1 00:00:05,631 --> 00:00:08,365 Welcome to Em pulse Brain research and expert 2 00:00:08,365 --> 00:00:10,925 opinion to the bedside. We're your hosts, Sarah 3 00:00:11,005 --> 00:00:12,464 Made. And Julia Mc. 4 00:00:16,620 --> 00:00:19,600 Welcome back to Ian impulse. Say it's summertime. 5 00:00:20,059 --> 00:00:21,820 So I think we should talk about something 6 00:00:21,820 --> 00:00:24,300 sunny like on ecological emergencies. 7 00:00:26,952 --> 00:00:30,149 Okay. Not super sunny, but definitely important. 8 00:00:30,708 --> 00:00:32,306 There are 16000000 9 00:00:32,466 --> 00:00:35,137 Americans living with cancer. Who account for approximately 10 00:00:35,275 --> 00:00:38,226 4000000 visits to emergency departments each year. 11 00:00:39,343 --> 00:00:42,214 Patients with advanced cancer, especially older patients are 12 00:00:42,214 --> 00:00:43,730 particularly vulnerable to emergencies. 13 00:00:44,303 --> 00:00:47,175 And to improve our recognition and response to 14 00:00:47,175 --> 00:00:50,207 oncology emergencies, we are talking today with a 15 00:00:50,207 --> 00:00:53,271 friend of mine who is actually an ecological 16 00:00:53,408 --> 00:00:53,908 emergency 17 00:00:54,442 --> 00:00:56,592 physician. That is a crazy job. 18 00:00:57,228 --> 00:01:00,193 And to be clear, she is a physician 19 00:01:00,193 --> 00:01:03,389 who only sees adult cancer patients in the 20 00:01:03,389 --> 00:01:05,646 emergency department. So while some of these principles 21 00:01:06,025 --> 00:01:09,550 apply, we're only talking about adults today, but 22 00:01:09,550 --> 00:01:11,385 that gives us the opportunity to do a 23 00:01:11,385 --> 00:01:12,103 follow up on kit. 24 00:01:12,900 --> 00:01:14,416 I like that. That's a great idea. 25 00:01:18,573 --> 00:01:20,959 So, Monica, I wanna start where most of 26 00:01:20,959 --> 00:01:23,107 us in the Ed initially interact with cancer, 27 00:01:23,426 --> 00:01:25,119 which is making that potential diagnosis. 28 00:01:25,828 --> 00:01:28,141 And we all know that ideally cancer is 29 00:01:28,141 --> 00:01:30,454 caught early with subtle signs in clinic or 30 00:01:30,454 --> 00:01:33,007 screening through primary care physician. But there's been 31 00:01:33,007 --> 00:01:35,375 a decrease in access to primary care and 32 00:01:35,652 --> 00:01:37,635 not everyone gets that screening that they should, 33 00:01:37,872 --> 00:01:39,221 so we are off in the first line. 34 00:01:39,934 --> 00:01:41,758 What types of cancer are most likely to 35 00:01:41,758 --> 00:01:42,789 be diagnosed in Ed? 36 00:01:43,919 --> 00:01:45,677 I would say the most common cancers would 37 00:01:45,677 --> 00:01:48,334 be breast, colon and lung, and 38 00:01:49,032 --> 00:01:51,210 studies have shown that it's probably around 39 00:01:51,920 --> 00:01:54,087 the range of 20 to 50 percent 40 00:01:54,460 --> 00:01:58,986 of, dynasties for these specific mali are actually 41 00:01:58,986 --> 00:02:00,097 through the emergency department. 42 00:02:00,747 --> 00:02:02,967 That's a lot. Yeah. For sure. I would 43 00:02:02,967 --> 00:02:05,188 not have expected that. You know, I think 44 00:02:05,188 --> 00:02:07,567 sometimes we struggle with our role in that 45 00:02:07,567 --> 00:02:08,067 diagnosis 46 00:02:08,534 --> 00:02:10,842 of cancer in the emergency department. 47 00:02:11,399 --> 00:02:13,150 Monica, what do you see as the role 48 00:02:13,150 --> 00:02:14,684 of the Ed physician 49 00:02:15,219 --> 00:02:17,629 in that initial discussion and diagnosis 50 00:02:18,099 --> 00:02:19,539 in the emergency department. 51 00:02:20,500 --> 00:02:23,319 I think that we have a very, very 52 00:02:23,379 --> 00:02:24,759 vital role to play 53 00:02:25,139 --> 00:02:27,305 and a role that maybe we had not 54 00:02:27,305 --> 00:02:30,424 initially thought of when we were in residency 55 00:02:30,559 --> 00:02:30,877 training. 56 00:02:31,432 --> 00:02:32,805 A lot of times when 57 00:02:33,179 --> 00:02:34,710 we are thinking of 58 00:02:35,178 --> 00:02:36,929 cancer patients comes to the emergency department. 59 00:02:37,645 --> 00:02:40,191 They might be symptomatic from something. But I 60 00:02:40,191 --> 00:02:41,862 wanna take a step back and they and 61 00:02:41,862 --> 00:02:43,691 talk about just, you know, incidental findings. 62 00:02:44,263 --> 00:02:47,362 So it's these patients that are actually common 63 00:02:47,362 --> 00:02:49,428 as well where you do a Ct scan 64 00:02:49,428 --> 00:02:51,255 or something else, and then, you know, maybe 65 00:02:51,255 --> 00:02:52,709 a trauma, and then you find 66 00:02:53,494 --> 00:02:54,209 incidental findings. 67 00:02:54,924 --> 00:02:58,418 In an emergency medicine physician's mind, an incidental 68 00:02:58,418 --> 00:03:00,641 finding that's not compressing something that's not making 69 00:03:00,641 --> 00:03:01,594 someone sick at the time. 70 00:03:02,482 --> 00:03:04,547 Might just be out of sight out of 71 00:03:04,547 --> 00:03:07,168 mind. And I know they did a study 72 00:03:07,168 --> 00:03:09,710 showing, you know, how many times these quote 73 00:03:09,710 --> 00:03:10,210 unquote 74 00:03:10,742 --> 00:03:11,639 were actually 75 00:03:11,949 --> 00:03:13,562 put on discharge diagnoses, 76 00:03:14,176 --> 00:03:16,165 and it was really low, like, 27 percent. 77 00:03:16,881 --> 00:03:18,574 And it's important 78 00:03:19,205 --> 00:03:21,205 to realize that even though we are, you 79 00:03:21,205 --> 00:03:22,724 know, the acute dermatologist, 80 00:03:23,205 --> 00:03:25,525 these are also important as well. So if 81 00:03:25,525 --> 00:03:28,169 you don't mention it to your patient who 82 00:03:28,169 --> 00:03:30,076 have baseline probably doesn't even really have a 83 00:03:30,076 --> 00:03:33,571 good understanding potentially of medical conditions. That's where 84 00:03:33,571 --> 00:03:35,183 we can fail really bad 85 00:03:35,494 --> 00:03:39,350 as emergency medicine physicians. I wanna have us 86 00:03:39,489 --> 00:03:41,726 think of ourselves as not just isolated, you 87 00:03:41,726 --> 00:03:43,419 know, doc in a box This is my 88 00:03:43,419 --> 00:03:45,500 shop, but we are a part of a 89 00:03:45,500 --> 00:03:47,040 great continuum. And 90 00:03:47,340 --> 00:03:50,552 fortunately, unfortunately, like you said, we will probably 91 00:03:50,552 --> 00:03:53,044 be the first providers to actually see 92 00:03:53,420 --> 00:03:56,050 and potentially diagnose cancer, whether we like it 93 00:03:56,050 --> 00:03:58,041 or not. I think that's a really important 94 00:03:58,041 --> 00:04:00,843 point in that communication is very key in 95 00:04:00,843 --> 00:04:02,753 all of this. Monica, I kinda walk us 96 00:04:02,753 --> 00:04:03,253 through, 97 00:04:03,866 --> 00:04:04,366 a 98 00:04:04,821 --> 00:04:05,321 conversation 99 00:04:05,776 --> 00:04:07,389 discussing that new 100 00:04:07,764 --> 00:04:08,264 found 101 00:04:09,132 --> 00:04:10,268 potential for cancer 102 00:04:10,723 --> 00:04:12,314 with a patient? Like, what are the components 103 00:04:12,314 --> 00:04:13,985 that we need to communicate to our patients? 104 00:04:15,258 --> 00:04:16,770 There are a few main things that patients 105 00:04:16,770 --> 00:04:17,326 want to hear. 106 00:04:17,977 --> 00:04:19,802 The first thing they'll ask is is a 107 00:04:19,802 --> 00:04:20,119 cancer. 108 00:04:20,912 --> 00:04:21,705 And the thing is, 109 00:04:22,419 --> 00:04:23,633 I don't want to 110 00:04:24,006 --> 00:04:24,506 say 111 00:04:24,973 --> 00:04:26,879 that we shouldn't be throwing out the word 112 00:04:26,879 --> 00:04:29,103 mali malignant or cancer to these patients because 113 00:04:29,103 --> 00:04:30,691 sometimes being direct is important. 