Friday, February 14, 2020

My First "Sick" Patient

Image credit: Pexels
Author: Alexandria Gregory, MD
AAEM/RSA Publications & Social Media Committee Chair
Originally published: Common Sense January/February 2020

Everyone knows the most fundamental part of emergency medicine residency is learning how to determine “sick versus not sick,” which is often easier said than done. One night, at the end of my shift, a nurse grabbed me, saying the patient in room six needed a doctor now. The patient was a young asthmatic who had apparently walked into the emergency department minutes earlier, but was now unresponsive, gray, and with an oxygen saturation in the 50s. I had no trouble determining she was sick; as a relatively new intern, the bigger problem was figuring out what to do next. To quote Michael Scott from The Office episode “Stress Relief,” in that moment, “I knew exactly what to do, but in a much more real sense I had no idea what to do.” I knew I needed to focus on the ABCs and I knew what medications the patient needed in terms of asthma management, but in the acuity of that moment, it all jumbled together. I quickly grabbed an attending and we worked through the ABCs together as the proper medications were administered and the patient stabilized.

That patient taught me several important lessons about intern year and residency as a whole:

Thursday, February 6, 2020

Sex Sent Her to the Emergency Department: A Rare Case of Postcoital Hemoperitoneum

Image credit: Pxfuel
Author: Christina Schramm, MSIV
Medical Student
St. George’s University School of Medicine
AAEM/RSA Social Media Committee

A 31-year-old gravida 0, para 0 female patient presented to the emergency department with lower abdominal pain that started during sexual intercourse three days prior. She presented with abdominal distension, diffuse, constant, and cramping bilateral lower abdominal pain, referred pain to her shoulders, exertional dyspnea, orthostatic hypotension, and near-syncopal episodes. The patient reported constipation that turned to loose stools on day three. The patient denied fevers, vomiting, vaginal discharge or foul odor, vaginal bleeding, and dysuria. The patient had a past medical history of anemia and stated that her hemoglobin was within normal limits during her last routine blood draw. The patient had Mirena intrauterine device (IUD) inserted three years prior, and her last menstrual period was unknown. The patient had been in a mutually monogamous relationship with a male partner and stated no concern for sexually transmitted infection (STI). Differential diagnosis included IUD displacement, ectopic pregnancy, pelvic inflammatory disease, ovarian cyst rupture, ovarian torsion, and appendicitis.

Thursday, January 30, 2020

Board Review: Debunking Dysbarism

Image credit: Brett Seymour
Authors: Patrick Wallace, DO PGY-2
Emergency Medicine Resident
University of Nevada Las Vegas
AAEM/RSA Education Committee

Laurie Bezjian Wallace, DO PGY-2
Family Medicine Resident
Mike O’Callaghan Military Medical Center

“Dysbarism” collectively refers to diving-related disorders. These disorders are relatively common and range in severity. This topic is high yield on board exams and is also important for emergency medicine providers to recognize so as to administer timely interventions. This article differentiates and categorizes disorders by those occurring with descent, at depth, and with ascent (Table 1).

Facial Barotrauma (Mask Squeeze)
Negative pressure within the mask and over the eyes must be equalized. This is often done by exhaling through the nose. Failure to equalize leads to a negative pressure effect on the periorbital and ocular vessels, resulting in edema and subconjunctival hemorrhage.[1,2] Emergent complications are rare but may include hyphema, subperiosteal orbital hemorrhage, and intraorbital hematoma. In these cases, emergent ophthalmology consultation should be obtained as surgery or needle aspiration may be required.[3,4] However, the majority of facial barotrauma cases are benign and do not require treatment.[1,3,4]
Key Phrases: Conjunctival edema, subconjunctival hemorrhage, and petechial hemorrhage after diving.

Thursday, January 23, 2020

Case Report: Detecting an Occult Open Globe Laceration with Pneumotonometry

Image credit: Wikimedia Commons
Author: Conner Murphy, MSIV
Medical Student
Uniformed Services University School of Medicine

Additional Authors:
Ivan Yue, MSIV
Medical Student
Uniformed Services University School of Medicine
AAEM/RSA Publications and Social Media Committee

Melisa Walsh, MSIII
Medical Student
Uniformed Services University School of Medicine

David Supinski, DSc EMPA-C
Emergency Medicine PA
Fort Belvoir Community Hospital Emergency Department

Grigory Charny, MD MS FAAEM
Assistant Professor
Department of Military and Emergency Medicine, Uniformed Services University School of Medicine

An open globe laceration is defined as a full-thickness penetration of the eye by a sharp object.[1] Observational studies suggest that male patients ages 10-19 are at highest risk for this type of injury due to types of sports they participate in, occupations, and involvement in physical altercations.[2,3] Obvious signs of trauma are not always apparent, and a negative Seidel’s test does not rule out an occult intraocular foreign body as the wound may temporarily seal itself if small enough.[4] Decreased visual acuity, chemosis, hypotony, and pain are often the only clues that the patient has an open globe injury.[5] Early diagnosis and evaluation by an ophthalmologist are crucial to preserving vision.[6] In this case report we present an atypical case of a 24-year-old male patient with penetrating eye trauma to his right eye that was not apparent on physical exam or computed tomography.

Friday, January 17, 2020

How to Approach Third Year (M3) as an EM-bound Medical Student

Image credit: Wikimedia
Author: Taylor Petrusevski, MS4
Loyola Stritch School of Medicine
AAEM/RSA Publications & Social Media Committee

You made it through the seemingly endless lectures and question blocks that consume the pre-clinical years of medical school. In third year, it’s time to bring your classroom knowledge to the bedside. It is an exciting and overwhelming transition, but it is such a transformative year and a pivotal point in your training. You are building the foundation of your clinical skills and the formulation of your practice patterns start now. Among many variables, including Standard Letters of Evaluation (SLOEs), performance on the emergency medicine (EM) clerkship, interviews, and Step scores, third year clerkship performance continues to be an important parameter that program directors use when evaluating candidates.[1] While some studies note that your third year clerkship grades do not carry as much statistical weight as these aforementioned application components, your third year clerkships serve as the foundation of clinical skills that will allow you to succeed on your EM rotations, which is heavily weighted.[2] There are several methods to successfully navigate this transition. Different learning models emphasize the best cognitive practices to bridge this transition, noting that active reflection is just as important as preparing and actually getting the clinical experience.[3] Ultimately, do what works for you. Here are some suggestions on how to approach M3 as an emergency medicine (EM) bound student: