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Pulmonary embolism (PE) in pediatric patients is high stakes but less frequent diagnosis. Because missing a PE can be devastating, clinicians frequently order diagnostic workups, including labs and imaging. The adult PERC rule identifies adults at very low risk for PE but includes age <50 and adult heart rate cutoffs, making it inapplicable to pediatric patients. And, as we all know, children are not small adults!

To help identify children at low risk for PE and prevent unnecessary radiation exposure, Dr. Jeffrey Kline and Dr. Angie Ellison led the BEEPER study through the PECARN network (published in Lancet Respiratory Medicine, July 2026). This study prospectively derived and validated the PERC-Peds rule.

The 8 Criteria of PERC-Peds

To rule out a PE in kids without a CT or labs, the patient must meet all 8 criteria:

1. Low Clinical Suspicion (Gestalt <15%): Your own clinical judgment estimates the probability of PE is under 15%.
2. No Prior Venous Thromboembolism (VTE): No history of PE or DVT.
3. No Recent Surgery: No surgery requiring general or epidural anesthesia within the last 30 days.
4. No Estrogen Use: Patient is not currently taking estrogen-containing medications (e.g., oral contraceptives).
5. No Hemoptysis: No coughing up blood.
6. Age-Adjusted Normal Heart Rate:
   • Age ≤12 years: Heart rate <120 bpm.
   • Age >12 years: Heart rate <100 bpm.

1. Normal Oxygen Saturation: SpO₂ ≥95% on room air at sea level throughout the ED stay.
2. No Unilateral Limb Swelling: No clinical features or examination findings suggesting a DVT.

The Rule of 8: if 8 out of 8 criteria met, PE can be ruled out at the bedside without further testing. If even one of the 8 criteria is not met, PE cannot be ruled out and the child requires further diagnostic evaluation (obtain D-dimer -> if elevated, obtain CTA chest).

Key Findings from the BEEPER Study

• Study Scale: Enrolled 4,039 pediatric patients across 21 emergency departments.
• Prevalence: Confirmed a 6.5% overall prevalence of VTE (4.5% image-proven PE and 2.0% proximal DVT).
• Diagnostic Accuracy:
  • Sensitivity: 99.6%
  • False Negative Rate: 0.1% (missed only 1 patient out of nearly 4,000)
  • Negative Predictive Value (NPV): 99.9%
  • Specificity: ~19.6% (low specificity, typical for broad screening rules)

Clinical Pearl: The study included proximal DVTs (above the knee/elbow) in the primary outcome because letting a child walk out of the ED with an undiagnosed proximal DVT carries an unacceptably high risk of subsequent PE.

Shift Takeaways

1. Integrated EMR for the win: Use EMR-integrated tools or decision-support apps to verify age-adjusted heart rate cutoffs.
2. Sequential Testing Saves Radiation: Utilizing PERC-Peds first, followed sequentially by a D-dimer for those who fail PERC-Peds, rules out PE in ~60% of evaluated children without needing a CT scan.
3. Alternative Diagnoses: Common pediatric triggers (viral illnesses, COVID-19, asthma exacerbations) are often alternative causes for symptoms rather than provoking factors for PE.

Have you used the PERC-Peds rule? Share your experience with us on social media @empulsepodcast or at ucdavisem.com

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guests:

Dr. Jeffrey Kline, Professor of Emergency Medicine ad Associate Chair of Research in the Department of Emergency Medicine at Wayne State University

Dr. Angela Ellison, Professor and Vice Chair Chair of Pediatrics at Children’s Hospital of Philadelphia

Resources:

Ellison AM, Kuppermann N, Shihabuddin BS, Hickingbotham H, Cator A, Lubell TR, Hoehn E, O’Connell KJ, Spencer S, Chumpitazi CE, Hennelly K, Kaplan R, Eisenberg MA, Powell EC, Mercurio L, Riney LC, Johnson TJ, Johnson MD, Bogie A, Schultz M, Mendelson J, DeLaroche AM, Race J, Casper TC, Kline JA. PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study. Lancet Respir Med. 2026 Aug;14(8):694-703. doi: 10.1016/S2213-2600(26)00086-X. Epub 2026 Jul 3. PMID: 42398511; PMCID: PMC13545990.

Betensky M, Goldenberg NA. The PERC-Peds rule: a promising step towards structured pulmonary embolism risk assessment in children. Lancet Respir Med. 2026 Aug;14(8):653-654. doi: 10.1016/S2213-2600(26)00222-5. Epub 2026 Jul 3. PMID: 42398513.

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Caring for patients with severe traumatic brain injury (TBI)—especially pediatric patients—is high-stakes and high-stress. In severe TBI, primary brain injury occurs at the moment of impact; our primary goal in the emergency department is preventing secondary brain injury caused by hypoxia, hypoperfusion, elevated intracranial pressure (ICP), seizures, hyperthermia, and dysglycemia.

In this episode, ED Clinical Pharmacist Haley Burhans returns to walk us through key medications for the acute management of severe TBI. We’ll cover airway management, rapid sequence intubation (RSI) drug choices, hyperosmolar therapy, seizure prophylaxis, TXA, and post-resuscitation care.