114 00:04:31,247 --> 00:04:35,099 But since we're not oncologists, and since sometimes 115 00:04:35,396 --> 00:04:37,649 findings that look like potential mali 116 00:04:38,106 --> 00:04:38,664 actually aren't. 117 00:04:39,301 --> 00:04:41,613 It's really important to be sensitive about this. 118 00:04:41,772 --> 00:04:43,862 And so what I like to say is 119 00:04:44,021 --> 00:04:47,214 I have found on said Ct scan. Something 120 00:04:47,214 --> 00:04:49,450 that is suspicious that really needs close follow 121 00:04:49,450 --> 00:04:51,126 up. And then I can give a few 122 00:04:51,126 --> 00:04:53,318 things like, It might be a concern for 123 00:04:53,377 --> 00:04:54,736 infection, it might be cancer. 124 00:04:55,215 --> 00:04:56,573 It might be a lot of things. And 125 00:04:56,573 --> 00:04:58,091 the reason that I want you to follow 126 00:04:58,091 --> 00:04:59,390 up closely is that 127 00:04:59,863 --> 00:05:01,533 I don't know what it is, but we 128 00:05:01,533 --> 00:05:03,363 need to work it up further. And so 129 00:05:03,363 --> 00:05:07,277 it gives the patience an idea of why 130 00:05:07,277 --> 00:05:08,952 they need to follow ups soon, but it 131 00:05:08,952 --> 00:05:10,866 doesn't lock in a diagnosis. And I think 132 00:05:10,866 --> 00:05:12,940 that's really important because we, at Md anderson 133 00:05:12,940 --> 00:05:15,811 get referrals for a lot of possible cancers 134 00:05:15,811 --> 00:05:17,890 and the patients have been told, you know, 135 00:05:17,969 --> 00:05:20,505 that it's cancer, and then we have a 136 00:05:20,505 --> 00:05:22,645 suspicion of cancer clinic, and after biopsy it 137 00:05:22,645 --> 00:05:23,121 actually isn't. 138 00:05:23,929 --> 00:05:25,441 And so they went through, like, 2 months 139 00:05:25,441 --> 00:05:27,272 of anxiety when it was something else. 140 00:05:27,909 --> 00:05:29,580 Yeah. I I think that's why I asked 141 00:05:29,580 --> 00:05:32,366 that question because in the emergency department, you 142 00:05:32,366 --> 00:05:33,423 know, pre biopsy 143 00:05:33,893 --> 00:05:35,267 you know, minimal labs, 144 00:05:35,641 --> 00:05:38,978 not a specialist. I struggle with putting that 145 00:05:38,978 --> 00:05:42,016 big c out there. You know, and that 146 00:05:42,016 --> 00:05:43,690 is really a fork and a erode for 147 00:05:43,690 --> 00:05:45,705 so many patients and families 148 00:05:46,640 --> 00:05:48,712 that changes the way that they live their 149 00:05:48,712 --> 00:05:51,117 lives and think about their future. And so... 150 00:05:51,834 --> 00:05:53,666 But you also want them to take it 151 00:05:53,666 --> 00:05:54,166 seriously 152 00:05:54,621 --> 00:05:57,568 And so, like, that balance is is really 153 00:05:57,568 --> 00:05:59,992 tough. But I think it is important to 154 00:06:00,208 --> 00:06:02,354 give a gravity to that conversation so that 155 00:06:02,354 --> 00:06:03,785 they get that proper follow up. 156 00:06:04,660 --> 00:06:06,744 Yeah. You know, I've been in too many 157 00:06:06,744 --> 00:06:09,141 of these where I am unfortunately giving some 158 00:06:09,141 --> 00:06:11,617 news of a new finding that's concerning for 159 00:06:11,617 --> 00:06:14,267 cancer. So how do you decide which of 160 00:06:14,267 --> 00:06:16,336 these findings might be concerning enough to warrant 161 00:06:16,336 --> 00:06:18,747 an admin today for an expedited work workout 162 00:06:18,884 --> 00:06:21,432 versus follow up in suspicion for cancer clinic. 163 00:06:22,725 --> 00:06:25,525 Really is practice specific because you have to 164 00:06:25,525 --> 00:06:28,425 take into account the patient, your practice environment 165 00:06:28,964 --> 00:06:29,464 and 166 00:06:29,845 --> 00:06:30,345 availability 167 00:06:30,725 --> 00:06:31,180 of 168 00:06:31,537 --> 00:06:33,605 the oncologist for you to even discuss these 169 00:06:33,605 --> 00:06:34,957 cases with because I know a lot of 170 00:06:34,957 --> 00:06:36,786 our colleagues, they probably can't pick up a 171 00:06:36,786 --> 00:06:38,297 phone and talk to an oncologist. 172 00:06:38,774 --> 00:06:39,513 And so 173 00:06:39,902 --> 00:06:41,493 do you trust that they will follow up? 174 00:06:42,368 --> 00:06:43,959 Because that's really important too. Do they have 175 00:06:43,959 --> 00:06:46,187 the wherewithal and the resources to be able 176 00:06:46,187 --> 00:06:48,264 to you know, say, hey, you know, in 177 00:06:48,264 --> 00:06:49,929 2 weeks, I want you to go to 178 00:06:49,929 --> 00:06:51,752 follow at this clinic appointment. 179 00:06:52,307 --> 00:06:54,862 If they can't even make it to that 180 00:06:54,862 --> 00:06:56,616 appointment. If they don't have a ride, things 181 00:06:56,616 --> 00:06:58,689 like that. That's going to be a really 182 00:06:58,689 --> 00:07:00,065 big issue. So 183 00:07:00,522 --> 00:07:02,276 patient specific factors is number 1 number 2. 184 00:07:02,768 --> 00:07:05,473 Where what type of practice environment are you 185 00:07:05,473 --> 00:07:06,268 in? Do, 186 00:07:07,064 --> 00:07:08,041 you routinely 187 00:07:08,734 --> 00:07:11,380 actually get close follow ups because you could 188 00:07:11,380 --> 00:07:13,455 put these follow ups in on their dispositions, 189 00:07:13,615 --> 00:07:15,610 but how long is the turnaround time? That's 190 00:07:15,610 --> 00:07:17,126 something important to think about too. 191 00:07:17,939 --> 00:07:20,810 And so the third thing that I think 192 00:07:20,810 --> 00:07:23,682 is easier for us as emergency physician. So 193 00:07:23,682 --> 00:07:25,357 if you take out all of these other 194 00:07:25,357 --> 00:07:25,835 factors, 195 00:07:26,553 --> 00:07:27,532 just seeing 196 00:07:28,003 --> 00:07:31,584 where these masses are or what potential issues 197 00:07:31,584 --> 00:07:33,835 might happen will be important as well 198 00:07:34,370 --> 00:07:34,870 because 199 00:07:35,897 --> 00:07:38,206 pain is a huge reason in my patients 200 00:07:38,206 --> 00:07:40,436 return to the emergency department. So a mass 201 00:07:40,436 --> 00:07:42,188 might not be in a specific area that 202 00:07:42,188 --> 00:07:44,751 might be compressing something or you know, your 203 00:07:44,751 --> 00:07:46,904 laps might not be showing, you know, an 204 00:07:46,904 --> 00:07:50,092 anemia that is borderline needing transfusion, but not 205 00:07:50,092 --> 00:07:52,107 yet. So subtle things 206 00:07:52,418 --> 00:07:53,873 might actually be even 207 00:07:54,248 --> 00:07:57,271 bigger reasons why you would want to have 208 00:07:57,271 --> 00:08:00,466 closer follow or even admit. And I wanted 209 00:08:00,466 --> 00:08:02,533 to just highlight cancer pain as 1 of 210 00:08:02,533 --> 00:08:05,712 them because in the general patient population, there's 211 00:08:05,712 --> 00:08:08,196 been a pull towards you know, not wanting 212 00:08:08,196 --> 00:08:09,732 to prescribe too much 213 00:08:10,190 --> 00:08:10,690 and 214 00:08:11,147 --> 00:08:12,981 really being very cautious. And while you'd still 215 00:08:12,981 --> 00:08:13,880 have to be cautious 216 00:08:14,497 --> 00:08:16,172 in the cancer patient population, 217 00:08:17,064 --> 00:08:19,694 pain is real and the amount that we 218 00:08:19,694 --> 00:08:20,194 usually 219 00:08:21,128 --> 00:08:23,758 prescribe for the general patient population will not 220 00:08:23,758 --> 00:08:26,330 be sufficient. So if a patient came to 221 00:08:26,330 --> 00:08:28,569 for abdominal pain with their newly diagnosed colon 222 00:08:28,569 --> 00:08:28,970 cancer. 223 00:08:29,689 --> 00:08:32,190 And, you know, you wanted discharge them home 224 00:08:32,330 --> 00:08:33,450 with pain medication, 225 00:08:34,343 --> 00:08:35,935 10 pills is not going to be enough. 