Welcome to Em pulse Brain research and expert
opinion to the bedside. We're your hosts, Sarah
Made. And Julia Mc.
Welcome back to Ian impulse. Say it's summertime.
So I think we should talk about something
sunny like on ecological emergencies.
Okay. Not super sunny, but definitely important.
There are 16000000
Americans living with cancer. Who account for approximately
4000000 visits to emergency departments each year.
Patients with advanced cancer, especially older patients are
particularly vulnerable to emergencies.
And to improve our recognition and response to
oncology emergencies, we are talking today with a
friend of mine who is actually an ecological
emergency
physician. That is a crazy job.
And to be clear, she is a physician
who only sees adult cancer patients in the
emergency department. So while some of these principles
apply, we're only talking about adults today, but
that gives us the opportunity to do a
follow up on kit.
I like that. That's a great idea.
So, Monica, I wanna start where most of
us in the Ed initially interact with cancer,
which is making that potential diagnosis.
And we all know that ideally cancer is
caught early with subtle signs in clinic or
screening through primary care physician. But there's been
a decrease in access to primary care and
not everyone gets that screening that they should,
so we are off in the first line.
What types of cancer are most likely to
be diagnosed in Ed?
I would say the most common cancers would
be breast, colon and lung, and
studies have shown that it's probably around
the range of 20 to 50 percent
of, dynasties for these specific mali are actually
through the emergency department.
That's a lot. Yeah. For sure. I would
not have expected that. You know, I think
sometimes we struggle with our role in that
diagnosis
of cancer in the emergency department.
Monica, what do you see as the role
of the Ed physician
in that initial discussion and diagnosis
in the emergency department.
I think that we have a very, very
vital role to play
and a role that maybe we had not
initially thought of when we were in residency
training.
A lot of times when
we are thinking of
cancer patients comes to the emergency department.
They might be symptomatic from something. But I
wanna take a step back and they and
talk about just, you know, incidental findings.
So it's these patients that are actually common
as well where you do a Ct scan
or something else, and then, you know, maybe
a trauma, and then you find
incidental findings.
In an emergency medicine physician's mind, an incidental
finding that's not compressing something that's not making
someone sick at the time.
Might just be out of sight out of
mind. And I know they did a study
showing, you know, how many times these quote
unquote
were actually
put on discharge diagnoses,
and it was really low, like, 27 percent.
And it's important
to realize that even though we are, you
know, the acute dermatologist,
these are also important as well. So if
you don't mention it to your patient who
have baseline probably doesn't even really have a
good understanding potentially of medical conditions. That's where
we can fail really bad
as emergency medicine physicians. I wanna have us
think of ourselves as not just isolated, you
know, doc in a box This is my
shop, but we are a part of a
great continuum. And
fortunately, unfortunately, like you said, we will probably
be the first providers to actually see
and potentially diagnose cancer, whether we like it
or not. I think that's a really important
point in that communication is very key in
all of this. Monica, I kinda walk us
through,
a
conversation
discussing that new
found
potential for cancer
with a patient? Like, what are the components
that we need to communicate to our patients?
There are a few main things that patients
want to hear.
The first thing they'll ask is is a
cancer.
And the thing is,
I don't want to
say
that we shouldn't be throwing out the word
mali malignant or cancer to these patients because
sometimes being direct is important.
But since we're not oncologists, and since sometimes
findings that look like potential mali
actually aren't.
It's really important to be sensitive about this.
And so what I like to say is
I have found on said Ct scan. Something
that is suspicious that really needs close follow
up. And then I can give a few
things like, It might be a concern for
infection, it might be cancer.
It might be a lot of things. And
the reason that I want you to follow
up closely is that
I don't know what it is, but we
need to work it up further. And so
it gives the patience an idea of why
they need to follow ups soon, but it
doesn't lock in a diagnosis. And I think
that's really important because we, at Md anderson
get referrals for a lot of possible cancers
and the patients have been told, you know,
that it's cancer, and then we have a
suspicion of cancer clinic, and after biopsy it
actually isn't.
And so they went through, like, 2 months
of anxiety when it was something else.
Yeah. I I think that's why I asked
that question because in the emergency department, you
know, pre biopsy
you know, minimal labs,
not a specialist. I struggle with putting that
big c out there. You know, and that
is really a fork and a erode for
so many patients and families
that changes the way that they live their
lives and think about their future. And so...
But you also want them to take it
seriously
And so, like, that balance is is really
tough. But I think it is important to
give a gravity to that conversation so that
they get that proper follow up.
Yeah. You know, I've been in too many
of these where I am unfortunately giving some
news of a new finding that's concerning for
cancer. So how do you decide which of
these findings might be concerning enough to warrant
an admin today for an expedited work workout
versus follow up in suspicion for cancer clinic.
Really is practice specific because you have to
take into account the patient, your practice environment
and
availability
of
the oncologist for you to even discuss these
cases with because I know a lot of
our colleagues, they probably can't pick up a
phone and talk to an oncologist.
And so
do you trust that they will follow up?
Because that's really important too. Do they have
the wherewithal and the resources to be able
to you know, say, hey, you know, in
2 weeks, I want you to go to
follow at this clinic appointment.
If they can't even make it to that
appointment. If they don't have a ride, things
like that. That's going to be a really
big issue. So
patient specific factors is number 1 number 2.
Where what type of practice environment are you
in? Do,
you routinely
actually get close follow ups because you could
put these follow ups in on their dispositions,
but how long is the turnaround time? That's
something important to think about too.
And so the third thing that I think
is easier for us as emergency physician. So
if you take out all of these other
factors,
just seeing
where these masses are or what potential issues
might happen will be important as well
because
pain is a huge reason in my patients
return to the emergency department. So a mass
might not be in a specific area that
might be compressing something or you know, your
laps might not be showing, you know, an
anemia that is borderline needing transfusion, but not
yet. So subtle things
might actually be even
bigger reasons why you would want to have
closer follow or even admit. And I wanted
to just highlight cancer pain as 1 of
them because in the general patient population, there's
been a pull towards you know, not wanting
to prescribe too much
and
really being very cautious. And while you'd still
have to be cautious
in the cancer patient population,
pain is real and the amount that we
usually
prescribe for the general patient population will not
be sufficient. So if a patient came to
for abdominal pain with their newly diagnosed colon
cancer.
And, you know, you wanted discharge them home
with pain medication,
10 pills is not going to be enough.
It's not gonna even get them through, you
know, the first 2 days sometimes. And so
having that idea of the subtle things or
the not so medically
catastrophic
diagnoses might actually be the reasons for repeat
emergency medicine visits is going to be important.
Yeah. And I wanna come back and talk
about pain a little later, But as an
ear physician, you know, as you mentioned, there
are some emergent things that we need to
know about So what are some of these
emergent conditions that are specific to patients with
cancer that we should be aware of?
There's a few studies that take a look
at
the most common visits for
patients with cancer visiting the ed, and some
of them include pneumonia, gas,
fever, of blown pain and Ill.
And so all of these
conditions as emerging medicine physicians, we are trained
to recognize
but everything in the cancer patient population is
just more subtle the way it presents.
Lung cancer
is a fairly common diagnosis in
the emergency department, and I wanted to use
the lung cancer patient as a case.
So they basically
will
come in about, you know,
it comp about 10 to 12 percent of
cancer related emergency department visits in overall. And
the admission rate is 66 percent. And so
with this type of cancer, what you're going
to be seeing is
besides fever respiratory symptoms, so worsening effusion along
with neurologic issues.
Other things to think about are subtle presentations
like just feeling fatigue can also
indicate
electrolyte abnormalities or anemia. Things like that as
well.
Can you speak to the neurological issues? Like,
what you mean by that specifically Monica?
Sure. So,
unfortunately,
a lot of times,
patients present to the emergency department for the
first time, for their first diagnosis,
and they were previously well.
And they might have had just, you know,
subtle symptoms, but
neurologic
findings that does indicate that there might be
a meta to the brain.
And when you think of patients that come
to the emergency department, a lot of times
it's for acute issues. And so that's 1
of the reasons why they would they would
present either seizure activity, really bad headaches and
unfortunately,
sometimes even altered levels of consciousness due cerebral
edema from meta.
So really any subtle
neuro based symptom or sign should be taken
seriously in our patients. That have cancer. Like,
we should really slow our role and stop
and think about it. Is that fair to
say?
I think it's such an important
thing to highlight
even
with trainings that come through emergency department, when
you think of the, you know, the path
and monica findings,
for certain things like core compression as an
example, you want to actually
catch things before you find these lower motor
neuron symptoms.
You wanna catch things before
there is a problem that potentially can't be
reversed. And so
just
presenting with pain. A lot of times these
patients have had back pain for a really,
really long time. And
they have either seen their primary care doctor.
Maybe they've gone through other emergency departments.
You want to be able to catch that
meta ta at that time.
With early cord compressions that you don't find
the...
III call it the
end symptoms because once you an end symptom.
It's harder for radiation oncologist or nurse neurosurgery
to really interact with things
and make them better.
So, Monica, I feel like 1 of the
other common things I see in the Ed,
often with the initial presentation of cancer or
sometimes the way we find the cancer. Is
Dv or Pe. So, you know, they come
in and we end up diagnosing that, and
then through some of those studies, we end
up also finding a potential mali.
Is there a different way that you would
treat Dv or Pe in a patient that
you also had a concern for new cancer?
Is that something that would warrant admission? Or
how do you approach that?
So at Md Anderson, we have our own
algorithm, and a lot of people are surprised
because we send a lot of patients home.
Not all
Dv or Pe
require
emission? And so there is risk strat justification.
Are they symptomatic when they're am, do they
saturate?
Do they get tachycardia
even on Ct, if it's a pulmonary embolism,
is their evidence of right heart strain or,
you know, with bedside ultrasound. And so if
you are in a
intermediate to higher risk, it does warrant some
observation or admission. But a lot of these
times Dv and Pe can be found incidentally,
and a lot of these patients can be
sent home. The big things that I will
always
ask is
is there a bleeding risk?
And then also, sometimes, these patients have not
had any imaging of the brain to make
sure that there's a meta. And so I
ask questions that might indicate that there might
be something neurologic, like headaches, vision changes,
stuff like that. Also certain cancers just tend
to bleed more. And so I'm more cautious.
Like melanoma,
I am more cautious
to prescribe anti to these patients because
when they're on it, if they do have
an intra meta,
it bleeds, and it's pretty bad when it
does.
Monica, once patients are started on their appropriate
therapies,
radiation, chemotherapy,
res reception, whatever it might be there are
way too many complications to all of those
interventions to hit all of them today. But
if we're just kinda, like break it down
as to what are some of the common
things we see about. 1 of the ones
that I feel like we run into a
lot. Maybe you can tell us the data
on that is Feb ne?
Okay? So what is the latest approach to
these patients? Like how fast do we need
to get antibiotics in What labs do we
need? What's our dis on those patients. Walk
us through feb ne?
There's a lot of data that is showing
that the sooner you get the antibiotics into
these patients the better. And so there's a
lot of metrics even at our institution. You're...
Once they hit triage, that's when the time
starts. And so it almost is, like, treating
a patient with stem or a stroke. So
the clock starts, and you really need to
be getting
antibiotics into these patients within the hour, ideally
30 minutes.
And I do wanna just add a little
caveat for antibiotics
because a lot of times, we think antibiotics
they need Van
and a broad spectrum beta lac antibiotic.
And so I see a lot of times
everyone does the combination, but you actually only
need 1. You only need to add brush
spectrum beta lac antibiotic. And so mono therapy
that has your anti activity like ce
is fine. You don't need to add the
van of my son unless you suspect Mrsa.
But the time that you initiate antibiotic administration
really does matter.
I think they did a study
where they basically looked and saw what the
mortality risk were. And basically, if you get
antibiotics in before 60 minutes, the decrease is
actually significant.
And for each hour of delay that you
have
it increases risk by 18 percent.
Now on the other side,
a lot of colleagues when they come to
md Anderson are surprised that how many people
we discharge. And The goal is trending towards
trying to transition them to home sooner
in a certain subset of patient population. Also,
feb ne is not treated the same with
hem mali,
like lymphoma leukemia, myeloma as solid tumors.
So solid tumors
depending on
if a patient is able to follow up
if they live within for us I think
it's a, like, a 30 minute radius.
We can actually discharge them home if they're
reliable.
And so we do it outpatient ne panic
follow up for patients that if we actually
work them up in the emergency department, and
they don't have a source of infection, we
can send home if they're reliable take their
antibiotics if they can come back for their,
repeat labs as well.
Solid tumors. Yeah. Solid tumors. For liquid tumors,
that's not the case. Liquid tumors they get
admitted because they just have a higher higher
risk for
morbidity and mortality
And the way that you can determine for
solid tumors
in the emergency department, they, they do have
a mask score and so mask stands for
a multi
multinational
association for supportive of care and cancer.
And it's an index score that basically when
you apply to the onset fever and take
a look at the the criteria.
If the score is less than 21 points.
There's a low risk.
For mortality, and you can you can consider
saying them home.
What do you recommend? Do you give a
dose of zone for those patients that you
discharge so that you have that kind deb
effect in last seen 24 hours Monica? Or
do you just go with that dose pain
when you're discharging,
the patients that can go home? So how
we would do it is if you're not
panic, and if there is no fever source,
you might not actually get sent home on
antibiotic.
Especially with a lot of these, you know,
viral illnesses
that are going around that sometimes the viral
panels don't check.
So the patients that are potentially okay to
send home would be solid tumor patients that
do not have a source of infection found
on your work up, the source.
Being when you do a chest x rate
to look for pneumonia along with a your
analysis to make sure that there's no urinary
tract infection. I will put a caveat in
for the respiratory
infections because if the patient is symptomatic
enough, it might warrant observation even though there
isn't
antibiotic or a treatment you need to give.
But for the patients that are well appearing.
At md Anderson, we have a
outpatient ne panic fever pathway, and there are
some criteria.
So the patient has to live within an
hour away from our institution. As well as
be reliable to be able to come back
for further work up and be able to
tolerate oral
to take Antibiotics
and also have someone with them to monitor
things.
And if you are gonna send these patients
home, then
the
antibiotic choice you give them 2. First line
therapy can be super in, 07:50
milligrams po twice daily.
Plus a
slash
acid,
and that is for 7 days. And if
there is a documented
like, really serious beta.
What you can do is tip
and cli mason, 600 milligrams.
Po,
3 times a day for 7 days.
So Monica talked to me about tumor l
syndrome.
When should we be looking for that in
the Ed and what kind of work workout
should we be doing?
With tumor l syndrome, you have tumors that
are high risk that have high risk tumor
burden?
So think of your
advanced b lymphoma,
advanced leukemia
or even your early diagnosis of leukemia.
So liquid tumors.
And then you can get it sometimes in
the solid cancers, but think more of
when the patients are receiving treatment because usually,
with tumor syndrome for the for lymphoma and
leukemia,
it's pre treatment with the solid tumors, you
think of it after post treatment when the
tumors are l.
But the thing that I want to share.
And again, I keep on saying this over
and over again is subtlety.
Because you wanted to catch things early on.
Most of these patients if they are solid
tumors They will have had labs previously. And
so there's grading criteria for tumor l syndrome.
And so on your lab values, they might
not be super high, but the trend has
been higher.
And these oncologists teams really definitely take that
seriously
and in our institution will actually put an
observation or admit for early tumor l syndrome.
There are lab values that normally we don't
routinely get
as emergency medicine positions. And so if you
are suspecting that you have a patient that
presented with fatigue of possible new leukemia. You
need to add these slabs on such as
uric acid and L.
I think those are the 2 main ones
that we don't think about.
That are important.
But with tumor l syndrome,
you have laboratory criteria and clinical.
And
for us really clinical,
it it's all about trends. So if the
clinical Tls is, like increase crab,
1.5 times upper limit of normal. So that's
easy for us to look at. But then
the other criteria is like cardiac arrhythmias or
sudden in death and seizures. These are end
stage things. So I don't wanna, you know,
put on my diagnosis clinical Tl. That means
that potentially, we've missed it multiple other times.
And so that's why I wanted to just
kinda put in a plug for making sure
to look at trends instead of just the
actual laboratory clinical because catching things early is
important.
Are there any specific symptoms that might tip
you off to be looking for tumor l
syndrome?
That's the problem.
Everything is subtle when
you think about a logic emergencies.
For tumor, it might just be fatigue. It
just might be some decreased Po and take
and decreased urination. And so being able to
pick up on these subtle sides, I think
it's important because
we're taught to look for, you know, bigger
findings even on r board to these big
findings, but it's the subtlety
that I think is the most important to
remember that once you see patients that presents
with your altered mental status with, you know,
your arrhythmias,
that's a bit late or a lot late.
I hate to see a child come into
the emergency department with mu.
Talk to us about which groups are at
highest risk from?
And then I think we can all kind
of visually see that diagnosis. But, like, what
can we do to help our patients with
mu?