1. Airway & Rapid Sequence Intubation (RSI)

Optimizing oxygenation and ventilation is critical, as hypoxemia directly contributes to secondary brain injury. Selecting hemodynamically neutral agents is essential to maintain cerebral perfusion pressure (CPP).

Induction Agents

• Etomidate (0.3 mg/kg, max 40 mg): Hemodynamically neutral, making it a reliable choice for TBI patients with unstable or uncertain blood pressures.
• Ketamine (1–2 mg/kg): Excellent option for borderline low or hypotensive patients. Historical concerns regarding ketamine-induced ICP spikes have been largely disproven; bolus doses <5 mg/kg do not cause sustained ICP elevations and offer valuable analgesia.

Paralytics

• Succinylcholine (1.5 mg/kg TBW, max 200 mg): Preferred if an immediate post-intubation neurological exam is required by neurosurgery, given its short duration (~10–15 min).
• Rocuronium (1.0–1.2 mg/kg): Higher dosing ensures rapid onset. Preferred when securing the airway smoothly and keeping the patient still for immediate CT scanning is the priority. Note: Paralyzes the patient for 45–60 minutes, so obtain a baseline neuro exam first or have a plan for reversal if an early exam is needed.

Pre-Medications (Lidocaine vs. Fentanyl)

• Lidocaine (1.5 mg/kg): Theoretically blunts airway-reflex-induced ICP spikes during intubation, but takes 2–5 minutes to reach peak effect and introduces cardiac risks in undifferentiated trauma patients. Generally omitted when rapid airway placement is required.
• Fentanyl (1–2 mcg/kg): Preferred pre-medication for hypertensive or tachycardic patients to blunt sympathetic surges and prevent ICP spikes during laryngoscopy.

2. Post-Intubation Sedation & Hemodynamic Support

• Hypotensive / Unstable: Push-dose Ketamine (1–2 mg/kg) provides deep sedation while preserving blood pressure.
• Hypertensive / Stable: Propofol infusion (Adults: ~40 mcg/kg/min; Pediatrics: ~60 mcg/kg/min due to faster metabolism) helps suppress ICP and optimize CPP.
• Pressors: If vasopressors are required to maintain target SBP (>100–110 mmHg depending on age), titrate carefully to clear hemodynamic goals. Avoid reflexively starting high-dose pressors if transient hypotension was primarily driven by hypoxia or cardiac arrest before airway placement.

3. Seizure Prophylaxis

Post-traumatic seizures increase metabolic demand and elevate ICP.

• First-Line Agent: Levetiracetam (Keppra) is non-inferior to Phenytoin for preventing early post-traumatic seizures (within 7 days) and carries a significantly lower risk of cardiac side effects and agitation at standard loading doses.
• Dosing:
  • Loading Dose: 20–25 mg/kg IV load (common adult loading dose is 20 mg/kg or a standard 1,000–2,000 mg IV dose).
  • Maintenance: 25 mg/kg IV BID in pediatrics; 1,000 mg IV BID in adults (adjusted for renal function).

4. Hyperosmolar Therapy for Cerebral Edema

When signs of impending herniation or acute ICP elevation are present:

• Hypertonic Saline (3% NaCl):
  • Pediatrics: First-line agent at 2–5 mL/kg IV. Avoids the diuretic/hypovolemic risks associated with mannitol in volume-dependent pediatric patients.
  • Adults: Strongly preferred over mannitol due to less rebound ICP elevation and easier administration (mannitol requires inline filters and can crystallize).
• Mannitol (0.5–1 g/kg): Alternative option in adults, but can cause osmotic diuresis, hypotension, and rebound ICP increases.
• Combining/Redosing: Avoid giving both hypertonic saline and mannitol simultaneously as initial therapy—if the patient deteriorates 30 minutes later, therapeutic options are exhausted. Hypertonic saline is easier to redose safely after monitoring serum sodium levels (peak effect around 1 hour).

5. Role of Tranexamic Acid (TXA)

• Isolated TBI in Adults: The CRASH-3 trial showed potential 30-day mortality benefits for mild-to-moderate TBI within 3 hours of injury, but limited clear benefit in isolated severe TBI. If a severe TBI is an isolated injury, routine TXA push is not strongly advocated if it delays primary line access for other resuscitation meds.
• Polytrauma / Pediatrics: If TBI is part of multi-trauma or severe pediatric trauma within 3 hours of injury, TXA is appropriate as part of overall trauma resuscitation protocols.

6. Critical ED Targets & Common Pitfalls

• Temperature Management: Target strict normothermia (36.0°C–38.0°C). Fevers (>38°C) double metabolic demand and worsen secondary brain injury. Consider bundling IV acetaminophen into post-RSI orders.
• Glucose Control: Avoid extreme hyperglycemia; treat severe elevations (>200 mg/dL or noted high levels on VBG) early in the ED.
• Communication & Lines: Hyperosmolar agents are incompatible with many continuous infusions. Clearly communicate upper and lower blood pressure limits with nursing to avoid over-titrating antihypertensives or sedatives.