226 00:08:36,095 --> 00:08:37,767 It's not gonna even get them through, you 227 00:08:37,767 --> 00:08:40,735 know, the first 2 days sometimes. And so 228 00:08:40,792 --> 00:08:43,518 having that idea of the subtle things or 229 00:08:43,518 --> 00:08:44,738 the not so medically 230 00:08:45,516 --> 00:08:46,016 catastrophic 231 00:08:46,555 --> 00:08:48,872 diagnoses might actually be the reasons for repeat 232 00:08:48,872 --> 00:08:51,030 emergency medicine visits is going to be important. 233 00:08:51,921 --> 00:08:53,511 Yeah. And I wanna come back and talk 234 00:08:53,511 --> 00:08:55,498 about pain a little later, But as an 235 00:08:55,498 --> 00:08:57,962 ear physician, you know, as you mentioned, there 236 00:08:57,962 --> 00:08:59,869 are some emergent things that we need to 237 00:08:59,869 --> 00:09:02,191 know about So what are some of these 238 00:09:02,191 --> 00:09:04,656 emergent conditions that are specific to patients with 239 00:09:04,656 --> 00:09:06,247 cancer that we should be aware of? 240 00:09:07,122 --> 00:09:08,872 There's a few studies that take a look 241 00:09:08,872 --> 00:09:09,245 at 242 00:09:09,681 --> 00:09:11,290 the most common visits for 243 00:09:11,742 --> 00:09:14,199 patients with cancer visiting the ed, and some 244 00:09:14,199 --> 00:09:16,364 of them include pneumonia, gas, 245 00:09:17,149 --> 00:09:18,910 fever, of blown pain and Ill. 246 00:09:19,549 --> 00:09:21,250 And so all of these 247 00:09:21,870 --> 00:09:24,769 conditions as emerging medicine physicians, we are trained 248 00:09:24,830 --> 00:09:25,649 to recognize 249 00:09:26,204 --> 00:09:28,921 but everything in the cancer patient population is 250 00:09:28,921 --> 00:09:30,519 just more subtle the way it presents. 251 00:09:31,399 --> 00:09:32,138 Lung cancer 252 00:09:32,517 --> 00:09:34,855 is a fairly common diagnosis in 253 00:09:35,169 --> 00:09:38,362 the emergency department, and I wanted to use 254 00:09:38,362 --> 00:09:40,038 the lung cancer patient as a case. 255 00:09:40,995 --> 00:09:42,134 So they basically 256 00:09:42,592 --> 00:09:43,092 will 257 00:09:43,884 --> 00:09:45,160 come in about, you know, 258 00:09:45,957 --> 00:09:48,191 it comp about 10 to 12 percent of 259 00:09:48,191 --> 00:09:51,700 cancer related emergency department visits in overall. And 260 00:09:51,700 --> 00:09:54,268 the admission rate is 66 percent. And so 261 00:09:54,268 --> 00:09:56,182 with this type of cancer, what you're going 262 00:09:56,182 --> 00:09:57,240 to be seeing is 263 00:09:57,777 --> 00:10:01,924 besides fever respiratory symptoms, so worsening effusion along 264 00:10:01,924 --> 00:10:03,041 with neurologic issues. 265 00:10:03,853 --> 00:10:06,956 Other things to think about are subtle presentations 266 00:10:06,956 --> 00:10:09,127 like just feeling fatigue can also 267 00:10:09,502 --> 00:10:10,002 indicate 268 00:10:10,457 --> 00:10:13,574 electrolyte abnormalities or anemia. Things like that as 269 00:10:13,574 --> 00:10:13,733 well. 270 00:10:14,529 --> 00:10:16,836 Can you speak to the neurological issues? Like, 271 00:10:16,915 --> 00:10:18,983 what you mean by that specifically Monica? 272 00:10:20,112 --> 00:10:20,907 Sure. So, 273 00:10:21,543 --> 00:10:22,043 unfortunately, 274 00:10:22,417 --> 00:10:23,212 a lot of times, 275 00:10:23,769 --> 00:10:25,358 patients present to the emergency department for the 276 00:10:25,358 --> 00:10:27,130 first time, for their first diagnosis, 277 00:10:27,505 --> 00:10:28,777 and they were previously well. 278 00:10:29,907 --> 00:10:31,981 And they might have had just, you know, 279 00:10:32,061 --> 00:10:33,438 subtle symptoms, but 280 00:10:34,055 --> 00:10:34,555 neurologic 281 00:10:34,932 --> 00:10:37,803 findings that does indicate that there might be 282 00:10:37,803 --> 00:10:39,000 a meta to the brain. 283 00:10:39,654 --> 00:10:42,215 And when you think of patients that come 284 00:10:42,215 --> 00:10:43,894 to the emergency department, a lot of times 285 00:10:43,894 --> 00:10:46,134 it's for acute issues. And so that's 1 286 00:10:46,134 --> 00:10:48,308 of the reasons why they would they would 287 00:10:48,308 --> 00:10:51,656 present either seizure activity, really bad headaches and 288 00:10:51,656 --> 00:10:52,156 unfortunately, 289 00:10:53,012 --> 00:10:55,803 sometimes even altered levels of consciousness due cerebral 290 00:10:55,803 --> 00:10:57,434 edema from meta. 291 00:10:58,534 --> 00:11:00,075 So really any subtle 292 00:11:00,615 --> 00:11:04,054 neuro based symptom or sign should be taken 293 00:11:04,054 --> 00:11:06,549 seriously in our patients. That have cancer. Like, 294 00:11:06,629 --> 00:11:09,029 we should really slow our role and stop 295 00:11:09,029 --> 00:11:10,789 and think about it. Is that fair to 296 00:11:10,789 --> 00:11:10,950 say? 297 00:11:11,669 --> 00:11:13,529 I think it's such an important 298 00:11:14,083 --> 00:11:15,061 thing to highlight 299 00:11:15,594 --> 00:11:16,094 even 300 00:11:16,469 --> 00:11:19,332 with trainings that come through emergency department, when 301 00:11:19,332 --> 00:11:20,843 you think of the, you know, the path 302 00:11:20,843 --> 00:11:21,877 and monica findings, 303 00:11:22,369 --> 00:11:24,442 for certain things like core compression as an 304 00:11:24,442 --> 00:11:27,016 example, you want to actually 305 00:11:27,473 --> 00:11:30,582 catch things before you find these lower motor 306 00:11:30,582 --> 00:11:31,300 neuron symptoms. 307 00:11:31,793 --> 00:11:33,644 You wanna catch things before 308 00:11:34,018 --> 00:11:36,402 there is a problem that potentially can't be 309 00:11:36,402 --> 00:11:37,617 reversed. And so 310 00:11:38,388 --> 00:11:38,888 just 311 00:11:39,438 --> 00:11:41,273 presenting with pain. A lot of times these 312 00:11:41,273 --> 00:11:43,826 patients have had back pain for a really, 313 00:11:43,985 --> 00:11:45,921 really long time. And 314 00:11:46,393 --> 00:11:48,220 they have either seen their primary care doctor. 315 00:11:48,379 --> 00:11:50,207 Maybe they've gone through other emergency departments. 316 00:11:50,763 --> 00:11:52,830 You want to be able to catch that 317 00:11:52,830 --> 00:11:54,498 meta ta at that time. 318 00:11:55,229 --> 00:11:57,717 With early cord compressions that you don't find 319 00:11:57,774 --> 00:11:58,092 the... 320 00:11:58,649 --> 00:12:00,263 III call it the 321 00:12:00,638 --> 00:12:02,880 end symptoms because once you an end symptom. 322 00:12:03,039 --> 00:12:05,744 It's harder for radiation oncologist or nurse neurosurgery 323 00:12:05,744 --> 00:12:07,278 to really interact with things 324 00:12:07,892 --> 00:12:08,687 and make them better. 325 00:12:09,658 --> 00:12:11,574 So, Monica, I feel like 1 of the 326 00:12:11,574 --> 00:12:13,410 other common things I see in the Ed, 327 00:12:13,969 --> 00:12:16,604 often with the initial presentation of cancer or 328 00:12:16,604 --> 00:12:18,931 sometimes the way we find the cancer. Is 329 00:12:19,090 --> 00:12:21,315 Dv or Pe. So, you know, they come 330 00:12:21,315 --> 00:12:23,380 in and we end up diagnosing that, and 331 00:12:23,380 --> 00:12:24,730 then through some of those studies, we end 332 00:12:24,730 --> 00:12:26,501 up also finding a potential mali. 333 00:12:27,369 --> 00:12:29,127 Is there a different way that you would 334 00:12:29,127 --> 00:12:31,205 treat Dv or Pe in a patient that 335 00:12:31,205 --> 00:12:33,043 you also had a concern for new cancer? 