Procedural Competency in Academic Emergency Medicine Attending Physicians

Joseph Esherick, M.D., FAAFP, FHM
More Articles – ACLS, advanced airway, Airway management, Central line insertion, central line placement, central lines, chest tube placement, cricothyroidotomy, difficult airway, difficult airway management, Endotracheal Intubation, Featured, HPC Updates, Intubation, Lumbar Puncture, Paracentesis, paracentesis, Procedural Sedation, Simulation Based Training, Simulation-based procedural training, Thoracentesis, Tube Thoracostomy
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A recent article summarizes a cross-sectional survey aimed at determining the processes in place to assess the procedural competency of academic emergency medicine attendings.[i] The survey was sent to the 39 ACGME-accredited Emergency Medicine programs in the U.S. and had…
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Periprocedural Bleeding Risk for Thrombocytopenia, Coagulopathy, Antiplatelets and Anticoagulation

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Anticoagulation, antiplatelets, central lines, Chest tube, chest tubes, coagulopathy, Featured Procedure, HPC Updates, Lumbar Puncture, Paracentesis, procedures, Thoracentesis
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This blog summarizes the 2019 Society of Interventional Radiology (SIR) for Periprocedural Management of Image-guided Procedures with regards to thrombocytopenia, coagulopathies, antiplatelets and anticoagulation.  The SIR guidelines are summarized as follows: Anticoagulation with heparin, LMWH, fondaparinux, argatroban, warfarin, DOAC, clopidogrel, ticagrelor…
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Recommendations for Invasive Hospital Procedures in Patients with Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – acute kidney injury, Arterial Line, Arterial line insertion, Arterial line placement, Arterial Lines, Central Line, Central line insertion, central line placement, central lines, Central Venous Catheter, central venous catheters, Chest tube, chest tube placement, Cirrhosis, Featured, hospital procedures, HPC Updates, Paracentesis, paracentesis, Procedures in Cirrhotic Patients, Radial Artery Catheterization, Sepsis, Small-bore chest tube, Spontaneous bacterial peritonitis, Thoracentesis, thrombocytopenia, transexamic acid, Tube Thoracostomy, ultrasound-guided arterial lines, Ultrasound-Guided Central Line Insertion, Ultrasound-Guided Paracentesis, Ultrasound-guided radial artery line placement, Ultrasound-Guided Thoracentesis
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This blog aims to summarize the data available on how to safely perform invasive hospital procedures in patients with cirrhosis. Unfortunately, no prospective randomized controlled trials have been conducted to inform the practice of procedural medicine in cirrhotic patients. Therefore,…
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Safety of Thoracentesis and Tube Thoracostomy in Patients with Uncorrected Coagulopathies

Tube Thoracostomy Insertion
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Anticoagulants and Procedures, Anticoagulation, Antiplatelet therapy, antiplatelets, Chest tube, chest tube placement, chest tubes, coagulopathy, Featured, HPC Updates, Thoracentesis
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Traditionally, it was felt that the INR had to be less than 1.5 and platelets had to be at least 50,000/µL to perform most bedside procedures. With more clinical evidence, we now know that low-risk bedside procedures can be performed…
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Thoracentesis-Associated Pneumothorax is Rare when Performed by Procedural Experts Using Ultrasound Guidance

Thoracentesis Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, HPC Updates, Pneumothorax, Thoracentesis, Ultrasound-Guided Thoracentesis
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Original studies of ultrasound-guided thoracentesis concluded a 2% risk of pneumothorax. A recent single center study of 9320 thoracenteses over 12 years all by procedural experts had pneumothorax rate of 0.6%. This same study also demonstrated a very low incidence…
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Management of Pleural Infections

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Chest tube, chest tube placement, chest tube size, chest tubes, empyema, Featured, HPC Updates, parapneumonic effusion, pleural effusions, pleural fluid analysis, Pleural space, pneumonia, Thoracentesis, Tube Thoracostomy
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Complicated parapneumonic effusions frequently represent pleural space infections. Approximately 1 in 7 cases of pneumonia have an associated parapneumonic effusion (PPE) on chest x-ray. Most of these effusions are small and usually resolve spontaneously with prompt antibiotic administration. However, moderate-to-large…
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In-person Procedural Education in the Era of COVID19

