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Tim : Emergency medicine is such
a humbling fulfilling you know,

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difficult path that we have chosen.

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We see people at their worst and
sometimes they can rise to the occasion

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and be at their best, but we have to
also rise to the occasion, be at our

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best and give them what they need.

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And if that's information, if
that's reassurance, if that's

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guidance that's what we try to do.

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Sam (2): Hi everyone, and welcome
to another episode of EMplify.

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00:00:24,103 --> 00:00:25,853
I'm your host, Sam Ashoo.

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Before we dive into this month's
episode, I want to say happy

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holidays . It is that time of year
again, and with so much joy I say.

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Thank you for being a subscriber.

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And if you're not a subscriber, no better
time than the present eb medicine.net.

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Get a free $50 Amazon gift card
for spending $300 or more in the

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00:00:48,738 --> 00:00:51,618
store and use that CME funding.

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00:00:51,673 --> 00:00:54,793
Emergency medicine practice,
pediatric emergency medicine practice,

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00:00:54,823 --> 00:00:59,293
evidence-based urgent care, the EKG
course, the laceration course, the abscess

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00:00:59,293 --> 00:01:01,573
course, the interactive clinical pathways.

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00:01:01,573 --> 00:01:04,753
So many things to help
you in your practice.

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00:01:04,843 --> 00:01:09,763
Go spend some money, get a gift
card, become a subscriber, and have

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00:01:09,763 --> 00:01:14,948
a wonderful Holiday . And now let's
jump into this month's episode.

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Tim : Good morning, Sam.

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I'm Tim Horeczko.

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I'm very happy to be here with you.

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I'm from Harbor, UCLA where I am the
program director for the Pediatric

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Emergency Medicine Fellowship.

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And more importantly, and to your own
heart, I am one of the co-editors in chief

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of pediatric emergency medicine practice.

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So I'm very happy to be here with
you and maybe even give you a little

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bit of a behind the scenes of how we
were able to develop this article.

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Sam: Awesome.

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Thank you so much for
agreeing to be on the podcast.

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Today we are talking about the
pediatric emergency medicine

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practice article from November, 2025.

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This one is specifically on the management
of measles, mumps, rubella, and varicella,

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which you would think would be mostly
historical, but in light of recent events,

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I thought the timing was actually perfect.

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This was authored by Dr. Sarah
Cavalero was an excellent review,

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I think, of all of those diseases.

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And so thank you for agreeing to be
on the podcast to discuss it with us.

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It's an interesting topic, and I
wanna start by saying in like my 20

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years of clinical practice, I have
seen varicella, I've seen chickenpox

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I think I've seen maybe two cases of
measles and maybe a handful of mumps.

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Never seen, at least that I
know of a case of rubella.

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And certainly the cases of measles
I saw were like very mild, and

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it was kind of questionable.

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And we got like a dermatologist
involved and they're like, yeah, sure.

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It could be like a mild, you know,
and somebody who's been partially

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vaccinated or something of that sort.

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So this is an interesting time
because in our country here in the

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United States, there are outbreaks
of measles in several areas.

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Pretty large outbreaks of
thousands of children involved.

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And so.

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If you're working in emergency
medicine, these are diseases that we

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previously learned about in textbooks
and took for board exams that now we

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have to learn to recognize clinically.

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And I would say most of the physicians
who worked in the pre vaccine era or in

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the newly vaccinated era are all retired.

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And so we've kinda lost
that clinical knowledge.

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We don't have a good core memory
for what these things look like.

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And I think today I would miss many
of these things when they first

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come to the emergency department.

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So, I really wanna say thanks for agreeing
to be on the podcast to talk about it.

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'cause I think this is going to be
a very important discussion and very

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pertinent to many of our listeners.

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Tim : Thank you, Sam.

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I love what you do on the podcast.

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You really bring it to life for people.

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And speaking of which, you know, Dr.
Cavalero took some oldies but goodies

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and really made it very accessible
to us and refreshed, I think, in our

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memories especially, you know, recent
epidemics, what our role is in the

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emergency department from a public health
standpoint, in addition to trying to

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help that individual in front of us.

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And you mentioned some good points about.

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It's sort of like our, I would say the
evolution of our experience over time.

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I am gen X as well and so, you
know, you see a little bit of the

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bridging of the generations where,
we would see pre varicella vaccine.

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that's chicken pox, right?

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That's there it is.

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And I'm teaching my residents and fellows
and we often will, if we see a case, it

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will be the attenuated version, right?

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This is somebody who would've already
gotten the vaccine maybe, or even a

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full -blown case, but you almost have
to couch and say, in my day, you know,

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no one wants to hear that phrase.

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But I think it's important that we can
continue to share our experience because

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we never know when these oldies but
goodies will come back and they are right

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there in front of our face right now.

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Sam: Yeah, and I think a lot of us, at
least I did not have a good appreciation

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for the severity of the diseases.

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You know, we just assume,
oh, we have a vaccine for it.

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But we forget that the reason why we put
so much effort into developing a vaccine

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is because these were diseases that
cause significant morbidity or mortality.

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So the epidemiology section is
always a fun place for me to

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start, because I like the numbers.

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And measles, I think of all
of these is probably the most

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striking the pre-vaccine era.

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The, data we have from then said
anywhere from 15 to 60,000 cases of

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blindness 2 million deaths per year
due to pneumonia or encephalitis as

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complications of measles and young
children less than five years old, and

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adults over 20 were the ones who actually
had the highest morbidity historically.

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And.

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In 2000, the United States was
among 42% of countries that said

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they had eliminated measles.

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Meaning there's , no spread
in the communities , or

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country or person to person.

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And then we've sort of
backtracked since then.

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So COVID kind of caused a large decrease
in community vaccination efforts.

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And then since then there have been
some other political factors that

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have even reduced them even further.

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And now our cases are actually
over 1500 cases in 2025.

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And two deaths already, which is
historically kinda unheard of in the last

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25 years here in the US from measles.

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Tim : Yeah, it is crazy.

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You know, we, sort of joke about
first world problems when we have

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inconveniences that we don't like.

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And we historically thought of
outbreaks of measles, mumps, rubella,

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et cetera, as a developing country
problem because of course we have

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all of the wonderful resources and
blessings to be in a developed country

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that we benefit from constantly.

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And so we're sort of seeing this funny
thing where we're not appreciating

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what's right there in front of us.

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These are the, again, tried and true
vaccines that have proven themselves

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to be very safe and effective.

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of course, you can make arguments that
there are always reportable complications

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of any intervention that we have, but, you
know, it's just as good as clean water.

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are you gonna test every
time we take a sip?

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I don't know about that, but I
think the thing is that we have to

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be careful about how we communicate
that to our people, right?

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Because the patient in front of us just
cares about trying to get better and

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trying to survive whatever the problem is.

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They'll come in worried about
measles, mumps, rubella, varicella.

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So we, you know, we as passionate as
we can be about our hats of public

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health and hats of emergency medicine, I
think that our messaging has to be very

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attuned to the patient in front of us.

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There's some people that
are very resistant, right?

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They're very hesitant and they are
not gonna listen to anything you say.

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And the moment that you start to
go into a diatribe, they will shut

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off any communications and then
anything that you wanna help them

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for, supportive care, whatever it
is, even just please stay away from

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pregnant women, from immunocompromised,
et cetera, they won't listen.

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So I've changed my interaction with
patients in that I will ask them if

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the, let's just say the topic, the
discussion gets to be around vaccinations.

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I try to see where they are, meet
them where they are, and I will

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say, you know, what questions would
you have about X, Y, and z about

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vaccinations ? I don't have any questions.

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Okay.

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Well, I'm always here to help and
I appreciate that you've Read about

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or heard about different things.

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I would just encourage you to
make sure that you've heard from

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various sources and sources are
referenced and that you can trust.

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And I'm very happy to speak with you
about anything   that you want to clarify.

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There are some times there's more
poignant where it is case of measles

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that comes in and really we need to
make sure that we have given some

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post-exposure prophylaxis to the family.

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it'll be more pointed and that we
can talk about different things.

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Sam, you tell me what direction you'd
like to go in, but what I would say

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about that is the connection with public
health, these are all reportable diseases

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Sam: Mm-hmm.

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Tim : so, you know, every jurisdiction's
gonna have their own way of reporting it.

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In Los Angeles County, we have a
pretty robust reporting mechanism.

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But you know, measles, mumps,
rubella, regardless of where

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you live, are all reportable.

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Varicella in general is mostly reportable
if for hospitalizations or deaths.

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But it comes into play when I have to
worry about the little kid that needs to

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be isolated from measles that goes home.

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It's not just about that little
kid, it's about every little child

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or every little person involved
because the r nought right.

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The R zero meaning the average
number of cases of infectivity

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that one person can cause.

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So little Johnny is three
years old and he has measles.

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He goes home to his
family of five to seven.

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He's gonna infect 12 to 18 people,
little Johnny, which means that,

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Johnny and Jane and whoever else will
then infect another 12 to 18 people.

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That is what we like to
call an exponential growth.

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Just as an example, we think we poo
poo measles sometimes because, ah,

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it's, you know, natural immunity
or whatever people wanna say.

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But when we think about the R noughts,
the infectivity, the average number of

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cases that one person can infect ,  we
worry about things like tb, tbs only six.

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We worry about things like COVID.

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COVID is only four.

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We worry about the common cold.

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That's two to three people
that you're gonna infect.

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Ebola, nobody likes Ebola.

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three is the rnot.

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Sam: Hmm.

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Tim : one case is gonna
affect three people.

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Do we like that?

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No, but just the magnitude.

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And then also I think our individual
responsibility of living in a society

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is that in order to have herd immunity
for something like measles, which I'm

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focusing on measles because this is
probably the highest morbidity of the

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diseases we're talking about today.

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You need 90% herd immunity in a community
in order for us to prevent an outbreak.

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Trying to get 90% of adult humans in
this world to do anything is hard.

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Sam: Yeah.

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Tim : I can get 90% of 'em to breathe.

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That's probably all I could do.

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So that's tough.

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So it's a lot of like stepwise
multifactorial, multi-tiered counseling

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and public health interventions.

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And our just every day just
trying to connect with our

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patients to get it to be 90%.

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And then when we have other factors
against us, man, we have to be

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so ready to diagnose on site.

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And now these diseases are all clinical
diagnoses that your public health

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mechanism may ask you to do a PCR or to do
some serologies to verify, but we should

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all be ready to diagnose these on site
and be able to counsel people even if you

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don't feel, you mentioned about, you know,
hey, there's some cases of maybe measles.

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The maybe measles.

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I am gonna treat like measles until
proven otherwise and say, listen, this

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is what we think it is and we're gonna
be careful for everyone involved.

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Sam: Yeah.

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00:11:04,922 --> 00:11:05,162
Yeah.

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So many good points there.

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And you know, that's just measles,
but the author talked about the

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epidemiology of mumps causing permanent
deafness or death due to encephalitis.

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And that's something that's not
so far removed historically.

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The author mentioned an outbreak on
college campuses in 2014 and one in

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00:11:23,692 --> 00:11:28,412
the National Hockey League in 2014
because of how highly infectious it is.

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And you know, thankfully neither of
those resulted in deaths but those are

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outbreaks that had to be contained.

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And probably involved
emergency departments.

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And then rubella a disease that at
least, again, I don't think I've

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had the privilege of treating in the
emergency department, but primarily

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devastating to fetuses, right?

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00:11:48,252 --> 00:11:52,372
So this is kind of in pregnancy where
it's the most lethal but it causes a lot

227
00:11:52,372 --> 00:11:56,386
of neonatal death, spontaneous abortions
and then congenital rubella syndrome

228
00:11:56,666 --> 00:12:00,416
which, you know, again here, the data
in the article says in the US between

229
00:12:00,416 --> 00:12:06,266
1964 and 1965, before vaccination,
we had 12 and a half million people

230
00:12:06,326 --> 00:12:13,366
with rubella, 11,000 women miscarrying
2100 newborn deaths and 20,000 infants

231
00:12:13,456 --> 00:12:15,316
born with congenital rubella syndrome.

232
00:12:15,326 --> 00:12:15,546
Tim : Yes.

233
00:12:15,616 --> 00:12:20,956
Sam: Uh, And since 2012, 10 cases,
so we've gone from like 20,000 in

234
00:12:20,956 --> 00:12:27,346
a year to 10 cases in over 20 years
because of the vaccine efficacy in

235
00:12:27,346 --> 00:12:32,741
that scenario which is just a, an
outstanding number to think about in my

236
00:12:32,741 --> 00:12:35,171
brain for how effective that has been.

237
00:12:35,567 --> 00:12:36,497
Tim : there's an old phrase.

238
00:12:36,497 --> 00:12:37,607
You make your own luck.

239
00:12:38,007 --> 00:12:39,207
And for example, rubella.

240
00:12:39,207 --> 00:12:42,477
What you're saying is the
hidden tragedy behind these

241
00:12:42,477 --> 00:12:44,037
vaccine preventable illnesses.

242
00:12:44,307 --> 00:12:49,477
Because rubella it is sort of the milder,
the baby version of measles, right?

243
00:12:49,477 --> 00:12:52,087
It's like German measles, it's called,
by the way, it's called German measles,

244
00:12:52,437 --> 00:12:56,837
only because it was first described by
German physicians in the 18 hundreds.

245
00:12:56,837 --> 00:12:58,457
It's nothing to do with
anything in particular.

246
00:12:58,737 --> 00:13:02,632
It is typically a milder course,
milder course of just clinically

247
00:13:02,632 --> 00:13:03,862
they're not as miserable.

248
00:13:04,292 --> 00:13:09,222
Uh, In fact, measles comes from the
old Latin miser, like miser in, you

249
00:13:09,222 --> 00:13:13,036
know, in English, miserellu, uh,
is like the little miserable one.

250
00:13:13,036 --> 00:13:15,466
So measles is the little miserable one.

251
00:13:15,716 --> 00:13:18,802
Rubella is like the little
reddened one the, the ruberus one.

252
00:13:19,092 --> 00:13:23,897
And I say that because , the actual
disease itself in a child is often mild

253
00:13:23,897 --> 00:13:28,607
and they're okay, but it's that hidden
tragedy the mother doesn't realize.

254
00:13:28,687 --> 00:13:30,697
And a blueberry muffin baby is born.

255
00:13:30,967 --> 00:13:32,677
Totally devastated, as you mentioned.

256
00:13:32,737 --> 00:13:37,817
And man, what a way to just
prevent misery by these vaccines

257
00:13:37,817 --> 00:13:38,807
that prevent these illnesses.

258
00:13:39,377 --> 00:13:43,957
So, it's tough because again, you know,
in the moment we are helping people

259
00:13:43,957 --> 00:13:48,217
in the emergency department and people
might not realize the long game here.

260
00:13:48,277 --> 00:13:50,624
And we have that perspective.

261
00:13:50,924 --> 00:13:54,114
So we try to balance out
how much counseling does

262
00:13:54,134 --> 00:13:55,394
this person need right now?

263
00:13:55,394 --> 00:13:57,314
What part of me do they need?

264
00:13:57,314 --> 00:13:59,594
Do they need my head,
my heart, or my hands?

265
00:13:59,594 --> 00:14:02,044
You know, what part of
myself can I help them with?

266
00:14:02,464 --> 00:14:04,174
Because again, you have to
bring people along with you.

267
00:14:04,174 --> 00:14:06,994
You can't lecture them into submission.

268
00:14:06,994 --> 00:14:09,874
And you need to really win
hearts and minds on this.

269
00:14:09,874 --> 00:14:13,824
And part of that is, I think
being open and honest, but also

270
00:14:13,824 --> 00:14:16,944
compassionate when we see people
who come in with these questions.

271
00:14:17,409 --> 00:14:17,829
Sam: Yeah.

272
00:14:18,219 --> 00:14:21,444
So difficult to do when you're
trying to convince someone of

273
00:14:21,444 --> 00:14:25,604
something who completely disagrees
with you but very, very important.

274
00:14:26,044 --> 00:14:26,964
Absolutely very important.