What are your go-to meds for severe TBI? What do you avoid? Share your experience with us on social media @empulsepodcast or at ucdavisem.com

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guests:

Haley Burhans, PharmD, Emergency Medicine Clinical Pharmacist at UC Davis

Resources:

ACEP Critical Care Medicine: Key Aspects in the Management of TBI in the ED to Minimize Secondary Injury by Miyant’e Newton, MD, March 12, 2024

Brain Trauma Foundation Guidelines for the Management of Severe TBI, 4th Edition

Brain Trauma Foundation Guidelines for the Management of Pediatric Severe TBI, 3rd Edition

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Ultrasound-guided nerve blocks are no longer just a niche skill for fellowship-trained ultrasound specialists—they are a core component of modern multimodal pain management in the ED. Endorsed by ACEP, nerve blocks can offer rapid, targeted pain relief without relying solely on systemic opioids, making everything from rest to imaging and procedural workups significantly more comfortable for patients.

Today, Dr. Carlos Mikell, UC Davis Emergency Ultrasound Faculty and nerve block expert, joins us to share why every emergency physician should adopt nerve blocks as part of their practice. We’ll break down the top ED blocks, explore innovative indications like genicular nerve blocks for knee pain, and discuss essential safety protocols and how to get started – or become more comfortable – with blocks in your ED.

Why Nerve Blocks Belongs in the ED

• Targeted Relief: Delivers effective, localized pain management as part of a multi-modal pain control approach, sparing patients some of the systemic side effects of opioids.
• Facilitates ED Workup: Relieves movement-related pain, making imaging, patient transport, and local procedures far easier and more comfortable for the patient.
• ACEP Endorsement: ACEP’s policy statement formalizes ultrasound-guided nerve blocks as an essential skill for all emergency physicians—not just ultrasound fellowship graduates.
• Analgesia, Not Complete Anesthesia: The goal in the ED is regional analgesia (taking pain down to a manageable, functional level safely) rather than dense, surgical anesthesia.

The Most Common ED Nerve Blocks

According to data from the National Ultrasound Guided Nerve Block Registry:

1. Fascia Iliaca Plane / Femoral Nerve Block (~36%):
   • Indications: Hip fractures, mid-shaft/distal femur fractures, hip dislocations, and severe thigh trauma.
   • Safety Profile: Highly safe; target plane is centimeters away from the main neurovascular bundle in a easily compressible site.

1. Erector Spinae Plane (ESP) Block:

1. • Indications: Back pain, renal colic, shingles, and rib fractures.

1. Forearm Blocks (Median, Ulnar, Radial):

1. • Indications: Distal forearm fractures, complex lacerations, and hand procedures.

1. Serratus Anterior Plane (SAP) Block (~7%):

1. • Indications: Rib fractures, pre/post-chest tube insertion pain, and chest wall abscesses.
   • Tip: Hydro-dissect with normal saline first to identify the fascial plane before injecting local anesthetic, and consider adding dexamethasone to extend duration.

Innovative Block Spotlight: Genicular Nerve Block

• Target: Three of the primary sensory branches of the sciatic/femoral nerves supplying the anterior knee.
• Indications: Acute knee trauma/fractures, acute-on-chronic knee pain, and severe osteoarthritic flare-ups.
• Safety & Execution: Low-volume block (~10 mL total). Pearl: Omit the inferior-lateral genicular injection to avoid unintentional peroneal nerve block and foot drop.

Streamlining Nerve Blocks in Your Department

To move nerve blocks from a rare procedure to a routine clinical tool:

• ED Infrastructure: Build standardized EMR order sets, procedure note templates, and dedicated nerve block supply carts/kits.
• Departmental Support: Designate a point person to coordinate credentialing, interdisciplinary pathways (e.g., trauma, orthopedics), and physician/nurse/tech education.
• Hands-on Training: Utilize cadaver labs, simulation, and scanning shifts to build faculty and resident confidence.

Non-Negotiable Safety Guidelines & LAST Prevention

Nerve blocks are generally low-risk, but vigilance is critical to avoid complications like Local Anesthetic Systemic Toxicity (LAST) or direct nerve injury:

1. Patient Selection: Avoid in uncommunicative patients (who cannot report paresthesias or tinnitus), areas at high risk for compartment syndrome, or pre-existing severe nerve deficits.
2. Monitoring: Keep patients on cardiac telemetry for 30–60 minutes post-block for central or high-volume blocks (>10 mL or above the elbow/knee).
3. Dosing Buffer: Calculate maximum weight-based local anesthetic doses every time; stay within 60–70% of the maximum dose to maintain a safety buffer.
4. Intralipid Availability: Ensure 20% Intralipid is immediately accessible in the ED pharmacy or brought directly to the bedside.
5. Injection Technique: Never point the needle directly at a nerve. Inject into the fascial plane, stop immediately if you encounter resistance, and perform frequent aspirations every 3–5 mL.