Joseph Esherick, M.D., FAAFP, FHM
More Articles – chest tube placement, emergency procedures course, Featured, hospital procedures course, HPC Updates, Intubation, Lumbar Puncture, medical procedures course, paracentesis, POCUS, Thoracentesis, Vascular access
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Medical procedural education in the era of COVID19 is still best conducted via HANDS-ON simulation-based procedural training. Procedural skills can NOT be attained via remote education, but in-person training must be conducted safely. There are many topics and skills that can be successfully be taught online,…
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Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line placement, central line placement, chest tubes, Cirrhosis, Featured, HPC Updates, Lumbar Puncture, Paracentesis, Thoracentesis, Tube Thoracostomy
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This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.  Unfortunately, there are no strong evidence-based guidelines for hospital procedures dedicated to the study of patients with decompensated cirrhosis.…
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Safety of Draining Patients Dry During Large Volume Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, HPC Updates, Pneumothorax, re-expansion pulmonary edema, Thoracentesis
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A historical myth in procedural medicine is the operator should limit removal of pleural fluid to 1.5 L during thoracentesis because of the risk of re-expansion pulmonary edema or pneumothorax.  New evidence supports safety of large volume thoracentesis until no…
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Alternative Tests to Differentiate Pleural Effusion Exudates from Transudates

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, HPC Blog Updates, HPC Updates, pleural effusions, Thoracentesis
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How to Differentiate Pleural Effusion Exudates from Transudates   Historically, Light’s criteria have been used to classify pleural effusions into transudates or exudates.  Light’s criteria were established by Dr. Richard Light in 1972.[1]  These criteria maximize sensitivity but have a…
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Review of the Management of Hepatic Hydrothorax

Joseph Esherick, M.D., FAAFP, FHM
More Articles – ascites, Featured, hepatic hydrothorax, HPC Updates, pleural effusions, Thoracentesis
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This blog summarizes a recent update reviewing current management recommendations for hepatic hydrothorax (HH).  Hepatic hydrothorax is a complication of decompensated cirrhosis with portal hypertension.  Sixty percent of patients accumulate both ascitic fluid and pleural fluid as a result of portal…
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Safety of Thoracentesis with Coagulopathy or Thrombocytopenia

Thoracentesis Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – coagulopathy, Featured Procedure, HPC Updates, Thoracentesis, thrombocytopenia
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Historically, it was felt that a platelet count below 50,000 or an INR>1.5 was a contraindication to thoracentesis because of an increased bleeding risk.  These were arbitrary cut-offs that have since been challenged with newer kits and the use of…
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How to Differentiate Pleural Effusion Exudates from Transudates

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, HPC Updates, pleural effusions, Thoracentesis
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How to Differentiate Pleural Effusion Exudates from Transudates Historically, Light’s criteria have been used to classify pleural effusions into transudates or exudates.  Light’s criteria were established by Dr. Richard Light in 1972.[1]  These criteria maximize sensitivity but have a lower…
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Factors that influence Pleural Fluid pH after Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Chest tube, HPC Updates, pleural fluid analysis, Thoracentesis, Tube Thoracostomy
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Pleural fluid pH is an important measure for determining the clinical management of pleural diseases. For example, a pleural fluid pH <7.2 in patients with suspected pleural infection should mandate the placement of a chest tube. However, pleural fluid pH…
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The Insertion Site for a Thoracentesis Should not be Close to the Spine

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Catheter, Guidelines, HPC Updates, Saftey techniques, Thoracentesis, Ultrasound-Guided Thoracentesis
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Recent studies have determined the best technique for improving the safety of thoracentesis. The patient should be sitting as upright as possible. Then, ultrasound the posterior back and locate a catheter insertion point at least 6 cm lateral to the…
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