Session 3: Stabilizing patients in emergent situations - Vitals first

So good morning, everybody. Welcome to the, uh, we are here today in our third session, I believe. Um, we're going to try to make it so that we speak about something that we, um, have in our schedule, and that is, um, differential diagnosis leading up 2, Dr. Diab will talk to us about how to stabilize someone in a variety of places, but we're going to take the emergency room as our example for today. So let me start first. You can use the chat and you can come off mute and interact if you wish. That would be the best. Or you can use the reactions. But if you would share with me, we are making some changes to our program to make it easier on you to interact. We now have a LinkedIn page. We have several links to the previous recordings, but also a pre-session gamified preparation that I have sent. How was that for you? If you can share with me your experience. Did you complete it? No problem if you had no chance to do it, but if you did, it would be fantastic to let me know how it worked for you.

Hello, Dr. Hassan.

Ahlan, ahlan, Ranim.

Actually, I tried a little bit. But it's my first time. We didn't start our clinical years yet. So it's a little bit hard. Not actually hard. It's a little bit confusing. Am I doing the right thing or not? And so on. I tried, but I don't know if that's the best I can do or not.

Excellent. I'm glad you tried. That is the whole point, is I wanted you to at least get your brain working with it. Inshallah, we're going to work today with this, and hopefully, let's see next week if you find it to be a little easier. And I'm looking at the chat, there is no other comments. So first of all, thank you, because as you will know, as you get more into your practice, you'll find out that the imposter syndrome never leaves you. You constantly feel that you are not Am I in the right place? You don't belong. Am I doing the right thing even at my stage? So when someone for whom that was destined tells you that, no, I tried, it was okay, then at least it settles down a little bit of my doubts and insecurities. So thank you, I appreciate that. So, Maana Youm, Dr. Diab, and she's an internal medicine and emergency medicine board-certified physician from Cleveland, Ohio. And we will be discussing a few things that I think you will find very, very useful because if you are like us, we started with rapid responses or your attending just tells you, go see that patient and you go see the patient, you don't know where to start. And as you are trying to make sense of your brain, unfortunately your patient's blood pressure your blood pressure drops, or maybe something else goes wrong and you ask yourself, I don't know what to do. And you don't want to look like you don't know what to do. So it's just very frustrating time. So what we're going to— I'm going to share some of my slides. They are anchors. They are not really the gist of what we're going to do. The gist is mainly the discussion Dr. Diab and I were going to have. So Starting from why differential diagnosis matters. When we speak of medicine, we speak of what we call a pattern recognition, meaning someone comes in with fever, cough, shortness of breath. You start to think bronchitis or pneumonia. Why? Because you recognize the pattern. You recognize that is, you've seen this before, and you've seen this before, therefore it must be that. Somebody comes in with chest pain, left shoulder moving to the left arm, and it happened during exercise. You start to think, could this be a heart attack? So similarly, as you are doing this pattern recognition, You cannot just anchor yourself to one diagnosis. It could be another and you are just not thinking about it. So as Dr. Diab and I will talk about in a minute, it's good to work in algorithms and framework. So I wanted to introduce one. And if you Google them, you will find that there are many. What does that mean? Well, if you have somebody who has chest pain, yes, you think heart attack, but what else could it be? You don't know how to start by just spitting out various options. So you have to have a framework. And we have one framework. Give me one diagnosis, for example, under vascular, like embolism or a blood occlusion or a stroke. If it's degenerative, maybe it's osteoarthritis, maybe Alzheimer's. If it's autoimmune, maybe it's rheumatoid arthritis, maybe lupus, infectious, inflammatory, traumatic. Maybe they hit their head and they could not remember. They hit their chest and they couldn't remember. Could this be cancer? It might be unlikely but not impossible. So we constantly keep it in the possibilities. Maybe congenital. They were born with that. Maybe endocrine, maybe it's diabetes or thyroid. So when you have an algorithm or when you have a framework, it helps you get started. It helps you organize your thought process. Dr. Diab, let me introduce you and let me get you into the conversation. What do you think about differentials and how do they help you before we delve into the conversation?

Like you said, differential is important, but when it is, when you are in the emergency setting, it's not all the differentials needed. If we think about medicine generally, there's a lot of diagnoses that's not going to kill you. There's a lot of things that can happen to you, to the patient, I mean, that are not actually an emergency life-threatening situation that we need to kind of all think about. So what matters in the emergency setting is the differential that actually going to affect the patient's life, and not all the differentials. So it's very important that when you are in an emergency setting, when you are managing a patient, let's say that they have like chest pain, you're not thinking about pericardial rheumatoid pericarditis, for example. No, we're thinking about chest pain, we're talking about heart attack, STEMI, non-STEMI, we're talking about PE, talking about something that would threaten the patient life. It's important that you concentrate on the life-threatening differential, not all the differential. And that is why it is important, the vitals, like we were going to talk later, that this is— it's not all the differential. You don't have— you have to make sure that when you are thinking about emergency setting, you are— you— the differential that pops in your mind when someone comes to you with a complaint, whether chest pain, whether unconscious, where there's a lot of things that you don't have to think about everything in medicine, you just think about that life-threatening differential. And that's basically what, you know, the concept of kind of emergency differential is important, but you have to think about the differential that it's going to affect the patient's life. It doesn't matter if the patient have, you know, kind of like infection. If it is a foot infection, this is not going to kill the patient directly, but if they're hypotensive, they're septic, then that is what you have to think about at that moment. Everything else would take time. Everything, everything else needs treatment you know, from the other differential that is not life-threatening, it can take its time to get better, can take time to get diagnosis. So diagnosis is very important, but when it comes to the emergency setting, I want every doctor to kind of think about what could be life-threatening so that you'll be alarmed yourself that this could be it. But if the differential that comes in mind is not an emergency differential, then that is, uh, that's not important at the moment. It can— we can take our time to realize that.