336 00:12:33,603 --> 00:12:35,601 Is that something that would warrant admission? Or 337 00:12:35,601 --> 00:12:36,400 how do you approach that? 338 00:12:37,529 --> 00:12:40,153 So at Md Anderson, we have our own 339 00:12:40,153 --> 00:12:42,537 algorithm, and a lot of people are surprised 340 00:12:42,537 --> 00:12:44,048 because we send a lot of patients home. 341 00:12:45,081 --> 00:12:45,820 Not all 342 00:12:46,368 --> 00:12:47,584 Dv or Pe 343 00:12:48,039 --> 00:12:48,539 require 344 00:12:49,073 --> 00:12:51,380 emission? And so there is risk strat justification. 345 00:12:51,619 --> 00:12:54,323 Are they symptomatic when they're am, do they 346 00:12:54,323 --> 00:12:54,721 saturate? 347 00:12:55,214 --> 00:12:56,432 Do they get tachycardia 348 00:12:56,889 --> 00:12:59,520 even on Ct, if it's a pulmonary embolism, 349 00:13:00,398 --> 00:13:02,232 is their evidence of right heart strain or, 350 00:13:02,311 --> 00:13:04,959 you know, with bedside ultrasound. And so if 351 00:13:04,959 --> 00:13:06,258 you are in a 352 00:13:07,276 --> 00:13:10,174 intermediate to higher risk, it does warrant some 353 00:13:10,313 --> 00:13:12,710 observation or admission. But a lot of these 354 00:13:12,710 --> 00:13:15,508 times Dv and Pe can be found incidentally, 355 00:13:15,667 --> 00:13:17,096 and a lot of these patients can be 356 00:13:17,096 --> 00:13:19,400 sent home. The big things that I will 357 00:13:19,400 --> 00:13:19,900 always 358 00:13:20,273 --> 00:13:21,170 ask is 359 00:13:21,544 --> 00:13:22,497 is there a bleeding risk? 360 00:13:23,069 --> 00:13:26,100 And then also, sometimes, these patients have not 361 00:13:26,100 --> 00:13:29,450 had any imaging of the brain to make 362 00:13:29,450 --> 00:13:31,364 sure that there's a meta. And so I 363 00:13:31,364 --> 00:13:34,014 ask questions that might indicate that there might 364 00:13:34,014 --> 00:13:36,414 be something neurologic, like headaches, vision changes, 365 00:13:37,054 --> 00:13:40,014 stuff like that. Also certain cancers just tend 366 00:13:40,014 --> 00:13:42,495 to bleed more. And so I'm more cautious. 367 00:13:42,908 --> 00:13:43,647 Like melanoma, 368 00:13:44,502 --> 00:13:45,639 I am more cautious 369 00:13:46,095 --> 00:13:49,622 to prescribe anti to these patients because 370 00:13:49,933 --> 00:13:51,604 when they're on it, if they do have 371 00:13:51,604 --> 00:13:53,217 an intra meta, 372 00:13:53,672 --> 00:13:56,058 it bleeds, and it's pretty bad when it 373 00:13:56,058 --> 00:13:56,217 does. 374 00:13:57,349 --> 00:14:00,305 Monica, once patients are started on their appropriate 375 00:14:00,305 --> 00:14:00,785 therapies, 376 00:14:01,504 --> 00:14:02,483 radiation, chemotherapy, 377 00:14:03,262 --> 00:14:05,932 res reception, whatever it might be there are 378 00:14:05,989 --> 00:14:08,875 way too many complications to all of those 379 00:14:09,091 --> 00:14:10,761 interventions to hit all of them today. But 380 00:14:10,761 --> 00:14:12,768 if we're just kinda, like break it down 381 00:14:12,768 --> 00:14:14,045 as to what are some of the common 382 00:14:14,045 --> 00:14:16,621 things we see about. 1 of the ones 383 00:14:16,839 --> 00:14:19,155 that I feel like we run into a 384 00:14:19,155 --> 00:14:20,671 lot. Maybe you can tell us the data 385 00:14:20,671 --> 00:14:23,103 on that is Feb ne? 386 00:14:23,802 --> 00:14:26,599 Okay? So what is the latest approach to 387 00:14:26,599 --> 00:14:28,756 these patients? Like how fast do we need 388 00:14:28,756 --> 00:14:30,928 to get antibiotics in What labs do we 389 00:14:30,928 --> 00:14:33,163 need? What's our dis on those patients. Walk 390 00:14:33,163 --> 00:14:34,700 us through feb ne? 391 00:14:35,557 --> 00:14:38,132 There's a lot of data that is showing 392 00:14:38,271 --> 00:14:40,752 that the sooner you get the antibiotics into 393 00:14:40,752 --> 00:14:42,659 these patients the better. And so there's a 394 00:14:42,659 --> 00:14:45,203 lot of metrics even at our institution. You're... 395 00:14:45,521 --> 00:14:48,504 Once they hit triage, that's when the time 396 00:14:48,561 --> 00:14:50,712 starts. And so it almost is, like, treating 397 00:14:50,712 --> 00:14:53,421 a patient with stem or a stroke. So 398 00:14:53,421 --> 00:14:55,174 the clock starts, and you really need to 399 00:14:55,174 --> 00:14:55,833 be getting 400 00:14:56,703 --> 00:15:00,851 antibiotics into these patients within the hour, ideally 401 00:15:00,851 --> 00:15:01,409 30 minutes. 402 00:15:02,127 --> 00:15:04,360 And I do wanna just add a little 403 00:15:04,360 --> 00:15:06,136 caveat for antibiotics 404 00:15:06,450 --> 00:15:08,850 because a lot of times, we think antibiotics 405 00:15:08,850 --> 00:15:10,149 they need Van 406 00:15:11,009 --> 00:15:13,970 and a broad spectrum beta lac antibiotic. 407 00:15:14,383 --> 00:15:15,896 And so I see a lot of times 408 00:15:15,896 --> 00:15:18,445 everyone does the combination, but you actually only 409 00:15:18,445 --> 00:15:21,152 need 1. You only need to add brush 410 00:15:21,152 --> 00:15:24,139 spectrum beta lac antibiotic. And so mono therapy 411 00:15:24,279 --> 00:15:26,779 that has your anti activity like ce 412 00:15:27,159 --> 00:15:28,839 is fine. You don't need to add the 413 00:15:28,839 --> 00:15:30,919 van of my son unless you suspect Mrsa. 414 00:15:31,480 --> 00:15:34,606 But the time that you initiate antibiotic administration 415 00:15:34,606 --> 00:15:35,484 really does matter. 416 00:15:36,042 --> 00:15:37,419 I think they did a study 417 00:15:37,797 --> 00:15:41,067 where they basically looked and saw what the 418 00:15:41,067 --> 00:15:44,033 mortality risk were. And basically, if you get 419 00:15:44,033 --> 00:15:47,782 antibiotics in before 60 minutes, the decrease is 420 00:15:47,782 --> 00:15:48,659 actually significant. 421 00:15:49,138 --> 00:15:51,132 And for each hour of delay that you 422 00:15:51,132 --> 00:15:51,632 have 423 00:15:51,944 --> 00:15:53,373 it increases risk by 18 percent. 424 00:15:54,088 --> 00:15:55,438 Now on the other side, 425 00:15:56,073 --> 00:15:57,979 a lot of colleagues when they come to 426 00:15:57,979 --> 00:15:59,805 md Anderson are surprised that how many people 427 00:15:59,805 --> 00:16:03,074 we discharge. And The goal is trending towards 428 00:16:03,074 --> 00:16:05,477 trying to transition them to home sooner 429 00:16:05,929 --> 00:16:08,884 in a certain subset of patient population. Also, 430 00:16:09,764 --> 00:16:11,845 feb ne is not treated the same with 431 00:16:11,845 --> 00:16:13,144 hem mali, 432 00:16:13,524 --> 00:16:16,804 like lymphoma leukemia, myeloma as solid tumors. 433 00:16:17,539 --> 00:16:18,758 So solid tumors 434 00:16:19,377 --> 00:16:20,356 depending on 435 00:16:20,735 --> 00:16:23,052 if a patient is able to follow up 436 00:16:23,052 --> 00:16:25,064 if they live within for us I think 437 00:16:25,064 --> 00:16:27,222 it's a, like, a 30 minute radius. 438 00:16:27,781 --> 00:16:30,018 We can actually discharge them home if they're 439 00:16:30,018 --> 00:16:30,418 reliable. 440 00:16:30,897 --> 00:16:33,235 And so we do it outpatient ne panic 441 00:16:33,948 --> 00:16:37,058 follow up for patients that if we actually 442 00:16:37,058 --> 00:16:38,494 work them up in the emergency department, and 443 00:16:38,494 --> 00:16:40,488 they don't have a source of infection, we 444 00:16:40,488 --> 00:16:42,402 can send home if they're reliable take their 445 00:16:42,402 --> 00:16:44,170 antibiotics if they can come back for their, 446 00:16:45,045 --> 00:16:46,158 repeat labs as well. 447 00:16:47,192 --> 00:16:50,215 Solid tumors. Yeah. Solid tumors. For liquid tumors, 448 00:16:50,548 --> 00:16:53,088 that's not the case. Liquid tumors they get 449 00:16:53,088 --> 00:16:55,310 admitted because they just have a higher higher 450 00:16:55,310 --> 00:16:56,048 risk for 451 00:16:56,580 --> 00:16:57,715 morbidity and mortality 452 00:16:58,105 --> 00:17:00,185 And the way that you can determine for 453 00:17:00,185 --> 00:17:01,085 solid tumors 454 00:17:01,625 --> 00:17:03,725 in the emergency department, they, they do have 455 00:17:03,785 --> 00:17:06,839 a mask score and so mask stands for 456 00:17:06,839 --> 00:17:07,500 a multi 457 00:17:07,880 --> 00:17:08,380 multinational 458 00:17:08,680 --> 00:17:10,359 association for supportive of care and cancer. 