Sunday, September 17, 2017

Calling Back, Checking Up, Finding Out

Image Credit: Pixabay
Author: Edward Siegel, MD MBA
2014-2015 AAEM/RSA Publications Committee Chair

With the exception of occasional resident research projects, most RSA members are insulated from efforts to improve efficiency, patient satisfaction, and the other dollars-and-cents concerns of running an emergency department (ED) that dog administrators. There is, however, a team in almost every ED that is focused solely on those things. These teams are constantly trying new innovations, methods, and systems to gain efficiency and improve (or reach) profitability.

Our hospital recently initiated a patient call-back system, following in the footsteps of many other EDs nationwide. This system was implemented with several goals in mind, with improved patient care chief among them. Our program is young, but it may interest those looking for ways to improve their own emergency departments.

Thursday, September 14, 2017

Consider an Away Elective. Now is Your Chance!

Image Credit: Pixabay
Author: Teresa M. Ross, MD
2011-2012 AAEM/RSA President

If the only medical world you’ve ever known is the infinite connecting hallways of a classic teaching hospital, you’re not alone. Medical school and residency naturally bring us to these oldies but goodies as the epicenter of our academic and clinical training.

But step away for a while – imagine a world where emergency docs come to work in jeans, know their colleagues (and their families) by name, and can’t count on off-hours, in-house consultants except medicine and pediatrics. There is an exciting world out there beyond formal department conferences and journal-quoting consultants.

Sunday, September 10, 2017

World Suicide Prevention Day 2017


September 10, 2017 is World Suicide Prevention Day and the AAEM Resident and Student Association (RSA) is asking everyone to Take 5 to Save Lives! Take 5 to Save Lives is a public awareness campaign started by the National Council for Suicide Prevention in support of World Suicide Prevention Day. The campaign provides prevention-focused tools to help keep yourself and others safe from suicide. What does it mean to Take 5 to Save Lives? Head to www.take5tosavelives.org to learn 5 steps you can take in just 5 minutes. The steps include:

Thursday, September 7, 2017

Teen Suicide in the United States: What Every Emergency Physician Should Know

Image Credit: Pixabay
Authors: Casey Grover, MD; David M. Carreon, MSIV; Michael K. Hole, MSIV
Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident August/September 2013

A 14-year-old boy is brought to the ED with a wrist laceration. Accident or suicide attempt?

Self-harm is the third leading cause of death in this age category behind violence and motor vehicle accidents.[3] One nationally representative sample suggests 7% of U.S. teens have attempted suicide in the last year, and 2% have made attempts serious enough to require medical attention.[2]

Sunday, September 3, 2017

Synthetic Cathinones (“Bath Salts”) and Gerbal Marijuana Alternatives – Resident Journal Review

Image Credit: Flickr
Authors: Susan Cheng, MD MPH; Jonathan Yeo, MD; Eli Brown, MD; Allison Regan, MD
Edited by: Michael C. Bond, MD FAAEM and Christopher Doty, MD FAAEM
Originally Published: Common Sense April/May 2012

This resident Journal review focuses on two popular designer drugs that have made their way into the media as well as our emergency departments: synthetic cathinones, also known as “bath salts,” and herbal marijuana alternatives. Due to the relative novelty of these drugs, not much literature or research exists to help ED physicians manage patients who come in with these acute intoxications. The pharmacology, clinical symptoms and management options, as well as a few case reports, will be discussed in this review.

Thursday, August 31, 2017

With You All the Way

Image Credit: Pixabay
Author: Meaghan Mercer, MD
2014-2015 RSA President
Originally Published: Common Sense May/June 2014

Emergency medicine is a specialty known for high burnout. Professional burnout is described and measured in many different ways, but it encompasses a loss of enthusiasm for work, emotional exhaustion, disparagement, depersonalization, a loss of empathy, and feeling a lack personal accomplishment. A study done in the 1990s showed that, of surveyed emergency physicians, 77-80% of physicians said that EM had met or exceeded their career expectations but 31-33% still noted that burnout was a significant problem in their work life. We have a dichotomous emotional response to our work: a love of what we do and a component of exhaustion from it. We can have large swings of daily highs and lows, or a day full of benign abdominal pains. We often present ourselves as emotionally open and able to look at all things objectively, but with burnout we can become emotionally blunted. How do we prevent this? There have been many proposals on how to prevent burnout, but fundamentally the answer is in rediscovering what drew us to EM initially and letting that continue to motivate us day to day.

Sunday, August 27, 2017

Thiamine Repletion in Alcohol Abuse

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Image Credit: Pixabay
Author: Alexandria Gregory, MS-3
Saint Louis University School of Medicine
AAEM/RSA Social Media Committee

Thiamine deficiency is commonly seen in patients with a history of chronic alcohol use and can have significant consequences if untreated. Therefore, repletion of thiamine in these patients is crucial, and appropriate administration should begin in the emergency department (ED).

Thursday, August 24, 2017

AAEM/RSA FIX Scholarship Winners - Women in EM: Essay Two

Kimberly M. Brown, MD
Author: Kimberly M. Brown, MD
University of Tennessee Health Science Center (Memphis)

RSA is proud to share the following essay from one of the 2017 FemInEM Idea Exchange (FIX) Scholarship winners, Kimberly Brown, MD. Congratulations, Dr. Brown! 


