https://www.issacprogram.com/blog daily 0.75 2023-12-12 https://images.squarespace-cdn.com/content/v1/64b9441f7fdae8708d5cd680/1689863208287-1KDPR47WKJKJ3WLS5Q0X/spaceship-blue%402x.png https://www.issacprogram.com/blog/11162023-ventricular-tachycardia-and-stroke monthly 0.5 2023-12-12 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/b0cf2193-7b0f-4e9d-b98a-eace2a857b9f/blob+%285%29.jpeg Blog - 11/16/2023 Ventricular Tachycardia and Stroke - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/c8f81264-e90e-4f7c-a784-4c34d2505387/blob+%286%29.jpeg Blog - 11/16/2023 Ventricular Tachycardia and Stroke - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.issacprogram.com/blog/10192023-opioid-od monthly 0.5 2023-12-12 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/9129d4d0-3762-408b-a2d5-1df86cd95ebe/opioid-overdose-scaled-e1629989473882.jpg Blog - 10/19/2023 Opioid OD - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.issacprogram.com/blog/10262023-stroke monthly 0.5 2023-11-28 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/907ccd51-320d-4214-bdf4-03f8a7931906/human-with-common-types-stroke_1308-111765.jpg Blog - 10/26/2023 Stroke - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.issacprogram.com/blog/1052023-ectopic-pregnancy monthly 0.5 2023-11-28 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/230080f4-bb1b-4682-b704-e6b2b8f46978/c7605296854cbc27276a69c24f0b72a6.jpeg Blog - 10/5/2023 Ectopic Pregnancy - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/787b8aaf-be61-4267-b4b6-eefb24ddac8d/image-12.jpeg Blog - 10/5/2023 Ectopic Pregnancy - Make it stand out https://med.emory.edu/departments/emergencymedicine/sections/ultrasound/case-of-the month/trauma/fluid_in_the_pelvix.html Despite your 1L bolus, the patients BP has dropped to 90/60 mmHg and her HR is now 125 bpm. At this point you have an unstable patient who is bleeding into her abdomen. Your most likely source is a ruptured ectopic pregnancy. Actions: - You ask a different nurse or tech to run to TCC and pull uncrossmatched blood from the refrigerator. You then activate MTP because you anticipate the requirement of further product administration Don’t forget to administer calcium with MTP! - You send a type and screen such that future blood can be prepared, as well as coagulation studies - Urgent consult to OB, making sure to include the unstable vitals and concern for ruptured ectopic in your “one-liner” - Unfortunately, the patient has been unable to provide a urine sample, so you have not been able to confirm a hCG level. You can (and should) send a blood quantitative level, but this will also take some time to result. Placing a foley to obtain urine may be difficult in this patient. One creative option may be to run the POC urine hCG test on a blood sample (yes, ask the nurse to dip the POC urine strip into blood instead of urine). This is certainly not a validated measure and should not be used to substitute a validated test, but may provide helpful real-time data for this critical patient (see end of write-up for further discussion) - Administer Rhogam if Rh negative - Consider moving the patient to trauma critical care (TCC). Discuss this with your attending and bedside nurse. You should consider the resource demand of this single patient on the nurse and entire pod as well as equipment availability and room capabilities Your patient responds to the initial units of blood. OB arrives quickly, agrees with your assessment and takes the patient to the OR. Of note, depending on the stability of the patient, OB can take patients to the Trauma OR housed closer to the ED instead of the long and treacherous journey to their normal OR in Parkview Tower. Latent safety threats identified while performing this simulation: - Curvilinear probe was not present on the ultrasound machine This is very frustrating, but we are EM physicians and have to roll with