459 00:17:10,839 --> 00:17:13,160 And it's an index score that basically when 460 00:17:13,160 --> 00:17:15,166 you apply to the onset fever and take 461 00:17:15,166 --> 00:17:17,173 a look at the the criteria. 462 00:17:17,864 --> 00:17:20,006 If the score is less than 21 points. 463 00:17:20,164 --> 00:17:20,958 There's a low risk. 464 00:17:21,609 --> 00:17:24,160 For mortality, and you can you can consider 465 00:17:24,160 --> 00:17:24,719 saying them home. 466 00:17:25,835 --> 00:17:27,509 What do you recommend? Do you give a 467 00:17:27,509 --> 00:17:30,220 dose of zone for those patients that you 468 00:17:30,220 --> 00:17:32,069 discharge so that you have that kind deb 469 00:17:32,069 --> 00:17:33,982 effect in last seen 24 hours Monica? Or 470 00:17:33,982 --> 00:17:35,496 do you just go with that dose pain 471 00:17:35,496 --> 00:17:36,373 when you're discharging, 472 00:17:37,090 --> 00:17:39,654 the patients that can go home? So how 473 00:17:39,654 --> 00:17:41,745 we would do it is if you're not 474 00:17:41,802 --> 00:17:43,950 panic, and if there is no fever source, 475 00:17:44,268 --> 00:17:46,677 you might not actually get sent home on 476 00:17:46,734 --> 00:17:47,132 antibiotic. 477 00:17:48,102 --> 00:17:49,374 Especially with a lot of these, you know, 478 00:17:49,533 --> 00:17:50,829 viral illnesses 479 00:17:51,522 --> 00:17:53,272 that are going around that sometimes the viral 480 00:17:53,272 --> 00:17:53,908 panels don't check. 481 00:17:54,878 --> 00:17:57,908 So the patients that are potentially okay to 482 00:17:57,908 --> 00:18:00,300 send home would be solid tumor patients that 483 00:18:00,300 --> 00:18:01,974 do not have a source of infection found 484 00:18:01,974 --> 00:18:03,170 on your work up, the source. 485 00:18:03,904 --> 00:18:05,502 Being when you do a chest x rate 486 00:18:05,502 --> 00:18:08,698 to look for pneumonia along with a your 487 00:18:08,698 --> 00:18:10,696 analysis to make sure that there's no urinary 488 00:18:10,696 --> 00:18:12,866 tract infection. I will put a caveat in 489 00:18:12,866 --> 00:18:13,765 for the respiratory 490 00:18:14,142 --> 00:18:16,556 infections because if the patient is symptomatic 491 00:18:16,934 --> 00:18:19,406 enough, it might warrant observation even though there 492 00:18:19,406 --> 00:18:19,906 isn't 493 00:18:20,363 --> 00:18:22,372 antibiotic or a treatment you need to give. 494 00:18:22,930 --> 00:18:25,321 But for the patients that are well appearing. 495 00:18:25,560 --> 00:18:27,575 At md Anderson, we have a 496 00:18:28,270 --> 00:18:31,395 outpatient ne panic fever pathway, and there are 497 00:18:31,395 --> 00:18:32,135 some criteria. 498 00:18:32,831 --> 00:18:35,384 So the patient has to live within an 499 00:18:35,384 --> 00:18:37,874 hour away from our institution. As well as 500 00:18:37,874 --> 00:18:39,631 be reliable to be able to come back 501 00:18:39,631 --> 00:18:41,788 for further work up and be able to 502 00:18:41,788 --> 00:18:42,848 tolerate oral 503 00:18:43,307 --> 00:18:44,765 to take Antibiotics 504 00:18:45,078 --> 00:18:47,861 and also have someone with them to monitor 505 00:18:47,861 --> 00:18:48,179 things. 506 00:18:48,974 --> 00:18:51,598 And if you are gonna send these patients 507 00:18:51,598 --> 00:18:52,814 home, then 508 00:18:53,363 --> 00:18:53,863 the 509 00:18:54,320 --> 00:18:56,631 antibiotic choice you give them 2. First line 510 00:18:56,631 --> 00:18:59,044 therapy can be super in, 07:50 511 00:18:59,261 --> 00:19:00,776 milligrams po twice daily. 512 00:19:01,427 --> 00:19:02,245 Plus a 513 00:19:02,858 --> 00:19:03,358 slash 514 00:19:03,733 --> 00:19:04,051 acid, 515 00:19:04,687 --> 00:19:07,788 and that is for 7 days. And if 516 00:19:07,788 --> 00:19:08,924 there is a documented 517 00:19:09,314 --> 00:19:10,609 like, really serious beta. 518 00:19:11,541 --> 00:19:13,155 What you can do is tip 519 00:19:13,689 --> 00:19:15,996 and cli mason, 600 milligrams. 520 00:19:16,566 --> 00:19:16,804 Po, 521 00:19:17,597 --> 00:19:19,182 3 times a day for 7 days. 522 00:19:20,689 --> 00:19:23,146 So Monica talked to me about tumor l 523 00:19:23,146 --> 00:19:23,543 syndrome. 524 00:19:24,192 --> 00:19:25,543 When should we be looking for that in 525 00:19:25,543 --> 00:19:27,211 the Ed and what kind of work workout 526 00:19:27,211 --> 00:19:27,846 should we be doing? 527 00:19:28,561 --> 00:19:31,182 With tumor l syndrome, you have tumors that 528 00:19:31,182 --> 00:19:32,929 are high risk that have high risk tumor 529 00:19:32,929 --> 00:19:33,247 burden? 530 00:19:33,740 --> 00:19:35,039 So think of your 531 00:19:35,500 --> 00:19:36,539 advanced b lymphoma, 532 00:19:37,019 --> 00:19:37,920 advanced leukemia 533 00:19:38,460 --> 00:19:41,180 or even your early diagnosis of leukemia. 534 00:19:41,672 --> 00:19:42,861 So liquid tumors. 535 00:19:43,337 --> 00:19:46,112 And then you can get it sometimes in 536 00:19:46,112 --> 00:19:48,831 the solid cancers, but think more of 537 00:19:49,539 --> 00:19:52,339 when the patients are receiving treatment because usually, 538 00:19:52,819 --> 00:19:55,940 with tumor syndrome for the for lymphoma and 539 00:19:55,940 --> 00:19:56,339 leukemia, 540 00:19:56,740 --> 00:19:59,547 it's pre treatment with the solid tumors, you 541 00:19:59,547 --> 00:20:01,861 think of it after post treatment when the 542 00:20:01,861 --> 00:20:02,578 tumors are l. 543 00:20:03,216 --> 00:20:05,769 But the thing that I want to share. 544 00:20:06,088 --> 00:20:07,699 And again, I keep on saying this over 545 00:20:07,699 --> 00:20:09,137 and over again is subtlety. 546 00:20:10,016 --> 00:20:12,333 Because you wanted to catch things early on. 547 00:20:12,653 --> 00:20:14,890 Most of these patients if they are solid 548 00:20:14,890 --> 00:20:17,694 tumors They will have had labs previously. And 549 00:20:17,694 --> 00:20:20,162 so there's grading criteria for tumor l syndrome. 550 00:20:20,481 --> 00:20:23,188 And so on your lab values, they might 551 00:20:23,188 --> 00:20:25,586 not be super high, but the trend has 552 00:20:25,586 --> 00:20:26,221 been higher. 553 00:20:26,697 --> 00:20:30,110 And these oncologists teams really definitely take that 554 00:20:30,110 --> 00:20:30,610 seriously 555 00:20:30,983 --> 00:20:33,859 and in our institution will actually put an 556 00:20:33,859 --> 00:20:36,641 observation or admit for early tumor l syndrome. 557 00:20:37,197 --> 00:20:39,661 There are lab values that normally we don't 558 00:20:39,661 --> 00:20:40,479 routinely get 559 00:20:41,107 --> 00:20:43,971 as emergency medicine positions. And so if you 560 00:20:43,971 --> 00:20:46,039 are suspecting that you have a patient that 561 00:20:46,039 --> 00:20:48,919 presented with fatigue of possible new leukemia. You 562 00:20:48,919 --> 00:20:50,751 need to add these slabs on such as 563 00:20:50,751 --> 00:20:52,264 uric acid and L. 564 00:20:53,060 --> 00:20:54,892 I think those are the 2 main ones 565 00:20:54,892 --> 00:20:55,928 that we don't think about. 566 00:20:56,898 --> 00:20:58,094 That are important. 567 00:20:58,731 --> 00:21:00,006 But with tumor l syndrome, 568 00:21:00,563 --> 00:21:02,715 you have laboratory criteria and clinical. 