Excellent. What I loved about what you said, and I wish somebody had told me, is that we doctors sometimes pursue perfection and completion. You don't need to be complete or perfect. You just need to get started because your life, your patient's life depend on it. So if you have chest pain or if you have an outside I'm sorry, inside the hospital where you come in, you guys are called to see a patient. You may see a patient who arrives unstable. In your context, the information may be incomplete. They may not have a history available. The family may be unreachable sometimes because they're no longer with us. Their old records are inaccessible because the person has displaced from one place to the other. So you work and make decisions in an information vacuum. And so you must act before certainty. That is the framework of today. So we have to have a mental shift, and the mental shift is stabilization buys you time in order to think. That is what we are going to be discussing today. So in order for us to discuss, um, that, Dr. Diab and I had a conversation, she taught me something about— there is something called the Nightmares Course, and the Nightmares Course are about 10 situations or 10 scenarios that are most common. If you know them, you know a certain amount of percentage of situations, and you will be ready when you start the hospital. So Before we start those cases, Dr. Diab, can you share with us what do you mean by the vital signs? You emphasized that this was important. Share with us a little bit about instabilization and in making a differential while you're taking care of your patient, what are these 5 vital signs, maybe even more? Tell us a little bit about them.

Okay, so like you said, I know that theoretical study, when you're talking, when you're reading about medicine, when you're reading about diseases, when you're reading about even the cases that we get in exam, they are like typical cases where the patient telling you everything, where there's family members, where there's family history. But when it comes to real life, a lot of the time, if the patient, if the patient actually is able to talk to you, sometimes the patient themselves, they concentrate on something that is not important as much as you at this moment is, you know, worried about, like You're in emergency, worried about what could kill the patient. He might, the patient, actually start talking about maybe yesterday grocery shopping. That's not important. For you, you have, in the emergency setting, you have time. You have to concentrate on what matters. And you have to make sure that, yes, that patient history is important. I'm not saying it's not. But sometimes it's not available. Like you said, sometimes the family is not there. Sometimes the patient is not concentrating on the right thing. Sometimes even the nurse that's with you maybe is telling you that the patient is having chest pain. But the patient himself, it's like maybe hypoxemic. So it's mostly shortness of breath more than the pain. There's a lot to go with that. So for us, from the emergency medicine standpoint, time is valuable. You cannot just be like wasting your time. The patient tell you about what happened with his neighbor yesterday and he hit him in the chest or something. And that is not related to this. So we have to concentrate on the algorithm so that we save ourselves time. It doesn't take a lot of knowledge to manage vitals or go through those algorithms. But it will save you time until you realize what's going on more with the patient. And like you said, there's nothing perfect about the emergency setting management. You cannot just think that managing a patient in half an hour will be equal to someone who spent 3 hours or like a day figuring out what's going on with the patient. This half an hour or an hour is not there for you to kind of realize what's going on with the patient. There's no way the knowledge that you get from patient contact half an hour will give you the same kind of management after, you know, kind of a day or so of managing the patient. So that's why there is a different setting when you take— manage the patient. That's why it matters if this is an emergency or a hospital, so we take our time. So we have to start always from the vitals. The most important thing when any— in any ER is triaging or making sure we take the vitals. If someone's, uh, if someone's like having any of those vitals abnormal, you have to concentrate on correcting their vitals. And our vitals in ER are usually, are the, you know, the basic 4 vitals, which are the heart rate, the pulse ox, the blood pressure, the temperature, and the patient blood sugar would be the 5th vital. And we have to remember that, to remember that 5th very important vital, which is the blood sugar, because we sometimes miss a lot of things not asking what the blood sugar of the patient— that is, that could be like a very big thing as well. So if you put them this way, if you always think every time anybody tell you someone coming or this is a new contact, if you look at their vitals and you make sure that you always start from there, you're gonna— you're not gonna miss anything that's life-threatening. Because if you miss it, if you don't look at the patient vitals and start talking to the patient, for example, if the one of the vitals— let's say it's hypotensive, but somehow this is a young patient But, and so they're holding themselves, they're sitting up. That doesn't change the fact that the way that you're managing the patient will be faster knowing that the patient's hypotensive. You're going to start correcting that while you're talking to the patient. In the emergency setting, nothing's perfect. So you are doing more than one thing together, but you always have to start from the vitals, which is the temperature, the heart rate, the pulse ox, the blood pressure, the temperature, and the blood sugar. These are the 5 things. If you know about any patient, you can always know what's wrong that needs to be corrected at the moment and how to manage it and how we can go from there.

