED Discharge Really Necessary?
46 patients treated with high-dose droperidol (10-40 mg) were studied prospectively with continuous holter recording.

What they did

Patients initially received 10 mg droperidol as part of a standardized sedation protocol (for aggression). An additional 10 mg dose was given after 15 min if required and further doses at the clinical toxicologist’s discretion.

Continuous 12-lead holter recordings were obtained for 2-24 hours. QTc > 500 msec was defined as abnormal (with heart rate correction – QTcF).

What they found

Only 4 patients had abnormal QT measurements, three given 10 mg and one 20 mg. All 4 had other reasons for QT prolongation. No patient given > 30 mg had a prolonged QT. There were no dysrhythmias.

What it means

There was little evidence supporting droperidol being the cause and QT prolongation was more likely due to pre-existing conditions or other drugs.

Calver L, et al. High dose droperidol and QT prolongation: analysis of continuous 12-lead recordings. Br J Clin Pharmacol 2014;77(5):880-6. [PMID 24168079]

Originally posted Jan 4, 2014 as University of Maryland (UMEM, @UMEmergencyMed) pearl.

Four small case series (one prospective, 3 retrospective) have concluded that dexmedetomidine (Precedex) may be a useful adjunct therapy to benzodiazepines for ethanol withdrawal in the ED or ICU. They are summarized in a previous ALiEM post.

A new randomized, double-blind trial evaluated 24 ICU patients with severe ethanol withdrawal.

Group 1: Lorazepam + placebo

Group 2: Lorazepam + dexmedetomidine (doses of 0.4 mcg/kg/hr and 1.2 mcg/kg/hr).

  • 24-hour lorazepam requirements were reduced from 56 mg to 8 mg in the dexmedetomidine group (p=0.037).
  • 7-day cumulative lorazepam requirements were similar.
  • Clinical Institute Withdrawal Assessment or Riker sedation-agitation scale scores were similar within 24 hours.
  • Bradycardia occurred more frequently in the dexmedetomidine group.

In my opinion, a major limitation of this study is that patients had more than 24 hours of treatment before randomization. Eleven of the 24 patients were already intubated when the trial started. The best place to use dexmedetomidine is probably in the early treatment course to help avoid intubation altogether. I’m not sure this very exclusive trial (24 patients included/209 excluded over 4 years) provides any answers for the patients who may benefit most from this therapy. A reduction in benzodiazepines is not even the correct outcome to measure. That may lead to the erroneous notion that we don’t need benzodiazepines (as has happened in some of the other studies). We should be looking at reduction in intubations and ICU length of stay.

Mueller SW, et al. A randomized, double-blind, placebo-controlled, dose range study of dexmedetomidine as adjunctive therapy for alcohol withdrawal. Crit Care Med 2014;42(5):1131-9. [PMID 24351375]

Originally posted May 3, 2014 as UMEM pearl.

Digoxin-specific antibody fragments (Fab) are safe and indicated in all patients with life-threatening dysrhythmias and an elevated digoxin concentration. However, full neutralizing doses of digoxin-Fab are expensive and may not be required (not to mention cumbersome to calculate).

Based on pharmacokinetic modeling and published data, a new review suggests a simpler, more stream-lined dosing scheme as follows:

  • In imminent cardiac arrest, it may be justified to give a full neutralizing dose of digoxin-Fab.
  • In acute poisoning, a bolus of 80 mg (2 vials), repeat if necessary, titrated against clinical effect, is likely to achieve equivalent benefits with much lower total doses.
  • With chronic poisoning, it may be simplest to give 40 mg (1 vial) at a time and repeat after 60 min if there is no response.

Chan BS, et al. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol 2014;52:824-36. [PMID 25089630]

In a precursor to a forthcoming international guideline on the management of calcium channel blocker poisoning, a new systematic review has been published assessing the available evidence.

A few findings from the systematic review:

  • The majority of literature on calcium channel blocker overdose management is heterogenous, biased, and low-quality evidence.
  • Interventions with the strongest evidence are high-dose insulin and extracorporeal life support.
  • Interventions with less evidence, but still possibly beneficial, include calcium, dopamine, norepinephrine, 4-aminopyridine (where available), and lipid emulsion therapy.