the punches. Grab the cardiac probe and see what you can see. Then send the MRN of this case to the chiefs and EM Operations team so we can build a case for better equipment - Make sure to ask for readback and confirmation with your verbal orders. This is especially important in a critical and unstable patient - Be cognizant of your available resources, especially when it comes to staff. If you only have one bedside nurse, request more support. There should be a charge nurse to help or at least rally more troops. If you have a single bedside nurse, they will be unable to pull meds, administer meds, obtain access, run to get blood, etc. - As discussed above, the POC hCG tests are designed to test urine and serum, but you may attempt to run this test with whole blood based on a published a study by Fromm et al. (2012) and Gottlieb et al. (2016). Both groups found similar sensitivity and specificity when comparing their POC hCG tests used with whole blood versus urine samples from the same patients. References: 1. Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776. 2. Gottlieb M, Wnek K, Moskoff J, Christian E, Bailitz J. Comparison of Result Times Between Urine and Whole Blood Point-of-care Pregnancy Testing. West J Emerg Med. 2016 Jul;17(4):449-53. doi: 10.5811/westjem.2016.5.29989. Epub 2016 Jun 22. PMID: 27429695;PMCID: PMC4944801. 3. Mullany K, Minneci M, Monjazeb R, C Coiado O. Overview of ectopic pregnancy diagnosis, management, and innovation. Womens Health (Lond). 2023 Jan-Dec;19:17455057231160349. doi: 10.1177/17455057231160349. PMID: 36999281; PMCID:PMC10071153. 4. Images Діагноз хвороб. Позаматкова вагітність-на УЗД: видно вагітність чи ні, якому терміні можна визначити, як виглядає в яєчнику і в трубах, показує на ранніх термінах (diagnoza.net.ua) https://www.issacprogram.com/blog/1052023-breech-ob monthly 0.5 2023-10-23 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/0f04e6f2-7ff7-4759-8a16-06566c542533/blob.jpeg Blog - 10/5/2023 Breech OB - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/6cf1395b-a89b-413f-aa20-e653e8cf5cce/blob+%282%29.jpeg Blog - 10/5/2023 Breech OB - Make it stand out In terms of room preparation, the essential items are the obstetrics tray, the infant warmer (Ohio Table), the ultrasound, and the fetal monitoring system. The Infant Warmer (Ohio Table) is kept outside of room 1 in TCC, the back-up warmer is located outside of BHP. The location of the supplies needed are listed below: • Precipitous delivery pack – in the cabinet to the left of TCC 5 • C-section pack – on top of cabinet to the left of TCC 5 • C-section instrument tray – in the cabinet to the left of TCC 5 • Tocometry is under the TCC Desk The patient arrives in TCC. She is screaming in pain and having active contractions. Her vital signs are below: BP: 120/70 HR: 110 RR: 20 O2 sat: 97% RA T: 36.8 C You attempt to obtain a history from her. She is a G5P4 She reports that she does not know her gestational age but says that her LMP was about 9 months ago. She has been unable to receive prenatal care. She has no medical history. She felt her water break about 30 minutes ago and is having contractions every few minutes. She continues to yell out in pain. What is your next move? You can now proceed to assess for crowning. If you don’t already feel the baby’s head, it would be helpful to perform a bedside ultrasound to see the presentation of the fetus. If the baby is breech, then re-page OB to let them know. It is important to note that it can take between 8-12 minutes for teams to arrive from Parkview Tower, once paged. If baby is already crowning, you may be performing the delivery without OB present. You examine the patient and perform a bedside ultrasound. You are able to palpate the fetal presenting part but are unsure if it is the head or buttocks. On your ultrasound you confirm that baby is in breech position. You ask nursing to apply