The Surviving Sepsis Guidelines have lost their way…

Hello everyone,

EM Basic will be back soon with new episodes but I am writing this post to bring your attention to the new 2018 Surviving Sepsis guidelines…and why I (and many others) think that they have to go.

Here’s the bottom line and the real sticking point: the 2018 Surviving Sepsis guidelines mandate antibiotics and 30 ml/kg fluid bolus now be given within 60 minutes of emergency department TRIAGE!?!?  This has zero evidence behind it and will only cause patient harm by rushing to implement antibiotics and fluids that most patients will not need.  Does anyone remember the “antibiotics within 4 hours of pneumonia diagnosis” debacle?

You learned from the sepsis update on this podcast that the goal of sepsis care (as stated by Scott Weingart from EmCrit) is that you don’t have to do a lot of crap, you just have to give a crap.  This means tailoring your interventions to what the patient needs- not a blind following of a rigid protocol or guidelines.  This tailored approach is supported by multiple multi-center international RCTs and it is what we should be doing in the ED for our patients with sepsis.

Josh Farkas and the EmCrit crew have spearheaded a petition to call for a retraction of the 2018 surviving sepsis guidelines and you should definitely read their take on this at the EmCrit page.  These guidelines were started with the best of intentions but have lost their way by mandating therapies that most patients won’t need.

If you want to contribute, go to the petition website and add your name to the list of those who think that the 2018 Surviving Sepsis guidelines should be retracted.

Until next time…


Big Picture Advice to New EM Interns

Just a few days after the new EM interns start, today’s episode will talk about my advice to new EM interns.  Think of this as the “big picture advice” or a 30,000 foot view of how to approach EM residency.  I’ll talk about 4 major big picture points to keep in mind as you start your residency.  This will go way beyond “arrive early, stay late, and always keep learning” and expand on some big picture ideas of how to function well as a new intern.

Big Picture Advice to New Interns Podcast

Below is a blog post version of the podcast in case you want to read it (edited for clarity):

4 Big Picture Pieces of Advice to New EM Interns

#1 EM residency is a 3 or 4 year exercise in figuring out what your attendings want. The earlier you accept this, the better and more productive you will be as a resident.

Every attending will have a different way of doing things. This can seem enormously frustrating at first because it may seem like you are getting so many different messages.  Think of this way- You are a single learner working with many different attendings.  Each attending has their own knowledge base, risk tolerance, and ways of doing things.  On the flip side, I am a single attending working with many different learners.  Each learner has a different fund of knowledge, a different way of thinking about things, and a different way in which they learn best.  As an attending, I wouldn’t expect every learner to be exactly the same- at the same time, as a learner you can’t expect every attending to practice the same way.

Instead of getting frustrated by what may be seen as many mixed messages, figure out a respectful way of asking your attending why they are doing it this way as compared to what you have seen other attendings do.  For example, you could say something such as “I’ve seen other attendings approach this differently” and explain what you have seen.  Anyone who works with residents or students should not take offense to this but rather should take this as an opportunity to acknowledge that there is practice variation and teach their thinking on this topic.

The best attendings will acknowledge upfront when they teach something that they know has wide practice variation.  One final way of looking at this is that residency is the opportunity to see many different styles of practice and mold your own practice, taking the best parts of each attending that you work with.

#2 Attendings teach what they know

When you first start off, the knowledge base of your attendings can seen overwhelming.  I found myself thinking “There is no way I will be able to know what they know when I graduate from residency in 3 years (or 4 years PRN)- it’s just too much to know!”  This can be frustrating and intimidating but I’m going to let you in on a little secret- attendings teach what they know.

Everyone has their own subset of knowledge that they are really great at so they will likely teach that frequently.  For example, if you’re on shift with me and we start talking about airway then you should get comfortable because we could be there for a while because I am a huge airway nerd.  However, if you ask about which toxic alcohols cause which lab abnormalities, yeah- I’m gonna need a minute and probably an up to date consult- but the next attending you work with may be really into tox and know that off the top of their head.  You can substitute airway and tox for critical care, ultrasound, sports medicine, pediatrics, and the list goes on and on.

Trust me there are attendings out there- the renaissance women and men, if you will- that truly know just about everything there is to know.  That’s its own skillset the same way people are experts in all the other topics and just about all of these attendings have more than a little gray hair.  So don’t get frustrated if it seems like the knowledge base in EM is endless and impossible.  Trust me that you will learn what you need to know during your residency and you will develop an area of mini-expertise if you work at it.

