EM Pulse Podcast™

Micro Skills, Macro Impact (Part 1)

“If you read this book on a Friday, we promise you will be better at your job on Monday.” In the high-stakes environment of the Emergency Department, we often focus on the “big saves,” but what if the secret to a thriving career lies in the tiny details? In part one of this special two-part series, we sit down with Dr. Resa Lewiss, an emergency and lifestyle medicine physician, TEDMED speaker, and co-author of the hit book Micro Skills: Small Actions, Big Impact. We dive into why the “workplace playbook” isn’t always handed to us and how breaking down overwhelming professional goals into small, actionable behaviors can transform your trajectory. What Exactly Are “Micro Skills”? Dr. Lewiss defines Micro Skills as the small, actionable behaviors and steps that serve as the building blocks for achieving massive goals. Whether it’s tackling an overwhelming project or building a habit you thought was “just for other people,” almost everything can be broken down into these manageable units. For Dr. Lewiss and her co-author, Dr. Adaira Landry, these skills are the “missing playbook” they wish they’d had earlier in their careers. Early Career: The Micro Skills of Self-Care For those just entering the workforce—from residents to new attendings—the focus must be on sustainability. Become an “Award-Winning Sleeper”: Stop wearing exhaustion as a badge of honor. Dr. Lewiss highlights why sleep is a professional necessity, not a luxury. The Personal Board of Directors: Create a “round table” of go-to people—mentors, peers, and sponsors—who can help you navigate professional and personal hurdles. Mid-Career: Navigating Conflict & Team Dynamics As physicians gain competence and move into leadership, the challenges become more interpersonal. The “Paper Tiger” Colleague: Learn how to identify coworkers who project authority they don’t actually have by trusting your “Spidey sense”, checking organizational charts, asking established leadership. Inquiring Carefully: When navigating workplace tension, focus on avoiding gossip and seeking clarity from trusted supervisors. Late Career: Modeling Culture & Professionalism Seasoned physicians have the greatest power to shift the culture of a department. The Scheduled Send: Protect your team’s “deliberate rest” by scheduling emails to arrive during standard business hours. From Bystander to Upstander: Use your seniority to shut down unprofessional behavior with simple scripts like, “I don’t understand the joke, can you explain it to me?” Coming Up in Part 2… The conversation continues! In the next episode, we explore the “Power of the Pause,” why Dr. Lewiss advocates for the “Joy of Missing Out” (JOMO), and a simple three-question framework (Start, Stop, Continue) to get the meaningful feedback you actually need to grow. We want to hear from you! Which of these micro skills resonated with you? Have you been able to apply these to your daily life and medical practice? Connect with us on social media @empulsepodcast or on our website ucdavisem.com. Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis Guest: Dr. Resa E. Lewiss, Emergency Medicine and Lifestyle Medicine Physician, Adjunct Professor of Emergency Medicine at the Warren Alpert Medical School of Brown University, TEDMED speaker, educator and mentor. Resources: Micro Skills: Small Actions, Big Impact, by Adaira Landry, MD and Resa E. Lewiss, MD The Visible Voices Podcast, hosted by Dr. Resa Lewiss Lewiss on Lifestyle Medicine, column on Healio by Dr. Resa Lewiss *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Do Clinical Decision Tools Reduce Bias? DFTB Collab