275
00:14:27,544 --> 00:14:27,634
Tim : Yeah.

276
00:14:27,694 --> 00:14:29,404
And a little story about mumps, right?

277
00:14:29,404 --> 00:14:31,654
So, you know, of course we talk
about measles and we see outbreaks.

278
00:14:31,654 --> 00:14:33,034
Disneyland is not far away.

279
00:14:33,034 --> 00:14:34,504
We get Disneyland measles.

280
00:14:34,504 --> 00:14:37,964
Oftentimes, all the little
kiddies have a magical connection.

281
00:14:37,964 --> 00:14:39,374
And then they give it to each other.

282
00:14:39,724 --> 00:14:42,254
The child him or herself is often okay.

283
00:14:42,254 --> 00:14:45,134
And it's more about just making sure
that the person who should never

284
00:14:45,134 --> 00:14:48,414
get measles, nobody should, but the
immuno immunocompromised will do okay.

285
00:14:48,744 --> 00:14:50,434
Mumps is tough.

286
00:14:50,434 --> 00:14:51,694
You mentioned the outbreaks.

287
00:14:52,394 --> 00:14:56,954
I had a, this is all very you know, I'm
gonna give you just the generics of it.

288
00:14:57,114 --> 00:15:00,194
A young teenager comes in with groin pain.

289
00:15:00,464 --> 00:15:04,064
Of course, like any teenage boy
doesn't tell mom about his groin

290
00:15:04,064 --> 00:15:05,654
pain 'cause it's super embarrassing.

291
00:15:05,714 --> 00:15:08,474
Oftentimes we'll see delayed
torsion for that reason.

292
00:15:08,474 --> 00:15:09,744
And there's already ischemia.

293
00:15:10,324 --> 00:15:13,144
So a kid comes in and everybody's
already thinking, let's do an ultrasound.

294
00:15:13,144 --> 00:15:14,284
Let's make sure it's not torsion.

295
00:15:14,984 --> 00:15:17,774
You know, the poor sheepish guy
explained a little bit more.

296
00:15:17,834 --> 00:15:19,694
You realize he actually has mumps.

297
00:15:19,694 --> 00:15:23,624
The family, just, you know, it
wasn't an access issue to vaccines.

298
00:15:23,624 --> 00:15:27,684
They just didn't really see the point
and they just, it fell off their radar.

299
00:15:28,374 --> 00:15:33,374
So here comes this boy who has
unilateral orchitis and the mother

300
00:15:33,374 --> 00:15:37,184
kind of also was feeling he'll
get over this and they'll be fine.

301
00:15:37,209 --> 00:15:37,899
And she's right.

302
00:15:37,929 --> 00:15:42,519
And I, again, we talked about choosing
the right amount of information or

303
00:15:42,519 --> 00:15:44,569
interaction for each presentation.

304
00:15:44,599 --> 00:15:47,569
And she kept pushing, is he gonna be okay?

305
00:15:47,569 --> 00:15:49,099
What are the long-term effects?

306
00:15:49,549 --> 00:15:53,809
And, you know, I don't want to be
definitive when I'm speaking to these

307
00:15:53,809 --> 00:15:54,979
families because what do I know?

308
00:15:54,979 --> 00:15:58,459
I don't have a crystal ball and this
is why longitudinal primary care is

309
00:15:58,503 --> 00:16:03,684
so important . But she's asking me in
earnest, I tell her, listen, the reason

310
00:16:03,684 --> 00:16:08,014
why we worry about this is because of
course you can have aseptic meningitis.

311
00:16:08,014 --> 00:16:08,884
You have encephalitis.

312
00:16:09,039 --> 00:16:12,019
I'm speaking to you in our
terms, not in her vernacular.

313
00:16:12,728 --> 00:16:15,140
I said, you're worried about
infertility and so am I, I'm

314
00:16:15,140 --> 00:16:16,310
worried about his sterility.

315
00:16:17,010 --> 00:16:22,500
And Sam, she went from having sort of
a, red faced sort of very frustrated

316
00:16:22,500 --> 00:16:24,630
speaking about this issue to her face.

317
00:16:24,630 --> 00:16:28,160
Just kind of had this gray curtain
go over her and it's landed.

318
00:16:28,160 --> 00:16:34,817
My only boy may not be able to have
children and he's a young teenager

319
00:16:35,357 --> 00:16:35,437
Sam: Hmm.

320
00:16:35,447 --> 00:16:38,147
Tim : it just like was a moment
and I just let her have the moment.

321
00:16:38,147 --> 00:16:39,527
I'm not gonna sit there and lecture her.

322
00:16:39,857 --> 00:16:41,747
And I tried to help her
with as much as I knew.

323
00:16:41,747 --> 00:16:44,184
And then of course this
conversation shouldn't end here.

324
00:16:44,184 --> 00:16:46,834
It should continue on with primary care.

325
00:16:47,534 --> 00:16:51,514
But you know, on the bright side,
we only had unilateral orchitis,

326
00:16:51,534 --> 00:16:53,874
which is often a bit more favorable.

327
00:16:53,874 --> 00:16:58,034
I believe the sterility rate is gonna
be about 20% or so, which is not great.

328
00:16:58,034 --> 00:17:02,310
If you have bilateral orchitis then
you're looking at sterility, infertility

329
00:17:02,310 --> 00:17:04,860
rates up to, you know, 90%, 80%.

330
00:17:05,794 --> 00:17:08,644
, So the way I couched that was
yes, that is always our concern.

331
00:17:08,989 --> 00:17:12,589
And yes, we'll see how this goes and,
you know, let's do what we can going

332
00:17:12,589 --> 00:17:15,019
from here and helping 'em feel better.

333
00:17:15,379 --> 00:17:19,279
And then I really would encourage a
larger discussion with your pediatrician,

334
00:17:19,279 --> 00:17:22,669
because I really don't want this to
happen to anyone that you know or love.

335
00:17:23,089 --> 00:17:25,279
And I kind of let it be again,
she had some other questions.

336
00:17:25,279 --> 00:17:25,729
I was okay.

337
00:17:25,729 --> 00:17:30,109
But you know, these poignant moments
come up and I think that this kind

338
00:17:30,109 --> 00:17:33,285
of article is important for us
because , forewarned is forearmed.

339
00:17:33,285 --> 00:17:37,575
If we're ready already with some
of this knowledge and some talking

340
00:17:37,575 --> 00:17:40,485
points, and maybe the way that we're
flushing this conversation out might

341
00:17:40,485 --> 00:17:44,165
be helpful to someone when they have
that next difficult conversation.

342
00:17:44,760 --> 00:17:45,050
Sam: Yeah.

343
00:17:45,750 --> 00:17:46,755
Yeah, absolutely.

344
00:17:47,455 --> 00:17:47,815
Okay.

345
00:17:47,845 --> 00:17:50,605
Let's talk about what
these things look like.

346
00:17:50,605 --> 00:17:52,495
So how about we start with measles?

347
00:17:52,545 --> 00:17:56,985
Since I think that's probably the one
we're most concerned about, at least

348
00:17:56,985 --> 00:18:01,371
for its infectious abilities and for
some of the outbreaks we've been seeing.

349
00:18:01,371 --> 00:18:05,885
So, when we're seeing a child
and we're suspecting measles,

350
00:18:05,885 --> 00:18:07,595
what are the common symptoms?

351
00:18:07,595 --> 00:18:09,005
There's a classic description.

352
00:18:09,005 --> 00:18:10,205
Does that actually happen?

353
00:18:10,205 --> 00:18:12,485
You know, does anything
classically present anymore?

354
00:18:13,185 --> 00:18:16,685
Tim : Yeah it's also hard because of
course you have the three C's, the

355
00:18:16,685 --> 00:18:21,458
cough, coryza and conjunctivitis,
that will be looking like pretty much

356
00:18:21,458 --> 00:18:22,648
any other cold right most of the time

357
00:18:22,803 --> 00:18:23,093
Sam: Yeah.

358
00:18:23,688 --> 00:18:26,988
Tim : And it's difficult when you
see a lot of patients all at once

359
00:18:26,988 --> 00:18:29,898
and you are just trying to do the
best you can for the waiting room.

360
00:18:30,168 --> 00:18:35,011
However, I would just say it is a good
moment to pause and say, wow, how often

361
00:18:35,011 --> 00:18:40,262
do you really see cough conjunctivitis
and coryza all at the same time?

362
00:18:40,262 --> 00:18:41,982
Oftentimes, you'll see it.

363
00:18:42,257 --> 00:18:43,457
One at a time.

364
00:18:43,457 --> 00:18:44,477
It'll evolve over time.

365
00:18:44,477 --> 00:18:46,397
This usually comes all at once.

366
00:18:47,097 --> 00:18:48,417
So what do we do with that?

367
00:18:48,657 --> 00:18:52,827
I'd say anyone who comes in looking a
little bit more miserable from their

368
00:18:52,827 --> 00:18:57,297
cold, that they should, this is before
the rash, cough coryza, conjunctivitis.

369
00:18:57,637 --> 00:19:00,277
you go, Hmm, lemme look
inside the buccal mucosa.

370
00:19:00,837 --> 00:19:04,287
At that point though, I want
you to put your mask on because

371
00:19:04,337 --> 00:19:08,417
as we know, measles is not only
airborne, but it's aerosolized,

372
00:19:08,417 --> 00:19:09,497
you know, it flips in the air.

373
00:19:09,497 --> 00:19:15,177
So anyone who in any concern whatsoever, I
say slap an N 95 on and just go for that.

374
00:19:15,177 --> 00:19:17,217
But let's just say you have
your normal surgical mask on.

375
00:19:17,917 --> 00:19:20,097
You should look at, some specific
things we can find in the

376
00:19:20,112 --> 00:19:21,897
buccal mucosa Koplik's spots.

377
00:19:22,327 --> 00:19:26,137
Henry Koplik was a pediatrician in
the late 18 hundreds in New York

378
00:19:26,167 --> 00:19:27,637
who basically had a measles clinic.

379
00:19:27,637 --> 00:19:31,747
This guy noticed all of these measles
outbreaks and he was the first to

380
00:19:31,747 --> 00:19:37,147
describe the bluish white, tiny little
grain of salt on a slight little red

381
00:19:37,177 --> 00:19:41,057
ring that you only see before the rash.

382
00:19:41,147 --> 00:19:42,737
It goes away before the rash.

383
00:19:42,737 --> 00:19:47,997
The moment that you have is with a cough
coryza conjunctivitis that comes in.

384
00:19:47,997 --> 00:19:49,167
It's so nonspecific.

385
00:19:49,377 --> 00:19:51,037
Look in that buccal mucosa.

386
00:19:51,057 --> 00:19:55,747
If you see little weird grains
of salt, do not pass go.

387
00:19:55,747 --> 00:19:57,247
This child has measles.

388
00:19:57,487 --> 00:19:58,327
He has measles.

389
00:19:58,537 --> 00:20:00,397
We've known this since 1896.

390
00:20:00,397 --> 00:20:01,557
Thank you, Dr. Henry Koplik.

391
00:20:02,112 --> 00:20:03,402
We should pay attention to these things.

392
00:20:03,402 --> 00:20:07,452
And that's clinical enough because
the next day or the day after will

393
00:20:07,452 --> 00:20:10,632
start a little morbilliform rash.

394
00:20:10,872 --> 00:20:14,262
It starts with a hairline, like some
paint that's dumped on your head.

395
00:20:14,472 --> 00:20:18,552
And it slowly, slowly drips to your
face, to your trunk, to your extremities.

396
00:20:19,252 --> 00:20:23,382
stay away from anyone who could
be really hurt by measles.

397
00:20:23,412 --> 00:20:27,042
And that is our real
detective work that we can do.

398
00:20:27,372 --> 00:20:32,082
Cough coryza conjunctivitis all at
once in a miserable measles little one.

399
00:20:32,082 --> 00:20:37,822
Look in that buccal mucosa, and
you're gonna save 12 to 18 people from

400
00:20:37,822 --> 00:20:39,742
being infected, the R nought measles.

401
00:20:40,442 --> 00:20:43,397
Sam: And those koplik spots,
those are gonna go away.

402
00:20:43,397 --> 00:20:47,717
So we'll see them before the rash, but
if the person already has a rash, no

403
00:20:47,717 --> 00:20:51,647
point in even looking really, because we
wouldn't expect to see the Koplik's spots.

404
00:20:51,782 --> 00:20:55,082
Tim : Yeah, it's risk benefit Sam, because
you do really wanna open that mouth

405
00:20:55,082 --> 00:20:56,672
that's gonna shoot measles in your face.

406
00:20:56,972 --> 00:20:59,822
So, you know, we look, when we
see cough coryza conjunctivitis,

407
00:20:59,822 --> 00:21:00,982
no rash, we look for the Kopliks.

408
00:21:01,262 --> 00:21:03,212
But once the rash happens, Koplik is gone.

409
00:21:03,582 --> 00:21:06,242
And also, you know, by this isn't
talked about very often, which is

410
00:21:06,242 --> 00:21:07,592
why I wanna emphasize it today.

411
00:21:08,072 --> 00:21:10,772
People will sometimes
see a weird looking rash.

412
00:21:10,772 --> 00:21:11,402
They're not sure.

413
00:21:11,402 --> 00:21:13,112
They'll look in the mouth and
say, there's nothing in the

414
00:21:13,112 --> 00:21:14,282
mouth, that can't be measles.

415
00:21:14,312 --> 00:21:15,212
That's not true.

416
00:21:15,512 --> 00:21:18,742
Koplik is gone by the
time the rash happens.

417
00:21:19,442 --> 00:21:19,682
Sam: Okay.

418
00:21:19,682 --> 00:21:19,922
Yeah.

419
00:21:19,922 --> 00:21:22,472
So very important to keep
in mind in that scenario.

420
00:21:22,472 --> 00:21:27,632
And then when we think about patients
who might present to the ED with

421
00:21:27,632 --> 00:21:32,642
complications of measles, now we've got
a whole host of things that can happen.

422
00:21:32,972 --> 00:21:38,955
Things like, otitis media, diarrhea,
pneumonia corneal complications so

423
00:21:39,045 --> 00:21:40,918
they can have corneal involvement.

424
00:21:40,988 --> 00:21:42,818
And then immunosuppression.

425
00:21:42,818 --> 00:21:46,478
Now this is interesting as the
cause for all of these issues.

426
00:21:46,668 --> 00:21:51,168
People who get measles and then
recover are immunosuppressed for

427
00:21:51,168 --> 00:21:52,638
quite a period of time, right.

428
00:21:52,693 --> 00:21:53,083
Tim : That's right.

429
00:21:53,083 --> 00:21:55,093
They're immunosuppressed from anything.

430
00:21:55,093 --> 00:21:56,503
It's not just from the measles.

431
00:21:56,833 --> 00:21:59,603
So, we treat them as
relatively immunocompromised.

432
00:21:59,633 --> 00:22:03,143
And that's why it's really important to
get a good history for people who come in.

433
00:22:03,143 --> 00:22:06,593
Often children will come in with serial
URIs, serial infections, but it's

434
00:22:06,593 --> 00:22:10,533
really important to say how has he or
she been over the past several months?

435
00:22:10,903 --> 00:22:14,653
There is something that, this is
actually a relatively new description,

436
00:22:14,653 --> 00:22:16,333
what's called immune amnesia.

437
00:22:16,383 --> 00:22:19,833
We've only really had this documented
for about the past 10 years or

438
00:22:19,833 --> 00:22:24,840
so, and this immune amnesia that
is kind of like a nuclear bomb to

439
00:22:24,840 --> 00:22:28,157
your immune system, measles, for
two to three years, it can last.

440
00:22:28,277 --> 00:22:34,283
So in a young child who's susceptible and
exposed to so many illnesses constantly

441
00:22:34,883 --> 00:22:37,073
that is why they'll get the pneumonia.

442
00:22:37,133 --> 00:22:38,793
That is the, the super infection.

443
00:22:39,193 --> 00:22:41,163
The encephalitis is another mechanism.