I sincerely love that you said the 5th vital sign is the blood sugar. I had a patient who I seen and she just did not feel well. Sometimes that's all they say, "I just don't feel well." And no matter what I asked, so finally I asked her about her blood sugar and she said, "You know, I don't know why, but it has been in the 300s suddenly the last 4 days." And I just told her, "Please strip, I need to see." And she had an abscess in her leg that she did not even know. Being a diabetic, she couldn't feel the way we feel. So sometimes that blood glucose is your only clue that something is wrong. Can you guys share with me with a show of hands who knew about the blood glucose as the fifth vital sign? Okay. Well, like me, like you, I did not know until somebody like Dr. Diab taught me. So speaking of stabilization, When we are thinking about stabilizing a patient, we start with the vital signs. How do they tie up to physiology? How do they tie up to perhaps preventing harm? Can you give us some examples before we delve into the cases?

So, okay, so it, like I said, now usually those vitals, the, you know, the four vitals and the blood sugar with it, the— which is the fifth vital. Um, it's very important. As I said, it's hard to kind of talk about everything in this hour that we're talking about. Each one of those vitals can have like a little bit a side note how to correct them, how to deal with them. But every one of those vitals are connected together. If someone is, for example, let's say someone is tired, you get this part, this patient, you don't know a lot about them. I'm just giving you the vitals. I'm telling you this patient have a fever, 38.9. He have a heart rate of 130. His blood pressure is low and blood sugar, you know, 120, not that bad. And his post-ox is 98 at room air. So you look at the vitals, the blood pressure, the patient heart rate is up, but he have, you have a temperature. So the temperature usually affect the heart rate as well. But there's a kind of like correlation. Let's say someone have a heart rate of 170 and they have a temperature You'll be like, no, that's not— this is not only because of the temperature. The same thing goes with the blood pressure. When someone's blood pressure is low, if I give you someone whose blood pressure is low and the heart rate is 170, you'll be like, okay, so the heart rate, we need to start from there. We start correcting the blood pressure, but we need to start from the heart rate. That will be where we— where the problem started. And if someone's heart rate is like 30 and the blood pressure is low, where that came from, we need to correct the heart rate as well. Uh, we always have, but the thing with these vitals, you have to know that when you look at them, you start correcting them, then you start connecting them together. Which means that if I saw someone with a pulse ox of 85 and I didn't give you the rest of the vitals, I'm right away gonna put oxygen in this patient until someone give me the blood pressure, put nasal cannula, put anything on him, start correcting that one. Then I give you the next vital, the patient heart rate is 120, 40. What are you going to do? Well, yes, we're still going to— I cannot get only the heart rate without the blood pressure. I need to know if that heart rate is, you know, affecting blood pressure or not. I give you a low blood pressure, you put some fluid in this patient, you put an IV, start fluid, heart rate is 150. So we'll get an EKG. This patient is in AFib or the regular rhythm. It matters if you correct the rhythm, maybe that will correct the blood pressure. So each one of those connected together. But the way you have to manage the patient in the ER, every one of those is incorrect. You start correcting them, then you start connecting them together and start realizing what could be wrong. You use every moment, every vital. You cannot just be like, oh, the patient blood pressure is like 60 over 40. Let me wait and see what the heart rate now. No, we're gonna start. Every second matters. You put IV, start patient in fluid, for example, or we'll talk more about correcting the vitals. But You start from every one of those, you start correcting together. And when you do that, you are managing every second that you have. And yeah, eventually you're going to get some idea what the differential, but in the ER, I'm not going to, we're not going to be 100% sure all the time. We have a plan, but a lot of the time this plan might change a day later. We might stop something and continue something. But as I said, we start from the vitals and we start correcting each one of those vitals and connect them together. But it's not, you know, we don't have time to kind of correct or, you know, give you all the differential that matter, but I'm trying to give some examples there.

Amazing. I think we started to discuss the first case. So I'm going to jump to the first case. And that is when we have somebody with hypotension. And you mentioned already that you start to look at the blood pressure and start restoring perfusion with IV fluids. Let's talk about the first case scenario, if you don't mind. We have the patient who, give me one second, I need to go back to the screen. We have the first patient who comes in with blood pressure 78 over 45. You mentioned the temperature, the heart rate is 128. The patient is confused. That is also something important, but you have no history. And you mentioned the teaching point is don't wait to understand why the blood pressure is low, restore perfusion immediately, get an IV, get fluids. And then once the patient is more stable, you buy yourself some time. Let's discuss the second patient who is a patient who has low oxygen. Now, the low oxygen, this patient is having now a respiratory rate that is elevated, 34, an O2 saturation of 82% on room air. The normal O2 saturation is 95 to 100%. 100. The patient is also agitated and confused, and also the story is complete. Take us through that.