What is your favorite ultrasound-guided nerve block? What barriers do you encounter to doing blocks in the ED? We’d love to hear form you! Connect with us on social media @empulsepodcast or connect with us on ucdavisem.com

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Pediatric Emergency Medicine at UC Davis

Guest:

Dr. Carlos Mikell, Assistant Professor of Emergency Medicine and Ultrasound Faculty at UC Davis

Resources:

ACEP Policy Satement: Ultrasound Guidelines: Emergency, Point-of-care, and Clinical Ultrasound Guidelines in Medicine, June 2016

ACEP Now: How To Build an Ultrasound-Guided Nerve Block Program

By Arun Nagdev, MD; Kaitlen Howell, MD; Akash Desai, MD; David Martin, MD; and Daniel Mantuani, MD, MPH | on January 6, 2023 

ACEP Sonoguide: Nerve Blocks

NURVE Block Registry

Brown J, Milgrim F, Driver L, et al. Efficacy and Safety of Adjunct Medications in ED Ultrasound-Guided Nerve Blocks: A National Ultrasound-Guided NeRVE (NURVE) Block Registry Study. Acad Emerg Med. 2025 Dec;32(12):1299-1308. doi: 10.1111/acem.70128. Epub 2025 Aug 27. PMID: 40873157.

Goldsmith A, Driver L, Duggan NM, et al. Complication Rates After Ultrasonography-Guided Nerve Blocks Performed in the Emergency Department. JAMA Netw Open. 2024 Nov 4;7(11):e2444742. doi: 10.1001/jamanetworkopen.2024.44742. Erratum in: JAMA Netw Open. 2024 Dec 2;7(12):e2455847. doi: 10.1001/jamanetworkopen.2024.55847. PMID: 39535792; PMCID: PMC11561692.

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Disclaimer: The opinions expressed on this podcast are those of the hosts or guests and do not necessarily reflect the views of UC Davis Department of Emergency Medicine, UC Davis Health, or their parent organizations.

The Outbreak

With over 17,000 cases reported across the U.S., a massive Cyclospora outbreak has taken center stage in public health news, marking it as the third-largest foodborne outbreak in modern American history (behind the 1994 Schwan’s ice cream salmonella outbreak and the 1985 Illinois milk outbreak). Infection causes gastrointestinal symptoms, including diarrhea, bloating, nausea and sometimes vomiting. 

So, what’s actually driving this surge? Is it safe to eat salad? Pediatric infectious disease expert Dr. Dean Blumberg joins us to break down the science behind the “explosive” symptoms, separate real outbreak epicenters from everyday travel cases, and when to test and treat.

Transmission & Geography

• •  Mechanism: Cyclospora is a parasite. It is often transmitted via produce contaminated with sewage or irrigation water.
  •  Not Person-to-Person: Requires ~1 week in the environment to mature and become infectious.
  •  Regional Risk: The epicenter for this outbreak is in the Midwest, related to processed lettuce distribution networks. Outside affected regions, cases remain at expected baseline levels (primarily tied to international travel). Fresh produce consumption remains safe. 

Pathophysiology & Presentation

• •  Cellular Damage: Cyclospora infects and kills small intestine epithelial cells, impairing fluid absorption and causing unabsorbed carbohydrates to ferment into gas.
  •  Symptoms: Large-volume, gas-driven “explosive” diarrhea, abdominal bloating, and cramping. Fever is rare; vomiting is variable.
  •  Duration: Unlike viral gastroenteritis (1–3 days), untreated Cyclospora can linger for weeks and frequently waxes and wanes.

Diagnostic Strategy

Routine “O&P x3” tests are obsolete—use multiplex PCR panels (e.g., GI BioFire).

• •  When to Test: Symptoms lasting >5–7 days, high-risk patients (infants <12 months, older adults, immunocompromised), fever, bloody stool, or symptoms seriously impacting daily life. (Negative panels can help rule out infectious causes and prompt work up for other etiologies, such as IBD)
  •  When to Skip: Patients with 1–2 days of mild symptoms or the “worried well.”

Treatment

• •  First-Line Agent: Trimethoprim-sulfamethoxazole (TMP-SMX / Bactrim).
  •  Indication: Treat anyone who tests positive and remains actively symptomatic to speed recovery and prevent relapses.
  •  Reporting: Confirmed cases are automatically reported to public health by the lab.
  •  Primary Complication: Severe dehydration and electrolyte derangements (the main drivers of hospitalization).

Have you seen many Cyclospora cases? Or an influx of concerned patients with mild GI symptoms?  Share your experience with us on social media @empulsepodcast or at ucdavisem.com

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guests:

Dr. Dean Blumberg, Chief of Pediatric Infectious Diseases at UC Davis

Resources:

CDC: Cyclosporiasis

AAP News: CDC offers guidance on cyclosporiasis outbreaks for clinicians, public    July 14, 2026 Melissa Jenco, Senior News Editor

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Cannabinoid Hyperemesis Syndrome (CHS) continues to be a major clinical challenge in the emergency department. Patients present with severe abdominal pain, intractable vomiting, and significant fluid and electrolyte derangements. CHS often affects people who have been using cannabis routinely for months to years – it can be difficult for patients to understand that their symptoms are related to cannabis. 

Today, emergency pharmacist Haley Burhans joins us to discuss first-line treatments, fluid management, discharge strategies, and how to navigate these tough bedside conversations.