444
00:22:41,163 --> 00:22:45,207
And of course, long-term, more
of a, autoimmune issue is the

445
00:22:45,207 --> 00:22:48,507
subacute sclerosing panencephalitis,
which, you know, you could have

446
00:22:48,507 --> 00:22:50,877
the, totally boring measles.

447
00:22:50,877 --> 00:22:52,047
It's a little bit of a rash.

448
00:22:52,047 --> 00:22:54,027
Everyone gets upset for a week or so.

449
00:22:54,147 --> 00:22:57,477
They go about their lives three
years, five years, 10 years later.

450
00:22:57,807 --> 00:22:59,337
They're neurologically devastated.

451
00:22:59,637 --> 00:23:03,237
Those hidden tragedies of
these vaccine preventable

452
00:23:03,237 --> 00:23:05,572
illnesses continue to sprout up.

453
00:23:05,572 --> 00:23:08,392
So those are the things that
I'll sometimes point to when

454
00:23:08,392 --> 00:23:10,522
people will be very hesitant.

455
00:23:11,222 --> 00:23:11,402
Sam: Yeah.

456
00:23:11,402 --> 00:23:15,872
And this complication, this
subacute sclerosing panencephalitis,

457
00:23:15,992 --> 00:23:17,702
thankfully is, is not very common.

458
00:23:17,702 --> 00:23:19,862
This says five to 10 cases per million.

459
00:23:20,082 --> 00:23:26,732
But this is a gradually deteriorating
neurological devastation that starts,

460
00:23:26,732 --> 00:23:30,812
you said, you know, anywhere from
three to 10 years, even after measles

461
00:23:30,812 --> 00:23:33,212
infection and is completely untreatable.

462
00:23:33,272 --> 00:23:38,012
There's no way to stop the progression
and it results in death for the child.

463
00:23:38,387 --> 00:23:40,067
Tim : Preventable, but untreatable

464
00:23:40,310 --> 00:23:41,645
Sam: that stuff just gives me the chills.

465
00:23:42,035 --> 00:23:45,235
Tim : Emergency medicine is such
a humbling fulfilling you know,

466
00:23:45,295 --> 00:23:47,185
difficult path that we have chosen.

467
00:23:47,215 --> 00:23:51,278
We see people at their worst and
sometimes they can rise to the occasion

468
00:23:51,278 --> 00:23:54,548
and be at their best, but we have to
also rise to the occasion, be at our

469
00:23:54,548 --> 00:23:56,378
best and give them what they need.

470
00:23:56,378 --> 00:23:58,658
And if that's information, if
that's reassurance, if that's

471
00:23:59,078 --> 00:24:00,818
guidance that's what we try to do.

472
00:24:01,518 --> 00:24:01,808
Sam: Yeah.

473
00:24:02,508 --> 00:24:02,798
Okay.

474
00:24:02,843 --> 00:24:07,913
So measles, cough, coryza, conjunctivitis,
fever, malaise, maybe not eating well.

475
00:24:08,243 --> 00:24:11,273
Koplik spots that are gonna
be there a couple of days.

476
00:24:11,433 --> 00:24:12,273
And then gone.

477
00:24:12,333 --> 00:24:16,503
And then the onset of rash with maybe
some lymphadenopathy, and then all of

478
00:24:16,503 --> 00:24:18,153
those complications we just talked about.

479
00:24:18,363 --> 00:24:18,813
Tim : That's right.

480
00:24:18,813 --> 00:24:21,243
And for measles speaking to the
family, of course, you know, you're

481
00:24:21,243 --> 00:24:24,813
infectious, four days before the rash
and then four days after the rash.

482
00:24:24,813 --> 00:24:26,753
So it's not a get outta jail free card.

483
00:24:26,753 --> 00:24:29,213
This child needs to be isolated,
and this is why it's important

484
00:24:29,213 --> 00:24:31,673
to get public health involved,
because they will make phone checks.

485
00:24:31,673 --> 00:24:33,833
They will continue to counsel people.

486
00:24:34,013 --> 00:24:36,713
How many times have people forgotten what
we tell them in the emergency department?

487
00:24:36,713 --> 00:24:39,923
We try to write everything down,
but that reinforcement later on with

488
00:24:39,923 --> 00:24:42,263
the public, the wonderful public
health nurses that are out there to

489
00:24:42,263 --> 00:24:44,513
help us to keep our system running.

490
00:24:45,213 --> 00:24:45,453
Sam: Okay.

491
00:24:45,453 --> 00:24:46,683
And then mumps.

492
00:24:46,743 --> 00:24:50,433
So, you know, we always think about the
parotid gland swelling in the kid with

493
00:24:50,433 --> 00:24:53,013
the classic swollen jaw on both sides.

494
00:24:53,013 --> 00:24:57,843
But mumps really is going to infect
any glandular organ in this scenario.

495
00:24:57,843 --> 00:25:00,863
So they're going to get
problems with pancreas.

496
00:25:00,893 --> 00:25:03,383
They're gonna get problems
with their reproductive organs.

497
00:25:03,383 --> 00:25:06,653
They're gonna get problems with
really , any gland in the body.

498
00:25:06,813 --> 00:25:10,903
And it doesn't have to be just the
jaw , but that may be the one symptom

499
00:25:10,903 --> 00:25:13,603
that brings them to the emergency
department that makes us think about it.

500
00:25:13,863 --> 00:25:16,423
But you already mentioned
like testicular pain or in a

501
00:25:16,423 --> 00:25:18,013
female might be abdominal pain

502
00:25:18,023 --> 00:25:20,733
Tim : You know, it can be surprising,
and I'm glad you brought that up,

503
00:25:20,733 --> 00:25:24,473
because again, mumps loves lacy tissue.

504
00:25:24,563 --> 00:25:28,927
Anything that has that lacy glandular
look to it from a histology standpoint.

505
00:25:29,327 --> 00:25:31,727
So we should be aware that it
can present in different ways.

506
00:25:31,727 --> 00:25:34,453
The, case that I mentioned of this
young teenager, he really didn't

507
00:25:34,453 --> 00:25:35,533
have a lot of facial swelling.

508
00:25:35,563 --> 00:25:37,453
You know, his habitus was a
little bit larger, and so it

509
00:25:37,453 --> 00:25:38,713
didn't really look much bigger.

510
00:25:38,713 --> 00:25:40,303
His face didn't seem much fuller.

511
00:25:40,303 --> 00:25:42,943
It was just unilateral swelling.

512
00:25:42,943 --> 00:25:47,113
And his doppler was normal and
it really, on exam, you could

513
00:25:47,113 --> 00:25:48,793
tell that this was a bit swollen.

514
00:25:48,943 --> 00:25:51,893
But, difficult because mumps,
of course, you know, I love

515
00:25:51,953 --> 00:25:53,303
etymology of words, as you can see.

516
00:25:53,303 --> 00:25:58,833
And mumps comes from the old English
of a grimace, pouty face is to mump.

517
00:25:58,833 --> 00:25:59,643
Is to pout.

518
00:25:59,883 --> 00:26:01,803
So we kind of think of someone
as just like, you know, sour

519
00:26:01,803 --> 00:26:03,693
face, their jaw line is down.

520
00:26:04,033 --> 00:26:05,743
That's what we think of for mumps.

521
00:26:06,163 --> 00:26:08,323
But man, we should be careful, right?

522
00:26:08,323 --> 00:26:09,023
Is it orchitis?

523
00:26:09,043 --> 00:26:09,833
Is it oophoritis?

524
00:26:09,853 --> 00:26:10,633
Is it mastitis?

525
00:26:10,633 --> 00:26:11,623
Is it pancreatitis?

526
00:26:11,953 --> 00:26:16,853
Or this kid who's now seeming a little
bit weird, why are you so weird?

527
00:26:16,853 --> 00:26:18,843
Sir? Your utox is normal.

528
00:26:19,113 --> 00:26:19,743
No trauma.

529
00:26:20,133 --> 00:26:24,383
Oh no, you have aseptic meningitis
because you have your mumps.

530
00:26:24,403 --> 00:26:27,790
So, we keep our differential
broad for that reason.

531
00:26:28,490 --> 00:26:31,720
Sam: And then, equally catastrophic
with the central nervous system

532
00:26:31,720 --> 00:26:37,400
encephalitis and hearing loss
myocarditis nephritis, multiple

533
00:26:37,460 --> 00:26:39,170
other complications that can occur.

534
00:26:39,470 --> 00:26:43,430
About a third of these cases of mumps
are asymptomatic, but these people are

535
00:26:43,430 --> 00:26:47,870
still contagious, so still out there
passing it along to everyone else.

536
00:26:47,870 --> 00:26:51,560
And so contact tracing may
not be a perfect science in

537
00:26:51,560 --> 00:26:52,850
this particular scenario.

538
00:26:53,465 --> 00:26:53,615
Tim : Yeah.

539
00:26:53,705 --> 00:26:55,805
You know, measles is very pathognomonic.

540
00:26:55,835 --> 00:27:00,007
Mumps should be, but I, find that a
lot of public health officials push

541
00:27:00,007 --> 00:27:02,037
more for confirmatory testing in mumps.

542
00:27:02,037 --> 00:27:06,887
So they'll ask for the PCR for the buccal
mucosa, or even like an IGM serology.

543
00:27:07,247 --> 00:27:09,437
I think also because, you
know, orchitis of course can

544
00:27:09,437 --> 00:27:11,057
be various infectious diseases,

545
00:27:11,307 --> 00:27:11,597
Sam: Yeah.

546
00:27:11,697 --> 00:27:15,637
Tim : From a public health standpoint,
the agency is dealing with people

547
00:27:15,637 --> 00:27:17,517
with varied degrees of experience.

548
00:27:17,817 --> 00:27:22,247
And so they wanna make sure that our
sensitivity and specificity is optimized.

549
00:27:22,427 --> 00:27:24,407
So that's why we say,
Hmm, is it really mumps?

550
00:27:24,407 --> 00:27:27,587
And that's why they will tend
to ask you for more testing.

551
00:27:27,937 --> 00:27:29,617
And it is, you know, supportive care.

552
00:27:30,317 --> 00:27:34,291
So it's not as infectious as the
others but it's still something

553
00:27:34,391 --> 00:27:35,861
that we need to pay attention to.

554
00:27:36,382 --> 00:27:38,452
Sam: all right, let's move on to rubella.

555
00:27:38,452 --> 00:27:42,682
So in this case, much like mumps,
a large percentage up to 50% can

556
00:27:42,682 --> 00:27:46,642
be asymptomatic, which again,
is problematic for transmission.

557
00:27:46,902 --> 00:27:52,212
But these in children are gonna
present with fever, headache, cough,

558
00:27:52,212 --> 00:27:54,192
congestion, sounds a lot like measles,

559
00:27:54,252 --> 00:27:54,672
Tim : Mm-hmm.

560
00:27:54,822 --> 00:27:55,782
Sam: and a rash.

561
00:27:55,942 --> 00:28:00,506
And then this is also gonna have
this prodrome for one to five days

562
00:28:00,506 --> 00:28:02,426
before the rash appears right.

563
00:28:02,591 --> 00:28:03,131
Tim : Yes.

564
00:28:03,131 --> 00:28:05,951
And you know, that's why
Rubella is the little red.

565
00:28:05,951 --> 00:28:08,571
From a clinical standpoint,
it is much milder.

566
00:28:08,621 --> 00:28:11,051
It's sort of the baby version of measles.

567
00:28:11,711 --> 00:28:15,461
and there may be cases where we
call it measles, but it ends up

568
00:28:15,461 --> 00:28:18,131
being rubella and we just never
got the confirmatory testing.

569
00:28:18,131 --> 00:28:21,191
But it's my understanding that
we don't have a lot of cases of

570
00:28:21,191 --> 00:28:22,406
rubella, at least in this country.

571
00:28:23,106 --> 00:28:28,206
You know, I'm okay over calling it, but
rubella often comes with this red rash

572
00:28:28,546 --> 00:28:32,926
there's often arthralgias and they're
just not as miserable as, our little

573
00:28:32,926 --> 00:28:34,686
miserable measles in children are.

574
00:28:35,166 --> 00:28:37,416
Having said that though, as you
mentioned, the sensory neural

575
00:28:37,416 --> 00:28:41,639
deafness can be devastating and
then devastating to a fetus who is

576
00:28:41,799 --> 00:28:43,589
exposed to this infectious disease

577
00:28:44,441 --> 00:28:48,176
.
Sam: And now the risk to a fetus
here is probably, I think, the

578
00:28:48,176 --> 00:28:49,766
highest of all of these diseases.

579
00:28:49,766 --> 00:28:54,176
It says approximately 85% of
fetuses exposed to rubella in

580
00:28:54,176 --> 00:28:57,146
the first trimester are gonna
develop some kind of birth defect.

581
00:28:57,491 --> 00:28:57,641
Tim : Yeah.

582
00:28:57,701 --> 00:28:58,851
And that's just not acceptable.

583
00:28:58,851 --> 00:28:59,001
Right.

584
00:28:59,001 --> 00:29:00,441
An 85% risk.

585
00:29:00,831 --> 00:29:05,211
I mean, that's a no go of all the
things we worry about in prenatal care.

586
00:29:05,421 --> 00:29:09,041
People are so, assiduous about
taking prenatal vitamins every day.

587
00:29:09,101 --> 00:29:09,671
I love it.

588
00:29:09,671 --> 00:29:10,165
So good.

589
00:29:10,375 --> 00:29:10,992
But Wow.

590
00:29:11,232 --> 00:29:13,002
You know, you're a little
bit low on the iron.

591
00:29:13,002 --> 00:29:16,692
We can get over that, but
not so much on the rubella.

592
00:29:16,962 --> 00:29:17,512
Sam: The rubella.

593
00:29:17,532 --> 00:29:17,892
Yeah.

594
00:29:18,592 --> 00:29:24,112
And mother's immunity is safeguarding
for the fetus in this sense.

595
00:29:24,112 --> 00:29:27,862
So as long as mom is vaccinated,
that passes to the fetus.

596
00:29:28,132 --> 00:29:28,582
Tim : yes.

597
00:29:28,942 --> 00:29:31,042
Sam: Okay, so let's talk
about varicella chickenpox.

598
00:29:31,042 --> 00:29:34,862
Probably the one I'm for sure
certain I have seen and had

599
00:29:35,012 --> 00:29:38,162
actually as a child, I guess I'm
old enough to have experienced it.

600
00:29:38,732 --> 00:29:42,142
So this is another rash, right?

601
00:29:42,142 --> 00:29:44,482
This one happens to be very itchy, right?

602
00:29:44,482 --> 00:29:48,992
So fever itchy rash has those
little vesicles that appear

603
00:29:49,152 --> 00:29:53,592
multiple stages of ages because
the rash comes in these waves.

604
00:29:53,862 --> 00:29:56,532
And equally miserable.

605
00:29:56,702 --> 00:30:00,702
But thankfully, actually probably
, the one of these that actually

606
00:30:00,702 --> 00:30:02,232
has some treatment options, right?

607
00:30:02,757 --> 00:30:03,657
Tim : Yeah, , that's exactly right.

608
00:30:03,677 --> 00:30:08,247
You know, varus in Latin is a
pimple, so varicella is like little

609
00:30:08,247 --> 00:30:09,537
pimples, little pimple disease.

610
00:30:09,837 --> 00:30:12,327
So all these little, you know,
pimple diseases are all over you.

611
00:30:12,327 --> 00:30:15,237
And , I'm gonna just expose my
own bias too, because again,

612
00:30:15,237 --> 00:30:18,567
like when we were little, you
know, everybody gets chickenpox.

613
00:30:18,567 --> 00:30:19,947
There were chickenpox parties.

614
00:30:20,067 --> 00:30:20,517
Sam: Yeah.

615
00:30:20,727 --> 00:30:22,047
Tim : Get it all over with everyone.

616
00:30:22,167 --> 00:30:24,567
And I think we took a little
bit of a laissez-faire approach.

617
00:30:24,567 --> 00:30:27,347
, And I think that we're all
probably pretty lucky for that.