So when it comes to hypoxemia, as I said, right now you guys are just starting your clinic around, so there's more to it when it comes to management of the patient in the hospital. So when it comes to, you know, oxygen being low, there's, uh, there's multiple steps for management, of course. Now this patient, for example, the pulse ox is low, the respiratory rate is up. These are the things that tell you that the patient is distressed. So if I tell you this patient is hypoxemic and tachypneic, what your job is to kind of try to correct that, because that's basically what could be causing someone hypoxemic. Of course their heart rate is up, agitated and confused. Now I don't want to go to the kind of like the more expert kind of point of exam, you know, kind of what to do for this patient, uh, from the hospital standpoint. Because in the, in the hospital, you guys will know more that, you know, it's not only like oxygen. When it comes to oxygenation, uh, we have like nasal cannula we can put in the patient, we have a mask on. If the patient confused, we have like more. If they're awake, we have like CPAP, we have something called BiPAP. There's more to it than just that. So when it comes to the hypoxemia management You have to start from correcting it. Now, of course, talking about correcting it, it needs like other— another lecture or another talking about that. But, uh, from the ER standpoint, I'm not gonna— I'm worried about differential, yes, but I'm worried about the corrected— the differential I can correct right away. Um, if someone's hypoxemic, they could be hypoxemic because they have pneumothorax, for example. In the ER setting, you have to listen to both lungs, see what is it exactly. Are you hearing crackles? Are you hearing One side there's no oxygenation to, the other one you cannot hear anything. Are you listening to someone and they're clear lungs? Maybe that they have a big PE. So it's very important that it's not— as I said, yes, you get the vitals and you start working on correcting the vitals by examining that one point. If someone short of breath, confused, hypoxemic, you're not going to be left looking at the pulse ox and trying to correct it without examining the patient. You're there at the bedside. You can take your stethoscope, you can start listening, and that will develop more differential, and that will help you how to manage. But yes, you are examining why you're actually putting oxygen in the patient, why you're trying to— you know, we already— the nurse is drawing blood. There's more to it, but knowing this in the vitals will tell you how to direct you where to correct and what to do. But you are looking also in the rest of the vitals. This patient, let's say that the same patient— I give you a confused patient, hypoxemic, blood pressure is 230 over 180— or for over 110, for example. This is a— you could think maybe pulmonary edema, you could think that maybe this is related to dissection. There's a lot can be related to that. But, but when it comes to the ER setting, yes, you are working on differential, but you are starting— you're trying to correct as well. I'm trying to kind of make sure not— I don't go to the part where I talk about intubation, I think, but trying to make it as simple as possible.

Amazing. Any questions? Any reactions? How do you think this is resonating with you guys? Where are you with this topic? Have you been in situations like this before? Do you feel like this resonates with what you expect to see? Tell us a little bit about where you are. You can chat, you can react.

Actually, I think all of this is very reasonable because if there is a low oxygen saturation or a low blood glucose, it may affect the brain directly. So it's very reasonable to think about these things before thinking about diagnosis and so on.

Excellent, excellent. And when do you think— when are you guys starting your clinicals?

It's by a month from now.

About a month from now, inshallah. Well, we wish you the best of luck once you start. I hope that you bring to us some questions, some situations. We want to make it real, and maybe you can just start to post them on the chat, and that way we can start to make think these things more about what you see. Now, a third scenario, we've started to touch upon it just a little bit, and that is somebody who is in altered mental status, confused, maybe combative, maybe not even responsive. They have no identification. They have no medical history. Their blood glucose is 28 after you've tested it at the bedside. So what is the first action? How do you stabilize this person? At what point do you think, oh, I may need imaging, but I may or may not have imaging available to me? Dr. Diab, what do you think about this patient?

Now, you see this patient, for example, In real life, nobody's going to be like telling you all, everything if you didn't ask for it. Yes, the blood sugar was mentioned here, but if you're someone who's just, you know, kind of walking by, you see someone who's unstable or confused, if you didn't ask for it, if you didn't keep in mind that I need those vitals from this patient, including the blood sugar, you are going to miss it. You're not going to know what's going on here. You might concentrate, the patient pulse ox might be perfect, This is a hypoglycemia. The patient might be okay, heart rate is, you know, up because he's, you know, you know, agitated, the blood pressure is up. All this is not going to tell you what's going on with the patient. But if you didn't ask for the vitals, if you didn't put your— if you didn't put it in your mind that this is where I'm going to start, I need those vitals. If those are okay, then will guide me how, you know, I have time to figure out what's going on. I'll sit there, talk to the patient, but Someone's blood sugar is 28. This is a key point. This is actually very big because most of the admission, most of the patients that get rapid response or arrest, honestly, a lot of them are, when you study them, especially the VTAC and V-FEB, if someone measured their blood sugar, you're gonna find that they actually were hypoglycemic and it got missed. So the point here is that we know that the blood sugar, and this is a major thing, this is not something, not everybody, whenever you go anywhere, they're gonna start by measuring blood sugar. But as a doctor, Your key point to know, to remember, that this is correct. This will be totally different if this patient, for example, have a normal blood sugar. Then you have more time to figure out what's going on with them if the rest of the devices are okay. So the key point here is to start from correcting the blood sugar, of course. The dementation of the patient will get better. Now let's say that you correct the blood sugar. It's not always one problem. Let's say that you correct the blood sugar. It goes up, you give the patient dextrose, the blood sugars go, goes up. They're still confused. In your exam, you can— of course, during the time you're ordering, you know, you want dextrose, you're just sitting there examining the patient, you look at them, you give them dextrose and you didn't change that much, the blood sugar goes up, then you have more time. Of course, I, you know, you're going to look at the rest of the vitals. The oxygenation is fine and the blood pressure is okay. And that, let's say the same one, this blood sugar 28, 28, You look at the blood pressure and it's 230, for example, again, or 230 over 90. So you correct the blood sugar, the patient agitation goes down, and he's still not 100% with it, and the blood pressure is high. This maybe you would start thinking maybe this is a stroke. I need to look at your stroke. But you can— that's why it's one of the, you know, when you call for someone's stroke, you always have to call them and tell them what the blood sugar could that give you a stroke-like differential. So It's all you— the key point here for all, you know, the medical students we have here, they have to remember to start from the vitals. Most of the patients I have— I, I still remember in, uh, uh, one of the lectures we gave before, it was someone, a patient who was just hypoglycemic, which was found in the patient after they like, of course, unfortunately passed away. Nobody actually paid attention. The whole— they— we were doing— they were doing code, you know, code blue and everything, but nobody ever asked What's going on with this patient? What could have been the blood sugar? Maybe that's the reason to be corrected. So it's very important to remember to ask for the truth. Now, once you know the blood sugar is low, of course you're going to correct it and go from there. But as I said, it's important— the key point here to remember to ask for that. If you didn't ask for it, you are going to be missing something big. If you get all the vitals without the blood sugar, nothing, you're going to be so late to realize this is basically just because the patient's blood sugar was low.