First-Line Therapies: Haldol vs. Droperidol

• Haloperidol (Haldol): Supported by the HAVOC trial (haloperidol vs. placebo), which showed a reduction in symptoms and ED length of stay.
• Droperidol: Highly effective alternative with similar dopaminergic mechanism of action. May carry a lower risk of extrapyramidal symptoms compared to haloperidol. 
• Capsaicin Cream: addresses the TRPV1 pathway thought to drive CHS. Patients often dislike it as it causes a burning sensation on the skin and can be inadvertently spread to eyes or face. Can be an option if symptoms persist after trying the above meds and hot showers aren’t feasible. 

Backup Options & Anti-Emetics

• Alternative Dopaminergic Agents: Metoclopramide or prochlorperazine can be used.
• Standard Anti-Emetics (e.g., Ondansetron):
  • Serotonergic anti-emetics generally fail to address the underlying CHS pathway.
  • However, a single dose of ondansetron given alongside a butyrophenone (haloperidol/droperidol) is reasonable if you suspect co-existing etiologies.

QTc Prolongation Warning:

Chronic vomiting leads to electrolyte depletion. Combining anti-emetics and haloperidol or droperidol increases the risk of QTc prolongation.

Baseline EKG: Not strictly required for every low-risk patient, but strongly recommended for patients with multiple risk factors (e.g., co-ingestion/use of methadone, history of heart failure, or severe baseline bradycardia).

Fluid Resuscitation & Electrolyte Management

CHS patients can vomit to the point of severe dehydration and profound electrolyte/acid-base derangements.

• Fluid Selection:
  • Normal Saline (NS): A solid choice for initial volume resuscitation when sodium and chloride are severely depleted.
  • Lactated Ringer’s (LR): Ideal as a follow-up or maintenance fluid because it contains a small amount potassium.
• Potassium Repletion: Oral repletion may not be tolerated in the acute setting. Consider IV potassium repletion in the ED, followed by oral home supplementation once nausea is controlled.
• Magnesium: While acute vomiting primarily drives potassium loss, consider IV magnesium if Mg is low or there is concern for QTc prolongation.

Discharge Planning: What to Send Home

• Low-Dose Olanzapine ODT:
  • Send the patient home with 2.5 mg Olanzapine ODT (orally disintegrating tablets).
  • Why it works: It dissolves instantly on the tongue, bypassing the stomach, and provides extended dopaminergic coverage over the multi-day washout period. 
• Pharmacokinetics Pearl:
  • Infrequent user THC half-life: ~1.3 hours (cleared in 5–6 hours).
  • Chronic user THC half-life: THC accumulates in adipose tissue. In heavy users, therapeutic levels can persist for up to 2 weeks, driving prolonged receptor dysregulation even after cessation.

Navigating the Bedside Conversation

Explaining to a chronic user that their daily cannabis—the very thing they use to relieve nausea—is causing their illness requires empathy and validation.

1. Explain the Neurological Link: Cannabis acts on receptors throughout the entire body, including the brain’s nausea center and the nervous system of the gut. Chronic, heavy saturation can paradoxically overload these pathways.
2. Validate Their Experience: Acknowledge how counterintuitive it feels: “I know it’s hard to believe that something you’ve used for years to feel better is causing this, but long-term daily use can change how your body processes it.”
3. Set Realistic Expectations: Reiterate that symptoms will not resolve overnight. Even after stopping, it takes time for the pathways to recalibrate.

What do you find most helpful for treating CHS? How do you have these difficult conversaions with your patients? Share your experience with us on social media @empulsepodcast or at ucdavisem.com

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guests:

Haley Burhans, PharmD, Emergency Medicine Clinical Pharmacist at UC Davis

Resources:

Borgundvaag B, Bellolio F, Miles I, et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. Acad Emerg Med. 2024 May;31(5):425-455. doi: 10.1111/acem.14911. PMID: 38747203.

Rech MA, Shalaby M, Gage KA, Gottlieb M. Managing Cannabinoid Hyperemesis Syndrome. Ann Emerg Med. 2026 Jun;87(6):717-722. doi: 10.1016/j.annemergmed.2025.12.024. Epub 2026 Feb 3. PMID: 41632059.

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

A landmark international trial published in the New England Journal of Medicine evaluated whether fluid type impacts patient outcomes.

In this episode, we welcome back guest host Dr. Neelou Weeker and ED nurse Leigh Clary to talk about a tough emergency medicine reality that we often avoid discussing: what teamwork looks like when, despite our best efforts, the patient doesn’t survive. We work though a recent, emotionally heavy resuscitation and explore how TeamSTEPPS tools—specifically the structured debrief—serve as a vital safety net for our own mental health, helping us find our footing and reclaim our humanity in a chaotic environment.

The Reality of “Doing Everything Right” and Still Losing

We often connect good teamwork with saving lives, but in the ED, bad outcomes sometimes happen. The true test of a team’s culture is how we handle the aftermath of those tough cases.