618
00:30:27,777 --> 00:30:32,127
The problem is though, of course
we have an effective vaccine that

619
00:30:32,127 --> 00:30:35,877
can really decrease morbidity
and sometimes mortality.

620
00:30:35,877 --> 00:30:39,297
You know, varicella is often
okay, but not in the wrong person.

621
00:30:39,297 --> 00:30:42,927
And the person who can't get vaccines,
immunocompromised, the chemotherapy

622
00:30:42,927 --> 00:30:47,487
patients, what have you, we're really
doing a service to ourselves as

623
00:30:47,487 --> 00:30:50,961
well as our community by becoming
vaccinated . But anyway, my bias

624
00:30:50,961 --> 00:30:52,341
is like, it's just chickenpox.

625
00:30:52,371 --> 00:30:52,911
It'll be okay.

626
00:30:53,121 --> 00:30:57,261
So I have to remind myself, no, it's not,
we really do have to be careful about

627
00:30:57,261 --> 00:31:03,261
once we've diagnosed it to isolate because
it is like all of , the things that

628
00:31:03,261 --> 00:31:04,666
we're talking about, , it is airborne.

629
00:31:04,666 --> 00:31:08,919
It's airborne and droplet and it's
extremely infectious , and preventable.

630
00:31:09,619 --> 00:31:12,674
Sam: And much like the other
viruses we just talked about, you

631
00:31:12,674 --> 00:31:16,304
get symptoms for a couple of days
before the rash appears, and then

632
00:31:16,304 --> 00:31:18,374
the rash scabs over in about a week.

633
00:31:18,374 --> 00:31:21,854
And at that point, you're finally
no longer infectious when you don't

634
00:31:21,854 --> 00:31:25,514
have any more vesicles that can
rupture and release the fluid right.

635
00:31:25,587 --> 00:31:26,457
Tim : That's exactly right.

636
00:31:26,547 --> 00:31:29,937
And then just kind of again, putting
on our emergency medicine hat.

637
00:31:29,937 --> 00:31:33,987
You know, here we are as clinicians
who are trying to make sure that

638
00:31:33,987 --> 00:31:35,367
everyone is safe in the department.

639
00:31:35,557 --> 00:31:37,747
Oftentimes the nurses will call
me and say, Hey, this is rash.

640
00:31:37,747 --> 00:31:39,307
Can you please see this person in triage?

641
00:31:39,367 --> 00:31:43,457
I'll run over there verify that
it may or may not be measles,

642
00:31:43,457 --> 00:31:44,442
varicella, what have you.

643
00:31:44,477 --> 00:31:49,131
If it is in any way, potentially
chicken pox I will say okay any of the

644
00:31:49,131 --> 00:31:53,731
nurses that are in any possibility of
becoming pregnant now or soon, get out

645
00:31:53,731 --> 00:31:57,731
of here, I will keep them away from
that patient and I'll make sure that we

646
00:31:57,761 --> 00:31:59,471
have the right staff, for that patient.

647
00:31:59,471 --> 00:32:02,561
And I say that, and it sounds kind
of like, you know, literally chicken

648
00:32:02,561 --> 00:32:07,532
little falling from the sky, but
wow, what an easy thing to do often.

649
00:32:07,812 --> 00:32:09,612
And if I just need to see
the patient myself, I will.

650
00:32:09,612 --> 00:32:12,372
Because often there's not a lot of
nursing intervention to be done.

651
00:32:12,372 --> 00:32:13,602
I can take my own vital signs.

652
00:32:13,917 --> 00:32:14,207
Sam: Yeah.

653
00:32:14,532 --> 00:32:17,142
Tim : but it's something simple that
we can do to really help people.

654
00:32:17,142 --> 00:32:21,732
And that's, that's how serious these
things are because it's not just, chances

655
00:32:21,732 --> 00:32:25,512
are in emergency medicine, we often
don't deal with, chances are we just say,

656
00:32:25,512 --> 00:32:30,277
listen, whether or not you, you know, we
don't think about necessarily population

657
00:32:30,277 --> 00:32:32,047
probabilities, like how likely it is?

658
00:32:32,047 --> 00:32:34,567
Does this person have whatever
we go, there's a possibility.

659
00:32:34,657 --> 00:32:35,647
I need to look into it.

660
00:32:36,067 --> 00:32:40,057
So we really deal with this sort
of catastrophic mindset because

661
00:32:40,057 --> 00:32:41,301
that's what society needs from us.

662
00:32:41,331 --> 00:32:44,779
So I Want to have that same mindset
for our own staff to keep them safe.

663
00:32:44,879 --> 00:32:46,916
Any possibility of chickenpox?

664
00:32:46,916 --> 00:32:51,386
Let's keep away the nurses,
clinicians, anyone around the

665
00:32:51,386 --> 00:32:53,513
techs that are of childbearing age.

666
00:32:53,703 --> 00:32:55,789
Let's get 'em away from
Potential chicken pox.

667
00:32:56,404 --> 00:32:59,284
Sam: And do you do that even if they've
been vaccinated and they're pregnant?

668
00:32:59,984 --> 00:33:03,628
Tim : You know, I'm just, I'm a little
bit overprotective maybe, but yes.

669
00:33:03,628 --> 00:33:04,974
cause you Know who Cares, right?

670
00:33:04,974 --> 00:33:08,204
These people are often fine and
it's something that I can do.

671
00:33:08,954 --> 00:33:10,194
gonna be a good bro to everyone.

672
00:33:10,424 --> 00:33:10,964
That's what I'm gonna do.

673
00:33:11,384 --> 00:33:11,714
Sam: I like it.

674
00:33:11,924 --> 00:33:12,254
I like it.

675
00:33:12,954 --> 00:33:15,424
And you know, speaking
of the possibilities.

676
00:33:15,424 --> 00:33:20,674
I thought that the appendix in this
article, pages 16 and 17 lists like

677
00:33:20,764 --> 00:33:25,474
this is, I think 26 different conditions
that can cause fever and rash.

678
00:33:25,504 --> 00:33:29,554
So if you're listening, we're
not trying to oversimplify this.

679
00:33:29,554 --> 00:33:33,364
, There's multiple diseases that we
previously had excellent vaccine

680
00:33:33,364 --> 00:33:36,284
coverage for, that were on the
list, but you didn't really have

681
00:33:36,284 --> 00:33:37,634
to put near the top of the list.

682
00:33:37,634 --> 00:33:41,414
But now we've got 26 different
things that can cause fever and

683
00:33:41,414 --> 00:33:43,094
rash and we're adding to it.

684
00:33:43,124 --> 00:33:47,264
The three or four things that we
previously could kind of go, eh, you

685
00:33:47,264 --> 00:33:50,084
know, they're vaccinated, not worried
about it, or everybody's vaccinated,

686
00:33:50,084 --> 00:33:51,464
I'm not so worried about this anymore.

687
00:33:51,784 --> 00:33:52,004
Tim : Yes.

688
00:33:52,499 --> 00:33:52,829
Wow.

689
00:33:52,959 --> 00:33:54,549
What a humbling reframe.

690
00:33:54,954 --> 00:33:55,374
Right.

691
00:33:55,654 --> 00:33:58,684
And that's why again, this discussion
and this article is so important to

692
00:33:58,774 --> 00:34:01,054
refresh our minds about what to look for.

693
00:34:01,104 --> 00:34:04,219
, And this sort of speaks a little bit
about the difference between inductive

694
00:34:04,219 --> 00:34:06,409
and deductive reasoning that we have
in the emergency department, right?

695
00:34:06,649 --> 00:34:09,439
Deductive reasoning will often say,
Hey, there's a fever and a rash.

696
00:34:09,439 --> 00:34:11,089
What are the 100 things that can cause it?

697
00:34:11,089 --> 00:34:13,549
And I'm gonna narrow it down with my
history and physical to 10 things,

698
00:34:13,549 --> 00:34:16,729
and maybe I spend some time with
them, or, or intervene or test.

699
00:34:16,939 --> 00:34:19,909
And I've narrowed it down
to the deductive one answer.

700
00:34:20,029 --> 00:34:20,719
This is what we try to do.

701
00:34:20,749 --> 00:34:22,589
This is when we, admit people
to internal medicine so that

702
00:34:22,589 --> 00:34:23,879
they have multiple days, right?

703
00:34:24,189 --> 00:34:25,359
Or pediatrics or what have you.

704
00:34:25,539 --> 00:34:28,449
So, we are trying to find for
deductive reason the answer.

705
00:34:28,479 --> 00:34:28,869
That's it.

706
00:34:28,869 --> 00:34:29,589
There's only one answer.

707
00:34:30,019 --> 00:34:32,299
We often, in immersive medicine
have inductive reasoning, right?

708
00:34:32,299 --> 00:34:34,669
Where we say, there's certain
things that I am responsible for.

709
00:34:34,669 --> 00:34:37,299
I'm responsible to make sure this is
not measles, mumps, rubella , it's

710
00:34:37,299 --> 00:34:40,359
really important that this person with
chest pain doesn't have a PE aortic

711
00:34:40,539 --> 00:34:41,889
dissection and a stemi, et cetera.

712
00:34:42,249 --> 00:34:44,919
How likely are any of those
things just given the chances

713
00:34:44,919 --> 00:34:45,879
you're gonna throw some dice?

714
00:34:45,879 --> 00:34:49,309
, they're not likely, they're
o ur responsibility.

715
00:34:49,309 --> 00:34:52,099
So we're using inductive reasoning,
the sort of sharpshooter reasoning

716
00:34:52,099 --> 00:34:55,289
of you send someone to a cardiologist
and what are they gonna do?

717
00:34:55,289 --> 00:34:57,149
They're gonna do an EKG and
they're gonna ask about chest pain.

718
00:34:57,449 --> 00:35:00,479
But maybe this is costochondritis,
it's the cardiologist's job

719
00:35:00,479 --> 00:35:01,259
to think about the heart.

720
00:35:01,319 --> 00:35:05,339
It's the emergency medicine physician
or clinician's job to think about the

721
00:35:05,339 --> 00:35:07,019
dangerous things, inductive reasoning.

722
00:35:07,229 --> 00:35:08,369
And that's why it's just sort of weird.

723
00:35:08,369 --> 00:35:09,859
You see , this long
list, you go, oh my gosh.

724
00:35:09,859 --> 00:35:10,339
All these things.

725
00:35:11,039 --> 00:35:14,239
Yes, that is already pre-programmed
into your mind as a clinician.

726
00:35:14,239 --> 00:35:19,239
this discussion is more about how do I
use my inductive reasoning when it counts?

727
00:35:19,419 --> 00:35:21,729
Oh no, there's something
that's weird about this.

728
00:35:22,059 --> 00:35:27,069
I need to explicitly make myself
stop and think about measles,

729
00:35:27,099 --> 00:35:28,929
mumps rubella and varicella.

730
00:35:29,629 --> 00:35:31,759
Oh, there no, doesn't,
doesn't match any of those.

731
00:35:31,759 --> 00:35:32,569
Great move on.

732
00:35:33,169 --> 00:35:37,726
But this is why , that's important for
us to hyperfocus sometimes and then relax

733
00:35:37,726 --> 00:35:40,156
back when we haven't found any red flags.

734
00:35:40,856 --> 00:35:43,976
Sam: Yeah, and I thought the author
did a particularly good job of

735
00:35:43,976 --> 00:35:49,296
reminding us that none of these
diseases are supposed to cause purpura.

736
00:35:49,586 --> 00:35:54,366
So if you see a purpuric rash, then,
even if you're in the midst of one of

737
00:35:54,366 --> 00:36:00,126
these massive measles outbreaks, stop and
reframe and make sure you're not looking

738
00:36:00,126 --> 00:36:04,156
at somebody whose sepsis has you know,
meningococcemia  or something of that

739
00:36:04,156 --> 00:36:07,016
sort as a cause for underlying sepsis.

740
00:36:07,021 --> 00:36:11,281
, The purpuric rash is not a normal
complication of any one of these diseases.

741
00:36:11,611 --> 00:36:12,571
Tim : Touch your patients.

742
00:36:12,571 --> 00:36:13,691
Look for capillary refill.

743
00:36:14,171 --> 00:36:16,661
look for blanching of those
petechia  and purpura.

744
00:36:16,936 --> 00:36:19,236
Put gloves on 'cause you know
no one likes meningococcemia.

745
00:36:19,726 --> 00:36:20,566
Sam: Yes, yes.

746
00:36:20,566 --> 00:36:21,466
Please put gloves on.

747
00:36:22,006 --> 00:36:22,276
Okay.

748
00:36:22,276 --> 00:36:24,233
Let's talk about our
pre-hospital colleagues.

749
00:36:24,233 --> 00:36:28,523
So, there are some who listen and
appropriately are concerned about

750
00:36:28,523 --> 00:36:30,233
themselves and their patients.

751
00:36:30,233 --> 00:36:35,813
And so if you are an EMS colleague
and you are now transporting a child

752
00:36:35,813 --> 00:36:41,093
with fever and a rash or, you know,
maybe not tolerating this URI very

753
00:36:41,093 --> 00:36:43,833
well and seems to be a little bit more
distressed than usual, and you happen

754
00:36:43,833 --> 00:36:47,523
to notice a rash, what are some of
the things they need to keep in mind?

755
00:36:47,553 --> 00:36:51,323
Tim : Yeah, , our watchers on the
wall, our front line, and these guys

756
00:36:51,323 --> 00:36:54,233
have to go into crazy environments.

757
00:36:54,413 --> 00:36:56,483
People are upset, there's bad lighting.

758
00:36:56,513 --> 00:36:57,593
No one knows anything.

759
00:36:57,713 --> 00:37:00,983
They get 'em into the rig and they
turn on the lights and go, oh, no, I

760
00:37:00,983 --> 00:37:02,603
just see something I'm worried about.

761
00:37:02,963 --> 00:37:06,303
So, this is a good example of our
continuing this conversation with our

762
00:37:06,303 --> 00:37:10,629
EMS colleagues and just, taking 'em
aside after they bring a patient in

763
00:37:10,629 --> 00:37:12,039
and saying, Hey, how was it for you?

764
00:37:12,429 --> 00:37:14,199
And giving 'em that little kind of tidbit.

765
00:37:14,199 --> 00:37:17,169
If they're in any way concerned or we are
concerned, we should communicate to them.

766
00:37:17,199 --> 00:37:20,439
And that, in fact, I would push it
even further to say that we should

767
00:37:20,719 --> 00:37:22,219
make sure that their medical director.

768
00:37:22,219 --> 00:37:26,579
And the EMS agency they came from knows
about this because public health takes a

769
00:37:26,579 --> 00:37:28,829
few days to track people down who go home.

770
00:37:29,159 --> 00:37:34,589
But I want that medic to know that he
maybe needs to be isolated because he

771
00:37:34,589 --> 00:37:36,929
was just exposed to measles or not.

772
00:37:36,929 --> 00:37:39,569
Or I just say, Hey, have you
been vaccinated for measles?

773
00:37:39,569 --> 00:37:41,009
And if he is, we'll wait and see.

774
00:37:41,399 --> 00:37:43,664
But if he hasn't been, because
there are some people, as you

775
00:37:43,664 --> 00:37:45,659
know, Sam, who can't be vaccinated.

776
00:37:46,369 --> 00:37:48,229
Or the vaccine doesn't take to them.

777
00:37:48,544 --> 00:37:50,254
Those are the people I
worry about even more.

778
00:37:50,494 --> 00:37:55,124
And those are the people also can get the
the post-exposure prophylaxis vaccine.

779
00:37:55,474 --> 00:38:01,354
so, just kind of to answer your question
though more broadly is that I think the

780
00:38:01,354 --> 00:38:05,514
most important thing is that we just
cultivate those relationships with the

781
00:38:05,514 --> 00:38:07,494
medics that we see on a regular basis.

782
00:38:07,524 --> 00:38:10,314
So they feel comfortable asking us,
and we feel comfortable to say, Hey,

783
00:38:10,404 --> 00:38:14,254
by the way, you know, gimme your
number, gimme your supervisor's number.