the fetal heart monitor and see that baby’s heart rate is 140. It is important to figure out which type of breech presentation the baby is in. Frank breech is a baby with flexed hips and legs directed towards the face in a pike position. In frank breech the thigh, trunk/buttocks are the presenting parts. In complete breech the baby is in a sitting position with both hips and legs flexed. This has the buttocks/trunk, thighs and legs presenting. Incomplete breech on the other hand is where the fetal feet/leg(s) are the presenting part. In incomplete breech, the presenting feet generally pass easily through an incompletely dilated cervix. However, the head may not pass as easily, and thus incomplete breech carries a high risk of head entrapment and subsequent complications. Importantly, frank breech or complete breech can be delivered vaginally, however incomplete breech is a contraindication to vaginal delivery for singleton pregnancies. If you feel a fetal foot as the initial presenting part, notify OB immediately as the patient likely needs to go for a Cesarean section. https://www.issacprogram.com/blog/8312023-trauma monthly 0.5 2023-10-23 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/fc883c09-d5a1-4709-bada-b2d645575d71/blob+%281%29.jpeg Blog - 8/31/2023 Trauma - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.issacprogram.com/blog/972023-stroke-warafin-ac monthly 0.5 2023-10-19 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/d4d1cb85-d6db-4eed-9cbe-8420c273f875/605ae403d12c9513af209e11_Banner+Image.png Blog - 9/7/2023 Stroke Warafin AC - Make it stand out 1. https://www.issacprogram.com/blog/9282023-posterior-circulation-pc-stroke monthly 0.5 2023-10-16 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/b5dedbf7-2fd7-43f4-9e79-e03613870121/OIP.jpeg Blog - 9/28/2023 – Posterior Circulation (PC) Stroke - Make it stand out 4. https://www.issacprogram.com/blog/8823-l-mca-stroke monthly 0.5 2023-10-13 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/736d9b12-8676-48a5-aa60-f83ea7c73c98/strokeservicestoo-min.jpg Blog - 8/8/23 L MCA Stroke - A middle cerebral artery MCA stroke occurs when blood flow from the MCA, one of the largest arteries of the brain, is suddenly impeded. The loss of blood flow causes tissue death, leading to brain injury. https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/b50e0258-b7fb-4bd2-ac0a-ade9076bb991/Weight_adapted_dosage_of_tenecteplase%28TNK%29.jpg Blog - 8/8/23 L MCA Stroke - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/78a691e1-1424-4bf7-8d2e-e8b4f9b77003/normal-ct-brain+%281%29.jpg Blog - 8/8/23 L MCA Stroke - Make it stand out References: Case courtesy of David Cuete, Radiopaedia.org, rID: 23768 Normal CT brain | Radiology Case | Radiopaedia.org normal head CT 2.TNK picture Boehringer Ingelheim - Value Through Innovation | Boehringer Ingelheim (boehringer-ingelheim.com) https://www.issacprogram.com/blog/ventriculartachycardia83123 monthly 0.5 2023-10-30 https://images.squarespace-cdn.com/content/v1/64b9441f7fdae8708d5cd680/1689863208249-L1MUE85UQOOGFF051JDM/wand.png Blog - 8/3/23 Ventricular Tachycardia https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/8f2f1ba3-37ea-4b4a-9a80-534e4d988353/image.png Blog - 8/3/23 Ventricular Tachycardia - Make it stand out Whatever it is, the way you tell your story online can make all the difference. https://www.issacprogram.com/home daily 1.0 2023-09-28 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/a9d279ad-1100-4ee5-a1bd-2fee81944674/noun-toy-robot-320129-2385c7.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/6ca86d10-7a83-463b-bf9e-34ac54d8490b/noun-healthcare-6055532-2385c7.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/4f4cd8bf-ebb9-45c6-9845-6b8fbc4fe2c9/noun-hospital-6056972-2385c7.