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The Curbsiders Internal Medicine Podcast | MedEd | FOAMed | Internist | Hospitalist | Primary Care | Family Medicine

Supercharge your learning and enhance your practice with this Internal Medicine Podcast featuring board certified Internists as they interview national and international experts to bring you clinical pearls and practice changing knowledge. Doctors Matthew Watto, Stuart Brigham, and Paul Williams deliver some knowledge food for your brain hole. No boring lectures here, just high value content and a healthy dose of humor. Fantastic podcast for Internal Medicine, Family Medicine, Primary Care, and Hospital Medicine. Topics include heart disease, obesity, diabetes, cardiac imaging, migraines, fibromyalgia, hypertension, cholesterol, osteoporosis, insomnia, testosterone, functional medicine, dementia, and more!
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Now displaying: November, 2016

Supercharge your learning and enhance your practice with this Internal Medicine Podcast featuring board certified Internists as they interview national and international experts to bring you clinical pearls and practice changing knowledge. Doctors Matthew Watto, Stuart Brigham, and Paul Williams deliver some knowledge food for your brain hole.

thecurbsiders@gmail.com

Nov 21, 2016

Summary:

Does the thought of responding to an in-flight emergency ruin your air travel? Then tune in because on this episode, Angelica Zen, MD, Chief Resident of Internal Medicine at UCLA, recounts a harrowing tale of heroism at 30,000 feet and schools us on how to throw down in an in-flight emergency. We review what’s available in the standard medical kit, common conditions encountered, and the medical legal implications of responding to in-flight emergencies. This episode is a must listen before you next step on a plane.  

Clinical Pearls:

  1. Stay Calm!  If you freak out, so will everyone else.
  2. Think outside the box and be prepared to improvise from available resources. (e.g. ask another passenger for a glucometer)
  3. Standard medical kit contains - manual BP cuff, stethoscope (cheap), gloves, oropharyngeal airways, CPR masks, bag-valve masks, IV set, 500 ml saline, needles, syringes, analgesic tabs, antihistamine (tabs or injection), aspirin, atropine, inhaler (bronchodilator), Dextrose 50%, Epi (1:1000 and 1:10000), IV lidocaine, nitroglycerin tabs, supplemental oxygen.
  4. Don’t forget to utilize the ground medical team!
  5. Legal repercussions very unlikely unless there is “gross neglect” or “intentional harm”. DON’T treat patients if YOU’VE BEEN DRINKING!
  6. Common emergencies in order of decreasing frequency - syncope and presyncope, dyspnea, acute coronary syndrome, altered mental status, psychiatric emergencies, stroke, cardiac arrest

Goal: Listeners will understand their role and potential liabilities during in-flight emergencies and effectively utilize available resources for triage, patient care, and decisions about diverting the plane.

Learning objectives:

By the end of this podcast listeners will:

  1. Be familiar with the contents of the standard medical kit
  2. Think outside the box to identify, improvise and utilize available resources for patient care
  3. Recognize the medical legal consequences of providing emergency medical care on a plane
  4. Confidently evaluate and manage common in-flight emergencies using the available resources

Disclosures:

Dr. Zen reports no relevant financial disclosures.

Time Stamps

00:26 Intro

02:06 Start of Interview

03:02 Rapid Fire Questions

07:08 Dr. Zen tells her story

17:27 Monitoring your patient in-flight

18:05 Contents of the standard in-flight medical kit

20:10 What Dr. Zen would have done differently

21:05 How to use available resources in-flight

22:20 Medical legal implications

26:07 How to respond to common in-flight emergencies and how to respond

27:35 Syncope and presyncope

29:52 Hypoxia altitude simulation test (HAST)

31:15 Altered mental status

31:52 Anaphylaxis

33:19 Stroke and acute coronary syndrome

34:51 Dr. Zen’s take home points

36:40 Outro

Links from the show:

  1. Baby delivered in-flight by Angelica Zen, MD http://newsroom.ucla.edu/stories/
  2. Pharmacy article detailing supplies in standard medical kit on plane http://www.ashp.org/menu/News/PharmacyNews/NewsArticle
  3. Great review article on In-Flight Emergencies. Nable JV, Tupe CL, Gehle BD, Brady WJ.  In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45. doi: 10.1056/NEJMra1409213.
  4. Article on the hypoxia (or high) altitude simulation test (HAST) https://www.ncbi.nlm.nih.gov/pubmed/18398121
  5. Interesting article: Passenger safely defibrillated 21 times during International Flight. Harve H1, Hämäläinen O, Kurola J, Silfvast T. AED use in a passenger during a long-haul flight: repeated defibrillation with a successful outcome. Aviat Space Environ Med. 2009 Apr;80(4):405-8.
  6. How Doctors Think by Jerome Groupman: Amazon.com link
  7. NEJM Physicians First Watch http://www.jwatch.org/medical-news
Nov 7, 2016

Summary:

On this episode, we got served! Endocrinologist, Dr. Pauline Camacho, current president of AACE and Professor of Medicine at Loyola University Chicago makes it rain clinical pearls as she schools us on the use of calcium, Vitamin D, bisphosphonate therapy and drug holidays. This is a must listen for anyone treating osteoporosis. Make sure to check out the new 2016 AACE guidelines, which include infographics for patients and their easy to use algorithm.

