We discuss capacity assessment, patient autonomy, safety, and documentation.
Hosts:
Anne Levine, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Capacity_Assessment.mp3
Download
Leave a Comment
Show Notes
The Importance of Capacity Assessment
Arises frequently in the ED, even when not formally recognized
Carries both legal implications and ethical weight
Failure to appropriately assess capacity can result in:
Forced treatment without justification
Missed opportunities to respect autonomy
Increased risk of litigation and poor patient outcomes
Defining Capacity
Capacity is:
Decision-specific: varies based on the medical choice at hand
Time-specific: can fluctuate due to medical conditions, intoxication, delirium
Distinct from competency, which is a legal determination
Relies on a patient’s ability to:
Understand relevant information
Appreciate the consequences
Reason through options
Communicate a clear choice
Real-World ED Examples
Intoxicated patient with head trauma refusing CT
Unreliable neuro exam
Potentially time-sensitive intracranial injury
Elderly patient with sepsis refusing admission due to caregiving responsibilities
Balancing autonomy vs. beneficence
Patient with gangrenous diabetic foot refusing surgery
Demonstrates logic and consistency despite high-risk decision
The 4 Pillars of Capacity Assessment
Understanding
Can the patient explain:
Their condition
Recommended treatments
Risks and benefits
Alternatives and outcomes?
Sample prompts:
--------
Episode 209: Blast Crisis
We dive into the recognition and management of blast crisis.
Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blast_Crisis.mp3
Download
2 Comments
Tags: Hematology, Oncology
Show Notes
Topic Overview
Blast crisis is an oncologic emergency, most commonly seen in chronic myeloid leukemia (CML).
Defined by:
>20% blasts in peripheral blood or bone marrow.
May include extramedullary blast proliferation.
Without treatment, median survival is only 3–6 months.
Pathophysiology & Associated Conditions
Usually occurs in CML, but also in:
Myeloproliferative neoplasms (MPNs)
Myelodysplastic syndromes (MDS)
Transition from chronic to blast phase often reflects disease progression or treatment resistance.
Risk Factors
10% of CML patients progress to blast crisis.
Risk increased in:
Patients refractory to tyrosine kinase inhibitors (e.g., imatinib).
Those with Philadelphia chromosome abnormalities.
WBC >100,000, which increases risk for leukostasis.
Clinical Presentation
Symptoms often stem from pancytopenia and leukostasis:
Anemia: fatigue, malaise.
Functional neutropenia: high WBC count, but increased infection/sepsis risk.
Thrombocytopenia: bleeding, bruising.
Leukostasis/hyperviscosity effects by system:
Neurologic: confusion, visual changes, stroke-like symptoms.
Cardiopulmonary: ARDS, myocardial injury.
Others: priapism, limb ischemia, bowel infarction.
--------
Episode 208: Geriatric Emergency Medicine
We explore the expanding field of Geriatric Emergency Medicine.
Hosts:
Ula Hwang, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Geriatric_Emergency_Medicine.mp3
Download
Leave a Comment
Tags: Geriatric
Show Notes
Key Topics Discussed
Importance and impact of geriatric emergency departments.
Optimizing care strategies for geriatric patients in ED settings.
Practical approaches for non-geriatric-specific EDs.
Challenges in Geriatric Emergency Care
Geriatric patients often present with:
Multiple chronic conditions
Polypharmacy
Functional decline (mobility issues, cognitive impairments, social isolation)
Adapting Clinical Approach
Core objective remains acute issue diagnosis and treatment.
Additional considerations for geriatric patients:
Review and caution with medications to prevent adverse reactions.
Address functional limitations and cognitive impairments.
Emphasize safe discharge and care transitions to prevent unnecessary hospitalization.
Identifying High-Risk Geriatric Patients
Screening tools:
Identification of Seniors at Risk (ISAR)
Frailty screens
Alignment with the “Age-Friendly Health Systems” initiative focusing on:
Mentation
Mobility
Medications
Patient preferences (what matters most)
Mistreatment (elder abuse awareness)
--------
Episode 207: Smoke Inhalation Injury
We discuss the injuries sustained from smoke inhalation.
Hosts:
Sarah Fetterolf, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3
Download
Leave a Comment
Tags: Environmental, Toxicology
Show Notes
Table of Contents
00:37 – Overview of Smoke Inhalation Injury
00:55 – Three Key Pathophysiologic Processes
01:41 – Physical Exam Findings to Watch For
02:12 – Airway Management and Early Intervention
03:23 – Carbon Monoxide Toxicity
04:24 – Workup and Initial Treatment of CO Poisoning
06:14 – Cyanide Toxicity
07:19 – Treatment Options for Cyanide Poisoning
09:12 – Take-Home Points and Clinical Pearls
Physiological Effects of Smoke Inhalation:
Thermal Injury:
Direct upper airway damage from heated air or steam.
Leads to swelling, inflammation, and possible airway obstruction.
Chemical Irritation:
Causes bronchospasm, mucus plugging, and inflammation in the lower airways.
Increases capillary permeability, potentially causing pulmonary edema.
Systemic Toxicity:
Primarily involves carbon monoxide and cyanide poisoning.
--------
Episode 206: Acute Back Pain
We discuss the evaluation of and treatment options for acute back pain.
Hosts:
Benjamin Friedman, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Back_Pain.mp3
Download
Leave a Comment
Tags: Musculoskeletal, Orthopaedics
Show Notes
**Please fill out this quick survey to help us develop additional resources for our listeners: Core EM Survey**
Clinical Evaluation:
Primary Goal: Distinguish benign musculoskeletal pain from serious pathology.
Red Flags: Look for indicators of spinal infection, spinal bleed, or space-occupying lesions (e.g., tumors, large herniated discs).
Assessment: A thorough history and neurological exam (strength testing, gait) is essential.
Additional Tools: Use bedside ultrasound for post-void residual assessment in suspected cauda equina syndrome
Imaging Guidelines:
Routine Imaging: Generally not indicated for young, healthy patients without red flags.
ACEP Recommendations: Avoid lumbar X-rays in patients under 50 without risk factors, as they do not change management and may increase costs and ED time.
Advanced Imaging: Reserve MRI for patients with red flags, neurological deficits, or suspected cauda equina syndrome; CRP may be a part of your calculus when evaluating for infectious causes of back pain
Treatment Options:
Evidence-Based First-Line:
NSAIDs offer modest benefit.
Ireland