Lessons from Rwanda’s Marburg Virus Outbreak and Building Resilient Systems in Global EM.
Hosts:
Tsion Firew, MD
Brian Gilberti, MD
Show Notes
Context and the Rwanda Marburg Experience
The Threat: Marburg Virus Disease is from the same family as Ebola and has historically had a reported fatality rate as high as 90%.
The Outbreak (Sept. 2024): Rwanda declared an MVD outbreak. The initial cases involved a miner, his pregnant wife (who fell ill and died after having a baby), and the baby (who also died).
Healthcare Worker Impact: The wife was treated at an epicenter hospital. Eight HCWs were exposed to a nurse who was coding in the ICU; all eight developed symptoms, tested positive within a week, and four of them died.
The Turning Point: The outbreak happened in city referral hospitals where advanced medical interventions (dialysis, mechanical ventilation) were available.
Rapid Therapeutics Access: Within 10 days of identifying Marburg, novel therapies (experimental drugs and monoclonal antibodies) and an experimental vaccine were made available through diplomacy with the US government/CDC and agencies like WHO, Africa CDC, CEPI and more.
The Outcome: This coordinated effort—combini...
Episode 214: Acute Pulmonary Embolism
Thu, 02 Oct 2025
We review the diagnosis, risk stratification, & management of acute pulmonary embolism in the ED.
Hosts:
Vivian Chiu, MD
Brian Gilberti, MD
Show Notes
Core Concepts and Initial Approach
- Definition: Obstruction of pulmonary arteries, usually from a DVT in the proximal lower extremity veins (iliac/femoral), but may be tumor, air, or fat emboli.
- Incidence & Mortality: 300,000–370,000 cases/year in the USA, with 60,000–100,000 deaths annually.
- Mantra: “Don’t anchor on the obvious. Always risk stratify and resuscitate with precision.”
- Risk Factors: Broad, including older age, inherited thrombophilias, malignancy, recent surgery/trauma, travel, smoking, hormonal use, and pregnancy.
Clinical Presentation and Risk Stratification
- Presentation: Highly variable, showing up as anything from subtle shortness of breath to collapse.
- Acute/Subacute: Dyspnea (most common), pleuritic chest pain, cough, hemoptysis, and syncope. Patients are likely tachycardic, tachypneic, hypoxemic on room air, and may have a low-grade fever.
- Chronic: Can mimic acute symptoms or be totally asymptomatic.
- Pulmonary Infarction Signs: Pleuritic pain, hemoptysis, and an effusion.
- High-Risk Red Flags: Signs of hypotension (systolic blood pressure < 90 mmHg for over 15...
Episode 213: Pneumothorax
Mon, 01 Sep 2025
We break down pneumothorax: risks, diagnosis, and management pearls.
Hosts:
Christopher Pham, MD
Brian Gilberti, MD
Show Notes
Risk Factors for Pneumothorax
- Secondary pneumothorax
- Trauma: rib fractures, blunt chest trauma (as in the case).
- Iatrogenic: central line placement, thoracentesis, pleural procedures.
- Primary spontaneous pneumothorax
- Young, tall, thin males (10–30 years).
- Connective tissue disorders: Marfan, Ehlers-Danlos.
- Underlying lung disease: COPD with bullae, interstitial lung disease, CF, TB, malignancy.
- Technically, anyone is at risk.
Symptoms & Differential Diagnosis
- Typical PTX presentation: Dyspnea, chest pain, pleuritic discomfort.
- Exam clues: unilateral decreased breath sounds, focal tenderness/crepitus.
- Red flags (suggest tension PTX):
- JVD
- Tracheal deviation
- Hypotension, shock physiology
- Severe tachycardia, hypoxia
- Differential diagnoses:
- Pulmonary: asthma, COPD, pneumonia, pulmonary edema (SCAPE), ILD, infections.
- Cardiac: ACS, CHF, pericarditis.
- PE and other acute causes of dyspnea.
Diagnostics
- Bloodwork: limited role, except type & screen if intervention likely.
- EKG: reasonable given chest pain/shortness of br...
Episode 212: Angioedema
Sat, 02 Aug 2025
Angioedema – Recognition and Management in the ED
Hosts:
Maria Mulligan-Buckmiller, MD
Brian Gilberti, MD
Show Notes
Definition & Pathophysiology
Angioedema = localized swelling of mucous membranes and subcutaneous tissues due to increased vascular permeability.
Triggers increased vascular permeability → fluid shifts into tissues.
Etiologies
- Histamine-mediated (anaphylaxis)
- Associated with urticaria/hives, pruritus, and redness.
- Triggered by allergens (foods, insect stings, medications).
- Rapid onset (minutes to hours).
- Bradykinin-mediated
- Hereditary angioedema (HAE): C1 esterase inhibitor deficiency (autosomal dominant).
- Acquired angioedema: Associated with B-cell lymphoma, autoimmune disease, MGUS.
- Medication-induced: Most commonly ACE inhibitors; rarely ARBs.
- Typically lacks urticaria and itching.
- Gradual onset, can last days if untreated.
- Idiopathic angioedema
- Unknown cause; diagnosis of exclusion.
Clinical Presentations
- Swelling
- Asymmetric, non-pitting, usually non-painful.
- May involve lips, tongue, face, extremities, GI tract.
- Respiratory compromise
- Upper airway swelling → stridor, dyspnea, sensation of throat closure.
- Airway obstruction is the most feared complication.
- Abdominal manifestations
Episode 211: Granulomatosis with Polyangiitis
Tue, 01 Jul 2025
Granulomatosis with Polyangiitis (GPA) – Recognition and Management in the ED
Hosts:
Phoebe Draper, MD
Brian Gilberti, MD
Show Notes
Background
- A vasculitis affecting small blood vessels causing inflammation and necrosis
- Affects upper respiratory tract (sinusitis, otitis media, saddle nose deformity), lungs (nodules, alveolar hemorrhage), and kidneys (rapidly progressive glomerulonephritis)
- Can lead to multi-organ failure, pulmonary hemorrhage, renal failure
Red Flag Symptoms:
- Chronic sinus symptoms
- Hemoptysis (especially bright red blood)
- New pulmonary complaints
- Renal dysfunction
- Constitutional symptoms (fatigue, weight loss, fever)
Workup in the ED:
- CBC, CMP for anemia and AKI
- Urinalysis with microscopy (hematuria, RBC casts)
- Chest imaging (CXR or CT for nodules, cavitary lesions)
- ANCA testing (not immediately available but important diagnostically)
Management:
- Stable patients: Outpatient workup, urgent rheumatology consult, prednisone 1 mg/kg/day
- Unstable patients: High-dose IV steroids (methylprednisolone 1 g daily x3 days), consider plasma exchange, cyclophosphamide or rituximab initiation, ICU admission
Conditions that Mimic GPA:
- Goodpasture syndrome (anti-GBM antibodies)
- TB, fungal infections
- Lung malignancy
- Other vasculitides (EGPA, MPA, lupus)
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