This is so important. I think both of us have been in a situation in which this happened where you don't think about the blood sugar or you don't think about something that otherwise would be obvious. And that should tell you why we're speaking about this, why emergency situations. I want to call it emergency medicine, but it's emergency situations. You could be out on the streets and somebody is having an emergency situation. You could be out on the wards, not just in the emergency room, and somebody's having an emergency and now you have to call for help and you need to know what to do at that moment. So like Dr. Diab and I so far have demonstrated to you specifically, which is why emergency medicine relies on algorithm. I think Dr. Diab, you mentioned that to me yesterday. So your speed is actually coming from structure, not from intuition.

To act in this situation.

The same thing that we also discussed in Nu, I'm going to repeat it because I think it's extremely important. Dr. Diab, you mentioned stabilizing the vitals means start correcting them before connecting them, and that is absolutely important when you're talking about for the next step. Once the patient is stable, you have time to think. And when you think, then you can think about the blood sugar otherwise, because at first you did not think about it, or we did not think about it. So anything that you want to add, Dr. Dia, before we move forward?

Yes, exactly. So I agree with you. As I said, it's algorithm. Now let me give you this example for the same patient, because, you know, from internal standpoint, from the emergency standpoint, everybody's management is different. Now, the same patient who's actually confused, okay, we have two doctors. One of them is, you know, depending on the algorithm, this patient, if let's say you're walking around and they call you for a patient, he's confused, a little bit agitated, you are an internal medicine doctor, you're gonna ask, oh yeah, get the vitals, let me look at him. You realize, okay, so look at the patient history. They take medication. He is diabetic. Maybe he took— did he take his medication? Did he take his food? Let's see what his— whatever. Is he taking his insulin? Did he eat with it? Of course, this is taking your time. There's a family member here. Okay, yes, maybe. Let's measure his blood sugar. Yes, it's low. Let's correct it. How long it took? Even talking about it, take it longer. Let's say that's an emergency medicine doctor. You walk around, the patient's confused. I want this patient vitals. Blood sugar is low, then correct it. Looking at the patient medication, that's basically what it took, like seconds. A lot less than what you're trying to manage. You're trying to correct it. Now, why is it low? I don't care why is it low. I, I just want to correct it now. Now, within, we'll figure it out. Is it because this is insulin? Is it kidney failure. What's going on here? This takes time, but you are correcting it. But if you're going to take your time to realize what's going on, this patient, this hypoglycemia, again, turn into confusion, then the coma, then the patient going to be in V-fib, and you're still trying to figure out what's going on this one. Why is he going that way? What happened there? If you look, think about it in algorithm, that's why we put it this way. Emergency medicine doesn't need a genius to kind of like manage the patient. It needs someone who's disciplined enough to know that we know this, we're going to start from this. And that's basically how we're trying to kind of manage. When we try to teach someone emergency management, usually we have to be in algorithm so we save time. Because time— you don't want to like be the one that missed this, because we all can realize eventually this patient's hypoglycemic. If you look at his insulin, you know that he didn't eat breakfast. Look at the, you know, the tray, he didn't eat. If someone told him he didn't eat, you're going to realize it eventually. But by that time, that brain damage happened. By that time, the patient became hypoglycemic, you know, hypoxemic because he's unconscious. By that time, it took you a long time. Whether you put it as algorithm, took like exactly seconds. You ask for them, they're wrong, you corrected them, then what? That's it, we got it. That's what you want. This is the emergency management.

