I had a patient last week brought into the Pediatric ED for an allergic reaction. The child had known allergies, and by the EMR, had been prescribed an EpiPen by the Pediatrician – but mom said she didn’t have one at home to use. “We have insurance, but when I tried to fill the prescription, they wanted $620! I just can’t afford that,” she apologetically told me. I sat there in disbelief, assuming she had crappy insurance.
Flash forward three days later when the news hits the mainstream media:
AEMTs and Paramedics, better check that drug box twice for your 1:1000 epi vials because you’ll be using them more often for anaphylaxis as parents and patients increasingly forgo the EpiPen. With a $400-$650 price tag (with insurance), and a 1 year expiration date, can you blame them? I certainly don’t. So brush up on your local protocols, and stay vigilant. For a good review on anaphylaxis, check out this post.
Emergency Department (ED) Implications
As with prehospital providers, we too need to be ready with the IM epinephrine. It’s always been recommended after EpiPen administration for patients to come to the ED to be observed for 4-6 hours in case they need a redose of epinephrine. As patients increasingly skip that first dose, we should expect more potential for respiratory distress and need for difficult airway management.
EpiPen Alternative
Thanks to the Facebook Group EM Docs, I learned of AdrenaClick, a reasonable alternative we can prescribe for patients with severe allergies. The mechanism of delivery is slightly different than the EpiPen (two caps to remove instead of one), but given that it’s 1/4 the cost – it’s what I’ll be prescribing moving forward. AdrenaClick has a good training video on their website with detailed instructions for use. With a coupon from GoodRx, AdrenaClick is available for as low as $141.67 at Wal-Mart. It’s still more than the original $57 cost of an EpiPen when acquired by Mylan, but better than current EpiPen prices.
If you want to learn more about the skyrocketing prices of the EpiPen and the not-so-coincidental tie to congressional mandates requiring EpiPens (like AEDs) in schools, check out this article on Bloomberg.
<Disclaimer> And, of course, I do not endorse the efficacy of, nor am I paid by AdrenaClick. They just happen to be the only other comparable epi auto-injector on the market right now. <Disclaimer />
In April, 2016, Richmond became the first city in Virginia to partner with the CPR crowdsourcing app PulsePoint, bringing their technology to our city. Across the US the incidence of sudden cardiac arrest is over 300,000/year, and survival rates are generally less than 10%. Early CPR and defibrillation can triple that number. Other municipalities have had success with the technology, with early data showing it to be an effective way to get a bystander’s hands on the chest prior to the arrival of EMS units.
While neither Steph nor I have been alerted by the app yet, one of our interns has had it go off not once but twice in just three months. I spent a while picking his brain about it last night so we could share his experience.
Amir: Ok Mike, you were telling me a couple of weeks ago that your PulsePoint actually went off. Could you just explain to anyone who maybe hasn’t heard of PulsePoint exactly what it is and why you have it?
Mike: Sure, PulsePoint is an app that’s tied with the local EMS dispatch. Whenever there’s someone nearby who needs CPR, people with the app get a notification and can respond to help. Essentially trying to do for CPR what tinder has done for online dating.
Amir: Perfect. Except preferable not to wait for the other person to swipe right as they have only moments to live. Got it. So it’s on your phone, just monitoring the EMS dispatch, waiting for some unsuspecting person to drop – and that’s where your story starts. Lay it on me and the rest of the English speaking world.
Mike: When the alert went off I was enjoying my day off watching Game of Thrones. I had received one alert previously that I didn’t respond to (that one was while I was in the hospital), so I recognized the alert. It was a nearby address, and “CPR Needed,” no other information. I threw a shirt on (always don appropriate PPE first) and ran out the door. When I got there, I identified myself as a doctor (liability much?) and was let in. The victim in question didn’t actually require CPR; I did a jaw thrust to keep the airway open, and literally 45 seconds later an EMS crew made their way in. And from there, EMS basically was running the show.
Amir: Ok so most importantly, have you seen this season’s finale? It was amazing.
Mike: I can’t believe they killed off [insert character you’ve only just finally felt an emotional connection to]. So unexpected.
Amir: Speaking of killing off, back to this maybe-dying person. How did you even know where to go?
Mike: Pulse Point has a pretty clean interface. When the alert came up it has a Google Maps type street grid.
Amir: How far away was the spot?
Mike: Just a block or so, looking into it the app will typically alert a provider within 1/4 of a mile, depending on the agency.
Amir: So pants on, shirt on, out the door – leisurely stroll down the block? Or were you hoofing it?
Mike: I think I had a decent clip going. Not a full on sprint.
Amir: You live about 1/4 mile from us. If that app ever puts a pin on our house I expect you to transform into Usain Bolt.
But ok so you’re keeping it cool, it’s their emergency not yours after all, and you show up. What kind of place? Apartment? House?
Mike: House; one I had biked past many times around the neighborhood.
Amir: What’s the etiquette here? Politely knock on the door or charge in like Superman? I imagine the latter comes with the risk of being, you know, shot to death. But for all you know it’s an innocent baby dying in there, and you’re literally the only person who can save her, right?
Mike: Yeah, the thought crossed my mind. There’s definitely a can of worms to be opened here: how do Good Samaritan laws apply to physicians, was the correct address sent through the app, the list probably goes on. But I knocked and was let in, so cross at least one of those concerns off the list.
Amir: Did they ask who you were or how you knew what was going on or what you were doing there? I mean no uniform, badge – you’re Joe Schmo for all they know.
Mike: It was pretty hectic and everybody just seemed to accept that I was there to help. No other questions asked.
Amir: What did you find in there?
Mike: Respiratory distress, cause unknown. As somebody who doesn’t have a background in EMS, approaching this in the field is definitely a different thought process than undifferentiated respiratory distress rolling into the ED. Differential diagnosis isn’t too important when your treatment options are limited to what you bring with you, which in this case was nothing.
Amir: Great point. Something more docs should keep in mind when EMS rolls in with a hot mess. So not breathing, could be overdose but could also be massive head bleed, who knows? You don’t even have gloves. So you jaw thrust, trying to avoid any and all fluid leakage, and just hope the cavalry arrives soon. You weren’t up for mouth to mouth?
Mike: In retrospect, I did have my Red Cross pocket mask in the depths of my closet. Now it’s been moved to the shelf in my kitchen.
Amir: That’s a great tip. If you’re going to use this app and respond to god-knows what, be as prepared as possible. Maybe a little kit for the car and home with some basic stuff – gloves and a barrier mask.
Mike: But that does lead into another thing I’ve been considering about PulsePoint. The cavalry in this case was less than a minute away. From their website, PulsePoint costs over $10,000 to implement, and another $10k to $28k a year to maintain. So the agencies most likely to be able to afford an extra service like PulsePoint are also the agencies that are well funded, and most likely to have an EMS crew right around the corner.
Amir: Ah so you think maybe we need to see some pre/post implementation outcome data. I’d say if that guy had been in cardiac arrest though, those 45 seconds could make a significant difference.
Mike: Oh sure, it’s definitely a good idea. Especially considering that you don’t need to be a doctor to get the app. Anybody who’s BLS certified or better can join up. And unless there are some hidden costs involved, it’s still less expensive than a lot of the other “bells and whistles” that EMS agencies can add to their toolkit.
Amir: {{*cough* ACLS drugs *cough*}} Any other tips for potential heroes out there?
Mike: Just the usual things that I’m sure are second nature to EMS providers. Expect the unexpected, prepare for as much as you can, and the number one rule, first do no harm to yourself. “Survey the scene, don’t expose yourself to harm” doesn’t get drilled into us a ton as docs, but there’s a reason it’s the first step in BLS training.
Amir: Perfect. So to sum up:
Get Dressed.
Don’t show up empty handed.
Watch your back. And your front.
Have a good lawyer, just incase.
Mike: Couldn’t put it better myself.
Amir: I love it. Thanks for sharing the story. I can’t believe it’s gone off not once but TWICE for you. I’ll let you have the last word to your now adoring public.
Mike: Flarhgunnstow.
I had to look up that last word. Apparently it’s this:
If you know CPR and are willing to help someone whose life depends on it, go to PulsePoint.org and see if your city has partnered. If you don’t know CPR yet, the American Heart Association website can help you find a CPR course.
~Amir
Michael Billet, MD is now a PGY-2 in Emergency Medicine at VCU Medical Center in Richmond, VA. He attended the University of Virginia for both his undergraduate and medical school training. He likes long walks on the beach, Settlers of Catan, and is definitely the guy you want on your trivia team.
If you work in the medical field, you’ve likely had to present a patient case report. You do a chart review, gather the physical exam and lab data, but often importing the CT scans, ultrasounds, MRIs and other video imaging for display in your PowerPoint can be a time-consuming and frustrating task.
I recently discovered an easy way to include multimedia medical images into PowerPoint in a fairly easy way. This process works on a Mac. For PCs, I’ve been told Pacstacker is the best available option for importing radiology imaging into PowerPoint.
You’ll need access to 3 things to get started. Make sure you have each of these available on the same Mac:
The radiology image you want to capture, with the ability to scroll through
QuickTime includes a feature similar to the “Print Screen” feature. Instead of capturing just one image that instant, it captures your desktop activity in a selected area over time. The result is a video file you can import into PowerPoint or other presentation software.
Step 1: Open up your Radiology imaging viewer and select the scan you wish to include.
Step 2: Open QuickTime. From the File menu, select “New Screen Recording.”
Step 3: When the “Screen Recording” box pops up, click the red circular button to begin.
Step 4: A tan box will appear, asking you either click once to record the full screen, or drag and select with your mouse the portion of your screen you want included in your screen capture. For capturing radiology images, you’ll want to make sure you include only the image and exclude any personal identifiers to be HIPAA compliant.
Step 5: While recording, scroll through your imaging study making sure to include everything you want to display. I recommend scrolling through by clicking the arrows on the keyboard rather than using the mouse, as the cursor may accidentally enter the image field and therefore appear in your presentation.
Step 6: Click the “Stop” button to stop recording your screen capture. The button is somewhat hidden in the bar at the top of the screen. It’s the circular icon with the square in the middle that you see in the image below (right side of the screen, leftmost).
Step 7: After you click “Stop,” you’ll be prompted to save your video to your computer. Remember the location; you’ll need to find it later when you import your video into PowerPoint.
Step 8: Open your PowerPoint presentation. To import your imaging study, Go to Insert>Movie>Movie from File. Then find your file and click OK.
Step 9: Your imaging study is now imported into PowerPoint as a video. You can scroll backward and forward as needed during your presentation. To preview your video, start your presentation and click the triangular “Play” button on the bottom left. Note: if you click anywhere else on the slide, it will advance to your next slide, not start your video.
PowerPoint has improved over the years, and videos are now automatically embedded with your presentation when you save your .PPTx file. You may need to save your presentation file to DropBox, Google Drive or another cloud storage app as the file size is usually too large to send via email.
So that’s it – a previously arduous task made surprisingly simple. I hope this saves you some stress and time.
In our lives, “tubing” has two distinct meanings… this and this:
Prior to moving to Richmond, I’d been river tubing just once. It involved finding a rental company, making reservations, and forking over a lot of cash. So, when I came to Richmond and learned people tube on their own, I was intrigued. Turns out, it’s not as difficult as you might think. Just use this simple guide to help plan your tubing adventure.
Buy yourself some tubes
While there are tons of options out there, we’ve had good luck with the Intex brand available on Amazon.com. You don’t have to spend a lot of money to get something fun and reliable. There are many options, including single, double and cooler tubs, or our new favorite, tubes that connect.
Double Tube
Cooler Tube
Connecting Tube
The other piece of equipment you should seriously consider is a life jacket. Depending where you decide to tube and the level of the river, life jackets may be required. There are some great alternatives to the huge orange foam things from the 70s and 80s.
Old Life Jacket
Today’s Life Jacket
Also, if you don’t have tubes that connect, you’ll want to bring along a sturdy rope so you can tie your team together to float as a group.
Plan the Route
The route we enjoy most runs from Pony Pasture to Reedy Creek and is a 3 to 4 hour float that takes you down 2.5 miles of beautiful James River scenery. Float time will vary with the water level, so be sure to check it and plan accordingly.
You’ll need at least two cars to execute the required drop-off and drive back. First, plug Reedy Creek (4190 Riverside Dr, Richmond, VA 23225) into your GPS. Have both cars meet there. Pile all of your tubes (deflated), coolers and friends into one car and lock the other one up safely. It will stay behind at Reedy Creek.
Next, enter Pony Pasture (7200 Riverside Dr, Richmond, VA 23225) into your GPS. When you get there, you can pull up to unload all your stuff and blow up your tubes, but you may have to parallel park in the neighborhood as the lot is often full. Don’t forget to lock your car!
Launch!
A few important tips:
Stay to the right – the rapids tend to be on the left in the James.
Butts up! – lift your bottom up when going over rapids to help ensure you don’t get stuck.
Be careful when walking on the bottom. There are major, abrupt drop offs as there are rocks lining the bottom.
I REPEAT: The rapids past Reedy Creek are intense, dangerous and not fit for amateurs in innertubes. Don’t do it, or you may end up a Trauma patient in the ED with us!
Don’t Miss the Take Out
After floating underneath the train bridge in the photo above, you should start keeping a lookout for the Reedy Creek Take Out. The James will fork temporarily, and it’s important you stay to the right if you want to end up anywhere near your car. There’s a sign you can’t miss that says “TAKE OUT” with a big arrow guiding you to the right. Don’t go left. Even an UberXL won’t be large enough to fit your whole crew plus all your gear if you miss it.
When you exit the water and walk up, you’ll see the Reedy Creek parking lot where you left your other car. Time to deflate the tubes and pile everyone in this car to head back to Pony Pasture and grab the other car.
Capture the Fun
If you don’t have a waterproof camera or a GoPro, you can easily take pictures or videos with your SmartPhone with the help of a $10 Joto Waterproof phone case.
So that’s it. Grab your tubes, +/- a life jacket, cooler and some friends, and get ready for an awesome afternoon on your schedule.
This recipe is a staple at nearly every event my mom and I host. It’s easy to make, requiring no actual cooking. It’s always a hit, palatable to both adults and kids.
In a medium bowl, stir the taco seasoning into the sour cream.
TeamLouka 