This episode of EM Pulse dives into a critical intersection of clinical practice: the overlap between objective evidence-based medicine and the subjective influence of implicit bias. In a special collaboration with Don’t Forget the Bubbles (DFTB), we are joined by experts from across the globe to discuss a landmark study on how clinical decision rules—specifically the PECARN (Pediatric Emergency Care Applied Research Network) imaging rules—impact disparities in pediatric trauma imaging. The Variables of Bias We often think of medical decision-making as a clean equation, but how much do factors like a patient’s perceived race or ethnicity “creep” into our choices? The team explores the concept of equitable care—providing the best possible outcome regardless of factors outside a patient’s control—and why awareness alone often isn’t enough to counteract the biases we all carry. Standardizing Equity: The Power of the Rule The core of this discussion centers on a prospective multicenter study titled “Perceived Race and Ethnicity on CT Use in Children with Minor Head or Abdominal Trauma.” * The Question: Do racial and ethnic disparities in CT use still exist in the “PECARN era”? The Twist: Why the researchers chose to look at clinician-perceived race rather than self-identification to capture what is actually happening in the provider’s mind during a shift. The Finding: The guests discuss the surprising (and encouraging) results regarding how structured clinical rules can act as “equity builders.” A Global Perspective Bias isn’t just a local issue. With representation from UC Davis, UCSF, Children’s National, and Athens, Greece, the panel looks at the international landscape of pediatric emergency care. They discuss: The barriers to implementing decision tools in different healthcare systems. The concept of “pediatric readiness” on a global scale. How these rules—originally developed in the U.S.—are being validated and adapted from Australia to Europe. Moving Beyond the “Black Box” While AI and machine learning are the buzzwords of the day, this episode highlights the beauty of “simple” statistical tools that are transparent and easy to use at the bedside. The guests share how they envision these findings changing their next shift—not by removing the “humanity” of the process, but by anchoring conversations with families in solid evidence. Check the Show Notes: We’ve included links to the original study and the companion blog post at Don’t Forget the Bubbles, which features a deep dive into the data. You can also find the PECARN Pediatric Head Injury and Intra-abdominal Injury (IAI) rules on MDCalc to use on your next shift.   We want to hear from you! Connect with us on social media @empulsepodcast or on our website ucdavisem.com. Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis Guests: Dr. Nate Kuppermann, Executive Vice President and Chief Academic Officer; Director, Children’s National Research Institute; Department Chair, Pediatrics, George Washington University School of Medicine and Health Sciences Dr. Nisa Atigapramoj, Pediatric Emergency Medicine Physician at UCSF Benioff Children’s Hospital Dr. Spyridon Karageorgos, Pediatric Emergency Medicine Physician at Aghia Sophia Children’s’ Hospital in Athens, Greece Resources: DontForgetTheBubbles.com: CT Use in Children with Minor Head or Abdominal Trauma Atigapramoj NS, McCarten-Gibbs K, Ugalde IT, Badawy M, Chaudhari PP, Yen K, Ishimine P, Sage AC, Nielsen D, Uppermann JS, Kravitz-Wirtz ND, Tancredi DJ, Holmes JF, Kuppermann N. Perceived Race and Ethnicity on CT Use in Children With Minor Head or Abdominal Trauma. Pediatrics. 2026 Feb 1;157(2):e2024070582. doi: 10.1542/peds.2024-070582. PMID: 41520991. PECARN Spotlight: Tools Validated Excuse Me, Your Bias is Showing PECARN **** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Penicillin Allergy Delabeling

We’ve all seen it: the patient whose chart is “flagged” with a penicillin allergy, but when you dig into the history, the story doesn’t quite add up. Maybe it was a stomach ache in the 90s, or maybe they’re just carrying a “inherited” allergy from a parent. In this episode of EM Pulse, we sit down with ED Clinical Pharmacist Haley Burhans to discuss why these labels are more than just a nuisance—they’re a clinical liability—and how a simple tool can empower you to fix them on the fly. The Hidden Danger of the “Safe” Choice Choosing a non-beta-lactam antibiotic because of a questionable allergy label feels like the path of least resistance, but the data tells a different story. We explore how “playing it safe” can actually lead to: Worse Outcomes: Why second line antibiotics often mean higher treatment failure rates. The “Superbug” Factor: The surprising link between penicillin allergy labels and the rise of MRSA and VRE in our communities. The C. diff Connection: Why alternative choices might be setting your patient up for a much more difficult recovery. The Solution: The PEN-FAST Score How do you move from “I think this might not be a true allergy” to “I am confident this antibiotic is safe”? Haley introduces the PEN-FAST score, a validated scoring tool designed to risk-stratify patients based on a few key historical questions. The Mnemonic: We break down the PEN-FAST acronym so you know exactly which three questions to ask to risk-stratify your patient in seconds. IgE vs. The Rest: Learn to distinguish between the “true” dangerous hypersensitivity and the delayed reactions that shouldn’t stop you from using the best drug for the job. The “Amoxicillin Rash”: We dive into this common pediatric “gotcha.”, why many kids end up with a lifelong allergy label after a routine ear infection, and why it often has nothing to do with the drug itself. The Bottom Line: Patients with low PEN-FAST scores are considered low risk, making an oral challenge under observation in the ED a reasonable option. Higher scores may require shared decision-making or referral. Why the ED is the Perfect Place for a “Challenge” Delabeling isn’t just for the allergist’s office. We argue that the Emergency Department is actually the ideal setting to challenge these allergies. The “Oral Challenge”: Learn the practical steps for performing a trial dose in the department. Safety First: Why your environment and expertise make you uniquely qualified to handle the “what-ifs” better than anyone else. Key Takeaways Question the Label: The vast majority of reported penicillin allergies are inaccurate due to patients outgrowing the allergy or misinterpreting common side effects as allergic reactions. History is Everything: Dig deeper than just “rash.” Ask about the timing relative to the dose, specific appearance (hives vs. flat rash), and what treatment was required (epinephrine vs. antihistamines). Use PEN-FAST: Utilize this tool to objectify the risk. Document Tolerance: Even if you don’t fully delete the allergy label, if you successfully treat the patient with another beta-lactam (like ceftriaxone), document that tolerance clearly to aid future clinicians. Cephalosporins are likely safe: Later-generation cephalosporins generally have very low cross-reactivity and are usually safe options even in truly allergic patients How do you handle documented penicillin allergies? Do you use the PEN-FAST tool? Share your experience with us on social media @empulsepodcast or at ucdavisem.com Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis Guests: Haley Burhans, PharmD, Emergency Medicine Clinical Pharmacist at UC Davis Resources: PEN-FAST Score on MDCalc Penicillin Allergy Evaluation Should Be Performed Proactively in Patients with a Penicillin Allergy Label – A Position Statement of the American Academy of Allergy, Asthma & Immunology Staicu ML, Vyles D, Shenoy ES, Stone CA, Banks T, Alvarez KS, Blumenthal KG. Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. J Allergy Clin Immunol Pract. 2020 Oct;8(9):2858-2868.e16. doi: 10.1016/j.jaip.2020.04.059. PMID: 33039010; PMCID: PMC8019188. Yang C, Graham JK, Vyles D, Leonard J, Agbim C, Mistry RD. Parental perspective on penicillin allergy delabeling in a pediatric emergency department. Ann Allergy Asthma Immunol. 2023 Jul;131(1):82-88. doi: 10.1016/j.anai.2023.03.023. Epub 2023 Mar 27. PMID: 36990206. *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.  

