EM Pulse Podcast™

MAY 5, 2026

It’s one of the most common—and most frustrating—complaints in the Emergency Department: the patient covered head-to-toe in hives, miserable, itching, and desperate for relief. In this episode of EM Pulse, we welcome back ED Clinical Pharmacist Haley Burhans to tackle the “uncomfortable” topic of urticaria. We move past the myths of one-and-done doses and explore why your standard allergy dosing might be leaving your patients itching for more. The Power of Second-Generation Antihistamines Haley explains why second-generation antihistamines (cetirizine, levocetirizine, fexofenadine) should be your first-line ED therapy, rather than the old school standard, diphenhydramine (Benadryl). <ul> <li>Xyzal vs. Zyrtec: We break down the L-enantiomer (levocetirizine) and whether it actually beats its predecessor in preventing drowsiness.</li> <li>The “Double Dose” Pearl: For acute urticaria in the ED, 10mg of cetirizine isn’t enough. Haley recommends starting with 20mg for adults (or doubling the weight-based dose for kids) to see relief within 20–60 minutes.</li> <li>The 4x Rule: Guidelines now support up to four times the standard daily dose for refractory cases (usually split BID). We discuss the safety data behind these higher regimens and why they are tolerated so well.</li> </ul> The Steroid Trap and the Rebound Effect Patients often come in requesting steroids but they are NOT the primary cure for urticaria. <ul> <li>The Antihistamine Backbone: Steroids treat inflammation, but the antihistamine treats the underlying stimulus. If a patient stops their antihistamines and only takes a steroid burst, they are set up for a miserable rebound.</li> <li>Dosing Strategies: If you do use steroids, keep it to a burst or taper of 10 days or less. We discuss the utility of methylprednisolone (Medrol Dosepak) versus a simple prednisone burst/taper or a course of longer-acting dexamethasone.</li> </ul> Beyond the Basics: Benadryl and the MABs <ul> <li>The Danger of “Dirty” Drugs: Why diphenhydramine has fallen out of favor due to its sodium channel blocking side effects, anticholinergic toxicity, and psychiatric risks.</li> <li>The Future of Itch: A look at emerging biologics like omalizumab. While these IgE-blockers shouldn’t be started in the ED, it’s important to know about them to treat patients who are taking them, or who present with rebound urticaria after recently stopping them.</li> </ul> Key Takeaways <ul> <li>Go Big on Second Generation Antihistamines: Start with a double dose of cetirizine in the ED. It’s safe, effective, and less sedating than first-generation alternatives. Discharge patients on that double dose twice a day.</li> <li>Think Long-Term: Urticaria pathways need time to “cool down.” Advise patients to stay on the prescribed meds/doses for 1–2 months, not 1–2 days.</li> <li>Steroids are Adjuncts: Use a short burst (<10 days) for severe distress, but never as monotherapy.</li> <li>The Taper is Key: Encourage a slow taper of medications to prevent symptom recurrence.</li> <li>Managing Expectations: Most urticaria has no identifiable cause (often viral or idiopathic). Reassure the patient that while we may not find the why, we can help manage the itch.</li> </ul> How do you handle the “itch that won’t quit”? Do you have a favorite antihistamine cocktail? Share your experience with us on social media @empulsepodcast or at ucdavisem.com Hosts: <a href="http://Twitter.com/julmagana">Dr. Julia Magaña</a>, Professor of Pediatric Emergency Medicine at UC Davis <a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html">Dr. Sarah Medeiros</a>, Professor of Emergency Medicine at UC Davis Guests: <a href="https://www.linkedin.com/in/haley-burhans?utm_source=share&utm_campaign=share_via&utm_content=profile&utm_medium=ios_app">Haley Burhans, PharmD</a>, Emergency Medicine Clinical Pharmacist at UC Davis Resources: <a href="https://eaaci.org/guidelines-position-papers/the-international-eaaci-ga%C2%B2len-euroguiderm-apaaaci-guideline-for-the-definition-classification-diagnosis-and-management-of-urticaria/">The international EAACI/ GA²LEN/ EuroGuiDerm/ APAAACI guideline for the definition, classification, diagnosis, and management of urticaria</a> <a href="https://www.chop.edu/clinical-pathway/urticaria-angioedema-clinical-pathway">Emergency Department and Primary Care Clinical Pathway for Evaluation/Treatment of Children with Urticaria or Angioedema (CHOP)</a> *** Thank you to the <a href="http://www.ucdmc.ucdavis.edu/emergency/">UC Davis Department of Emergency Medicine</a> for supporting this podcast and to Orlando Magaña at <a href="http://www.orlandomagana.com/">OM Productions</a> for audio production services.