I think patients receiving
radiation to, you, the head and neck are
really at most risk because
It's not just the pain, but it's also
being able to hydrate. And so with the
dehydration, everything gets worse as well. And so
I
want to put in a plug to get
specialist onboard early if you have the resources.
I think that's the most important thing because
mu is not going to go away. A
lot of times these regiments,
for radiation, it's multiple times.
And so
someone needs to be following up to make
sure that symptoms are improving and to catch
things early. A lot of times patients might
need hydration,
hopefully not in the most, but it can
be set up as an outpatient. And so
we have our palliative care services
that help with symptom management and getting them
onboard early, not at end of life is
going to be the most important because I
have a few
medications that I can prescribe from my toolbox
but really, it's the follow ups. So if
I just discharged on this medication in 3
days did it help. And if it didn't,
having someone
in the outpatient setting, be able to work
with that patients that they don't come back
to the emergency department even worse than before
is going to be the most important thing.
What medications do you usually
prescribe for somebody who has mu?
So you can do topical mouth washes.
And rinse for
treatment,
there isn't in a 1 size fits all
approach. So sometimes vis lid might help as
well. But personally for me, I'm not as
successful in treatment.
That's why it's 1 of the things that
I actually get my palliative care colleagues on
board early.
Because it is very, very difficult to treat.
Things that you shouldn't use, I think I
just wanted to highlight as well. Ci fate
isn't as helpful for radiation, induced oral mu.
And then another thing is sometimes you will
need to use
systemic anal logistics.
Like oral op.
That's something for for us that we use
quite commonly. It doesn't
target specifically the area but but it does
help as while. And so doing a, you
know, topical mouth washer rinse and then giving
an oral anal music is something that I
usually do in the mercy department.
Another very common thing that patients come in
with,
especially those who are currently in treatment. The
are coming in with nausea or vomiting. And
they've already tried whatever they have at home
and they still can't keep anything down. So
they end up coming to the Ed.
Do you have any recommendations for approaching treatment
for these patients.
Nausea vomiting is
notoriously difficult to treat.
I think education is important because sometimes you
think that the patient has failed their medications,
but they weren't educated to take something around
the clock, or they didn't have, like, a
first line and a second line agent that
you could
alternate as well.
We have an observation unit
because
sometimes even with the best intentions and then
the patients have tried their best
it just doesn't work. And so making sure
that
you
have a low threshold to act really observe
or admit these patients important to because getting
dehydrated and not being able to tolerate Po
also has its
issues and things can go downhill really fast.
Consider
observing them for some prolonged Iv fluid hydration
because a lot of times, there's no overnight
magical pill that'll make things better.
And is on, your go to anti.
I have generally been taught that on oncology
patients often get very high doses of on
So what is your threshold? How high do
you go in terms of dosing? And are
you getting Ekg to check their Q?
A lot of our patients
have Ekg already, but if they don't, prior
to starting Z, I actually will get an
Ekg just to get a good baseline
because to be honest, most of the anti
medics cause some sort of, like, Q prolong.
There's always the side effects that we need
to just make sure at baseline we're not
making anything worse.
Z is our go to. It's even on
our order sets. I don't know how high
you guys do for regular because I haven't
seen a regular quote unquote, like a regular
patient in the general population. But we we
start off with 8 milligrams.
We don't really keep on trying
the same medication once 8 milligrams doesn't work
because there's many different types. That you can
use. And so
using a different medication as a second line
is what I and what we do at
Md Anderson.
If z, 8 milligrams milligram didn't work at
that time, then we'll switch to something different.
What about chemotherapy
induced diarrhea, how do we help those patients
that are having per diarrhea.
I sound like a broken record.
Everything is subtle.
Even if the patient isn't having
explosive diarrhea. Sometimes they're really
embarrassed to say how many times, but ask
how many times.
This is a a story that I had
when I was a fellow. You know I
said, how many times have you been having
diarrhea only once, but it basically was a
cost leak the whole day.
So that's that's pretty bad. Isn't it? But
but
it's important to know that
patients receiving chemotherapy treatments and other therapies.
When they start having diarrhea, they're just more
frail. And so have a lower threshold to
actually and I and it like, this is
why it sound like broken record, observe the
patient or admit them for Iv hydration. Also,
it's important to find out why
they're having the diarrhea.
We like to think most common things are
common.