Tiny Hot Patients And The PECARN Febrile Infant Rule

This episode of EM Pulse dives into one of the most stressful scenarios in the ED: the febrile infant in the first month of life. Traditionally, a fever in this age group has meant an automatic “full septic workup,” including the dreaded lumbar puncture (LP). But times are changing. We sit down with experts Dr. Nate Kuppermann and Dr. Brett Burstein to discuss a landmark JAMA study that suggests we might finally be able to safely skip the LP in many of our tiniest patients. The Study: A Game Changer for Neonates Our discussion centers on a massive international pooled study evaluating the PECARN Febrile Infant Rule specifically in infants aged 0–28 days. While previous guidelines were conservative due to a lack of data for this specific age bracket, this study provides the evidence we’ve been waiting for. The Cohort: A large pool of infants across multiple countries. The Findings: The PECARN rule demonstrated an exceptionally high negative predictive value for invasive bacterial infections. The Big Win: The rule missed zero cases of bacterial meningitis. Defining the Danger: SBI vs. IBI The experts break down why we are shifting our terminology and our clinical focus. Serious Bacterial Infection (SBI)  Historically, this was a “catch-all” term including Urinary Tract Infections (UTIs), bacteremia, and meningitis. However, UTIs are generally more common, easily identified via urinalysis, and typically less life-threatening than the other two. Invasive Bacterial Infection (IBI)  This term refers specifically to bacteremia and bacterial meningitis. These are the “high-stakes” infections the PECARN rule is designed to rule out. Dr. Kuppermann notes that we should ideally view bacteremia and meningitis as distinct entities, as the clinical implications of a missed meningitis case are far more severe. The HSV Elephant in the Room One of the primary reasons clinicians hesitate to skip an LP in a neonate is the fear of missing Herpes Simplex Virus (HSV) infection. Low Baseline Risk: While the overall risk of HSV in a febrile infant is low, the risk of “isolated” HSV (meningitis without other signs or symptoms) is even rarer. Screening Tools: Most infants with HSV appear clinically ill. Clinicians can also use ALT (liver function) testing as a secondary screen – transaminase elevation is a common marker for systemic HSV. Clinical Judgment: If the baby is well-appearing, has no maternal history of HSV, no vesicles, and no seizures, the risk of missing HSV by skipping the LP is exceptionally low. Practical Application: Shared Decision-Making This isn’t just about the numbers—it’s about the parents. “Families don’t mind their babies being admitted… They do not want the lumbar puncture. It is the single most anxiety-provoking aspect of care.” — Dr. Brett Burstein The PECARN “Low-Risk” Criteria:  (Remember, this rule applies only to infants who are not ill-appearing.) Urinalysis: Negative Absolute Neutrophil Count (ANC): ≤ 4,000/mm³ Procalcitonin (PCT): ≤ 0.5 ng/mL The Bottom Line: If an infant is well-appearing and meets these criteria, physicians can have a nuanced conversation with parents about the risks and benefits of forgoing the LP, while still admitting the child for observation (often without empiric antibiotics) while cultures brew. Key Takeaways The “Well-Appearing” Filter: If an infant looks ill, the rule does not apply. These patients require a full workup, including an LP, regardless of lab results. Meticulous Physical Exam: Assess for a strong suck, normal muscle tone, brisk capillary refill, and any rashes or vesicles. History is Key: Always ask about maternal GBS/HSV status, pregnancy or birth complications, prematurity, sick contacts, and any changes in feeding, stooling or activity. Procalcitonin: PCT is the superior inflammatory marker for this rule. If your facility only offers traditional markers like CRP, the PECARN negative predictive value cannot be strictly applied. In the words of Dr. Kuppermann: “If you don’t have it, for God’s sakes, just get it! ALT to Screen for HSV: While not part of the official PECARN rule, our experts suggest that significantly elevated liver enzymes should raise suspicion for systemic HSV. Observe, Don’t Discharge: Being “low risk” does not mean the infant goes home. All infants ≤ 28 days still require admission for 24-hour observation and blood/urine cultures. We want to hear from you! Does this change how you approach febrile neonates in the ED? How do you handle shared decision-making with parents? Connect with us on social media @empulsepodcast or on our website ucdavisem.com. Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis Guests: Dr. Nate Kuppermann, Executive Vice President and Chief Academic Officer; Director, Children’s National Research Institute; Department Chair, Pediatrics, George Washington University School of Medicine and Health Sciences Dr. Brett Burstein, Clinician-Scientist and Pediatric Emergency Medicine Physician at Montreal Children’s Hospital, McGill University Resources: Burstein B, Waterfield T, Umana E, Xie J, Kuppermann N. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. 2026 Feb 3;335(5):425-433. doi: 10.1001/jama.2025.21454. PMID: 41359314; PMCID: PMC12687207“Hot” Off the Press: Infant Fever Rule “Hot” Off the Press: Infant Fever Rule Do I really need to LP a febrile infant with a UTI? PECARN Infant Fever Update: 61-90 Days Kuppermann N, Dayan PS, Levine DA, Vitale M, Tzimenatos L, Tunik MG, Saunders M, Ruddy RM, Roosevelt G, Rogers AJ, Powell EC, Nigrovic LE, Muenzer J, Linakis JG, Grisanti K, Jaffe DM, Hoyle JD Jr, Greenberg R, Gattu R, Cruz AT, Crain EF, Cohen DM, Brayer A, Borgialli D, Bonsu B, Browne L, Blumberg S, Bennett JE, Atabaki SM, Anders J, Alpern ER, Miller B, Casper TC, Dean JM, Ramilo O, Mahajan P; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019 Apr 1;173(4):342-351. doi: 10.1001/jamapediatrics.2018.5501. PMID: 30776077; PMCID: PMC6450281. Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, O’Leary ST, Okechukwu K, Woods CR Jr; SUBCOMMITTEE ON FEBRILE INFANTS. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021 Aug;148(2):e2021052228. doi: 10.1542/peds.2021-052228. Epub 2021 Jul 19. Erratum in: Pediatrics. 2021 Nov;148(5):e2021054063. doi: 10.1542/peds.2021-054063. PMID: 34281996. ****Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.  