18 MIN

APR 29, 2026

When the Ovaries Retire: Menopause in the ED

Menopause is not just “hot flashes”—it is a systemic hormonal shift that affects almost every organ system. For the emergency clinician, recognizing the symptoms of perimenopause and menopause is crucial for expanding the differential diagnosis once life-threatening conditions are ruled out. Dr. Pam Dyne joins us for a crash course on evaluating menopausal and perimenopausal patients in the ED. The “Why”: Why Menopause Matters in the ED <ul> <li>The Mimic: Menopausal symptoms can mimic emergencies, including cardiac events, neurologic issues, and acute musculoskeletal injuries.</li> <li>The “Nothing Bad” Trap: After a negative workup (e.g., for chest pain or abdominal pain), telling a patient “everything is normal” often leaves them without answers. Identifying menopause as a potential etiology provides patient-centered closure and a path to treatment.</li> <li>Empowerment: Many medical providers are insufficiently trained when it come to menopause – ED clinicians can help patients advocate for themselves.</li> </ul> Physiology Refresher: When the Ovaries Retire <ul> <li>The Signal: Prior to menopause, the brain sends FSH/LH to the ovaries, and the ovaries answer with estrogen.</li> <li>The Shift: In menopause, the ovaries “retire.” The brain keeps shouting (higher FSH levels), but the ovaries don’t respond.</li> <li>Perimenopause: Hormones fluctuate wildly, cycles become irregular, and symptoms are often at their peak due to inconsistency.</li> </ul> Hormone Therapy (MHT): Debunking the Myths A major barrier to treatment is the “mass hysteria” caused by the 2002 Women’s Health Initiative (WHI) study. <ul> <li>The Correction: Modern re-analysis shows that for healthy females under 60 and within 10 years of menopause, hormone therapy is extremely safe. (There are some exceptions, including females at high risk for certain cancers)</li> <li>The Benefits: It has been shown to reduce all-cause mortality by 30% and has many potential health benefits, including lower the risk of Alzheimer’s, Parkinson’s, and osteoporotic fractures.</li> </ul> The Difficult Pelvic Exam: ED “Hacks” Examining older female patients can be challenging for myriad reasons, including physical limitations and lack of proper ED pelvic exam gurneys. <ol> <li>The Upside-Down Speculum: If you can’t use stirrups, keep the patient flat on the bed. Turn the speculum upside down (handle facing up) so it doesn’t hit the gurney. Tip: Push down on the handle; don’t pull up like a laryngoscope.</li> <li>Lateral Decubitus: Perform the exam with the patient on their side (top leg held up) if they cannot flex their hips.</li> <li>Comfort: Use liberal lubrication and consider topical lidocaine gel.</li> <li>The “Hidden” Problem: Always check for old/forgotten pessaries or fecal impaction in cases of pelvic pain or recurrent UTIs.</li> </ol> Clinical Pearls: Specific Presentations 1. Post-Menopausal Bleeding <ul> <li>Rule: Cancer until proven otherwise.</li> <li>Workup: Speculum exam (confirm source) + Ultrasound (measure endometrial thickness) + Endometrial biopsy (usually outpatient).</li> </ul> 2. Genitourinary Syndrome of Menopause (GSM) <ul> <li>Symptoms: Vaginal dryness, thinning tissue, pH changes, and recurrent UTIs (≥3 culture-proven UTIs in 12 months or ≥2 in 6 months).</li> <li>ED Treatment: ED docs can and should prescribe vaginal estrogen cream. It is not absorbed systemically and is highly effective at preventing future UTIs.</li> </ul> 3. Pelvic Organ Prolapse <ul> <li>Types: Cystocele (bladder), Rectocele (rectum), or Uterine prolapse.</li> <li>Exam Tip: Symptoms are often gravity-dependent. If you don’t see the bulge while the patient is supine, ask them to bear down.</li> </ul> 4. Musculoskeletal (MSK) Syndrome of Menopause <ul> <li>Presentation: atraumatic joint pain, tendinopathies.</li> <li>Cause: Estrogen receptors are located throughout the MSK system; loss of estrogen leads to inflammation and ligamentous changes.</li> </ul> Key Takeaways for the ED Clinician <ol> <li>Keep menopause on your differential: Don’t dismiss vague aches, mood changes, or urinary issues in women aged 45–60 as “just stress.”</li> <li>Look at the Problem: If a patient has pelvic pain or bleeding, do the exam. You might find a simple fix, like a forgotten pessary or local atrophy.</li> <li>Connect to Care: If you suspect menopause is the culprit, point them toward menopause.org to find a certified practitioner.</li> </ol> Hosts: <a href="http://Twitter.com/julmagana">Dr. Julia Magaña</a>, Professor of Pediatric Emergency Medicine at UC Davis <a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html">Dr. Sarah Medeiros</a>, Professor of Emergency Medicine at UC Davis Guest: <a href="https://www.linkedin.com/in/pamela-dyne-685386241/">Dr. Pamela Dyne</a>, Professor of Clinical Emergency Medicine and Chief Physician Wellness Officer at Olive View UCLA Medical Center Resources: <a href="https://menopause.org">North Americal Menopause Society (NAMS) – Menopause.org</a> <a href="https://www.acepnow.com/article/utis-and-estrogen-the-overlooked-link/">UTIs and Estrogen: the Overlooked Link</a>, By Ashley Winter, MD; Rachel Rubin, MD; and Howie Mell, MD, MPH. ACEP Now, February 16, 2022 <a href="https://www.acog.org/topics/menopause">American College of Obstetricians and Gynecologists (ACOG): Menopause</a> *** Thank you to the <a href="http://www.ucdmc.ucdavis.edu/emergency/">UC Davis Department of Emergency Medicine</a> for supporting this podcast and to Orlando Magaña at <a href="http://www.orlandomagana.com/">OM Productions</a> for audio production services.

35 MIN

APR 8, 2026

Micro Skills, Macro Impact (Part 2)

“Time can only be spent. Think of it as your most valuable currency.” Welcome back to EM Pulse. We are continuing our deep dive with Dr. Resa Lewiss into the world of Micro Skills. If you missed it, go back and listen to Part 1 where we definite micro skills and discuss how they can help you as an early, mid or late career physician. In the second half our interview, we move beyond the career stages and into the daily habits that protect our time, our energy, and our sanity. Protecting Your Time and Energy The “Failure Friend” and the Board of Directors Building on the concept from Part 1, Dr. Lewiss emphasizes that your Personal Board of Directors isn’t just for networking—it’s for survival. <ul> <li>The “No-Judgment” Call: In EM, bad outcomes happen. You need a person you can call to simply be heard without needing a solution. Whether it’s a mistake or just a really rough shift, having a “failure friend” is a vital micro skill for psychological health.</li> </ul> Networking as an Introvert (and for Women) Networking often feels “creepy” or superficial, but Dr. Lewiss re-frames it as connecting. <ul> <li>Arrive Rested: For introverts, the best micro skill for networking is showing up with a full battery.</li> <li>Deliberate Rest: This is the practice of doing non-work activities (nature, exercise, meals with loved ones) specifically to return to work with more focus.</li> </ul> Meaningful Feedback: Start, Stop, Continue Tired of vague “Good job!” feedback? Dr. Lewiss shares her own mistakes in giving feedback and offers a better way to receive it: <ul> <li>The “One Thing” Rule: When someone praises your work, ask: “What is one thing that stood out?”</li> <li>The Framework: To get honest feedback from subordinates or peers, ask them: “What is one thing I should start doing, one thing I should stop doing, and one thing I should continue doing?”</li> </ul> Reclaiming the Calendar: Meetings and JOMO Emergency physicians often suffer from FOMO (Fear Of Missing Out), but Dr. Lewiss argues for JOMO (Joy Of Missing Out). <ul> <li>Break the “one-hour meeting” mold. Most one-hour meetings can be 30 minutes. Most 30-minute meetings can be 15 minutes. Most 15-minute meetings could be a text or a phone call. Not everything needs a meeting!</li> <li>The Power of the Pause: Before saying “yes” to a new committee or project, pause. Ask, “Can you tell me more?” Ask key questions like, what are the goals? What is the timeline? What are the deliverables? </li> </ul> Is Lifestyle Medicine the new frontier? Dr. Lewiss discusses why many EM physicians are pivoting toward Lifestyle Medicine. By focusing on the “pillars” (sleep, movement, community, and food), physicians can move from treating chronic disease in the ER to preventing it in the community. 