A Rational Approach to Emergency Ebola Preparedness

In this special 15 minute EM Cases podcast on Ebola preparedness we bring you an interview with Professor Howard Ovens, the director of emergency medicine at Mount Sinai Hospital in Toronto. As an EM physician who took care of many SARS patients and the chief of the ED during the SARS outbreak, Dr. Ovens has a very rational approach to how to prepare our emergency departments for patients who present with fever who have been traveling in an Ebola outbreak region, including triaging and personal protective equipment (PPE).

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Sepsis and Ppm Failure

85 yo M with PMHx of CHF, paroxysmal atrial fibrillation and dual chamber PPM placed for sick sinus syndrome, who presents with lightheadedness, confusion and progressive lethargy x 1 day. At arrival to the ED patient hypotensive 70/30, bradycardic 46 x min, febrile 102 F.

EKG is obtained






Initial labs are remarkable for pH 7,10 HCO3 10 and Lactate of 5, with normal electrolytes

Patient’s pacemaker is set at a rate of 60 and recent interrogation showed no abnormalities.

What is the diagnosis and most likely explanation for this problem? 

Dx: Failure to capture 

EKG shows low voltage pacing spikes (circles) which are not associated with ventricular activity.

Following initial standard resuscitation measures (fluids, abx, etc.) in the setting of suspected severe sepsis, pacemaker dysfunction was addressed.

CXR showed no evidence of lead displacement or fractures and further pacemaker interrogation showed no problems with output failure or pacemaker sensing.

Problem was thought to be pacemaker’s failure to capture in the setting of metabolic acidemia due to sepsis from urinary source. Patient was temporarily supported with noreepineprhine and IV fluids and pacemaker function normalized once metabolic disturbances were corrected.


Main causes to consider for a malfunctioning pacemaker can be classified as:

1. Problems with sensing

- Undersensing: pacemaker fails to sense native cardiac activity

- Oversensing: artifact signals such as skeletal muscle contractions or lead contact problems are inappropriately recognized as native cardiac activity and pacing is inhibited

2. Problems with pacing:

- Output failure: paced stimulus is not generated (common causes include wire fracture and lead displacement)

- Failure to capture: when pacemaker stimulus does not result in myocardial depolarisation


In a patient who presents with pacemaker malfunction in the setting of sepsis, metabolic acidemia should be considered as a potential underlying factor causing failure of the device to capture. Additional attempts of pacing such as placement of a intravenous pacing wire will likely not be effective until correction this problem.



PHARM PODCAST 106 : Prehospital airway


Image from Twitter. No financial disclosures

Image from Twitter. No financial disclosures

Hi Folks

On today’s show, I deliver Part one of a Two part podcast on Prehospital Airway.

Show note references:

  1. Courtesy of Dr Nicholas Chrimes at clinicalcred.com

Register for SMACC please!


Now, onto the PODCAST!


Click and Choose Save-as to Download the


Filed under: airway, Emergency medicine and critical care, FOAMEd, Interviews of interesting people, Online critical airway training, prehospital and retrieval medicine podcast, Prehospital medicine Tagged: airway, itunes, prehospital

Healthcare Update Satellite — 10-21-2014

More medical news from around the web on my other blog over at DrWhitecoat.com

Study from University of Maryland proves that emergency physicians are idiots … at least when treating pediatric extremity injuries. Splints were placed improperly in 93% of suspected pediatric fractures treated in emergency departments. “The researchers found that the most common reason for improper placement of a splint was putting an elastic bandage directly on the skin, which occurred in 77% of the cases. In 59% of the cases, the joints were not immobilized correctly, and in 52%, the splint was not the appropriate length. Skin and soft-tissue complications were observed in 40% of the patients.”
Of course, I’m sure that the orthopedists evaluated the patients immediately after the splints were placed to make sure that the patients had not readjusted the splints prior to their orthopedic follow up. That almost never happens.
This study makes a good case for requiring orthopedic evaluation in the emergency department for every pediatric patient suffering from any type of bone or joint injury – regardless of the time of day or night.

What no one is telling you about Ebola … from a Hazmat Trained Hospital Worker. The gear used to protect providers from Ebola is difficult to put on, difficult to remove, and can usually only be worn for 30 minutes at a time. The medical providers in Dallas who contracted Ebola had no protocols in place and this author believes that the “system failed them.”

Patients apparently believe that being in the same hospital as an Ebola patient is bad for their health. Patients at Texas Health Presbyterian Hospital are canceling outpatient procedures, no one is walking in the hallways, and the ED wait times have dropped from an average of 52 minutes to … zero.
“It feels like a ghost town,” said one vendor who recently visited the hospital.

Ketamine has almost immediate positive effect on anhedonia and depression associated with bipolar patients who are resistant to other treatments. The more remarkable thing is that the effects can also be seen on PET scans and effects from a single dose of medication last for over two weeks.

Another example of why doctors should be wary of treating VIP patients. Former NFL running back sues orthopedic surgeon after alleging that his Achilles tendon tore during Baltimore Ravens tryout. Alleges that the surgeon misrepresented the fact that the Achilles tendon had fully healed after his prior Achilles surgery.

Ambulances line up outside North Wales hospital waiting to drop off emergency patients. At one point the line was 13 ambulances long and the wait was hours just to get into the emergency department. One of the government administrators recommended that patients go to NHS Direct or pharmacies for speedy health advice.
At least the patients are covered by insurance, though — just like many of the patients in the US now.
Australian nurses want penalties to be imposed on hospitals if patients aren’t seen within four hours in emergency departments.

If this penalty materializes, a few things will happen. First, nurses will be penalized by hospitals for not effectively moving patients through the emergency department. Second, there will be massive fudging of statistics during busy times. Third, patients who have exceeded the four hour threshold wait will be passed over so that patients who have been waiting less than four hours can be evaluated within the threshold.
When you pay for a statistic, you get the statistic … not necessarily the intended benefits behind the statistic.

From comments at Overlawyered.com
Employee of a surgicenter goes to facility for a colonoscopy. When he wakes up, he was wearing pink underwear. As a result, he suffered extreme emotional distress, humiliation, loss of wages and loss of earning capacity. He is now suing.
While I probably would have laughed off a prank like this, I can understand why some people would have been upset. But suffering a loss of earning capacity from being dressed in pink panties as a prank? I’d like to see how that happened.

Hide And Seek: Button Batteries in the Emergency Department

St Emlyns - Meducation in Virchester #FOAMed

We see lots of kids presenting to the ED with “things” where they shouldn’t be (we see adults too, sometimes – but that’s a whole set of different stories).  Foreign bodies show up in all sorts of forms in all sorts of places, typically in the preschool and early school age kids who display a potentially […]

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