And so
we'll be the first to say, okay. It's
just due to chemotherapy.
But In this patient population, I think it's
important to also make sure that our first
offer for diagnosis is actually true. So sending
stool studies, making sure that
it's not due to colitis because cancer therapeutics
have changed dramatically over the last 10 years.
So when you say someone's on chemotherapy, the
first thing that comes to mind in my
head is, are they only on chemotherapy?
Or have they had a treatment prior and
then they're back on chemotherapy?
Or are they chemotherapy planning for another different
treatment because it changes things. A lot of
times chemotherapy now are used in conjunction with
immune checkpoint inhibitors, other treatments. And so when
you say chemotherapy
related diarrhea, it could actually potentially mean an
immune checkpoint inhibitor diarrhea.
And there's grading skills for that and
treatments that need to be followed if it's
due to that. And so if the patient
has on immune checkpoint inhibitors,
do a Ct scan. If you find colitis,
that is also concerning other labs for me
checkpoint inhibitors would be Es Crp,
checking if other body systems are affected like,
adding a Tsa chunk because that's usually silent
too. So doing more of a work up
than what you would normally do is going
to be the most important for these patients
even with chemotherapy and do area. Make sure
it's not c diff. A lot of times
these patients have had antibiotic usage prior.
It's kind of a
big black box of babies.
The next thing I wanted to get to
is anemia and t.
Because I know that this may be managed
differently in our oncology patients than in our
patients without cancer.
For us, if the patient has hemoglobin below
8, then we routinely trans,
but most of our patients are walking around
with hemoglobin less than 12. For sure. Platelets
will be less than 15 trans fuse. That's
our criteria.
Monica, some of our patients come through
with
radiation specifically
as a treatment modality. What are some of
the
complications that are specific to radiation interventions.
So it depends on the area that's being
radiate.
But we already talked about
or having bowel absorption symptoms, diarrhea,
if you're getting it to your thoracic area
having p,
and p is a little bit difficult because...
It can present with a lot of symptoms
that are similar to pneumonia. So those are
some of the common things that you will
see with patients with radiation.
I also wanna say with patients with radiation,
you have
acute symptoms, but also don't really about chronic
symptoms.
And so a lot of times in the
emergency department, we all always think about, you
know, what brings you to emergency department. And
your time to present illness is, you know
when the last 2 weeks or 3 weeks.
And you don't think that certain things that
happened maybe a year or 2 years prior
could be the the reason for that.
Radiation
side effects
There's a lot of chronic
complications too like diarrhea and m absorption and
p meningitis as well that can present long
term
it's a reason for patients to represent to
the Emergency department too for the chronic complications.
Communication with the patient is key. When you
find something that might be cancer, please tell
the patient put it on the discharge summary
and help with the follow up, but don't
lock in the diagnosis.
Feb Ne.
Antibiotics need to be given within 1 hour
of hitting triage
ideally within 30 minutes.
Treat with ce and Van mice if you
suspect Mrsa.
Standardize with order sets and policies and set
up discharge and ad criteria with your colleagues.
When it comes to tumor l syndrome, it
is important to look at trends
not just the current values.
You may catch it early if the values
are trending up.
Mu is tricky to treat and worth involving
specialist for treatment and disposition.
Nausea and vomiting can be a sign of
something greater.
Dehydration can be problematic and hard to treat,
so consider admitting for Iv fluids and figuring
out why we have the nausea vomiting.
You can use z, 8 milligrams right off
the bat. If it doesn't work, the first
time they'll move on.
Just like vomiting,
diarrhea can also be a symptom of a
more complicated diagnosis.
Consider Iv fluids and observation.
Most of these patients have abnormal platelets and
hemoglobin levels.
Refer to your local policy, but a good
baseline is to trans fuse Rbc for hemoglobin
less than 8 and platelets less than 15000.
Remember that any neurologic symptom in a patient
with cancer can be a sign of something
more serious, and often requires further work up.
Don't blow these off.
Okay. That was a lot, but there is
still more to become because this is a
big topic. And as we now know, 1
that people do entire fellowship about.
So join us next time for part 2
when we talk about pain management
goals of care in the Ed and a
few ethical dilemma. Thank you to our department
for doing process improvement projects to improve the
care of this population of patients.
And thank you to Owen productions for improving
our production quality.
Until next time, stay curious,
stay transpired, and stay tuned.