#3 When presenting a patient, you should rarely ask your attending how they would manage the patient without giving your own plan first.

My next piece of advice has to deal with moving on from the reporter stage to the manager stage.  As an early medical student, the expectation is that you can report your findings accurately.  As a more senior medical student and intern, we want you to move beyond this reporter stage and into the manager stage.  We need to know that you have thought through a plan on how you want to manage the patient.  As an intern, that plan does not have to be 100% correct- you just need to have a plan.

For example, let’s say you have a young female with chest pain and shortness of breath.  The not as good way of giving your assessment and plan would be “This is a 20 year old female with chest pain and shortness of breath. Should we scan her for pulmonary embolism?”

The much better way of presenting this would be “This is a 20 year old female with chest pain and shortness of breath.  I don’t think I would scan her for PE because she has no risk factors for PE and normal vital signs”.  This is a much better way of presenting this because it has shown that you have made a gestalt assessment of the patient and what their plan should be instead of just reporting what you found.

If you present it the first way, you haven’t made a management decision yet.  If you present it the second way, we can have a conversation about Well’s and PERC criteria and ways of risk stratifying patients for PE and tie it into your own gestalt assessment.  So if you ask an attending a management question such as “would you get a CT for PE on this patient” don’t be offended or think the attending is lazy when they say “What would you like to do”.  This is our way of forcing you to think through the patient management plan and committing to it which is a vital skill to learn in EM.

As an attending, my number 1 job is to keep patients safe so I won’t let you do anything unsafe.  That is your permission to make that management decision when you present the patient.  If I don’t think it’s the right plan, I’ll tell you so and teach why I think a different plan would be better.  As a resident, you will be wrong sometimes and that’s ok- you are learning and remember what I said about practice variation between different attendings.  So resist the temptation to ask your attending what you should do in regards to a management decision without first making the call yourself.

#4 Residency is a long 3 (or 4) years but it is finite and your life will get better as an attending.

Residency is fun sometimes and it’s hard a lot of times.  You are going to work a lot.  When you start as an intern everything is new and exciting and you should hold onto that feeling for as long as humanely possible.

However, somewhere around the middle of your first year, maybe sometime in your second year after a few intense rotations in a row you’ll probably get a little frustrated.  You’ll probably think to yourself “this sucks and its never going to end, I’m going to work this hard for the rest of my life”.  I am here to tell you that this is not true.  Yes, you will work hard during residency and the hours will be long but trust me, it does get better- much better.

As an EM attending, the only reason you would work as many hours as you did as a resident is because, for some insane reason, you choose to.  I don’t think you would get much argument from EM attendings when I say that if your attending job has you working as much as your residency hours, you should find a new job.  Your life as an attending will get better.  You will have multiple days off in a row without having to give up one of your kidneys or work 15 days straight.  So called “golden weekends” in residency will just become “weekends”.  Sure, you’ll have to work weekends, nights, and holidays but having a full weekend off will not become a rare luxury any more.

Don’t get me wrong- you will work hard as an attending but your work life balance will be much, much better than it is in residency. You will have more time off and fewer demands on your time. So keep this in mind when the hours are long and seem like they are endless- I assure you that life gets better.

Finally, if you are feeling burned out or are having a tough time, please seek out support from your residency director or someone you can talk to in your residency program. We are all there to help and we are there to support you. We do not want anyone to feel like they are doing this alone. There have been far too many suicides in medical residents and we want them to stop. So please take care of yourself and seek out support if you are struggling.


Sickle Cell Anemia by Dr. Jared Walker

Today’s episode is on the evaluation and management of sickle cell anemia in the Emergency Department. Dr Jared Walker, a third year EM resident at the University of Florida Jacksonville, has written and recorded this excellent review of sickle cell disease. This episode will discuss how to properly assess patients with sickle cell, how to order the right labs and imaging, what red flags to look out for, how to control sickle cell pain, how to catch the various complications of sickle cell, and proper patient disposition.

Sickle Cell Anemia Podcast

Sickle Cell Disease Show Notes (Word Format)

Sickle Cell Disease Show Notes (PDF)

Check out our bandwidth sponsor, EB medicine. They several issues on sickle cell disease in both kids and adults- check them out here.  Residents can get free access to all their great resources by going to the ebmedicine EM Basic page and attendings can get a discount on their products that offer CME.