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/053a604e-43b7-46d2-b9c3-a78f4670271c/20230907_093106.jpg https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/1f334ac9-a3b9-4b9d-91e3-8b23b5974cfe/IMG_3941.JPG https://images.squarespace-cdn.com/content/v1/64b9441f7fdae8708d5cd680/1689863218952-8LUI61KSDDRCTCSGPPJ7/spaceship%402x.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/1ed0a10f-dcfc-4273-842f-73074b6cabf0/IMG_3919.jpg https://www.issacprogram.com/about daily 0.75 2024-12-16 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/50d3a4a1-ec84-425b-b820-e918f6c1f79a/noun-mission-5126232-2385c7.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/d739819b-bd76-438c-ad60-bd6ab3a8bfcb/Croft%2C+Alexander_EM_%2301_1400x1930.jpg About https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/32ef86d0-5a71-46c0-8ed4-c0a4c0d35855/Romo+headshot.JPG About https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/f47c3eba-70bb-47d2-9232-7e8fb934ad8e/yearyGetPersonaPhoto.jpg About https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/d2b1bef8-3b27-473d-bb92-17f31fe21830/CG+ERAS+Edit+%282%29.jpg About https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/0032f1bb-79bc-46e9-818f-33ba32f1662d/HeitgerdHeidi_1_8x12%5B82%5D.jpg About https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/982e348e-f4d4-4e11-b7e7-0e7bfd37f9d7/Seper-Arlene+%281%29.jpg About https://www.issacprogram.com/contactus daily 0.75 2023-09-19 https://www.issacprogram.com/contact daily 0.75 2025-05-09 https://www.issacprogram.com/welcome daily 0.75 2025-05-09 https://images.squarespace-cdn.com/content/v1/64b9441f7fdae8708d5cd680/1689863213369-G6IO6M8LV4HK4VX6Q2XZ/wand-blk%402x.png https://www.issacprogram.com/partners daily 0.75 2023-10-13 https://www.issacprogram.com/partners/trauma monthly 0.5 2023-09-06 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/f599265c-1d93-49bf-89a5-35e054452c03/7393077.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/c6c0002f-958c-4fd4-bc15-63628cfe1ed2/8004064.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/4c36ed1c-3618-4881-8263-98f8df639316/3557584.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/40ba651a-1ee4-483a-bda5-44a1ac7072dd/processed-539A1301-0BBA-44F8-A921-213D13710D77-BE43C46D-A436-439B-A56D-6C25ACAF90FD.jpeg https://www.issacprogram.com/partners/neurology monthly 0.5 2023-09-06 https://images.squarespace-cdn.com/content/v1/64b9441f7fdae8708d5cd680/1689863201151-L8ASO2DQ367TK6OCLV28/schedule%402x.jpg https://images.squarespace-cdn.com/content/v1/64b9441f7fdae8708d5cd680/1689863201154-ZBEHF3QGLE15VNZNRLNH/wand%402x.jpg https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/5d429a33-1016-48ee-8eb4-5724e2dbb389/7740689.png https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/f23c69c8-7b2f-43b9-bf1d-e680ec26c9e5/20230907_093106.jpg https://www.issacprogram.com/partners/edmfmprogram monthly 0.5 2023-09-08 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/12faf680-ad1a-4dae-99f5-d80677bc352e/BreePorcelli-280x386.jpeg https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/57da8f16-d5b2-4496-a83b-f53de380fa2e/White+Coat+Photo.jpg https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/3068f5a3-e118-45c6-ae8f-6a141c280b84/Obstetrics-Gynecology.jpg Partners - Maternal and Newborn Resuscitation Program https://www.issacprogram.com/partners/pediatric-emergency monthly 0.5 2023-09-08 https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/753bc003-9cbf-42ed-b7c9-0023a8d9d34e/56158311_10156632388338702_5714774503557431296_n.jpg Partners - Pediatric Emergencies Preparedness Initiative https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/c1a316d7-263f-4de7-bc82-b54e0c38eb29/55869239_10156643715958702_4599387375280324608_n.jpg Partners - Pediatric Emergencies Preparedness Initiative https://images.squarespace-cdn.com/content/v1/64ee6d5a5be7230b95c64d89/21243a05-deb9-40a4-a2d1-0fa91fd66ac0/119955479_10158115196093702_9064825363999748171_n.jpg Partners - Pediatric Emergencies Preparedness Initiative