569 00:21:03,193 --> 00:21:03,693 And 570 00:21:04,481 --> 00:21:05,992 for us really clinical, 571 00:21:06,469 --> 00:21:08,536 it it's all about trends. So if the 572 00:21:08,536 --> 00:21:10,762 clinical Tls is, like increase crab, 573 00:21:11,637 --> 00:21:14,360 1.5 times upper limit of normal. So that's 574 00:21:14,360 --> 00:21:16,519 easy for us to look at. But then 575 00:21:16,519 --> 00:21:19,320 the other criteria is like cardiac arrhythmias or 576 00:21:19,320 --> 00:21:21,400 sudden in death and seizures. These are end 577 00:21:21,400 --> 00:21:23,248 stage things. So I don't wanna, you know, 578 00:21:23,407 --> 00:21:25,712 put on my diagnosis clinical Tl. That means 579 00:21:25,712 --> 00:21:28,176 that potentially, we've missed it multiple other times. 580 00:21:28,335 --> 00:21:29,606 And so that's why I wanted to just 581 00:21:29,606 --> 00:21:32,004 kinda put in a plug for making sure 582 00:21:32,004 --> 00:21:34,149 to look at trends instead of just the 583 00:21:34,149 --> 00:21:37,484 actual laboratory clinical because catching things early is 584 00:21:37,484 --> 00:21:37,723 important. 585 00:21:38,850 --> 00:21:41,312 Are there any specific symptoms that might tip 586 00:21:41,312 --> 00:21:43,138 you off to be looking for tumor l 587 00:21:43,138 --> 00:21:43,377 syndrome? 588 00:21:44,330 --> 00:21:45,203 That's the problem. 589 00:21:45,918 --> 00:21:47,530 Everything is subtle when 590 00:21:48,240 --> 00:21:50,180 you think about a logic emergencies. 591 00:21:50,559 --> 00:21:53,279 For tumor, it might just be fatigue. It 592 00:21:53,279 --> 00:21:55,440 just might be some decreased Po and take 593 00:21:55,440 --> 00:21:58,335 and decreased urination. And so being able to 594 00:21:58,335 --> 00:21:59,934 pick up on these subtle sides, I think 595 00:21:59,934 --> 00:22:01,075 it's important because 596 00:22:01,454 --> 00:22:03,214 we're taught to look for, you know, bigger 597 00:22:03,214 --> 00:22:05,869 findings even on r board to these big 598 00:22:05,869 --> 00:22:07,329 findings, but it's the subtlety 599 00:22:07,710 --> 00:22:09,549 that I think is the most important to 600 00:22:09,549 --> 00:22:12,190 remember that once you see patients that presents 601 00:22:12,190 --> 00:22:14,353 with your altered mental status with, you know, 602 00:22:14,512 --> 00:22:15,148 your arrhythmias, 603 00:22:15,863 --> 00:22:17,929 that's a bit late or a lot late. 604 00:22:20,489 --> 00:22:23,119 I hate to see a child come into 605 00:22:23,119 --> 00:22:25,374 the emergency department with mu. 606 00:22:25,910 --> 00:22:28,461 Talk to us about which groups are at 607 00:22:28,461 --> 00:22:30,013 highest risk from? 608 00:22:30,788 --> 00:22:32,143 And then I think we can all kind 609 00:22:32,143 --> 00:22:34,535 of visually see that diagnosis. But, like, what 610 00:22:34,535 --> 00:22:36,448 can we do to help our patients with 611 00:22:36,448 --> 00:22:36,948 mu? 612 00:22:38,454 --> 00:22:40,067 I think patients receiving 613 00:22:40,759 --> 00:22:42,985 radiation to, you, the head and neck are 614 00:22:42,985 --> 00:22:45,313 really at most risk because 615 00:22:45,702 --> 00:22:47,766 It's not just the pain, but it's also 616 00:22:47,766 --> 00:22:50,250 being able to hydrate. And so with the 617 00:22:50,384 --> 00:22:53,241 dehydration, everything gets worse as well. And so 618 00:22:53,479 --> 00:22:53,979 I 619 00:22:54,369 --> 00:22:56,704 want to put in a plug to get 620 00:22:56,763 --> 00:22:59,635 specialist onboard early if you have the resources. 621 00:22:59,875 --> 00:23:01,811 I think that's the most important thing because 622 00:23:02,203 --> 00:23:04,033 mu is not going to go away. A 623 00:23:04,033 --> 00:23:05,067 lot of times these regiments, 624 00:23:05,544 --> 00:23:07,056 for radiation, it's multiple times. 625 00:23:07,772 --> 00:23:08,510 And so 626 00:23:08,885 --> 00:23:10,317 someone needs to be following up to make 627 00:23:10,317 --> 00:23:13,044 sure that symptoms are improving and to catch 628 00:23:13,044 --> 00:23:15,358 things early. A lot of times patients might 629 00:23:15,358 --> 00:23:16,395 need hydration, 630 00:23:17,432 --> 00:23:19,042 hopefully not in the most, but it can 631 00:23:19,042 --> 00:23:21,194 be set up as an outpatient. And so 632 00:23:21,194 --> 00:23:23,367 we have our palliative care services 633 00:23:23,823 --> 00:23:26,783 that help with symptom management and getting them 634 00:23:26,783 --> 00:23:28,770 onboard early, not at end of life is 635 00:23:28,770 --> 00:23:30,518 going to be the most important because I 636 00:23:30,518 --> 00:23:31,336 have a few 637 00:23:32,267 --> 00:23:34,865 medications that I can prescribe from my toolbox 638 00:23:35,064 --> 00:23:37,378 but really, it's the follow ups. So if 639 00:23:37,458 --> 00:23:39,773 I just discharged on this medication in 3 640 00:23:39,773 --> 00:23:41,768 days did it help. And if it didn't, 641 00:23:42,247 --> 00:23:43,066 having someone 642 00:23:43,459 --> 00:23:46,409 in the outpatient setting, be able to work 643 00:23:46,409 --> 00:23:48,482 with that patients that they don't come back 644 00:23:48,482 --> 00:23:50,475 to the emergency department even worse than before 645 00:23:50,475 --> 00:23:51,671 is going to be the most important thing. 646 00:23:52,402 --> 00:23:54,092 What medications do you usually 647 00:23:54,465 --> 00:23:56,155 prescribe for somebody who has mu? 648 00:23:56,766 --> 00:23:59,067 So you can do topical mouth washes. 649 00:23:59,558 --> 00:24:01,013 And rinse for 650 00:24:01,786 --> 00:24:02,104 treatment, 651 00:24:02,741 --> 00:24:04,332 there isn't in a 1 size fits all 652 00:24:04,332 --> 00:24:07,435 approach. So sometimes vis lid might help as 653 00:24:07,435 --> 00:24:10,475 well. But personally for me, I'm not as 654 00:24:10,475 --> 00:24:11,988 successful in treatment. 655 00:24:12,625 --> 00:24:13,898 That's why it's 1 of the things that 656 00:24:13,978 --> 00:24:16,048 I actually get my palliative care colleagues on 657 00:24:16,048 --> 00:24:16,606 board early. 658 00:24:17,258 --> 00:24:19,565 Because it is very, very difficult to treat. 659 00:24:20,201 --> 00:24:22,747 Things that you shouldn't use, I think I 660 00:24:22,747 --> 00:24:25,071 just wanted to highlight as well. Ci fate 661 00:24:25,071 --> 00:24:28,121 isn't as helpful for radiation, induced oral mu. 662 00:24:28,577 --> 00:24:31,525 And then another thing is sometimes you will 663 00:24:31,525 --> 00:24:32,423 need to use 664 00:24:33,039 --> 00:24:33,915 systemic anal logistics. 665 00:24:34,409 --> 00:24:35,368 Like oral op. 666 00:24:35,847 --> 00:24:38,244 That's something for for us that we use 667 00:24:38,244 --> 00:24:40,422 quite commonly. It doesn't 668 00:24:40,801 --> 00:24:43,214 target specifically the area but but it does 669 00:24:43,214 --> 00:24:45,212 help as while. And so doing a, you 670 00:24:45,212 --> 00:24:47,689 know, topical mouth washer rinse and then giving 671 00:24:47,689 --> 00:24:50,566 an oral anal music is something that I 672 00:24:50,566 --> 00:24:51,845 usually do in the mercy department. 673 00:24:53,136 --> 00:24:55,767 Another very common thing that patients come in 674 00:24:55,767 --> 00:24:56,006 with, 675 00:24:56,644 --> 00:24:58,956 especially those who are currently in treatment. The 676 00:24:58,956 --> 00:25:01,204 are coming in with nausea or vomiting. And 677 00:25:01,204 --> 00:25:03,525 they've already tried whatever they have at home 678 00:25:03,525 --> 00:25:05,924 and they still can't keep anything down. So 679 00:25:05,924 --> 00:25:07,125 they end up coming to the Ed. 680 00:25:07,684 --> 00:25:09,924 Do you have any recommendations for approaching treatment 681 00:25:09,924 --> 00:25:10,740 for these patients. 