Stay tuned for the international guideline coming out soon. One treatment recommendation from the new guideline, reported at the 8th European Congress on Emergency Medicine September 2014, is not to use glucagon.

St-Onge M, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol 2014;52:926-44. [free full-text PDF]

Originally posted October 9, 2014 as UMEM pearl.

A new population-based case-control study in older adults has linked the administration of trimethoprim-sulfamethoxazole (Bactrim, TMP-SMX) to increased risk of sudden death in patients also receiving angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB).

Hyperkalemia is the suspected cause. Compared to amoxicillin, TMP-SMX was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76) within 7 days of exposure to the antibiotic.

Practice Change

In older patients receiving ACE-Is or ARBs, TMP-SMX is associated with an increased risk of sudden death. When appropriate, alternative antibiotics should be considered.

Fralick M, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population-based study. BMJ 2014;349:g6196. [Free open access link]

Many of the oral antibiotics prescribed in the ED have good bioavailability. So, a one-time IV dose before discharge generally won’t provide much benefit.

In fact, a new prospective study found that a one-time IV antibiotic dose before ED discharge was associated with higher rates of antibiotic-associated diarrhea and Clostridium difficile infection. One-time doses of vancomycin for SSTI before ED discharge are also not recommended (see Academic Life in EM post by Zlatan Coralic).

Bottom Line

Though there are a few exceptions, if a patient has a working gut, an IV dose of antibiotics before ED discharge is generally not recommended and may cause increased adverse effects. An oral dose is just fine.

Haran JP, et al. Factors influencing the development of antibiotic associated diarrhea in ED discharged patients home: risk of administering IV antibiotics. Am J Emerg Med 2014;32(10):1195-9. [PMID 25149599]

Originally posted December 6, 2014 as UMEM pearl.

Image credit: (c) Can Stock Photo

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

ALiEM Associate Editor

Clinical Assistant Professor, University of Maryland (UM)

Clinical Pharmacy Specialist, EM and Toxicology

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Welcome Dr. Matthew Zuckerman: 2015 ALiEM-AAEM Social Media and Digital Scholarship Fellow

Matthew Zuckerman

Welcome to the newest member of our team, Dr. Matthew Zuckerman (@matthew608b), who is an Assistant Professor in Emergency Medicine at the University of Colorado, Anschutz Medical Campus. He will serve as our inaugural 2015 ALiEM-AAEM Social Media and Digital Scholarship Fellow, working on advancing medical education and upgrading the AAEM e-book “Rules of the Road for Young Emergency Physicians.”

Matt is a medical toxicologist and practicing emergency physician, who is the creator and host of the ToxTalk toxicology podcast. This podcast has been downloaded over 100,000 times, recognized by iTunes and the National Science Foundation’s Radio360 website, and has been cited as a social media toxicology resource by BMJ and Annals of Emergency Medicine. His current interests include the use of social media in medical education and obesity as a special population in medical toxicology.

ALiEM-AAEM brochure front



We are very excited to have Matt join our team and our other fellows Sam Shaikh (ALiEM-CORD) and Scott Kobner (ALiEM-EMRA). We anticipate great things from this collaboration!


Author information

Michelle Lin, MD

ALiEM Editor-in-Chief

Editorial Board Member, Annals of Emergency Medicine

UCSF Academy Endowed Chair for EM Education

UCSF Associate Professor of Emergency Medicine

San Francisco General Hospital

The post Welcome Dr. Matthew Zuckerman: 2015 ALiEM-AAEM Social Media and Digital Scholarship Fellow appeared first on ALiEM.

I am Dr. Felix Ankel, VP for Health Professions Education at HealthPartners Institute: How I Work Smarter

How I Work Smarter LogoIt’s no coincidence that Dr. Felix Ankel (@felixankel) is Vice President for Health Professions Education at HealthPartners in Minneapolis. Dr. Ankel lives and breaths education and self-improvement. He has been active with CORD, SAEM, ACEP, ABEM, AAEM, among others. He is the recipient of the prestigious ACGME Parker J. Palmer Courage to Teach Award for his contributions to medical education and his work in competency based learning. Today he was generous enough to take some time to share not only insights about the logistics of working smarter but also an approach to the mindset for success.