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 <a href="https://bsky.app/profile/empulsepodcast.bsky.social">@empulsepodcast</a> or on our website <a href="http://ucdavisem.com">ucdavisem.com</a>. Hosts: <a href="http://Twitter.com/julmagana">Dr. Julia Magaña</a>, Professor of Pediatric Emergency Medicine at UC Davis <a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html">Dr. Sarah Medeiros</a>, Professor of Emergency Medicine at UC Davis Guest: <a href="https://www.resalewiss.com">Dr. Resa E. Lewiss</a>, 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: <a href="https://www.resalewiss.com/microskills-the-book">Micro Skills: Small Actions, Big Impact</a>, by Adaira Landry, MD and Resa E. Lewiss, MD <a href="https://podcasts.apple.com/us/podcast/the-visible-voices/id1510254235">The Visible Voices Podcast</a>, hosted by Dr. Resa Lewiss <a href="https://www.healio.com/authors/rlewiss">Lewiss on Lifestyle Medicine</a>, column on Healio by Dr. Resa Lewiss *** Thank you to the <a href="http://www.ucdmc.ucdavis.edu/emergency/">UC Davis Department of Emergency Medicine</a> for supporting this podcast and to Orlando Magaña at <a href="http://www.orlandomagana.com/">OM Productions</a> for audio production services.

18 MIN

MAR 18, 2026

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. <ul> <li>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.</li> <li>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.</li> </ul> Mid-Career: Navigating Conflict & Team Dynamics As physicians gain competence and move into leadership, the challenges become more interpersonal. <ul> <li>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.</li> <li>Inquiring Carefully: When navigating workplace tension, focus on avoiding gossip and seeking clarity from trusted supervisors.</li> </ul> Late Career: Modeling Culture & Professionalism Seasoned physicians have the greatest power to shift the culture of a department. <ul> <li>The Scheduled Send: Protect your team’s “deliberate rest” by scheduling emails to arrive during standard business hours.</li> <li>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?”</li> </ul> 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 <a href="https://bsky.app/profile/empulsepodcast.bsky.social">@empulsepodcast</a> or on our website <a href="http://ucdavisem.com">ucdavisem.com</a>. Hosts: <a href="http://Twitter.com/julmagana">Dr. Julia Magaña</a>, Professor of Pediatric Emergency Medicine at UC Davis <a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html">Dr. Sarah Medeiros</a>, Professor of Emergency Medicine at UC Davis Guest: <a href="https://www.resalewiss.com">Dr. Resa E. Lewiss</a>, 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: <a href="https://www.resalewiss.com/microskills-the-book">Micro Skills: Small Actions, Big Impact</a>, by Adaira Landry, MD and Resa E. Lewiss, MD <a href="https://podcasts.apple.com/us/podcast/the-visible-voices/id1510254235">The Visible Voices Podcast</a>, hosted by Dr. Resa Lewiss <a href="https://www.healio.com/authors/rlewiss">Lewiss on Lifestyle Medicine</a>, column on Healio by Dr. Resa Lewiss *** Thank you to the <a href="http://www.ucdmc.ucdavis.edu/emergency/">UC Davis Department of Emergency Medicine</a> for supporting this podcast and to Orlando Magaña at <a href="http://www.orlandomagana.com/">OM Productions</a> for audio production services.