682 00:25:12,100 --> 00:25:13,480 Nausea vomiting is 683 00:25:14,259 --> 00:25:15,539 notoriously difficult to treat. 684 00:25:16,180 --> 00:25:18,994 I think education is important because sometimes you 685 00:25:18,994 --> 00:25:21,069 think that the patient has failed their medications, 686 00:25:21,229 --> 00:25:22,985 but they weren't educated to take something around 687 00:25:22,985 --> 00:25:25,699 the clock, or they didn't have, like, a 688 00:25:25,699 --> 00:25:27,535 first line and a second line agent that 689 00:25:27,535 --> 00:25:27,990 you could 690 00:25:28,508 --> 00:25:29,465 alternate as well. 691 00:25:30,262 --> 00:25:31,879 We have an observation unit 692 00:25:32,336 --> 00:25:32,836 because 693 00:25:33,372 --> 00:25:35,924 sometimes even with the best intentions and then 694 00:25:35,924 --> 00:25:37,494 the patients have tried their best 695 00:25:38,089 --> 00:25:40,549 it just doesn't work. And so making sure 696 00:25:40,549 --> 00:25:41,049 that 697 00:25:41,976 --> 00:25:42,476 you 698 00:25:43,087 --> 00:25:45,247 have a low threshold to act really observe 699 00:25:45,247 --> 00:25:47,560 or admit these patients important to because getting 700 00:25:47,560 --> 00:25:49,576 dehydrated and not being able to tolerate Po 701 00:25:49,634 --> 00:25:50,852 also has its 702 00:25:51,229 --> 00:25:53,144 issues and things can go downhill really fast. 703 00:25:53,941 --> 00:25:54,441 Consider 704 00:25:54,913 --> 00:25:58,500 observing them for some prolonged Iv fluid hydration 705 00:25:58,500 --> 00:26:00,892 because a lot of times, there's no overnight 706 00:26:00,892 --> 00:26:02,486 magical pill that'll make things better. 707 00:26:03,694 --> 00:26:06,238 And is on, your go to anti. 708 00:26:06,794 --> 00:26:08,884 I have generally been taught that on oncology 709 00:26:08,940 --> 00:26:11,507 patients often get very high doses of on 710 00:26:12,214 --> 00:26:14,123 So what is your threshold? How high do 711 00:26:14,123 --> 00:26:15,873 you go in terms of dosing? And are 712 00:26:15,873 --> 00:26:18,259 you getting Ekg to check their Q? 713 00:26:19,308 --> 00:26:20,444 A lot of our patients 714 00:26:20,898 --> 00:26:24,156 have Ekg already, but if they don't, prior 715 00:26:24,156 --> 00:26:26,222 to starting Z, I actually will get an 716 00:26:26,460 --> 00:26:27,993 Ekg just to get a good baseline 717 00:26:28,464 --> 00:26:30,144 because to be honest, most of the anti 718 00:26:30,144 --> 00:26:33,044 medics cause some sort of, like, Q prolong. 719 00:26:33,424 --> 00:26:35,184 There's always the side effects that we need 720 00:26:35,184 --> 00:26:37,434 to just make sure at baseline we're not 721 00:26:37,434 --> 00:26:38,472 making anything worse. 722 00:26:39,110 --> 00:26:41,185 Z is our go to. It's even on 723 00:26:41,185 --> 00:26:43,394 our order sets. I don't know how high 724 00:26:43,594 --> 00:26:45,352 you guys do for regular because I haven't 725 00:26:45,352 --> 00:26:47,929 seen a regular quote unquote, like a regular 726 00:26:48,148 --> 00:26:50,146 patient in the general population. But we we 727 00:26:50,146 --> 00:26:51,105 start off with 8 milligrams. 728 00:26:51,680 --> 00:26:53,779 We don't really keep on trying 729 00:26:54,240 --> 00:26:57,599 the same medication once 8 milligrams doesn't work 730 00:26:57,599 --> 00:26:59,612 because there's many different types. That you can 731 00:26:59,612 --> 00:27:00,590 use. And so 732 00:27:01,126 --> 00:27:03,459 using a different medication as a second line 733 00:27:03,597 --> 00:27:05,749 is what I and what we do at 734 00:27:05,988 --> 00:27:06,546 Md Anderson. 735 00:27:07,039 --> 00:27:08,951 If z, 8 milligrams milligram didn't work at 736 00:27:08,951 --> 00:27:11,262 that time, then we'll switch to something different. 737 00:27:12,377 --> 00:27:13,753 What about chemotherapy 738 00:27:14,130 --> 00:27:17,733 induced diarrhea, how do we help those patients 739 00:27:17,733 --> 00:27:19,651 that are having per diarrhea. 740 00:27:20,770 --> 00:27:21,969 I sound like a broken record. 741 00:27:24,446 --> 00:27:25,485 Everything is subtle. 742 00:27:26,379 --> 00:27:28,476 Even if the patient isn't having 743 00:27:29,333 --> 00:27:31,749 explosive diarrhea. Sometimes they're really 744 00:27:32,446 --> 00:27:34,362 embarrassed to say how many times, but ask 745 00:27:34,362 --> 00:27:35,080 how many times. 746 00:27:35,733 --> 00:27:37,161 This is a a story that I had 747 00:27:37,161 --> 00:27:38,590 when I was a fellow. You know I 748 00:27:38,590 --> 00:27:39,780 said, how many times have you been having 749 00:27:39,780 --> 00:27:42,796 diarrhea only once, but it basically was a 750 00:27:42,796 --> 00:27:43,669 cost leak the whole day. 751 00:27:44,319 --> 00:27:47,917 So that's that's pretty bad. Isn't it? But 752 00:27:48,609 --> 00:27:49,109 but 753 00:27:49,880 --> 00:27:51,365 it's important to know that 754 00:27:51,884 --> 00:27:55,025 patients receiving chemotherapy treatments and other therapies. 755 00:27:55,565 --> 00:27:57,164 When they start having diarrhea, they're just more 756 00:27:57,164 --> 00:28:00,125 frail. And so have a lower threshold to 757 00:28:00,125 --> 00:28:01,890 actually and I and it like, this is 758 00:28:01,890 --> 00:28:03,637 why it sound like broken record, observe the 759 00:28:03,637 --> 00:28:06,733 patient or admit them for Iv hydration. Also, 760 00:28:06,892 --> 00:28:08,344 it's important to find out why 761 00:28:08,654 --> 00:28:10,174 they're having the diarrhea. 762 00:28:10,494 --> 00:28:12,414 We like to think most common things are 763 00:28:12,414 --> 00:28:12,654 common. 764 00:28:13,294 --> 00:28:14,034 And so 765 00:28:14,335 --> 00:28:15,774 we'll be the first to say, okay. It's 766 00:28:15,774 --> 00:28:16,835 just due to chemotherapy. 767 00:28:17,375 --> 00:28:19,613 But In this patient population, I think it's 768 00:28:19,613 --> 00:28:21,675 important to also make sure that our first 769 00:28:21,675 --> 00:28:23,578 offer for diagnosis is actually true. So sending 770 00:28:23,578 --> 00:28:25,694 stool studies, making sure that 771 00:28:26,132 --> 00:28:29,471 it's not due to colitis because cancer therapeutics 772 00:28:29,471 --> 00:28:32,173 have changed dramatically over the last 10 years. 773 00:28:32,332 --> 00:28:34,161 So when you say someone's on chemotherapy, the 774 00:28:34,161 --> 00:28:36,562 first thing that comes to mind in my 775 00:28:36,562 --> 00:28:38,096 head is, are they only on chemotherapy? 776 00:28:38,471 --> 00:28:41,096 Or have they had a treatment prior and 777 00:28:41,096 --> 00:28:42,050 then they're back on chemotherapy? 778 00:28:42,542 --> 00:28:44,605 Or are they chemotherapy planning for another different 779 00:28:44,605 --> 00:28:46,826 treatment because it changes things. A lot of 780 00:28:46,826 --> 00:28:49,500 times chemotherapy now are used in conjunction with 781 00:28:50,019 --> 00:28:53,136 immune checkpoint inhibitors, other treatments. And so when 782 00:28:53,136 --> 00:28:54,115 you say chemotherapy 783 00:28:54,814 --> 00:28:57,611 related diarrhea, it could actually potentially mean an 784 00:28:57,611 --> 00:28:58,970 immune checkpoint inhibitor diarrhea. 785 00:28:59,463 --> 00:29:01,395 And there's grading skills for that and 786 00:29:01,849 --> 00:29:04,554 treatments that need to be followed if it's 787 00:29:04,554 --> 00:29:07,037 due to that. And so if the patient 788 00:29:07,037 --> 00:29:08,553 has on immune checkpoint inhibitors, 789 00:29:09,112 --> 00:29:11,585 do a Ct scan. If you find colitis, 790 00:29:11,984 --> 00:29:14,314 that is also concerning other labs for me 791 00:29:14,314 --> 00:29:16,471 checkpoint inhibitors would be Es Crp, 792 00:29:16,951 --> 00:29:19,908 checking if other body systems are affected like, 793 00:29:20,067 --> 00:29:22,225 adding a Tsa chunk because that's usually silent 794 00:29:22,225 --> 00:29:24,559 too. So doing more of a work up 795 00:29:24,559 --> 00:29:26,880 than what you would normally do is going 796 00:29:26,880 --> 00:29:29,119 to be the most important for these patients 797 00:29:29,119 --> 00:29:31,214 even with chemotherapy and do area. Make sure 798 00:29:31,214 --> 00:29:32,494 it's not c diff. A lot of times 799 00:29:32,494 --> 00:29:35,454 these patients have had antibiotic usage prior. 