  • Name:  Felix Ankel, MDFelix Ankel
  • Location: Minnesota
  • One word that best describes how you work: Networked
  • Current job:  VP for Health Professions Education, HealthPartners Institute
  • Current mobile device: iPhone 4S
  • Current computer: Macbook Air


What’s your office workspace setup like?

Felix Ankel Workplace

Macbook Air, iPad mini with Pandora playing Moby radio, iPhone, and old-school Franklin planner.

What’s your best time-saving tip in the office or home?

Failing to plan is planning to fail. I have moved from work-life balance to work-life integration. I plan for both during both.

What’s your best time-saving tip regarding email management?

E-mail management is a discipline, not a goal. Try to improve the process a little bit, every time.

What’s your best time-saving tip in the ED?

Communicate early, communicate often. Discuss thought processes with residents, with nurses, with patients. Communicating only when something is needed will lead people to disengage from you, mostly on a subconscious level.

What’s the best advice you’ve ever received about work, life, or being efficient?

  • Manage narrative, delegate the rest
  • Make yourself obsolete, not indispensable
  • Give up power, maintain strength
  • Give up authority, maintain accountability
  • Give up resources, maintain responsibility

Is there anything else you’d like to add that might be interesting to readers?


These are more philosophical musings that have helped me work smarter over the years. Work is a discipline to be mastered rather than a task to be completed. Have a growth mindset and try to continuously learn, especially in domains outside of #meded. Key for me is constant reflective practice that includes journaling. Journaling has allowed me to “pet the lizard”, “feed the mouse”, and “hug the monkey” and move projects that may have brainstem or limbic system roots into the neocortex for higher-level impact. Journaling allows me to recognize the importance of Kairos aka “timing”, project sequencing and cadence, rather than Chronos aka “time” alone. Journaling also helps me identify and avoid non-helpful workplace patterns that impact efficacy such as the Karpman triangle.

My main work goal is to create value by moving from novice to expert in the domains of resilience, complexity, and context both individually and in groups (see Program Milestones Talk).

  1. From a resilience point of view I try to see how anything I do fits into my values, try to connect, try to bend, and try to engage in systematic reflective practice.
  2. In the complexity domain, I follow organizations such as the Plexus Institute and the Santa Fe Institutes.
  3. In the context domain, I build an org chart GPS and see how what I do fits into the bigger picture. I am a member of the American Evaluation Association (AEA), which has an active group looking at social network analysis.

Just like there is a triple aim in health care, there is a triple aim (quality, experience, stewardship) in #meded. The most efficient value creation occurs in networks. My roadmap for #meded value creation involves 3 Cs:

  • (C)uration,
  • (C)ommunities of practice
  • (C)reation of value

My #meded value creation goals are attempts to improve patient health and well-being with patient, clinician, and learner support tools.

Successful organizations of the future will adapt and thrive in an organic, exponential world by incorporating the left and the right: e.g. left brain “facts” and right brain “story” and “design”, left heart “carrots and sticks” and right heart “autonomy, mastery, and purpose”, and left soul “six sigma, LEAN”, and right soul “appreciative inquiry”.

#FOAMed is a great example of this and its has been exciting to see the impact it has had on #meded.

Who would you love for us to track down to answer these same questions?

  1. Dr. Eric Holmboe @Boedudley
  2. Dr. Richard Horton @Richardhorton1
  3. Dr. Rob Cooney @EMEducation

Author information

Benjamin Azan, MD

Benjamin Azan, MD

Emergency Medicine Resident

Icahn School of Medicine at Mount Sinai

Founder/Editor of

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ALiEM Bookclub: Brain on Fire – My Month of Madness

jpeg“Looking back at this time, I see that I’d begun to surrender to the disease, allowing all the aspects of my personality that I value – patience, kindness, and courteousness – to evaporate. I was a slave to the machinations of my aberrant brain. We are, in the end, a sum of our parts, and when the body fails, all the virtues we hold dear go with it.” – Brain on Fire, Susannah Cahalan