Clinical Pearls:

Vitamin D

  1. Vitamin D for postmenopausal osteoporosis prevention (women ≥ 50 yo)
    1. Optimum Vit D level between 30-50 ng/ml recommend
    2. Check PTH if Vit D is very low
    3. If secondary hyperparathyroidism then treat until PTH normalizes
    4. Usual dose is Vit D2 or D3 1000 to 2000 IU daily
    1. Weekly dosing may be required for loading
    2. Vit D3 preferred if malabsorption (e.g. post gastric bypass)
  2. Vitamin D2 or D3 50,000 IU dosed monthly or biweekly is probably safe despite trials suggesting increased falls2-3

Calcium

  1. Calcium recommended total daily intake through diet +/- supplements
    1. postmenopausal women 1200 mg daily
    2. Men 1000 mg
  2. Calcium citrate has better absorption, especially in the elderly or those on PPI

Osteoporosis and drug therapy

  1. AACE’s four criteria for diagnosis osteoporosis
    1. T-score –2.5 or below in the lumbar spine, femoral neck, total, and/or 33% (one-third) radius
    2. Low-trauma spine or hip fracture (regardless of BMD)
    3. Osteopenia or low bone mass (T-score between –1 and –2.5) with a fragility fracture of proximal humerus, pelvis, or possibly distal forearm
    4. Low bone mass or osteopenia and high FRAX® fracture probability based on country-speci c thresholds
  2. Bisphosphonate therapy
    1. Treat for 5-10 years with oral or 3-6 years with IV bisphosphonates
    2. High fracture risk: elderly patients or those with hx of fracture then consider IV agents 1st line (zoledronic acid, denosumab, teriparatide)
  3. Therapy is successful if:
    1. Stable bone mineral density (BMD)
    2. Increasing BMD
    3. Diminishing levels bone turnover markers (e.g. N-terminal and C-terminal cross-linked telopeptides)4
  4. Therapy is a failure if:
    1. Significant or progressive loss of BMD (using a reliable machine)
    2. Fracture occurs
  5. Drug holiday may last several years, but ends if:
    1. Fracture occurs
    2. BMD declines significantly
    3. Rising bone turnover markers (telopeptides)
  6. After drug holiday the clock resets. Meaning patient may start another full treatment course with bisphosphonate, denosumab or teriparatide
  7. After a hip fracture
    1. Check Vit D level and replete
    2. Start bisphosphonate once Vit D level corrected (usually takes 2-3 months)
  8. Routine testing of BMD is recommended for men >70 yo
    1. If you can get it covered!

Disclosures:

Dr. Camacho did not report any relevant financial disclosures.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Make recommendations for daily intake of vitamin D, recognize appropriate levels, and treat secondary hyperparathyroidism
  2. Ensure adequate calcium intake through diet and/or supplementation and counsel patients on risks and benefits
  3. Select appropriate bone preserving therapy, treatment course, and learn to monitor for treatment failure
  4. Identify appropriate timing of drug holidays and reinitiation of drug therapy 

Links from the show:

  1. Hot off the press! 2016 AACE Guidelines for postmenopausal osteoporosis https://www.aace.com/files/final-appendix-sept-7.pdf
  2. Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline RCT JAMA Int Med Jan 2016
  3. Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women JAMA 2010
  4. Eastell R et al. Bone turnover markers and bone mineral density response with risedronate therapy: relationship with fracture risk and patient adherence. J Bone Miner Res. 2011 Jul;26(7):1662-9. doi: 10.1002/jbmr.342. 

Further recommended reading:

  1. Calcium intake and bone mineral density: systematic review and meta-analysis
  2. Calcium intake and risk of fracture: systematic review
  3. Dr. Camacho responds to reader response about physiologic norm for Vit D level http://ajcn.nutrition.org/content/101/2/413.2.full.pdf
  4. Dr. Camacho’s review article on prediction of fracture risk from Jul 2015 https://www.ncbi.nlm.nih.gov/pubmed/26236988
  5. Differing Vit D levels by latitude challenge idea of a physiologic norm https://www.ncbi.nlm.nih.gov/pubmed/25008852
  6. VITAL Study for Vit D and Omega 3 fatty acids for prevention of cancer, heart attack and stroke http://www.vitalstudy.org
 
 
 
 
 
 
 
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