784
00:38:14,674 --> 00:38:18,034
I'm gonna check in with you because if
I'm worried enough that this case is

785
00:38:18,064 --> 00:38:23,374
a morbilliform rash that is now to the
chest, it was at the face yesterday

786
00:38:23,744 --> 00:38:27,074
I'm gonna call you later on with
our final thoughts or stick around.

787
00:38:27,074 --> 00:38:28,564
Let's make a decision right now.

788
00:38:29,304 --> 00:38:31,371
Other things they could think about,
of course is just this is a good

789
00:38:31,371 --> 00:38:35,111
opportunity if you are interested
in jumping into being more involved

790
00:38:35,111 --> 00:38:36,611
with pre-hospital education.

791
00:38:36,941 --> 00:38:41,501
I'd say as a community clinician,
jump in, talk to the EMS agency.

792
00:38:41,621 --> 00:38:43,301
Hey, can I give my little CME?

793
00:38:44,298 --> 00:38:46,778
again, that, ongoing relationship
I think is more important.

794
00:38:46,808 --> 00:38:49,658
'cause in the hustle and bustle of
what we do, you may forget, oh my

795
00:38:49,658 --> 00:38:50,741
gosh, they, they're already gone.

796
00:38:51,371 --> 00:38:52,411
oh no, this kid has measles.

797
00:38:52,431 --> 00:38:53,811
And then you've missed that opportunity.

798
00:38:54,161 --> 00:38:57,021
But if you have that relationship
with people, they're much more likely

799
00:38:57,021 --> 00:39:01,701
to recontact you, you recontact them
and have us be a cohesive spectrum.

800
00:39:01,701 --> 00:39:06,501
'cause EMS care to emergency care,
to hospital care, to even outpatient

801
00:39:06,501 --> 00:39:09,321
care, is all a long spectrum.

802
00:39:09,591 --> 00:39:11,601
And we should all be
as unified as possible.

803
00:39:12,021 --> 00:39:12,321
Sam: Yeah.

804
00:39:13,021 --> 00:39:18,061
And if you are an EMS person and
you know, in advance you're going in

805
00:39:18,061 --> 00:39:23,131
to pick up a child with fever and a
rash, then, you know, a PPE an N95 is

806
00:39:23,131 --> 00:39:26,251
probably called for until you know for
sure what it is you're dealing with.

807
00:39:26,641 --> 00:39:29,941
And then decontaminating
the rig afterwards.

808
00:39:29,941 --> 00:39:33,331
So you've gotten the patient out, now
you have to decontaminate everything.

809
00:39:33,611 --> 00:39:38,081
The viruses can live on surfaces for
a short while, so you've gotta be

810
00:39:38,141 --> 00:39:41,411
really good about cleaning all of
those surfaces, especially if they were

811
00:39:41,411 --> 00:39:43,151
coughing in the back of your ambulance.

812
00:39:43,481 --> 00:39:45,911
And then having that good handoff.

813
00:39:46,484 --> 00:39:51,224
I always like to get a direct report from
paramedics, but it's not always practical.

814
00:39:51,224 --> 00:39:54,744
Sometimes it does come through nursing
channels but if at all possible

815
00:39:54,744 --> 00:39:57,554
sticking around the extra couple of
minutes to just make sure that the

816
00:39:57,554 --> 00:40:00,704
physician has the same report, so
nothing slips through the cracks.

817
00:40:00,854 --> 00:40:01,814
I've found always to be helpful.

818
00:40:02,084 --> 00:40:04,244
Tim : and just hearing what you're
saying too, Sam, makes me think of

819
00:40:04,544 --> 00:40:07,634
how many times have you been in a case
where, you know, we don't have a room

820
00:40:07,634 --> 00:40:11,834
and the poor medics are hugging a wall
for, you know, 20, 30 minute longer.

821
00:40:11,834 --> 00:40:12,134
Right.

822
00:40:12,614 --> 00:40:14,444
And somebody's coughing in there.

823
00:40:14,444 --> 00:40:15,324
Look, they have a rash.

824
00:40:15,374 --> 00:40:18,591
It's important for us to just say,
listen, maybe this is an issue.

825
00:40:18,591 --> 00:40:19,851
And put a mask on everybody.

826
00:40:20,301 --> 00:40:21,321
Put a mask on everybody.

827
00:40:21,321 --> 00:40:21,771
And.

828
00:40:22,121 --> 00:40:26,828
I love what you say about decontaminating
the rig because of all of these, you

829
00:40:26,828 --> 00:40:28,568
know, measles is the airborne one.

830
00:40:28,568 --> 00:40:31,478
It will be suspended in the
air for long periods of time.

831
00:40:31,478 --> 00:40:34,814
And I would say that, I mean, I'm not an
expert at this, but I would say that that

832
00:40:34,814 --> 00:40:38,834
particular vehicle should probably be
outta commission until they've completely

833
00:40:38,914 --> 00:40:41,328
decontaminated the should be wide open.

834
00:40:41,398 --> 00:40:43,354
It should be terminally cleaned.

835
00:40:43,624 --> 00:40:43,941
Sam: Yeah.

836
00:40:43,981 --> 00:40:46,071
Tim : But it also goes to the fact
where people are always worried

837
00:40:46,071 --> 00:40:47,421
about, well, what's aerosol?

838
00:40:47,811 --> 00:40:48,831
What's airborne?

839
00:40:48,831 --> 00:40:50,781
What's respiratory
droplets, what's contact?

840
00:40:51,171 --> 00:40:51,951
It's so confusing.

841
00:40:51,951 --> 00:40:55,791
It doesn't do us any service
to try to be so specific.

842
00:40:55,941 --> 00:41:00,371
But just broad strokes, when we talk
about aerosol, we're talking about

843
00:41:00,401 --> 00:41:04,391
these little tiny fine particulates
that float in the air measles, when

844
00:41:04,391 --> 00:41:06,131
we talk about respiratory droplets.

845
00:41:06,554 --> 00:41:10,514
They, you know, are spittle that just like
flies on people's faces in their eyes.

846
00:41:10,844 --> 00:41:13,124
Those are larger molecules,
and that's where we're talking

847
00:41:13,124 --> 00:41:14,174
about mumps and rubella.

848
00:41:14,504 --> 00:41:18,614
And then varicella can be
both aerosol and droplet.

849
00:41:18,944 --> 00:41:23,154
You know, when you're in a rig in front
of someone's face, in their home as a

850
00:41:23,154 --> 00:41:26,874
medic or in the emergency department,
one of us comes in and sees people,

851
00:41:27,034 --> 00:41:30,514
there's no magical curtain that's gonna
stop people from being airborne versus

852
00:41:30,514 --> 00:41:32,194
respiratory droplet versus contact.

853
00:41:32,464 --> 00:41:36,544
We should just treat all of these as
potential airborne until we can peel back.

854
00:41:36,544 --> 00:41:38,194
And so that's an N95.

855
00:41:38,404 --> 00:41:40,504
And that's maybe even
wearing a face shield too

856
00:41:40,704 --> 00:41:40,994
Sam: Yeah.

857
00:41:41,214 --> 00:41:42,204
Tim : for the high risk cases.

858
00:41:42,204 --> 00:41:46,449
I'm not advocating going into every
patient room with that get up, but I don't

859
00:41:46,449 --> 00:41:50,979
like to try to split hairs and say, what's
a respiratory droplet and what's aerosol?

860
00:41:50,979 --> 00:41:54,579
You know what, when you're that close
to someone's face, it's all aerosol.

861
00:41:55,083 --> 00:41:58,593
And then you can kind of take a
moment once you've made your diagnoses

862
00:41:58,593 --> 00:42:00,933
and you can then counsel people.

863
00:42:00,933 --> 00:42:03,363
You can just, you can say,
okay, well, you're infectious.

864
00:42:03,363 --> 00:42:04,473
You're not as infectious.

865
00:42:04,503 --> 00:42:04,833
Here.

866
00:42:04,833 --> 00:42:05,793
You wear a surgical mask.

867
00:42:05,853 --> 00:42:07,506
You wear an n95 you go home.

868
00:42:07,716 --> 00:42:10,566
You need to stay, but you need to
stay in a negative pressure room.

869
00:42:11,061 --> 00:42:11,421
Sam: Yeah.

870
00:42:11,991 --> 00:42:12,201
Yeah.

871
00:42:12,201 --> 00:42:13,281
And I'll add one other point.

872
00:42:13,281 --> 00:42:16,671
If you happen to be picking up the
patient and you do suspect something

873
00:42:16,671 --> 00:42:21,051
like measles on the way in, notifying
the ED ahead of time so you don't end

874
00:42:21,051 --> 00:42:24,971
up waiting on the wall when spreading
this everywhere so they can get you

875
00:42:24,971 --> 00:42:29,181
directly to that negative isolation
room would be exceedingly helpful.

876
00:42:29,311 --> 00:42:32,531
So that, you know, somebody can get in
there quickly, examine the child and

877
00:42:32,531 --> 00:42:34,471
make sure nobody else gets exposed.

878
00:42:35,171 --> 00:42:37,271
So on that note, they're in the ED.

879
00:42:37,271 --> 00:42:40,271
We've got a bunch of questions we're
gonna ask, and I thought the author

880
00:42:40,271 --> 00:42:42,521
did a great job just listing them.

881
00:42:42,521 --> 00:42:44,381
There's like 20 questions here.

882
00:42:44,381 --> 00:42:49,038
Everything from how long have you had
fever, what did the initial rash look

883
00:42:49,038 --> 00:42:53,638
like, if there's already one, how did it
spread from where to where did it occur

884
00:42:53,638 --> 00:42:56,578
in crops or did it spread gradually?

885
00:42:56,578 --> 00:42:57,328
Is it itchy?

886
00:42:57,328 --> 00:42:58,258
Is it painful?

887
00:42:58,508 --> 00:43:01,508
What kind of other symptoms
were associated before the rash?

888
00:43:01,508 --> 00:43:03,428
Are they having any respiratory symptoms?

889
00:43:03,708 --> 00:43:07,218
And then kinda like
screening for complications.

890
00:43:07,218 --> 00:43:10,008
Are they having any mental
status problems, headaches?

891
00:43:10,058 --> 00:43:10,898
Are they acting funny?

892
00:43:10,898 --> 00:43:12,488
Are they having difficulty walking?

893
00:43:12,878 --> 00:43:15,608
They've been exposed from
sick contacts at school.

894
00:43:15,738 --> 00:43:16,968
Who else is at home?

895
00:43:16,968 --> 00:43:19,548
And now we're kind of expanding
these questions to who

896
00:43:19,548 --> 00:43:20,898
else may have been exposed.

897
00:43:20,898 --> 00:43:22,788
You know, is there anybody
sick at home on chemo?

898
00:43:23,058 --> 00:43:26,473
Has cancer, is immunocompromised
or is this patient have

899
00:43:26,473 --> 00:43:27,628
any of those risk factors?

900
00:43:27,838 --> 00:43:32,848
So a whole bunch of questions you gotta
ask for the very quick and simple,

901
00:43:33,028 --> 00:43:34,888
Hey, here's a fever and a rash kid.

902
00:43:35,068 --> 00:43:35,338
Tim : Yeah.

903
00:43:35,458 --> 00:43:38,188
Sam: it's like, well, it's the quick and
simple visit because I don't have to order

904
00:43:38,188 --> 00:43:41,848
a lot of testing, but I actually have
a whole lot questions I've gotta ask.

905
00:43:42,198 --> 00:43:42,858
Tim : Absolutely.

906
00:43:43,048 --> 00:43:46,078
And again, this is a good example
of like, if you've front loaded your

907
00:43:46,078 --> 00:43:49,498
mental work like we're doing right
now, then it'll become natural because

908
00:43:49,498 --> 00:43:50,728
you'll see, you know, fever and rash.

909
00:43:50,728 --> 00:43:53,828
You're okay, you have a viral
exam, goodbye, you go home but

910
00:43:53,828 --> 00:43:56,668
fever and rash, and there's
something in you that resonates.

911
00:43:56,668 --> 00:43:59,968
There's something a little spark in you
because you remember Dr. Ashoo saying,

912
00:43:59,968 --> 00:44:01,798
wait a minute, ask these questions.

913
00:44:02,178 --> 00:44:04,548
That's when you should stop and
then try to remember what you

914
00:44:04,548 --> 00:44:05,658
can and look up what you can't.

915
00:44:05,658 --> 00:44:09,488
Because again, we can't remember
everything off the top of our heads.

916
00:44:09,668 --> 00:44:13,638
A lot of our education just goes, and
our training goes back to, is there

917
00:44:13,638 --> 00:44:15,108
something else that I'm missing?

918
00:44:15,168 --> 00:44:18,888
And you take that pause, that moment
that you have to say, is this more

919
00:44:18,888 --> 00:44:20,978
than just a typical viral exanthem?

920
00:44:21,418 --> 00:44:23,683
Then you start thinking about
measles, mumps, and varicella.

921
00:44:24,103 --> 00:44:27,243
And if it doesn't pass any of those
red flags in your mind, great.

922
00:44:27,243 --> 00:44:28,053
If it does.

923
00:44:28,469 --> 00:44:32,759
Hey, pull up this article, look
things up, ask the right questions,

924
00:44:32,759 --> 00:44:35,399
because there's no way in a busy
shift that we're gonna remember these

925
00:44:35,399 --> 00:44:36,659
things off the top of our heads.

926
00:44:37,359 --> 00:44:37,659
Sam: Yeah.

927
00:44:37,659 --> 00:44:41,319
And speaking of that busy
shift, your examination equally

928
00:44:41,319 --> 00:44:44,649
important may occur in triage.

929
00:44:44,829 --> 00:44:49,009
And it may not occur to you to check
things like the inguinal area for

930
00:44:49,009 --> 00:44:54,194
lymphadenopathy or the scrotal area
for testicular tenderness or swelling

931
00:44:54,194 --> 00:44:55,674
if you're considering orchitis.

932
00:44:55,691 --> 00:44:58,931
And so some of these things may be
difficult to check out in the waiting

933
00:44:58,931 --> 00:45:02,411
room, and you may need to take that extra
effort and go, I'm gonna bring you over

934
00:45:02,411 --> 00:45:06,821
here where there's a curtained area,
and then I need to do this kind of exam.

935
00:45:06,911 --> 00:45:07,131
Tim : Mm.

936
00:45:07,211 --> 00:45:10,421
Sam: you may get a funny look from a
parent going, why are you undressing

937
00:45:10,421 --> 00:45:14,411
my child who come in with a, you
know, a cough congestion and a rash?

938
00:45:14,831 --> 00:45:17,171
And you go, okay, well let me
explain what's going on here.

939
00:45:17,226 --> 00:45:18,476
Tim : We are very thorough here, ma'am.

940
00:45:18,748 --> 00:45:19,708
Sam: but for the right reasons.

941
00:45:20,083 --> 00:45:20,683
Tim : For the right reasons.

942
00:45:20,863 --> 00:45:23,873
You know, it also goes
to our dynamic approach.

943
00:45:23,873 --> 00:45:27,293
We have an iterative way
of seeing a patient, right?

944
00:45:27,293 --> 00:45:29,783
We don't wanna anchor and
say, ah, fever and we're done.

945
00:45:30,253 --> 00:45:33,813
With the new information we have now, what
are the new things I need to think about?

946
00:45:34,113 --> 00:45:35,463
And that's a great example.

947
00:45:35,493 --> 00:45:38,523
They come in and then the
triage may also bias us.

948
00:45:39,183 --> 00:45:41,373
Triage is meant to just say, are you okay?

949
00:45:41,373 --> 00:45:41,913
Can you wait?

950
00:45:41,913 --> 00:45:42,243
Right?

951
00:45:42,693 --> 00:45:46,783
But we should really take that, read the
nursing notes, read the triage notes.

952
00:45:47,233 --> 00:45:50,673
There's lots of little nuggets that
sometimes are not repeated, but

953
00:45:50,913 --> 00:45:53,673
great opportunity to just rethink.

954
00:45:53,793 --> 00:45:55,293
Does this make sense?