Amazing. I want to take a few things that you said, and I want to repeat them. So emergency medicine does not need brilliance. It needs discipline. It allows you to be disciplined to use these algorithms. The second thing that you said is the algorithms differ between an internal medicine doctor and an emergency medicine doctor. Algorithms and workflows and frameworks. And in order for you to act, you need to have speed to come up with actions. And that speed comes from using these frameworks in order for you to arrive to conclusions. Sometimes, as you said, and I'll repeat that, you don't have time to search for why. You need to correct and stabilize first. I wanted to at least reframe this and reemphasize it because these are some of the pearls that we need to use today for stabilizing our patients. Any questions? Go ahead.

Let me just add this. That's why usually in the emergency medicine, one doctor can manage like 20 or 30 patients because, you know, you're taking attention from one patient to another. When I look at the board of patients that I have, I'm just not looking at their name, not even their differential. I'm looking at their vitals. Someone hypoxemic, I'm running there. Someone's hypotensive, I'm running there. Everybody else who's normal vitals can take time. I can realize I can grab my chair and sit there and chat with them, but I'm not going to leave that one while someone else is unstable. So that's why it's, you know, emergency medicine. That's why we have to talk vitals. It cannot be like, as I said, you know, thinking about the patient history, if they have chest pain. It doesn't matter at that moment. If you put it at algorithm, I'll say you can manage a lot of patients in a small time. You don't— and the more that you, you discipline yourself to always ask these questions, the more that you're going to be having more confidence to kind of manage the patient. You know, if I, if I give you someone with totally normal vitals, your heart is racing, your heart starts racing very fast, you know, if it's to someone who's, if I told you someone who's having chest pain, you look at their vitals, they're perfect, heart rate is 65, blood pressure is 130, pulse ox is 98% in room air, they're not tachypneic, the temperature is normal, the blood sugar is fine. And they're telling me I have chest pain. How serious is that gonna be compared to someone who's like chest pain, blood pressure is 200, the heart rate is 140, their pulse ox is dropping. That one you're gonna ask faster than one, yet when your heart rate will be a little bit, you know, kind of like a little bit faster, there's more an emergency here. And that one. So you will know, you'll know how to react, you will know how to take your time. You don't have to be like nervous about someone who's normal vitals and you is telling you a complaint. It's totally different when you're around someone who is actually having a problem. So you need to know how to shift your attention from one person to another and how to kind of, you know, when exactly you should be alarmed. Sometimes you should not be alarmed. It's an emergency room, but yeah, the patient does not have normal vitals, they have a complaint that we can take our time to realize what's going on. That That saves you a lot of effort. That saves you a lot of kind of like nervousness and kind of like being alarmed about cases that you don't need to be alarmed about.

Very good. I love this. I love this. That is why an emergency medicine doctor can manage 10 to 20 patients because you're working on stabilizing and buying time to think. Fantastic. And that's how you gain confidence. I will just not even delve into that because that was gold just the way you said it. What I would like to perhaps close with is, can you tell us about a case recently that you can remember that stayed with you? An example that perhaps you felt a little nervous because you were acting and something happened where it taught you something, or it was unusual about a patient. Tell us something that we can visualize you working with.

Okay, uh, okay, one of the cases I remember, it was in like this year, of course, been like what, 8, 9 years ago, but I still remember till now. This is a patient that I— it was like a busy ER that day and I had a lot of patients, but this patient was not in any distress at all. He was hypotensive. His, you know, blood pressure was like 60 over 40. And although he was like sitting up talking, which was weird, and for some reason the nurses told me and the adult— the patient family— that he had a cardiac cath or some procedure the day before. So I was worried about bleeding. So I kind of like rushed into like look at thinking into what's going on. We need to give him fluid, maybe he's bleeding. But if I actually looked at the rest of the vitals, I would have realized that this patient was, his heart rate was 30s, temperature was fine, SpO2 was great. It was like 99% in room air. And mentally he was okay, his blood sugar was also as well was good, was like 120, 130. But if I had a look at his heart rate, I would have realized that was 35. If I look at the heart rate that moment, which I did look, but after I started kind of panicking about bleeding, I would realize that this patient's heart rate was like very low. If I took an EKG, it would have showed that he had a block, not a bleeding. All this management, all this trying to get him to where they can do, you know, kind of correct the bleeding site, it would have not been that problem because we were talking about internal bleeding, so it wasn't something obvious. He was hypotensive because he's got that third-degree heart block. I always want to kind of emphasize about. You take— look at the whole vitals. You're not talking about one. Don't depend on what the patient say all the time. Sometimes they will direct you to what they think is wrong, but maybe it's not that. Don't look at what exactly— even the, you know, sometimes the history— don't anchor yourself only on the history. Look at the vitals. Look at the differential depending on the patient. Look at the differential depending on those vitals. And don't anchor your diagnosis and what the patients say all the time. Sometimes they not— a lot had— we had a lot of patients that said that we have like you know, kind of, you know, my leg hurts, but the pulse ox is low and they have like an AFib at that moment. It was like all more of an embolism because of that. We have— you have to kind of think about the— start from the vitals and take your time. And when you look at them, look at all of them. Don't depend on one. Don't take only the part of the history and run with it. Start from the whole vitals and take your time managing that patient.

I took something from what you said, which is sometimes the patient can orient you and sometimes the patient can distract you. How do you know the difference? You must make sure that those things that the patient shares with you, does it fit or not with what you are seeing in front of you. And that should reassure you that knowing the basics already puts you ahead.