1. The Emotional Roller Coaster of the ED

• The “Would-Have, Could-Have, Should-Haves”: When a patient comes in talking and dies in the ED, it carries a heavy psychological weight for everyone and we often replay these cases over and over in our minds.
• Flipping the Switch to Withdrawal of Care: Putting your heart and soul into a long resuscitation, getting pulses back, and then having to pivot and make the decision to withdraw care is an exhausting emotional shift for the whole team.
• The Illusion of the Robot: The ED forces us to “code switch” instantly—moving from declaring a death straight to treating a minor complaint. Without a moment to pause, you start to feel like a robot, which takes a signficant toll on your wellbeing.

2. The Anatomy of a High-Quality Debrief

Debriefing after a tough case should be a priority, not a luxury. A solid debrief balances a clinical review with immediate psychological first aid.

The Power of Prioritization: The emergency department is chronically busy, but a culture of safety means charge nurses actively shuffle staff and adjust coverage to carve out the 10 to 15 minutes required for a team to debrief.

Applying TeamSTEPPS to Team Longevity

1. The Need for a Clinical Respite

Data shows that the most important thing for a clinician after a bad outcome is just a brief break from the clinical area to regroup and compose themselves. Since we physically can’t just leave the ED to get a breath of fresh air, a structured debrief acts as that necessary “bubble” outside of active patient care.

2. Modeling Vulnerability as Leaders

To move away from the expectation that healthcare workers must act as emotionless automatons, leaders must intentionally model healthy processing.

• Visible Humanity: When Attendings and nurse leaders show vulnerability and admit that a case hit them hard, it builds a culture where it’s okay to not be okay.
• Creating “Fence Posts”: We can’t carry the weight of every patient we lose on our backs and still function. Structured debriefs allow us to package the experience into a “fence post” of clinical learning, honoring the patient while protecting the provider’s mental health.

Key Takeaways

• De-Link Teamwork from the Outcome: Perfect teamwork can’t always override catastrophic pathology. Evaluate the team’s performance based on coordination, communication, and execution, not solely on whether the patient survived.
• Establish a Standard Debrief Script: Protect your team by starting every post-event huddle with a reminder that the space is confidential, educational, and completely non-punitive.
• Invest in Your Team: Implementing a formal debrief infrastructure requires minimal resources and builds team morale and resilience. (Pro-tip: bring candy to engage all the senses in a sensory reset!)

Do you use TeamSTEPPS or a similar model in your ED? We’d love to hear what has been successful for your team. Hit us up on social media @empulsepodcast or connect with us on ucdavisem.com

Host:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Guest Host:

Dr. Neelou Tabatabai, Assistant Professor of Emergency Medicine at UC Davis

Guest:

Leigh Clary, RN, BSN, RN, CEN, ADCES, MICN , ED Nurse and TeamSTEPPS Project Lead at UC Davis

Resources:

TeamSTEPPS Player of the Month Program, Presentation by Leigh Clary and Jose Metica

TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety Heidi B. King, MS, CHE, James Battles, PhD, David P. Baker, PhD, Alexander Alonso, PhD, Eduardo Salas, PhD, John Webster, MD, MBA, Lauren Toomey, RN, BSBA, MIS, and Mary Salisbury, RN, MSN.

TeamSTEPPS Pocket Guide – Agency for Healthcare Research and Quality

EM Pulse: TeamSTEPPS, September 17, 2021 

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Disclaimer: The opinions expressed on this podcast are those of the hosts or guests and do not necessarily reflect the views of UC Davis Department of Emergency Medicine, UC Davis Health, or their parent organizations.

In this episode, the we welcome back guest host, Dr. Neelou Weeker, and ED nurse, Leigh Clary, to discuss the critical intersection of language barriers, patient equity, and emergency care. Through two powerful clinical scenarios, the team explores the “gold standards” of medical translation, the challenges of resource-limited community settings, and how TeamSTEPPS tools—specifically closed-loop communication and situational monitoring—can be leveraged to ensure true informed consent and patient safety.

The Gold Standard vs. Clinical Reality

Providing equitable care means ensuring every patient, regardless of language or culture, fully understands their medical team. While academic centers are often highly resourced, executing communication seamlessly remains a universal challenge.

1. Translation Tools and Hierarchy

• The Gold Standard: Video- or audio-based professional interpretation tablets allow face-to-face or direct vocal translation.
• The Secondary Backup: In-house dual-handset “blue phones” connect directly to professional phone lines when tablets experience connectivity issues.
• The Tertiary Backup: Multilingual staff members can help act as a bridge. Many institutions feature language fluencies on staff ID badges.
  • Note: Staff members should only be used to establish initial rapport or identify the required dialect, not as official medical interpreters.
• The Danger of Family Interpreters: While family members bring invaluable cultural context and an understanding of the patient’s baseline, studies show they only correctly interpret medical dialogue 19% of the time.
• The Bottom Line: Always utilize the official route first. When technology fails, do your absolute best—never settle for “good enough” when better communication is possible.

2. Academic vs. Community and Rural Settings

• Emergency medicine requires extreme adaptability. In resource-limited community or rural hospitals, finding an interpreter for less commonly spoken languages can take upwards of 30 minutes.
• Physicians must sometimes physically carry translation phones from room to room while managing other patients just to maintain an open line with a rare-dialect interpreter.

Applying TeamSTEPPS to Patient Communication

We routinely use TeamSTEPPS tools to communicate with our fellow clinicians, but we must remember that the patient is the most important member of the healthcare team.

1. Closed-Loop Communication & The Teach-Back Method

To confirm true patient understanding, avoid simple “yes or no” questions, nods, or smiles. Instead, utilize the Teach-Back Method, requiring the patient to repeat the instructions or choices back to you in their own words.

• How to Phrase It (Taking Responsibility):
  • “I want to make sure that I have been clear in what I’ve said to you. To help me feel reassured that I communicated everything correctly, could you tell me what you understand is going on?”
• Clinical Value: This is particularly vital for high-stakes decisions and ED discharge instructions.
• Multimodal Approach: In high-stakes moments, combine professional translation, family context, and teach-back to minimize errors.

2. Situational Monitoring

Resuscitative environments are chaotic, and the primary physician trying to run a cod or secure an airway has immense cognitive load.

• The Team Safety Net: Other team members (nurses, techs, scribes) can help monitor the situation and catch critical communication errors.

Reconciling Clinical Urgency with Informed Consent

How do you balance the immediate need to save a life with the time-consuming process of formal translation?

• The ABC Priority: First and foremost, secure Airway, Breathing, and Circulation. If a patient presents to the ED in extremis and cannot communicate, clinicians must operate under the assumption that the patient wants life-saving measures performed.
• Task Delegation: While the medical team manages the immediate ABCs, immediately task support staff (such as social workers) with finding an official interpreter, locating family members, and gathering background information.
• Next Steps: Once the ABCs are stable, the team has the time and space to pause, establish formal translation, and dive deeper into informed consent for further procedures.

Key Takeaways

• Acknowledge the Bias of Urgency: Time pressure can tempt us to bypass official translation channels. Guard against this by maintaining an equity-first mindset.
• Close the Loop with Patients: Ensure they can paraphrase their care plan or consent choices.
• Protect the Team via Shared Roles: Trust your teammates to monitor the big picture and catch subtle communication gaps during high-stress resuscitations.

Do you use TeamSTEPPS or a similar model in your ED? We’d love to hear what has been successful for your team. Hit us up on social media @empulsepodcast or connect with us on ucdavisem.com

Host:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Guest Host:

Dr. Neelou Tabatabai, Assistant Professor of Emergency Medicine at UC Davis

Guest:

Leigh Clary, RN, BSN, RN, CEN, ADCES, MICN , ED Nurse and TeamSTEPPS Project Lead at UC Davis

Resources:

TeamSTEPPS Player of the Month Program, Presentation by Leigh Clary and Jose Metica

TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety Heidi B. King, MS, CHE, James Battles, PhD, David P. Baker, PhD, Alexander Alonso, PhD, Eduardo Salas, PhD, John Webster, MD, MBA, Lauren Toomey, RN, BSBA, MIS, and Mary Salisbury, RN, MSN.

TeamSTEPPS Pocket Guide – Agency for Healthcare Research and Quality

EM Pulse: TeamSTEPPS, September 17, 2021 

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Disclaimer: The opinions expressed on this podcast are those of the hosts or guests and do not necessarily reflect the views of UC Davis Department of Emergency Medicine, UC Davis Health, or their parent organizations.

It is getting hot in California, which has us thinking about the massive carbon footprint of healthcare. The emergency department is famously resource-heavy, but can we save lives and reduce waste? Dr. David Barnes joins us to explain how going green isn’t just about being a “tree hugger”—it’s about saving money, cutting waste, and making our hospitals resilient against supply chain chaos.

Defining Healthcare Sustainability

• Balancing Safety and Footprint: Sustainability in healthcare means delivering efficient, affordable care that minimizes resource waste while remaining clinically safe and meaningful.
• The Power of Resiliency: A sustainable healthcare system is inherently a resilient one. Reducing reliance on single-use items and utilizing local renewable energy sources (like microgrids) protects hospitals from supply chain disruptions caused by geopolitical conflicts or weather-driven power grid failures.

The Three Scopes of Emissions

• Scope 1 (Direct): Emissions directly produced by hospital operations, such as idling fleet vehicles and leaking anesthetic gases.
• Scope 2 (Indirect): Purchased energy used to power and heat the facilities (e.g., local electricity and steam lines).
• Scope 3 (Supply Chain): The largest bucket, making up 60% to 80% of healthcare emissions. This includes employee commutes, medical waste incineration, manufacturing of disposable devices, and food production.

Clinical Traps: Where We Waste the Most

• Pre-packaged Kits: Studies show 75% to 80% of items inside specialized kits (like central lines) go completely unused and are thrown away.
• Over-Preparation: Opening multiple single-use items (like various ET tube sizes) or donning full trauma PPE for minor injuries creates an immediate, unnecessary trash stream.
• Pharmaceutical Waste: Standard packaging size leads to heavy drug wasting (e.g., using 5 mL from a 100 mL propofol bottle). This regulated medical waste is costly and energy-intensive to incinerate.
• The Glove Epidemic: Glove overuse skyrocketed during COVID-19 and became a habit. Most routine encounters carry no contamination risk, making glove use clinically unnecessary.