955
00:45:55,533 --> 00:45:59,553
Why are you complaining of belly pain
when you have a, you know, a little bit of

956
00:45:59,553 --> 00:46:01,653
arthralgia and maybe a cough or something?

957
00:46:01,838 --> 00:46:05,678
Oh, no, you have bronchitis
as an example for mumps.

958
00:46:06,181 --> 00:46:08,923
Sam: And then we talk
about diagnostic testing.

959
00:46:08,923 --> 00:46:10,303
We like to order a bunch of tests.

960
00:46:10,303 --> 00:46:15,133
These are mostly clinical in their
presentation, and if you can identify

961
00:46:15,133 --> 00:46:18,823
the rash, that is sufficient, but if
not, and there's a question, there

962
00:46:18,823 --> 00:46:22,033
is PCR testing for these viruses.

963
00:46:22,318 --> 00:46:22,618
Tim : Yeah.

964
00:46:22,918 --> 00:46:25,858
You know, and just to give you a
little bit of a, kind of a behind the

965
00:46:25,858 --> 00:46:29,568
scenes of how we think about this when
we're developing an article as editor

966
00:46:29,568 --> 00:46:34,058
in chief, we wanna make sure that
this is scholarly and this is very

967
00:46:34,058 --> 00:46:36,008
helpful, but also practical, right?

968
00:46:36,008 --> 00:46:38,928
So we are always very careful about the
messaging that we have, and Dr. Cavallaro

969
00:46:38,948 --> 00:46:41,408
did a fantastic job of balancing that out.

970
00:46:41,408 --> 00:46:44,408
So there's a lot of good, scholarly,
nerdy things that we talked about.

971
00:46:44,618 --> 00:46:46,688
But when the rubber hits
the road, what do you do?

972
00:46:46,838 --> 00:46:50,228
It's all clinical, so that I
want to be the main message.

973
00:46:50,528 --> 00:46:54,668
You should trust your eyes and your
ears, and if you're not sure, you can

974
00:46:54,668 --> 00:46:56,488
look up different reference images.

975
00:46:56,668 --> 00:47:01,088
So if at any way you're worried, treat
it as if it's measles, mumps, rubella,

976
00:47:01,108 --> 00:47:04,918
varicella, because these tests won't
necessarily come back immediately.

977
00:47:04,948 --> 00:47:09,173
However, either your public health
department will ask for it or you're

978
00:47:09,173 --> 00:47:12,623
just, you know, let's just put it
in the record or you're not sure.

979
00:47:13,043 --> 00:47:14,093
Most of these are PCR.

980
00:47:14,093 --> 00:47:18,113
So for example measles is a PCR in
the nasal pharynx or oral pharynx.

981
00:47:18,413 --> 00:47:21,053
You can do it in measles, IGM serology.

982
00:47:21,053 --> 00:47:23,843
So the IGM as we remember
is the early version of your

983
00:47:23,843 --> 00:47:25,433
IGs as opposed to your IgG.

984
00:47:26,133 --> 00:47:31,393
the IGM is better after the rash
has actually come into view.

985
00:47:31,753 --> 00:47:33,373
Whereas the PCR can be at any time.

986
00:47:33,403 --> 00:47:36,133
'cause as we mentioned with
measles, you're infectious four days

987
00:47:36,133 --> 00:47:37,483
before and until four days after.

988
00:47:37,483 --> 00:47:40,153
So PCR will work for any time for measles.

989
00:47:40,423 --> 00:47:43,813
The IgM is more specific after the rash.

990
00:47:43,933 --> 00:47:47,893
Four, most of the time that's when you're
doing serologies because you see the rash.

991
00:47:48,223 --> 00:47:49,199
What i s this rash?

992
00:47:49,869 --> 00:47:54,944
For mumps similar thing you can do PCR
mumps again, I encourage us to look

993
00:47:54,944 --> 00:47:58,254
these things up because, you know,
you're you're asking me now, and I'm

994
00:47:58,254 --> 00:48:02,184
telling you, you ask me five hours
from now when my coffee is worn off.

995
00:48:02,184 --> 00:48:05,094
And I don't know if I'm gonna tell
you this, but mumps, the PCR is a

996
00:48:05,244 --> 00:48:10,884
buccal swab, specifically buccal
swab, and then IGM serology for mumps.

997
00:48:11,154 --> 00:48:14,484
But if the person is vaccinated,
it's not as reliable.

998
00:48:14,484 --> 00:48:18,774
So there's all these like ins and outs,
intricacies, shout out, public health

999
00:48:19,054 --> 00:48:22,354
rubella similar thing is also the PCR.

1000
00:48:22,624 --> 00:48:26,164
You can do either IgM or IgG for rubella.

1001
00:48:26,524 --> 00:48:30,429
And then varicella of course is really
kind of pathognomonic to be honest with

1002
00:48:30,429 --> 00:48:32,229
you, but you can do PCR for that as well.

1003
00:48:32,929 --> 00:48:36,709
Sam: Now I am curious, in your
hospital you have PCR available for

1004
00:48:36,709 --> 00:48:37,949
these or are they all send outs?

1005
00:48:38,134 --> 00:48:40,988
Tim : These are all send outs for
us, and I think that's true of most

1006
00:48:40,988 --> 00:48:45,308
hospitals, I would say, unless you're at
a tertiary facility that has, you know,

1007
00:48:45,308 --> 00:48:47,138
research capability immediately there.

1008
00:48:47,138 --> 00:48:48,528
So , we send that out.

1009
00:48:48,888 --> 00:48:51,198
And the serologies for sure we send out.

1010
00:48:51,258 --> 00:48:52,518
I work in a county hospital.

1011
00:48:52,518 --> 00:48:55,251
We have a lot to offer, but,
still , we need to send it out for

1012
00:48:55,251 --> 00:48:57,231
any community hospital for sure.

1013
00:48:57,231 --> 00:49:00,061
They're not gonna know right away,
which is why I really emphasize

1014
00:49:00,391 --> 00:49:02,341
trusting your clinical diagnosis.

1015
00:49:02,341 --> 00:49:05,891
I would rather you be
overprotective than underwhelmed.

1016
00:49:06,021 --> 00:49:10,251
It's always better to get people
excited and the worst that we've

1017
00:49:10,251 --> 00:49:15,471
done is that we've taught the people
around us to consider and just

1018
00:49:15,471 --> 00:49:19,371
sort of refresh the anxiety that we
should have about these illnesses.

1019
00:49:19,771 --> 00:49:20,061
Sam: Okay.

1020
00:49:20,526 --> 00:49:23,916
And then there is the
reporting responsibility.

1021
00:49:23,916 --> 00:49:27,156
So know your public health rules
in whatever county you're in, but

1022
00:49:27,156 --> 00:49:29,826
all of these diseases should be
reportable, especially, and that's

1023
00:49:29,826 --> 00:49:32,046
reportable based on suspicion.

1024
00:49:32,316 --> 00:49:35,676
You don't have to have a, you know, I
am kind of hammering a nail and I've

1025
00:49:35,676 --> 00:49:38,676
made this diagnosis for sure, but if
you're clinically suspected, that's

1026
00:49:38,676 --> 00:49:40,686
good enough for reporting and isolation.

1027
00:49:41,256 --> 00:49:43,116
And then treatment.

1028
00:49:43,176 --> 00:49:47,286
So what do we have in
the way of treatment?

1029
00:49:47,316 --> 00:49:49,446
Let's just start with measles.

1030
00:49:49,611 --> 00:49:51,761
Tim : I'll just mention that your
public health will ask there'll

1031
00:49:51,761 --> 00:49:54,381
be different tiers of reporting.

1032
00:49:54,381 --> 00:49:56,961
So measles is so bad,
they need a phone call.

1033
00:49:57,021 --> 00:49:59,511
They need you to pick up
the phone and call whomever.

1034
00:49:59,511 --> 00:50:02,151
There's always gonna be someone
who can pick up the phone

1035
00:50:02,151 --> 00:50:03,111
even at three in the morning.

1036
00:50:03,561 --> 00:50:06,651
Something like Rubella,
oftentimes, at least in Los Angeles

1037
00:50:06,651 --> 00:50:09,891
County, is a snail mail report.

1038
00:50:09,891 --> 00:50:12,871
They just kind of wanna know, just
for your information et cetera.

1039
00:50:12,871 --> 00:50:17,441
So just be sure that you have that
awesome chart plastered somewhere

1040
00:50:17,441 --> 00:50:22,701
on , your wallpaper of, of algorithms
that you have around your doc box.

1041
00:50:23,101 --> 00:50:26,641
But getting back to what we do, let's
say, I think this could be measles.

1042
00:50:27,191 --> 00:50:27,701
What do we do?

1043
00:50:28,031 --> 00:50:30,401
Measles, as you know, is
going to be supportive.

1044
00:50:30,481 --> 00:50:35,566
In developing countries the morbidity
increased with people who don't have

1045
00:50:35,566 --> 00:50:36,976
a lot of vitamin A in their diets.

1046
00:50:36,976 --> 00:50:41,429
And so the idea was in these resource
countries, vitamin A supplementation,

1047
00:50:41,699 --> 00:50:46,319
that recommendation I've seen shift to the
point where give vitamin A for anybody.

1048
00:50:46,319 --> 00:50:46,889
, And that's fine.

1049
00:50:46,889 --> 00:50:50,009
It's not going to save lives,
but it may make them feel better.

1050
00:50:50,009 --> 00:50:53,789
It's just two doses, 24 hours
apart, boost up their vitamins.

1051
00:50:53,849 --> 00:50:54,509
It's good for you.

1052
00:50:54,859 --> 00:50:56,813
I do have a really just
brief case of this.

1053
00:50:56,863 --> 00:51:00,103
Family came in, in Los Angeles
County we have people come to us

1054
00:51:00,103 --> 00:51:04,543
from all over the world all over the
nation, come and go all the time.

1055
00:51:04,903 --> 00:51:07,693
So we're always sort of
thinking about these things.

1056
00:51:08,023 --> 00:51:09,163
Family came from Pakistan.

1057
00:51:09,383 --> 00:51:11,783
They were so worried about measles.

1058
00:51:11,843 --> 00:51:13,253
No one had been vaccinated.

1059
00:51:13,733 --> 00:51:17,033
And I'm saying, ma'am, can I ask
why are you, what is your concern?

1060
00:51:17,423 --> 00:51:21,593
And the child had had a rash, you
know, two weeks ago in Pakistan.

1061
00:51:21,593 --> 00:51:22,763
That is completely resolved.

1062
00:51:23,093 --> 00:51:25,193
And just wanted us to make
sure that it wasn't measles.

1063
00:51:25,193 --> 00:51:27,536
And I'm thinking to myself,
okay, you know, I'm gonna try my

1064
00:51:27,536 --> 00:51:29,176
best, but I can't see anything.

1065
00:51:29,806 --> 00:51:32,596
She was so anxious that I said,
listen, the only one thing that I

1066
00:51:32,596 --> 00:51:35,926
can do based on where you're coming
from is to give you some Vitamin A.

1067
00:51:36,316 --> 00:51:37,546
And she was very happy with that.

1068
00:51:37,546 --> 00:51:37,726
Right.

1069
00:51:37,726 --> 00:51:40,636
Got her, got her door prize for coming
in the emergency room department.

1070
00:51:41,026 --> 00:51:41,521
Everyone's great.

1071
00:51:41,701 --> 00:51:42,791
And , I wasn't concerned.

1072
00:51:42,831 --> 00:51:46,858
What she was describing did not seem
to be something that I would associate

1073
00:51:46,898 --> 00:51:50,208
with measles, but it also keys into our
anxiety that we've been talking about.

1074
00:51:50,223 --> 00:51:54,233
So the funny little twist to the story
was that an old school pediatrician

1075
00:51:54,233 --> 00:51:59,279
later on saw this patient and chastised
me for giving her vitamin A because

1076
00:51:59,279 --> 00:52:00,436
there's no evidence, et cetera.

1077
00:52:00,436 --> 00:52:01,696
And I, I just go, okay, great.

1078
00:52:01,696 --> 00:52:04,576
Like anything in emergency
medicine, I'm happy to be wrong.

1079
00:52:04,606 --> 00:52:06,676
Or not, I'm happy to be criticized or not.

1080
00:52:06,676 --> 00:52:08,476
I'm just trying to be the
best I can with what I got.

1081
00:52:08,476 --> 00:52:10,276
So a little bit of
Vitamin A can't hurt you.

1082
00:52:10,456 --> 00:52:12,226
It really won't save you.

1083
00:52:12,496 --> 00:52:16,066
But , the thing to really think
about is the post-exposure to

1084
00:52:16,066 --> 00:52:17,536
people who have not been vaccinated.

1085
00:52:17,536 --> 00:52:21,586
So if you have never been vaccinated,
and let's say, I'm gonna make up the

1086
00:52:21,586 --> 00:52:25,766
scenario you know, little Johnny is
three, has measles is okay to go home,

1087
00:52:26,156 --> 00:52:30,536
but his sister is five years old and
no one's been vaccinated in the family.

1088
00:52:30,936 --> 00:52:34,086
She should get the MMR vaccine
within 72 hours if she's an

1089
00:52:34,086 --> 00:52:35,166
otherwise healthy person.

1090
00:52:35,506 --> 00:52:39,361
Now we worry about people who can't
get the vaccine, like for example

1091
00:52:39,441 --> 00:52:43,071
the immunocompromised, et cetera,
or infants less than six months of

1092
00:52:43,071 --> 00:52:47,741
age they should get the IgG because
that's gonna be more protective of

1093
00:52:47,741 --> 00:52:51,318
them, the immunoglobulin six months.

1094
00:52:51,318 --> 00:52:53,568
So, just to back up a little bit,
you know, your first dose, you

1095
00:52:53,568 --> 00:52:56,658
typically get as an infant from 12
to 15 months, and that's gonna be

1096
00:52:56,658 --> 00:52:58,868
a really robust immuno response.

1097
00:52:59,138 --> 00:53:01,418
Your second dose is gonna be a
booster in four to six years.

1098
00:53:01,778 --> 00:53:03,128
There are some people that can get it.

1099
00:53:03,218 --> 00:53:05,858
If there's an outbreak, you can
get it you know, at six months of

1100
00:53:05,858 --> 00:53:07,328
age is early six months of age.

1101
00:53:07,878 --> 00:53:11,748
And that's really the earliest we'll
often give it, but that first early

1102
00:53:11,748 --> 00:53:16,938
dose, as an exception, doesn't count
as part of the two dose regimen.

1103
00:53:16,938 --> 00:53:21,528
So the idea is that infants just
don't respond as well to the vaccines.

1104
00:53:21,858 --> 00:53:23,808
These things are all very
calibrated over time.

1105
00:53:23,808 --> 00:53:25,968
We should really trust our
decades of experience on this.

1106
00:53:26,238 --> 00:53:30,443
So if the kid comes in, let's say
this is another case in which there's

1107
00:53:30,443 --> 00:53:33,683
international travel or an epidemic
and someone's really interested in

1108
00:53:33,683 --> 00:53:36,973
getting it as an infant at seven
months, eight months of age, 10

1109
00:53:36,973 --> 00:53:38,673
months of age, that's that's fine.

1110
00:53:38,673 --> 00:53:39,423
And that's okay.

1111
00:53:39,483 --> 00:53:42,033
It'll cover them probably for a few
months, but they still should go

1112
00:53:42,033 --> 00:53:45,483
back on the regimen of the 12 to 15
months, first dose and their second

1113
00:53:45,483 --> 00:53:46,683
dose at four to six years of age.

1114
00:53:46,953 --> 00:53:49,873
So, to answer your question, more
mostly supportive, but all of those

1115
00:53:49,873 --> 00:53:53,153
little intricate questions, as you
mentioned in the appendices, make

1116
00:53:53,153 --> 00:53:54,953
sure that they get their follow up.

1117
00:53:54,953 --> 00:53:57,803
Make sure that you've kind of
thought about this person thoroughly

1118
00:53:57,803 --> 00:53:59,273
and whoever else is in the family.