Exactly. Now let me just add this, let me just add this just quickly.

Please.

I needed to add it. So now at this time, you know, right now everybody have like internet and phone and maybe they're gonna Google something. I know it's different from one country to another, but they all have, even if they're not gonna Google things. It's going to be us, you know, our, our culture. Usually, our neighbor, I have chest pain, I, I think I have a heart attack because my neighbor had chest pain and they had heart attack. So they come to you and they say, we have a heart attack. We'll be like, really? So tell me more, what's going on? If you start from the vitals of this patient, you're going to be like, no, this is normal vitals, this is a younger patient, the chest pain is totally something, someone, you know, some other differential with this one. So you always have to depend. If you make it as a rule that I'm always going to start from the vitals, then I'm going to listen to the patient, it will be a lot better than just listening to the patient. Because the patient, as I said, they're going to direct you in different— what they think is going on, what they read online is going to go on, what their neighbor maybe told them, or maybe what one of the family had something similar. And a lot of the patient doesn't even come and tell you, we have chest pain. It'll be like, I'm having a heart attack. I was like, they don't even go through the symptoms. These are directly the differential. And that's why you— we have to have a disciplined way to kind of manage the patient. Otherwise we are going to panic. If you say heart attack and the nurse comes and tells you he's saying he's having a heart attack, and you go around there and the patient is like 23 who doesn't have any— who have normal vitals, we'll be like, no, we're not gonna panic about this. This patient, no, he doesn't have any heart attack. So it's very important if you put it this way and put it as a rule that you are going to discipline yourself to start from the vitals and take it from there. Totally, this is going to be like a— it's going to be life-changing for you as well as a— who's any physician can manage any patient and can take their time thinking about it, you know, because we eventually— if the patient is stable, take your time, look online, look at the up-to-date, read about what could be causing chest pain while you're doing some workup for the patient. But it's totally different if this is a hypoxemic patient who cannot breathe and pulse ox is low and you're just kind of thinking, let's see, what could it be? It doesn't matter. Just start correcting this and take your time, you know, buying time to kind of to get better. We all gonna— we all, all the doctors are, you know, we are overthinkers. We all someone who is actually most of the time are smart. We all are someone who actually know the differential. We always reach the differential. When it comes to the ER, we want to try not to reach only differential. We're trying to kind of correct the patient vitals so that we actually have the time to reach the differential. So that's basically what I just want to add.

Excellent. So if I were to take what you said, we have to be disciplined and we have to have a way that is disciplined to handle the patients so we don't get distracted By what the patient says unless it fits the viral. We cannot be distracted unless you and I had spoken about the nightmares course, which is several cases about what are the most common cases of urgent matters that you can see in your practice. I'm going to post this on the chat for Arsat Amal and as well as on the LinkedIn page. But do you want to tell us a couple of words before we end the session about this course and why did you recommend it?

So yes, so this course actually, uh, when I was trying to reach my resident about, you know, a simulation lab and what to be scared of and whatnot, apparently there was a study that say that the intern, which is, you know, the first year of being, uh, uh, you know, kind of in training, they are always having a nightmare about what could someone call them at night to tell them to come. And, you know, because at night you are covering the whole hospital They can call you for anything, honestly, basically. So this study will show you— this course will teach you usually 10 cases. Those are the cases that are called for in an acute setting between, you know, they are like, I think I remember the 10 cases were, I think bradycardia, someone with infection, a seizure, embolism, heart rate is up, someone's heart rate is up, someone You know, how to recognize, for example, the potassium being up, that mostly also something we called for. How to call for someone who have anaphylaxis. So these are the— this nightmare course is just prepare you to what could you could be called for and what do you need to remember. We kind of struggle a lot with the medication. For example, when I was a resident, I remember I struggled memorizing all kind of medication. You cannot remember all kind of medication. And then medicine is growing and we're adding more medication and we're adding more doses. And they're like trillion doses. So there's no way in mind you think that we are going to remember all the doses, we remember all the things. There is, you know, kind of few medications that you have to remember that are life-saving. You have to remember the epinephrine and the dose. You have to remember the dextrose, how much you gave the patient, which doesn't matter, you can give that. But that means that we have to remember the atropine. Those doses, you need to remember them. You cannot just be the one doctor who's searching online what the dose of atropine need to be given for a patient who is Heart rate is 35. So these are the— in this course, to tell you what medication you have to remember, you have— it's not that much, by the way. It's like few medication. You have to remember the doses, and when you remember those doses, you're going to be able to manage the patient until you have more time to realize what else can be given. Those are always the first line that if it didn't work, you have time to realize with the second line. And that is something we also tell in the course. You don't— it's not like in and the typical cases that we teach in, you know, kind of the resident and the Q&A and asking questions. It's not like life is different. Usually you'll be okay, the patient might— the first line might not work, you need the second line. What's the second line after that? So you always have— in this course, it's not only going to only tell you the first line of treatment, I'm going to tell you what the second line— it will buy you time until you have more time to talk to someone else, or maybe another specialist to talk to, like You need— so this course is very important because it gives you the confidence to manage anything. And it started initially in Canada and Queen University, but apparently with time, all— a lot of hospitals tried implementing it so that all the interns does not get nightmares. Everybody was, you know, apparently it was studied that all the first-year residents always are scared of being called at night. This is the most thing that will be worried about. And so that's basically— it will give you the confidence all these vitals, the 5 vitals, it would take— it will give you every one of those vitals, how to correct whether it's high, you know, blood pressure, what to give the patient, heart rate, what to correct AFib, how to correct VTAC, how to correct SVT. It's kind of like very simplified, but it will give you all the pinpoint for what could be an acute management. Okay, so I, I honestly do recommend that they read this, although it's very simplified, so it doesn't give you everything, but it gives you what matters and to until you figure out what's going on. So that I definitely recommend this.