Brief Synopsis

Brain on Fire is the New York Post’s reporter Susannah Cahalan’s (@scahalan) captivating account of her battle with a mysterious and life-threatening illness. Her progressive physical, cognitive, and psychological symptoms worried her family and stumped physicians, who searched for an explanation. Cahalan pieces together her “month of madness” by supplementing her limited recollections of her illness with those provided by family and friends—as well as scouring through her medical records. Here, the reader is exposed to the sometimes confusing and harsh world of healthcare seen from the perspective of Cahalan as the patient. In addition to telling her story, Cahalan also applies her reporting skills to meticulously research her ultimate diagnosis, Anti-N-methyl D-aspartate Receptor (Anti-NMDAR) encephalitis—a disease that has only recently been acknowledged. All together the memoir gives the reader an intimate and informed testimony of her experience as a patient.


Cahalan describes her visits to the emergency department, various doctors’ offices, and finally a prolonged hospitalization in an epilepsy unit. As medical professionals, we know these environments intricately, but rarely from the viewpoint of our patients. The author’s recollections of her and her family’s experience as a patient give the medical reader a different perspective into our profession. Especially frustrating was how often her initial symptoms were dismissed as consequence of a young person living the party life in NYC, even though Cahalan and her family would deny excessive drug and alcohol abuse. But as a medical professional, it is easy to see how that type of conclusion could be made from a young person presenting to the ED with complaints of paranoia, hallucinations, and otherwise odd behavior. And thus the beauty of this book, in reading the patient’s narrative, we are able to better understand the impact of our practice, unintended judgement, clinical decisions, and communication with our patients and their families during times that are often the scariest and most uncertain in their lives.

Clinical Application

Cahalan’s book forces the reader to take a hard look at the current methods of medical training. In medical and nursing training, our focus is on understanding pathology, diagnosing disease, and acquiring the language of medicine. During the time patients spend in our care, it is common for us to identify them by their disease—for example, the chest pain in room 5, or the laceration in the hallway. In Brain on Fire, Cahalan recounts her experience during medical rounds after she is diagnosed with Anti-NMDAR encephalitis:

“Now that we had a diagnosis that had never before been seen at NYU, young MDs, hardly a day older than me, stared at me as if I were a caged animal in a zoo and made muffled assessments, pointing at me and craning their heads as more experienced doctors gave a rundown of the syndrome.”

Teaching by way of clinical rounds is a necessity in the medical world, but have we given enough thought to what it feels like from the other side of the bed—as the person being rounded upon? We know the details of our patients’ medical history and clinical course, but we also need to be aware of our patients’ own perspective on their illness, and we should be sensitive to what they experience emotionally during their treatment.

Reading a patient’s memoir, gives us this crucial and often overlooked insight that could make us more compassionate physicians. This makes this book applicable, not only to the junior learner in the medical setting, but also to the seasoned practitioner to serve as a gentle reminder that our patients’ narratives and recollections of their medical experience goes beyond the simple and sterile labeling of a diagnosis.

Discussion Questions

  1. Medical professionals often use defense mechanisms to separate themselves from the many difficult situations we face at work. Cahalan recounts an interaction between her mother and one of her doctors in which the doctor refers to a bet she has regarding the final diagnosis. Have you ever found yourself using a defense mechanism and why?
  2. Many different physicians evaluate Cahalan during her illness before her ultimate diagnosis is made. Do you think she was initially misdiagnosed?
  3. The author acknowledges the good fortune she had in finally reaching a diagnosis and receiving the appropriate treatment.  What factors do you believe contributed to her eventual diagnosis and treatment?

Google Hangout Bookclub Discussion


Want to join in the bookclub discussion?
Tweet us directly at @ALiEMBook
Use hashtag #ALiEMbook.

Further Resources

Online Reading Guide PDF

Greenberg, M. Back from Madness, Sunday Book Review New York Times, Dec 21, 2012. [Link]

Disclaimer: We have no affiliations financial or otherwise with the authors, the books, or Amazon.

Edited by:
Jordana Haber MD (@jojohaber)
Nikita Joshi MD (@njoshi8)

Author information

Aimee Tang, MD

Aimee Tang, MD

Emergency Medicine Resident
Maimonides Medical Center
Brooklyn, NY

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