1119
00:53:59,303 --> 00:54:01,883
And then think about just,
you know, good hydration.

1120
00:54:01,883 --> 00:54:03,573
That's the number one thing
that's gonna hurt people that

1121
00:54:03,573 --> 00:54:04,893
are well enough to go home.

1122
00:54:04,983 --> 00:54:09,783
And then secondly is to make sure nobody
else needs a post-exposure mMR vaccine.

1123
00:54:10,483 --> 00:54:10,773
Sam: Okay.

1124
00:54:11,148 --> 00:54:13,188
Two things, two questions.

1125
00:54:13,188 --> 00:54:15,348
First on the vitamin A issue.

1126
00:54:15,348 --> 00:54:18,958
So, if you're gonna provide some kind
of supplementation, you do also have

1127
00:54:18,958 --> 00:54:23,038
to warn the family that they shouldn't
overdose their child on vitamin A.

1128
00:54:23,038 --> 00:54:24,718
That's one of those that can be toxic,

1129
00:54:24,853 --> 00:54:25,363
Tim : yes.

1130
00:54:25,378 --> 00:54:26,278
Sam: and can build up.

1131
00:54:26,278 --> 00:54:28,288
So very important to mention that.

1132
00:54:28,568 --> 00:54:33,888
And then second, the IgG, like this
immunoglobulin is not, I mean, I haven't

1133
00:54:33,888 --> 00:54:37,348
never actually asked my pharmacy to
see if they even have it, but is that

1134
00:54:37,348 --> 00:54:40,573
something that's difficult to get or do
you have to get that from like the health

1135
00:54:40,573 --> 00:54:41,833
department or where does that come from?

1136
00:54:42,007 --> 00:54:45,363
Tim : immunoglobulin, Is
good for Kawasaki disease.

1137
00:54:45,363 --> 00:54:48,543
It's good for, you know, any of
these things where you need to have a

1138
00:54:48,573 --> 00:54:50,883
biochemical mop in your blood, right?

1139
00:54:50,883 --> 00:54:52,533
Just like mops up all the junk.

1140
00:54:52,623 --> 00:54:52,983
Right?

1141
00:54:53,293 --> 00:54:56,013
So, it's available in many hospitals.

1142
00:54:56,163 --> 00:55:00,044
Sometimes if you have a, let's say a
smaller community hospital, oftentimes

1143
00:55:00,044 --> 00:55:03,974
they'll have a network where the
pharmacist can call either a satellite

1144
00:55:03,974 --> 00:55:05,984
pharmacy or an affiliated institution.

1145
00:55:05,984 --> 00:55:08,504
And you can have that
shipped over within hours.

1146
00:55:08,504 --> 00:55:10,334
I wouldn't let the person
go until they've gotten it.

1147
00:55:10,704 --> 00:55:16,314
So immunoglobulin it does cost $10,000 a
shot, so you wanna really think about it.

1148
00:55:16,314 --> 00:55:19,071
But it's important in the
people  that are vulnerable.

1149
00:55:19,231 --> 00:55:22,411
But it's not so uncommon, Sam,
it's not such a weirdo thing.

1150
00:55:22,411 --> 00:55:23,311
It's just something you gotta ask for.

1151
00:55:23,971 --> 00:55:27,481
Sam: Yeah, and this is not immunoglobulin
that's specific to measles.

1152
00:55:27,481 --> 00:55:30,451
It's the generic immunoglobulin
you'd give for multiple other

1153
00:55:30,451 --> 00:55:33,301
conditions, and Hopefully it's got
some antibodies from measles in there.

1154
00:55:33,721 --> 00:55:34,171
Tim : that's right.

1155
00:55:34,651 --> 00:55:34,981
Sam: Perfect.

1156
00:55:35,161 --> 00:55:36,066
Tim : Infectious mop,

1157
00:55:36,766 --> 00:55:37,156
Sam: Okay.

1158
00:55:37,226 --> 00:55:37,856
Mumps.

1159
00:55:37,856 --> 00:55:41,036
So again, no treatment for mumps.

1160
00:55:41,036 --> 00:55:42,506
This is kind of one of those things.

1161
00:55:42,506 --> 00:55:45,416
You diagnose it great, but we
don't have anything we're gonna

1162
00:55:45,416 --> 00:55:47,186
do to make it go away any faster.

1163
00:55:47,246 --> 00:55:47,486
Right.

1164
00:55:48,056 --> 00:55:48,236
Tim : Yeah.

1165
00:55:48,236 --> 00:55:50,216
Don't take any family photos
in the next couple weeks.

1166
00:55:50,216 --> 00:55:54,453
Basically, you're gonna have a pretty
swollen face, but it's supportive.

1167
00:55:54,453 --> 00:55:57,363
It's, you know, NSAIDs,
it's lots of fluids.

1168
00:55:57,613 --> 00:55:58,963
You could try ice packs.

1169
00:55:58,993 --> 00:56:01,448
Although, you know, depending
on how old the child is, they

1170
00:56:01,448 --> 00:56:02,858
may or may not tolerate it.

1171
00:56:03,238 --> 00:56:04,943
Sam: This is ice packs to their face.

1172
00:56:05,018 --> 00:56:05,528
Tim : Ice packs to the face.

1173
00:56:05,528 --> 00:56:07,343
You could even do ice packs to the groin.

1174
00:56:07,403 --> 00:56:10,853
No one likes any of these things,
but you just do the best you can.

1175
00:56:10,853 --> 00:56:14,303
You could if it's really bad orchitis
you could also wear, like, for example,

1176
00:56:14,303 --> 00:56:18,038
a jock strap, something supportive
for males , and really just kind

1177
00:56:18,038 --> 00:56:20,208
of, you know, weather, the storm.

1178
00:56:20,308 --> 00:56:21,388
Sam: And no steroids.

1179
00:56:21,538 --> 00:56:22,468
Tim : and no steroids.

1180
00:56:22,498 --> 00:56:23,098
No steroids.

1181
00:56:23,098 --> 00:56:23,278
Yeah.

1182
00:56:23,278 --> 00:56:24,988
That won't, that won't
help them potentially harm.

1183
00:56:25,633 --> 00:56:25,933
Sam: Okay.

1184
00:56:26,053 --> 00:56:29,113
Yeah, and I saw that the author
mentioned the steroids might actually

1185
00:56:29,353 --> 00:56:33,103
decrease testosterone concentration
and worsen testicular atrophy,

1186
00:56:33,103 --> 00:56:36,943
which kinda seems like a big deal if
you're already concerned about that.

1187
00:56:37,138 --> 00:56:38,608
Tim : we need you to be strong like bull.

1188
00:56:39,133 --> 00:56:39,403
Sam: Yeah.

1189
00:56:39,553 --> 00:56:40,813
Uh, Okay.

1190
00:56:40,933 --> 00:56:43,993
Then rubella again, no treatment.

1191
00:56:44,023 --> 00:56:45,553
Just supportive care.

1192
00:56:45,553 --> 00:56:48,103
And make sure you isolate the
people who are most at risk.

1193
00:56:48,328 --> 00:56:49,078
Tim : yeah, that's right.

1194
00:56:49,078 --> 00:56:51,844
And you know, full disclosure,
I don't know that I've seen

1195
00:56:51,844 --> 00:56:53,344
a case of rubella either.

1196
00:56:53,654 --> 00:56:56,054
And again, it's not as common in
this country, and maybe I called

1197
00:56:56,054 --> 00:56:57,344
it measles and it was rubella.

1198
00:56:57,654 --> 00:57:01,751
But it is reported to be
a much milder version.

1199
00:57:01,804 --> 00:57:05,314
And for any of these children, I just
worry about their hydration status.

1200
00:57:05,464 --> 00:57:08,644
So , that I think merits a
quick, just a little discussion.

1201
00:57:08,644 --> 00:57:10,744
I think a lot of times people come
to us in emergency care and they

1202
00:57:10,744 --> 00:57:14,944
just, even though we feel like it's
obvious or pedantic or like too much,

1203
00:57:15,194 --> 00:57:16,244
you know, they just feel reassured.

1204
00:57:16,244 --> 00:57:18,054
We're like, Hey, listen, this
is what I want you to do.

1205
00:57:18,054 --> 00:57:21,654
I want you to take a tablespoon
of apple juice mixed with water,

1206
00:57:21,894 --> 00:57:24,354
and I want you to give a little
sip every three to five minutes.

1207
00:57:24,504 --> 00:57:25,434
Or, what's a sippy cup?

1208
00:57:25,434 --> 00:57:28,204
What do they like to have, you know,
or even like, Hey, will this child

1209
00:57:28,204 --> 00:57:32,104
take a popsicle great anything to get
hydration in this child because of any

1210
00:57:32,104 --> 00:57:37,489
of these really inflammatory diseases,
the child is gonna feel you know,

1211
00:57:37,519 --> 00:57:42,079
fussy and really cranky and not want
to take in, and it's the dehydration

1212
00:57:42,079 --> 00:57:45,619
that hurts a lot of these children
more and faster than anything else

1213
00:57:46,319 --> 00:57:46,859
Sam: Fantastic.

1214
00:57:47,559 --> 00:57:47,829
Okay.

1215
00:57:47,829 --> 00:57:49,179
And then Varicella.

1216
00:57:49,179 --> 00:57:53,949
So this is one where we actually do have a
treatment that might be indicated, right?

1217
00:57:54,539 --> 00:57:54,904
Tim : we do.

1218
00:57:55,044 --> 00:57:58,554
And, you know, again, I always look
this up because I feel like it's

1219
00:57:58,554 --> 00:58:00,984
changed over time and I will not try to.

1220
00:58:01,239 --> 00:58:02,199
commit it to memory.

1221
00:58:02,559 --> 00:58:05,439
Having said that, though Sam most
cases don't need anything, really.

1222
00:58:05,439 --> 00:58:07,119
It is mostly supportive care.

1223
00:58:07,399 --> 00:58:12,529
But again, I, will look up myself this
article and say, Hmm, what are the

1224
00:58:12,529 --> 00:58:18,419
indications for, for varicella treatment,
90% of the cases are gonna be isolation

1225
00:58:18,479 --> 00:58:21,169
Don't pick at the scabs, wash your hands.

1226
00:58:21,529 --> 00:58:25,259
Can't go back to school until all
of the pimples are scabbed over.

1227
00:58:25,559 --> 00:58:29,129
Don't share toothbrushes like a,
you know, a chicken pox party.

1228
00:58:29,429 --> 00:58:30,899
And that's pretty much it.

1229
00:58:31,469 --> 00:58:31,959
Sam: Perfect.

1230
00:58:32,659 --> 00:58:33,049
Okay.

1231
00:58:33,049 --> 00:58:38,179
And in the article, it looks like the
author has said that the children at

1232
00:58:38,179 --> 00:58:42,979
highest risk who might be candidates
for post-exposure prophylaxis are the

1233
00:58:42,979 --> 00:58:48,849
children who are unvaccinated and age
over 12 in persons who are pregnant in

1234
00:58:48,849 --> 00:58:54,679
people who have chronic cutaneous diseases
or chronic pulmonary disorders or those

1235
00:58:54,679 --> 00:58:59,849
with exposure, interestingly to long-term
steroid therapy or salicylate therapy.

1236
00:59:00,029 --> 00:59:00,359
So,

1237
00:59:00,734 --> 00:59:01,094
Tim : yes.

1238
00:59:01,204 --> 00:59:03,934
You know, the older that you are
when you first have varicella

1239
00:59:03,934 --> 00:59:06,994
chickenpox, the more miserable you
are and the sicker you can get.

1240
00:59:07,424 --> 00:59:11,204
And again, like in a weird
epidemiological way, the older

1241
00:59:11,204 --> 00:59:15,434
people before the vaccine have robust
immunity because they got chickenpox

1242
00:59:15,434 --> 00:59:17,054
and they mostly did okay with it.

1243
00:59:17,564 --> 00:59:19,784
Uh, I wonder what it's gonna be
like, and I don't know the answer

1244
00:59:19,784 --> 00:59:23,384
to this, but, you know, the MMRV
is only a couple decades old.

1245
00:59:23,474 --> 00:59:28,604
And so I'm wondering what we're gonna
see in the next 10 to 20 years when

1246
00:59:28,694 --> 00:59:35,364
these mostly millennials have gotten
the MMRV and Gen Z, et cetera, and

1247
00:59:35,364 --> 00:59:38,724
they, in their middle age, how they're
gonna do, because when they do get

1248
00:59:38,724 --> 00:59:40,464
chickenpox, it's the attenuated version.

1249
00:59:40,464 --> 00:59:41,994
It's a very mild version of it.

1250
00:59:42,294 --> 00:59:44,544
And sometimes it's hard to
say, like, is that chickenpox?

1251
00:59:44,934 --> 00:59:47,244
And again, it's just trying to
be more sensitive than specific.

1252
00:59:47,674 --> 00:59:51,609
, It's still important to go through
those lists of risk factors as you

1253
00:59:51,609 --> 00:59:55,709
mentioned and verify and, I would err
on the side of treatment, especially

1254
00:59:55,709 --> 01:00:00,239
since a lot of these diseases as they
should be more and more rare, I think

1255
01:00:00,239 --> 01:00:04,319
that we should not kind of like rest in
our laurels and say, it can't be fill

1256
01:00:04,319 --> 01:00:06,059
in the blank because fill in the blank.

1257
01:00:06,299 --> 01:00:07,679
We should just be open to it.

1258
01:00:07,679 --> 01:00:12,059
And I would rather over isolate
overtreat over vaccinate because

1259
01:00:12,539 --> 01:00:13,469
they're becoming more rare.

1260
01:00:13,709 --> 01:00:14,339
Hallelujah.

1261
01:00:14,579 --> 01:00:16,889
But that means that we
can let our guard down.

1262
01:00:17,589 --> 01:00:18,039
Sam: Perfect.

1263
01:00:18,739 --> 01:00:22,729
And this is one of those diseases
where you can get post-exposure

1264
01:00:22,729 --> 01:00:24,739
prophylaxis with the vaccine.

1265
01:00:24,889 --> 01:00:32,189
So if you are un immunized age over
a year and you've been exposed, you

1266
01:00:32,189 --> 01:00:35,549
have, you know, three to five days
to go and get a vaccine and hopefully

1267
01:00:35,549 --> 01:00:37,109
prevent you from getting the illness.

1268
01:00:37,409 --> 01:00:37,889
Tim : That's right.

1269
01:00:38,199 --> 01:00:41,519
Again, that, that's gonna be a little
tricky because, in a perfect world someone

1270
01:00:41,519 --> 01:00:44,369
who has, you know, great insurance,
everything works out great for them.

1271
01:00:45,069 --> 01:00:47,829
they get in to see their PMD
within three to five days?

1272
01:00:47,859 --> 01:00:48,849
Maybe, maybe not.

1273
01:00:49,549 --> 01:00:52,999
And so we have to rethink like
uh, is this plan gonna work?

1274
01:00:53,059 --> 01:00:56,419
And, I'm not a big fan of doing
things that are not necessary

1275
01:00:56,419 --> 01:00:57,469
in the emergency department.

1276
01:00:57,469 --> 01:01:00,019
And sometimes, you know, giving vaccines
and all this kind of stuff is like,

1277
01:01:00,049 --> 01:01:03,769
oh, I've lost the opportunity for
that primary care longitudinal care.

1278
01:01:04,099 --> 01:01:07,219
But this might be the case in which
you say, let's order that vaccine

1279
01:01:07,249 --> 01:01:08,749
in the ED and just get it done.

1280
01:01:09,229 --> 01:01:09,619
Sam: Yeah.

1281
01:01:09,799 --> 01:01:13,219
Tim : make sure that I've written a little
note or make sure they've communicated

1282
01:01:13,219 --> 01:01:15,289
that to the primary care physician.

1283
01:01:15,499 --> 01:01:16,369
This is what we did.

1284
01:01:16,489 --> 01:01:17,419
Please make a note of it.

1285
01:01:17,419 --> 01:01:18,829
Please update the vaccine record.

1286
01:01:19,529 --> 01:01:19,919
Sam: All right.