Wonderful, wonderful. I think that this is extremely important. I will post it. I already posted it in the WhatsApp. I want to thank Dr. Diab for being with us today. I want to thank all that were able to attend.

Raneem, yeah, I have a question about vital signs. Is oxygen saturation enough, or I also have to look for the respiratory rate, or it just will be obvious if the patient is having a tachypnea or a bradypnea? Or did you get my question?

Yes. Dr. Dia?

Okay, so the pulse ox is the other thing. Why do we say pulse ox? Because usually it's the fastest thing that you kind of measure, which is, you know, you put it in the finger, the patient measure it right away. But tachypnea is more of a clinical. Like, the respiratory rate, of course it matters, because, you know, the patient— let's say someone hypoxemic is not barely breathing, it could be opioid overdose. Uh, someone hypoxemic who's tachypneic, it could be, uh, you know, kind of distress. But the pain that— when I'm talking here right now, as I said, we're not talking about all the differential, we're not talking about everything, but it will— that this part of the vital, the respiratory rate, usually it kind of— it, it goes without saying because the patient at 'cause you're at the side, you are seeing that. And you're not gonna stop and measure their respiratory rate. So you kind of clinically will know that this patient is not breathing that much or this patient breathing fast. So when you kind of ask for vitals, you cannot just wait till the nurse at the side tell you, oh yeah, let's just wait, give it like a half a minute. Let's just measure how much their pulse ox, how much respiratory rate is. So it's kind of like, it's very important, of course, but when it comes, let's say that someone hyperventilates hypoxemic, but they're not breathing that much. Yes, the differential will be like maybe overdose medication, something like a central respiratory drive decrease, but that doesn't change the fact that you're going to give the patient oxygen. You're going to put him in oxygen, you're going to, you know, oxygenate. Even the patient that have opioid overdose, while I'm asking for Narcan to reverse this, I'm putting the patient oxygen until they wake up. So the management not going to change by the respiratory rate, kind of the acute management which correcting the bite is not going to change. But yes, definitely this is part the vitals. But, uh, if I'm gonna, you know, respiratory rate is one of the vitals that's mentioned in every hospital setting. But when you ask, let's say that you called for rapid and the patient is there, you're not going to be like when you ask for vitals, you're going to ask for respiratory rate, because that's something you can see at the bedside. So it's important, it's very important, it's part of the vitals, usually always part of the vitals. But it's not, uh, as I said, when it comes to acute setting, you're going to be there to see the patient. That's something that's part of your clinical exam more than anything. If I— I'm not sure if I answered that question correctly.

Yeah, you did.

Yeah, thank you. Yeah, thank you.

Most excellent. Out of respect to everybody's time, we're going to thank Dr. Diab for being with us today. I do know that all of the videos, when I post them in the next few days, there are almost 100 to 120 views. So people do watch this on their own time when they have the ability to have an internet connection and the time to do this. So, Ranim, I thank you. Everybody else who was here, I thank them as well. I hope this was useful. In the next few days, I will interact in the WhatsApp group as well as the LinkedIn in order to crystallize these with some exercises. And I hope that you have a wonderful day. Dr. Diab, I hope you stay warm and stay safe. And, uh, I just wanted to—

I just want to kind of thank you guys for the opportunity. I'm hoping that I added something. I know that, uh, you know, I know, you know, from being a medical student, you're overwhelmed with the information that you're given to you. But when it comes to your life, not all this— yes, it's very important. You have— you have to have that strong base of having a lot of knowledge. That at that. But you have to remember what to remember when there's an emergency. You cannot be like the one that's looking at the patient finger and still, you know, be like, oh, he have clubbing. Why? He's hypoxemic. Doesn't matter, give him some oxygen. So that's what I wanted to reach, that it, you know, it will, it will give us— I, when I started reaching that, I, it, my main concept was usually in emergency medicine, what would be at the end of the shift after like a long shift, you have to make sure that you don't have that regret that I wish I have done this differently, and this course will help you not have that regret. And I, I'm hoping that this is, you know, the goal of this, all this, just to make sure that you did your best. And this is— when you follow these things, you actually definitely, definitely doing your best. So thank you guys for the opportunity.

Thank you for being here. I think for me, I learned one thing, which is how to simplify the approach from being brilliant and perfect and complete to just start with the vitals, stabilize them, buy yourself time so that you can think. This is brilliant. I'd never learned that before. So I, for one, thank you. Please take care, and we'll see you in the next week for another episode of Gharset Emel. Take care.

Thank you.