Medicine on the Go: Care at Home

  Reimagining Care Beyond Hospital Walls Hospitals are a finite resource—but patient needs are not. This episode continues our multi-part series on taking medicine to where patients are—rather than making them come to us. From preventative care to pediatricians meeting families in their own environments, the series has explored how medicine is evolving beyond traditional settings. In this episode, we explore one of the most compelling—and long-overdue—ideas yet: care at home. What Is Home-Based Medical Care? Joined by Dr. Kelly Owen, Professor of Emergency Medicine at UC Davis and Medical Director for Express Care and Dispatch Health, the conversation dives into what home-based care really looks like—from urgent care at home to ED-to-home follow-ups and post-hospital discharge support designed to prevent readmissions. A Patient-Centered Solution That Works Through a powerful real-world case, the team illustrates how mobile medical units can deliver wraparound care—medications, follow-up appointments, and clinical evaluation—right in a patient’s living room, avoiding unnecessary hospital stays while improving outcomes and patient satisfaction. Why This Model Matters Now With emergency departments stretched thin, home-based care offers ways to: Reduce avoidable ED visits and hospitalizations Improve continuity of care after discharge Support vulnerable, homebound, or transportation-limited patients Deliver care that insurance covers and patients prefer The model is compelling: high patient satisfaction, low ED escalation rates, and health care dollars saved—all while keeping patients at the center. The Future of “Medicine on the Go” As technology and remote monitoring continue to evolve, this episode makes the case that home-based care isn’t a niche experiment—it’s a scalable, sustainable future for emergency and outpatient medicine. Tune in to hear how taking medicine to where patients are is transforming care—for the better. Was this series helpful for you? What other topics would you like to see us cover? Let us know on social media @empulsepodcast or at ucdavisem.com Hosts: Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis Guests: Dr. Kelly Owen, Professor of Emergency and Medical Director of Express Care and Dispatch Health at UC Davis Resources: ‘The next frontier of emergency medicine’: House calls following emergency room by Liam Connolly, April 30, 2024. UC Davis Health embarks on innovative care at home journey by Liam Connolly, July 18, 2023.  AMA’s Return on Health: Telehealth framework for practices. *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.