1287
01:01:19,949 --> 01:01:25,379
And on that note, there has been a lot
of discussion, especially recently about

1288
01:01:25,379 --> 01:01:29,939
adverse events associated with vaccines,
and I thought the author did a pretty

1289
01:01:29,939 --> 01:01:32,909
good job of tackling that in the article.

1290
01:01:33,149 --> 01:01:35,939
Where does that controversy come from?

1291
01:01:35,939 --> 01:01:37,769
What does that controversy
surrounding you think?

1292
01:01:38,084 --> 01:01:42,824
Tim : Oh, we all know about our
buddy who loved to have a falsified

1293
01:01:42,884 --> 01:01:47,354
article about autism I won't give,
won't breathe life into the name.

1294
01:01:47,954 --> 01:01:50,844
But  that's where that
comes from, number one.

1295
01:01:50,844 --> 01:01:54,414
Number Number two, I think this also, I
don't wanna get too philosophical with

1296
01:01:54,414 --> 01:02:01,604
you today, Sam, but think this also just
goes to our role in our patients' lives in

1297
01:02:01,604 --> 01:02:04,004
public health and in the larger discourse.

1298
01:02:04,084 --> 01:02:07,984
I think it's important for people
to see us as fighting for them

1299
01:02:08,074 --> 01:02:12,954
and individuals and not having any
particular you know, espousing certain

1300
01:02:12,954 --> 01:02:14,844
beliefs or certain sides of whatever.

1301
01:02:15,114 --> 01:02:17,064
I think we just need to go like,
what does this patient need in

1302
01:02:17,064 --> 01:02:18,654
front of me and just follow suit.

1303
01:02:19,104 --> 01:02:22,219
But we've broken trust, I think
with , a lot of the public and

1304
01:02:22,219 --> 01:02:25,259
they don't believe us because they
get news from different sources.

1305
01:02:25,259 --> 01:02:26,069
People don't believe.

1306
01:02:26,069 --> 01:02:28,529
They believe their own family
who might have different ideas.

1307
01:02:28,559 --> 01:02:31,009
And that's, for pro and con.

1308
01:02:31,009 --> 01:02:36,429
They can be way too pro, like everyone
needs all of these extra vaccines

1309
01:02:36,429 --> 01:02:37,569
and maybe they do, maybe they don't.

1310
01:02:37,866 --> 01:02:41,603
long story short, I would say this
there is skepticism and that ties

1311
01:02:41,726 --> 01:02:44,816
into what I was mentioning before
about our interaction with patients.

1312
01:02:45,026 --> 01:02:48,716
People need to see that we're there for
them and that we're not there for a cause.

1313
01:02:48,716 --> 01:02:49,406
We're there for them.

1314
01:02:49,956 --> 01:02:53,846
And the reason I'm worried about
you is because you as an individual

1315
01:02:53,846 --> 01:02:57,206
can get really hurt by measles
mumps, rubella and varicella.

1316
01:02:57,206 --> 01:02:58,886
And I'm glad that you came in.

1317
01:02:58,886 --> 01:03:00,206
I'm glad today it's not measles.

1318
01:03:00,416 --> 01:03:04,376
But I'm glad today that we had a
discussion because I would never want

1319
01:03:04,376 --> 01:03:08,903
you to have to go through what people
went through, what our, grandparents,

1320
01:03:08,903 --> 01:03:10,223
great-grandparents had to go through.

1321
01:03:10,923 --> 01:03:12,003
We are so lucky.

1322
01:03:12,063 --> 01:03:13,233
This is a great opportunity.

1323
01:03:13,293 --> 01:03:14,793
I want you to talk to
more people about it.

1324
01:03:14,793 --> 01:03:16,953
I encourage you to talk to
your physician about it.

1325
01:03:17,293 --> 01:03:19,043
And I just kind of leave it at that.

1326
01:03:19,043 --> 01:03:21,463
'cause I wanna be seen as an asset.

1327
01:03:21,523 --> 01:03:23,533
I don't want to be seen
as somebody who divides.

1328
01:03:23,533 --> 01:03:25,693
I wanna be seen as someone
who can be supportive of them.

1329
01:03:25,953 --> 01:03:28,393
And I have to kind of
navigate that discussion.

1330
01:03:28,393 --> 01:03:30,653
Again, this is just me, Sam, and
i'm interested to see what your

1331
01:03:30,653 --> 01:03:32,633
thoughts are on the interaction.

1332
01:03:32,633 --> 01:03:36,489
But, you know, that's my strong
feeling is that I do my best

1333
01:03:36,489 --> 01:03:39,009
to give what that person needs.

1334
01:03:39,009 --> 01:03:40,959
Do they need my heart,
my head, or my hands.

1335
01:03:41,199 --> 01:03:43,599
And I try to fill in that
blank as best as I can.

1336
01:03:43,599 --> 01:03:45,109
And I think people, when
they see that you have good

1337
01:03:45,109 --> 01:03:46,839
intentions, they'll listen to you.

1338
01:03:46,839 --> 01:03:50,719
When you are just sort of speaking
kind of at them, I don't know

1339
01:03:50,719 --> 01:03:51,679
how much they're gonna listen.

1340
01:03:52,379 --> 01:03:54,639
Sam: Yeah, I've always found that
the strongest thing I could ever

1341
01:03:54,639 --> 01:03:57,159
say in that scenario was that
all my children were vaccinated.

1342
01:03:57,859 --> 01:03:58,969
And I just kinda leave it at that.

1343
01:03:58,999 --> 01:03:59,719
I go, you know,

1344
01:03:59,914 --> 01:04:00,394
Tim : same here.

1345
01:04:00,719 --> 01:04:03,889
Sam: I do it for my children, so I
would do it for anyone else's child.

1346
01:04:04,039 --> 01:04:04,489
Tim : I love that.

1347
01:04:04,969 --> 01:04:07,879
Sam: I think the author did a really
good job of kind of just laying out the

1348
01:04:07,879 --> 01:04:12,744
evidence there, talking about things like
febrile seizures and are they more common

1349
01:04:12,934 --> 01:04:18,514
with the MMR or the MMRV, you know, should
a parent decide to split the MMR , from

1350
01:04:18,514 --> 01:04:21,724
the Varicella component and do those in
two separate, you know, as long as you're

1351
01:04:21,724 --> 01:04:23,484
getting the vaccine, I don't really care.

1352
01:04:23,704 --> 01:04:27,404
It just means more trips to your
pediatrician and maybe less compliance.

1353
01:04:27,528 --> 01:04:29,838
and then I thought the author also
did a great job of just kind of

1354
01:04:29,838 --> 01:04:34,288
laying out the controversy there
around autism and vaccines and the

1355
01:04:34,288 --> 01:04:37,793
history of it and all of the things
that happened around that one article

1356
01:04:37,793 --> 01:04:41,723
that was redacted and the author who
eventually had their license suspended.

1357
01:04:41,723 --> 01:04:43,853
So it's a great section to read.

1358
01:04:43,853 --> 01:04:46,953
It's good for your own education
if you're a listener to understand

1359
01:04:46,953 --> 01:04:48,513
the history of that argument.

1360
01:04:48,813 --> 01:04:52,743
And then, you know, it gives you something
to say about how the House of Medicine

1361
01:04:52,743 --> 01:04:57,913
responded to it which I think is helpful
when people are genuinely concerned

1362
01:04:57,913 --> 01:04:59,413
and want to have a discussion about it.

1363
01:04:59,413 --> 01:05:01,663
Now, if they don't wanna have a
discussion about it, there's no point

1364
01:05:01,803 --> 01:05:03,813
in reiterating all that information.

1365
01:05:03,993 --> 01:05:05,883
But if they do, it was a helpful section.

1366
01:05:06,378 --> 01:05:07,698
Tim : Well, you know,
what would Mark Twain say?

1367
01:05:07,698 --> 01:05:10,348
He would say that a lie can get
halfway around the world before

1368
01:05:10,348 --> 01:05:11,518
the truth puts his shoes on.

1369
01:05:11,728 --> 01:05:13,228
So , the damage is done.

1370
01:05:13,228 --> 01:05:15,058
And I think we need to recognize that.

1371
01:05:15,358 --> 01:05:18,718
And again, our personal relationship with
patients is helpful, and I love that idea.

1372
01:05:18,718 --> 01:05:20,128
My children are vaccinated, your children.

1373
01:05:20,128 --> 01:05:22,648
I mean, it's a great
way to connect that way.

1374
01:05:22,918 --> 01:05:28,258
Now, that's not to say that of course,
MMR does have a big immunogenic response.

1375
01:05:28,258 --> 01:05:30,808
There's some kids that come in and I
see after they got their MMR, their

1376
01:05:30,838 --> 01:05:33,178
whole little chunky thigh is red.

1377
01:05:33,478 --> 01:05:34,018
That's normal.

1378
01:05:34,018 --> 01:05:34,468
That's okay.

1379
01:05:34,468 --> 01:05:37,268
That's what we expect from MMR
whether we separate or not.

1380
01:05:37,633 --> 01:05:39,073
You know, that's okay.

1381
01:05:39,073 --> 01:05:42,103
The old school pediatricians will say
it's better to have just one bad day

1382
01:05:42,103 --> 01:05:44,107
than a multiple semi not good days.

1383
01:05:44,107 --> 01:05:46,001
Meaning you know, It's not fun to
have a shot, then you might get

1384
01:05:46,001 --> 01:05:47,351
a little mild fever, et cetera.

1385
01:05:47,621 --> 01:05:48,371
That's normal.

1386
01:05:48,371 --> 01:05:48,851
That's good.

1387
01:05:48,851 --> 01:05:51,791
That means your immune system's working
is so great that your immune system

1388
01:05:51,791 --> 01:05:54,041
says, I'm gonna do something with this.

1389
01:05:54,041 --> 01:05:54,941
That's a great thing.

1390
01:05:54,941 --> 01:05:58,971
So I think kind of normalizing
what we expect contextualizing

1391
01:05:58,971 --> 01:06:02,491
for patients without overselling
it, just balancing out the best.

1392
01:06:02,491 --> 01:06:07,111
And again, like there's some  people
who are like to have very niche vaccine

1393
01:06:07,111 --> 01:06:08,771
schedules and they have some conflict.

1394
01:06:08,791 --> 01:06:11,701
They check the star charts and the moon
charts and decide when it should happen.

1395
01:06:12,121 --> 01:06:13,021
You know what, God love them.

1396
01:06:13,021 --> 01:06:15,451
As long as they get longitudinal
care and they get it in, great.

1397
01:06:15,771 --> 01:06:17,481
I won't opine on that.

1398
01:06:17,481 --> 01:06:20,691
I'll just say, listen, there's
a reason why we have a schedule.

1399
01:06:21,021 --> 01:06:22,041
It's cool.

1400
01:06:22,161 --> 01:06:23,181
Just keep going.

1401
01:06:23,361 --> 01:06:23,841
It's fine.

1402
01:06:24,541 --> 01:06:24,781
Sam: Yep.

1403
01:06:25,481 --> 01:06:27,551
All right, well that brings us to the end.

1404
01:06:27,551 --> 01:06:31,901
If you are listening and you are
a subscriber, then this is the

1405
01:06:31,931 --> 01:06:34,751
peds EMP November, 2025 article.

1406
01:06:34,751 --> 01:06:40,111
It's got figures, pictures of the
measles, the mumps and the rubella rashes.

1407
01:06:40,141 --> 01:06:41,641
The neonatal complications.

1408
01:06:41,641 --> 01:06:46,151
You can see common presentations
and the exceedingly helpful appendix

1409
01:06:46,211 --> 01:06:50,511
of differential diagnosis for
fever and rash on pages 16 and 17.

1410
01:06:50,740 --> 01:06:54,215
I highly recommend you just kind
of keep this article close at hand.

1411
01:06:54,395 --> 01:06:57,825
There's so much information packed
in here that it would be exceedingly

1412
01:06:57,825 --> 01:07:00,765
helpful the next time you see
a child with fever and a rash.

1413
01:07:01,105 --> 01:07:04,078
And I wanna say thanks Tim
for being on the podcast.

1414
01:07:04,315 --> 01:07:05,665
Tim : Sam, thanks for having me.

1415
01:07:06,161 --> 01:07:07,571
Been meaning to come on for a long time.

1416
01:07:07,571 --> 01:07:11,081
I'm glad we finally got a chance to
connect and I love what you're doing.

1417
01:07:11,441 --> 01:07:11,861
Keep it up.

1418
01:07:12,561 --> 01:07:12,891
Sam: Yeah.

1419
01:07:12,951 --> 01:07:13,881
Thank you very much.

1420
01:07:13,881 --> 01:07:16,671
This is a exceedingly important
topic and definitely something

1421
01:07:16,671 --> 01:07:18,711
we're gonna see more of in the ED.

1422
01:07:18,961 --> 01:07:22,171
Before we leave, tell
me about your podcast.

1423
01:07:22,171 --> 01:07:22,831
Let's hear about it.

1424
01:07:22,876 --> 01:07:23,086
Tim : you.

1425
01:07:23,086 --> 01:07:25,200
Uh, The Pediatric Emergency Playbook.

1426
01:07:25,450 --> 01:07:27,180
So I'm your host and coach there.

1427
01:07:27,350 --> 01:07:30,482
We do a monthly podcast where I
think of this way of all the things

1428
01:07:30,482 --> 01:07:33,842
that I keep telling my residents
and fellows and lecture about.

1429
01:07:33,842 --> 01:07:38,312
I go, wow, wouldn't it be nice
if I just spoken to the mic

1430
01:07:38,342 --> 01:07:39,962
as if I'm talking just to you?

1431
01:07:39,962 --> 01:07:43,802
And I say, let's talk about, we just
had a talk on congenital heart disease.

1432
01:07:43,952 --> 01:07:47,787
So , I try to make it, you know, a
bit of a conversational type of tone.

1433
01:07:47,787 --> 01:07:50,607
I try to bring up cases, bring
up the latest research, I tell

1434
01:07:50,607 --> 01:07:54,687
you what is established research
and what is my practice and I

1435
01:07:54,687 --> 01:07:55,527
just wanna get it out there.

1436
01:07:55,527 --> 01:07:59,797
It's in a 152 countries out there
in the world, and I love that

1437
01:07:59,797 --> 01:08:01,607
I'm able to just shout it out.

1438
01:08:01,807 --> 01:08:04,937
It's so amazing, and you get the same
thing too Sam, is that you get people

1439
01:08:04,937 --> 01:08:08,837
from all over the place saying, I
listened to this and I applied it the

1440
01:08:08,837 --> 01:08:10,787
next day, and it's just so fulfilling.

1441
01:08:11,067 --> 01:08:14,517
Please have a listen or tell me what
you'd like to hear more of, less of.

1442
01:08:14,517 --> 01:08:17,007
And I, I'd love to be
there to meet your needs.

1443
01:08:17,697 --> 01:08:18,177
Sam: Awesome.

1444
01:08:18,177 --> 01:08:20,637
And we'll put a link to
that in the show notes.

1445
01:08:20,637 --> 01:08:23,397
If you are not a current listener,
I'd highly recommend you go

1446
01:08:23,397 --> 01:08:27,477
become one and improve your
pediatric emergency education.

1447
01:08:27,817 --> 01:08:32,797
Thanks again for being on the podcast
and until next time, be safe everyone.

1448
01:08:33,147 --> 01:08:34,967
And that's a wrap for
this month's episode.

1449
01:08:35,007 --> 01:08:37,587
I hope you found it
educational and informative.

1450
01:08:37,787 --> 01:08:42,647
Don't forget to go to ebmedicine.net
to read the article and claim your CME.

1451
01:08:42,817 --> 01:08:46,007
And of course, check out all three
of the journals and the multitude of

1452
01:08:46,007 --> 01:08:50,367
resources available to you, both for
emergency medicine, pediatric emergency

1453
01:08:50,367 --> 01:08:52,637
medicine, and evidence based urgent care.

1454
01:08:52,947 --> 01:08:54,917
Until next time, everyone be safe.