Shifting the Culture

• “Take What You Need, Leave What You Don’t”: Avoid opening supplies you may not need or bringing extra gauze or syringes into a room. Due to infection safety protocols, these often end up in the trash.
• Watch Where You Toss: Keep coffee cups and paper out of the red biohazard bins. Regulated medical waste costs six times more to process and must be incinerated, creating massive greenhouse gas emissions.
• Embrace Reprocessing & Reusables: Support partnerships with companies that safely clean and reuse devices historically labeled “single-use” (like EKG leads or waffle mattresses). Swap disposable plastic gowns for reusable cloth gowns that survive 90 washes.
• Model the Behavior: Culture change takes patience and persistence. Instead of finger-wagging or shaming colleagues, visibly adopt sustainable habits to drive grassroots practice changes.

Key Takeaways for the ED Clinician

• Speak up on bad design: Clinicians are on the front lines of waste. Advocate for local sustainability initiatives to grab the attention of hospital executives who handle major purchasing contracts.
• Normalize virtual alternatives: Protect staff well-being and slash commuting emissions by offering Zoom or Teams options for short, solitary administrative meetings.
• Keep it in perspective: Healthcare sustainability is about finding the sweet spot where clinical safety, resource utilization, and environmental impact meet.

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guest:

Dr. David Barnes, Professor of Emergency Medicine, Director of ED Sustainability, and Member of the Sustainability Committee at UC Davis Health

Resources:

Practice Greenhealth

Health Care Without Harm

Green ED (Royal College of Emergency Medicine)

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

It’s one of the most common—and most frustrating—complaints in the Emergency Department: the patient covered head-to-toe in hives, miserable, itching, and desperate for relief. In this episode of EM Pulse, we welcome back ED Clinical Pharmacist Haley Burhans to tackle the “uncomfortable” topic of urticaria. We move past the myths of one-and-done doses and explore why your standard allergy dosing might be leaving your patients itching for more.

The Power of Second-Generation Antihistamines

Haley explains why second-generation antihistamines (cetirizine, levocetirizine, fexofenadine) should be your first-line ED therapy, rather than the old school standard, diphenhydramine (Benadryl).

• Xyzal vs. Zyrtec: We break down the L-enantiomer (levocetirizine) and whether it actually beats its predecessor in preventing drowsiness.
• The “Double Dose” Pearl: For acute urticaria in the ED, 10mg of cetirizine isn’t enough. Haley recommends starting with 20mg for adults (or doubling the weight-based dose for kids) to see relief within 20–60 minutes.
• The 4x Rule: Guidelines now support up to four times the standard daily dose for refractory cases (usually split BID). We discuss the safety data behind these higher regimens and why they are tolerated so well.

The Steroid Trap and the Rebound Effect

Patients often come in requesting steroids but they are NOT the primary cure for urticaria.

• The Antihistamine Backbone: Steroids treat inflammation, but the antihistamine treats the underlying stimulus. If a patient stops their antihistamines and only takes a steroid burst, they are set up for a miserable rebound.
• Dosing Strategies: If you do use steroids, keep it to a burst or taper of 10 days or less. We discuss the utility of methylprednisolone (Medrol Dosepak) versus a simple prednisone burst/taper or a course of longer-acting dexamethasone.

Beyond the Basics: Benadryl and the MABs

• The Danger of “Dirty” Drugs: Why diphenhydramine has fallen out of favor due to its sodium channel blocking side effects, anticholinergic toxicity, and psychiatric risks.
• The Future of Itch: A look at emerging biologics like omalizumab. While these IgE-blockers shouldn’t be started in the ED, it’s important to know about them to treat patients who are taking them, or who present with rebound urticaria after recently stopping them.

Key Takeaways

• Go Big on Second Generation Antihistamines: Start with a double dose of cetirizine in the ED. It’s safe, effective, and less sedating than first-generation alternatives. Discharge patients on that double dose twice a day.
• Think Long-Term: Urticaria pathways need time to “cool down.” Advise patients to stay on the prescribed meds/doses for 1–2 months, not 1–2 days.
• Steroids are Adjuncts: Use a short burst (<10 days) for severe distress, but never as monotherapy.
• The Taper is Key: Encourage a slow taper of medications to prevent symptom recurrence.
• Managing Expectations: Most urticaria has no identifiable cause (often viral or idiopathic). Reassure the patient that while we may not find the why, we can help manage the itch.

How do you handle the “itch that won’t quit”? Do you have a favorite antihistamine cocktail? Share your experience with us on social media @empulsepodcast or at ucdavisem.com

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guests:

Haley Burhans, PharmD, Emergency Medicine Clinical Pharmacist at UC Davis

Resources:

The international EAACI/ GA²LEN/ EuroGuiDerm/ APAAACI guideline for the definition, classification, diagnosis, and management of urticaria

Emergency Department and Primary Care Clinical Pathway for Evaluation/Treatment of Children with Urticaria or Angioedema (CHOP)

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.