17 MIN

MAR 10, 2026

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 <a href="https://dontforgetthebubbles.com/ct-use-in-children-with-minor-trauma/">Don’t Forget the Bubbles (DFTB)</a>, we are joined by experts from across the globe to discuss a landmark study on how clinical decision rules—specifically the <a href="https://ucdavisem.com/2024/04/18/pecarn-spotlight-tools-validated/">PECARN (Pediatric Emergency Care Applied Research Network)</a> imaging rules—impact disparities in pediatric trauma imaging. The Variables of Bias 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”? <ul> <li>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.</li> <li>The Finding: The guests discuss the encouraging results regarding how structured clinical rules can act as “equity builders.”</li> </ul> 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. We discuss: <ul> <li>The barriers to implementing decision tools in different healthcare systems.</li> <li>How these rules—originally developed in the U.S.—are being validated and adapted from Australia to Europe.</li> </ul> Our 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 <a href="https://bsky.app/profile/empulsepodcast.bsky.social">@empulsepodcast</a> or on our website <a href="http://ucdavisem.com">ucdavisem.com</a>. Hosts: <a href="http://Twitter.com/julmagana">Dr. Julia Magaña</a>, Professor of Pediatric Emergency Medicine at UC Davis <a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html">Dr. Sarah Medeiros</a>, Professor of Emergency Medicine at UC Davis Guests: <a href="https://www.childrensnational.org/about-us/leadership/nathan-kuppermann">Dr. Nate Kuppermann</a>, 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 <a href="https://www.linkedin.com/in/nisa-atigapramoj-77b74125/">Dr. Nisa Atigapramoj</a>, Pediatric Emergency Medicine Physician at UCSF Benioff Children’s Hospital <a href="https://www.linkedin.com/in/nisa-atigapramoj-77b74125/">Dr. Spyridon Karageorgos</a>, Pediatric Emergency Medicine Physician at Aghia Sophia Children’s’ Hospital in Athens, Greece Resources: <a href="https://dontforgetthebubbles.com/ct-use-in-children-with-minor-trauma/">DontForgetTheBubbles.com: CT Use in Children with Minor Head or Abdominal Trauma</a> <a href="https://publications.aap.org/pediatrics/article-abstract/157/2/e2024070582/206080/Perceived-Race-and-Ethnicity-on-CT-Use-in-Children?redirectedFrom=fulltext">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.</a> <a href="https://ucdavisem.com/2024/04/18/pecarn-spotlight-tools-validated/">PECARN Spotlight: Tools Validated</a> <a href="https://ucdavisem.com/2018/09/17/excuse-me-your-bias-is-showing/">Excuse Me, Your Bias is Showing</a> <a href="https://pecarn.org">PECARN</a> **** Thank you to the <a href="http://www.ucdmc.ucdavis.edu/emergency/">UC Davis Department of Emergency Medicine</a> for supporting this podcast and to Orlando Magaña at <a href="http://www.orlandomagana.com/">OM Productions</a> for audio production services.

29 MIN

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