800 00:29:36,174 --> 00:29:37,394 It's kind of a 801 00:29:38,108 --> 00:29:39,858 big black box of babies. 802 00:29:40,971 --> 00:29:42,801 The next thing I wanted to get to 803 00:29:42,801 --> 00:29:44,256 is anemia and t. 804 00:29:45,043 --> 00:29:46,866 Because I know that this may be managed 805 00:29:46,866 --> 00:29:49,799 differently in our oncology patients than in our 806 00:29:49,799 --> 00:29:50,592 patients without cancer. 807 00:29:51,861 --> 00:29:55,301 For us, if the patient has hemoglobin below 808 00:29:55,301 --> 00:29:57,396 8, then we routinely trans, 809 00:29:57,774 --> 00:30:00,028 but most of our patients are walking around 810 00:30:00,247 --> 00:30:04,268 with hemoglobin less than 12. For sure. Platelets 811 00:30:04,563 --> 00:30:07,824 will be less than 15 trans fuse. That's 812 00:30:07,824 --> 00:30:08,722 our criteria. 813 00:30:09,909 --> 00:30:11,925 Monica, some of our patients come through 814 00:30:12,303 --> 00:30:12,803 with 815 00:30:13,421 --> 00:30:14,479 radiation specifically 816 00:30:15,017 --> 00:30:17,651 as a treatment modality. What are some of 817 00:30:17,651 --> 00:30:18,151 the 818 00:30:19,099 --> 00:30:22,122 complications that are specific to radiation interventions. 819 00:30:23,951 --> 00:30:25,940 So it depends on the area that's being 820 00:30:25,940 --> 00:30:26,440 radiate. 821 00:30:26,989 --> 00:30:28,765 But we already talked about 822 00:30:29,461 --> 00:30:31,955 or having bowel absorption symptoms, diarrhea, 823 00:30:32,971 --> 00:30:35,683 if you're getting it to your thoracic area 824 00:30:35,683 --> 00:30:36,422 having p, 825 00:30:37,372 --> 00:30:39,284 and p is a little bit difficult because... 826 00:30:39,444 --> 00:30:41,117 It can present with a lot of symptoms 827 00:30:41,117 --> 00:30:43,348 that are similar to pneumonia. So those are 828 00:30:43,348 --> 00:30:44,782 some of the common things that you will 829 00:30:44,782 --> 00:30:46,376 see with patients with radiation. 830 00:30:47,109 --> 00:30:49,826 I also wanna say with patients with radiation, 831 00:30:50,225 --> 00:30:51,125 you have 832 00:30:51,504 --> 00:30:54,300 acute symptoms, but also don't really about chronic 833 00:30:54,300 --> 00:30:54,700 symptoms. 834 00:30:55,113 --> 00:30:56,226 And so a lot of times in the 835 00:30:56,226 --> 00:30:58,293 emergency department, we all always think about, you 836 00:30:58,293 --> 00:31:00,439 know, what brings you to emergency department. And 837 00:31:00,439 --> 00:31:02,505 your time to present illness is, you know 838 00:31:02,505 --> 00:31:04,015 when the last 2 weeks or 3 weeks. 839 00:31:04,269 --> 00:31:06,347 And you don't think that certain things that 840 00:31:06,347 --> 00:31:08,765 happened maybe a year or 2 years prior 841 00:31:08,905 --> 00:31:10,663 could be the the reason for that. 842 00:31:11,862 --> 00:31:12,362 Radiation 843 00:31:12,820 --> 00:31:13,640 side effects 844 00:31:14,034 --> 00:31:15,171 There's a lot of chronic 845 00:31:15,628 --> 00:31:18,577 complications too like diarrhea and m absorption and 846 00:31:18,577 --> 00:31:21,366 p meningitis as well that can present long 847 00:31:21,366 --> 00:31:21,866 term 848 00:31:22,336 --> 00:31:24,398 it's a reason for patients to represent to 849 00:31:24,398 --> 00:31:26,699 the Emergency department too for the chronic complications. 850 00:31:30,211 --> 00:31:32,285 Communication with the patient is key. When you 851 00:31:32,285 --> 00:31:35,476 find something that might be cancer, please tell 852 00:31:35,476 --> 00:31:37,981 the patient put it on the discharge summary 853 00:31:38,037 --> 00:31:40,263 and help with the follow up, but don't 854 00:31:40,263 --> 00:31:41,319 lock in the diagnosis. 855 00:31:42,329 --> 00:31:43,306 Feb Ne. 856 00:31:44,414 --> 00:31:46,572 Antibiotics need to be given within 1 hour 857 00:31:46,572 --> 00:31:47,631 of hitting triage 858 00:31:48,010 --> 00:31:49,289 ideally within 30 minutes. 859 00:31:49,928 --> 00:31:52,566 Treat with ce and Van mice if you 860 00:31:52,566 --> 00:31:53,205 suspect Mrsa. 861 00:31:54,098 --> 00:31:56,488 Standardize with order sets and policies and set 862 00:31:56,488 --> 00:31:58,878 up discharge and ad criteria with your colleagues. 863 00:31:59,595 --> 00:32:01,667 When it comes to tumor l syndrome, it 864 00:32:01,667 --> 00:32:03,362 is important to look at trends 865 00:32:03,673 --> 00:32:05,344 not just the current values. 866 00:32:05,742 --> 00:32:07,573 You may catch it early if the values 867 00:32:07,573 --> 00:32:08,289 are trending up. 868 00:32:09,005 --> 00:32:12,450 Mu is tricky to treat and worth involving 869 00:32:12,507 --> 00:32:14,276 specialist for treatment and disposition. 870 00:32:15,153 --> 00:32:16,828 Nausea and vomiting can be a sign of 871 00:32:16,828 --> 00:32:17,785 something greater. 872 00:32:19,141 --> 00:32:21,135 Dehydration can be problematic and hard to treat, 873 00:32:21,294 --> 00:32:24,601 so consider admitting for Iv fluids and figuring 874 00:32:24,740 --> 00:32:26,814 out why we have the nausea vomiting. 875 00:32:27,452 --> 00:32:30,005 You can use z, 8 milligrams right off 876 00:32:30,005 --> 00:32:31,700 the bat. If it doesn't work, the first 877 00:32:31,700 --> 00:32:32,900 time they'll move on. 878 00:32:33,859 --> 00:32:34,660 Just like vomiting, 879 00:32:35,059 --> 00:32:37,140 diarrhea can also be a symptom of a 880 00:32:37,140 --> 00:32:38,359 more complicated diagnosis. 881 00:32:39,072 --> 00:32:40,822 Consider Iv fluids and observation. 882 00:32:41,697 --> 00:32:44,584 Most of these patients have abnormal platelets and 883 00:32:44,641 --> 00:32:45,197 hemoglobin levels. 884 00:32:46,007 --> 00:32:47,754 Refer to your local policy, but a good 885 00:32:47,754 --> 00:32:51,351 baseline is to trans fuse Rbc for hemoglobin 886 00:32:51,486 --> 00:32:54,742 less than 8 and platelets less than 15000. 887 00:32:55,551 --> 00:32:57,693 Remember that any neurologic symptom in a patient 888 00:32:57,693 --> 00:32:59,438 with cancer can be a sign of something 889 00:32:59,438 --> 00:33:01,976 more serious, and often requires further work up. 890 00:33:02,469 --> 00:33:03,348 Don't blow these off. 891 00:33:04,866 --> 00:33:07,103 Okay. That was a lot, but there is 892 00:33:07,103 --> 00:33:09,180 still more to become because this is a 893 00:33:09,180 --> 00:33:11,431 big topic. And as we now know, 1 894 00:33:11,431 --> 00:33:13,426 that people do entire fellowship about. 895 00:33:14,064 --> 00:33:16,379 So join us next time for part 2 896 00:33:16,379 --> 00:33:17,916 when we talk about pain management 897 00:33:18,309 --> 00:33:19,910 goals of care in the Ed and a 898 00:33:19,910 --> 00:33:22,470 few ethical dilemma. Thank you to our department 899 00:33:22,470 --> 00:33:24,950 for doing process improvement projects to improve the 900 00:33:24,950 --> 00:33:26,710 care of this population of patients. 901 00:33:27,284 --> 00:33:29,442 And thank you to Owen productions for improving 902 00:33:29,442 --> 00:33:30,401 our production quality. 903 00:33:31,200 --> 00:33:32,958 Until next time, stay curious, 904 00:33:33,437 --> 00:33:35,035 stay transpired, and stay tuned.