Author Bio: Kimberly M. Brown, MD is a senior emergency medicine resident at the University of Tennessee Health Science Center in Memphis, TN. She was born and raised in Milwaukee, WI, then left the Midwest to complete her BA in Biology from Fisk University in Nashville, TN. Loving the warm weather, she moved to Gainesville, FL and completed a Master in Public Health from the University of Florida. She completed her medical education at Ross University School of Medicine. After completing residency, she will start a fellowship in neurocritical care at the University of Tennessee.

“YOU’RE Doctor Brown?” my elderly patient incredulously asks. I turn my badge around to squint at it and then look at my embroidered scrubs to double check. “That’s what it says on here!” My patient and her family members laugh. My patient touches my hand and tells me, “I am so proud of you.” Being black and female, I'm no stranger to a surprised reaction to my initial introduction. However, this time was different.

Sunday, August 20, 2017

Combat and Cruise Ships: Reviving the Practice of Fresh Whole Blood Transfusion in Remote Environments

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Image Credit: Pixabay










Author: Scott Bland, MSIV
Campbell University School of Osteopathic Medicine

Whole blood was the only available transfusion product prior to the development of Cohn’s plasma fractionation process in 1947.[1] However, with advances in laboratory technology and more targeted therapies in hospital settings, the medical community has greatly increased the use of individual blood components, including red blood cells, platelets, and plasma. These components allow for more specific treatment effects, fewer unintended effects, potentially longer shelf life, and more uses per donation than whole blood.[2] In optimal situations, the contemporary choice of processed and screened donations is clearly the safest, but there are uses for fresh whole blood that merit consideration.

Thursday, August 17, 2017

AAEM/RSA FIX Scholarship Winners - Women in EM: Essay One

Trisha Morshed, MD
Author: Trisha Morshed, MD
UCSD Department of Emergency Medicine

RSA is proud to share the following essay from one of the 2017 FemInEM Idea Exchange (FIX) Scholarship winners,
Trisha Morshed, MD. Congratulations, Dr. Morshed!

Author bio: Trisha Morshed is an Emergency Medicine Resident at UC San Diego. She is originally from Portland, Oregon and went to undergraduate and medical school in Arizona. Her professional interests include a passion to make a difference both locally and globally. She is the Resident representative on the Board of Delegates of the San Diego County Medical Society, a physician group that meets regularly with local legislators for medical advocacy. She is also excited about global health and has been involved in international collaborative research as well as overseas projects to improve access to healthcare in resource limited settings. Trisha is a strong advocate for work/life balance and physician wellness-- on her downtime, she can be found traveling, playing outdoors, and practicing partner acrobatics.

When I was growing up, I was always told by my parents that with hard-work and perseverance, I could make my dreams a reality. I realized my passion for emergency medicine during third year of medical school during a shadowing experience, and feel so fortunate to find a field where I look forward to going to work most days and can’t imagine myself doing anything else. I have never felt that my gender hindered me at any point previously in my life; however, was surprised when I entered my residency at a place which is predominantly male, at how much I noticed the difference between how I was perceived differently from my male colleagues.

Sunday, August 13, 2017

Acute Management in Pediatric Congestive Heart Failure

Image Credit: Wikimedia
This post was peer reviewed.
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Author: Alfred Morrobel, M.D
Universidad Iberoamericana

Epidemiology
Congestive heart failure (CHF) in children is diverse due to the myriad underlying etiologies that can occur from birth to adolescence. In the United States, CHF is estimated to affect 12,000 to 35,000 children below the age of 19 years and there are approximately 11,000 to 15,000 heart failure-related hospitalizations in children per year.[1]

Thursday, August 10, 2017

Board Review: Making Decisions Based on the EKG

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Image Credit: US Air Force










Author: Nick Pettit, DO PhD, PGY-2
Indiana University
AAEM/RSA Social Media Committee

Case
The setting is a busy shift in your high-acuity pod of your emergency department. You just walked out of room 1 after resuscitating a tricyclic antidepressant (TCA) overdose. Then overhead you hear, “trauma 1 here, room 4,” and at the same time your nurse hands you the below electrocardiogram (EKG).

As you are walking toward room 4 and scribble “non-ST-elevation myocardial infarction (non-STEMI),” she gives a quick history about this patient. The patient is a 77-year-old male with a past medical history of some kidney and heart issues, and he now has fatigue, shortness of breath, and bilateral lower extremity edema. Just as you pop into the trauma in room 4, you tell your nurse you will be right over, but to please draw a rainbow of labs and:
  1. Administer 40 mL/kg 0.9% NaCl bolus.
  2. Administer 3 g calcium gluconate.
  3. Administer 6 vials of digi-bind.
  4. Administer 40 mEQ of potassium chloride
  5. Place pads and pull up ketamine for procedural sedation and immediate cardioversion.
  6. Call poison control.
Correct answer
B. Administer 3 g calcium gluconate. This patient has hyperkalemia, and based on the EKG, it should not be surprising if their potassium returns at greater than 9.0.

This review will focus on the causes of hyperkalemia, its identification, and its immediate treatment.

Causes
  1. Decreased excretion, such as in renal failure (as in this case)
  2. Excessive potassium intake
  3. Increased production of potassium (rhabdomyolysis, tumor lysis, trauma)
  4. Redistribution (digoxin, acidosis)[1]
Identification
  1. Basic metabolic panel (BMP). Be sure to watch for hemolysis, which can cause pseudohyperkalemia.
  2. EKG. Different levels of potassium elevation can cause unique EKG findings:[2]
    • ~6.0 = peaked T waves
    • ~7.0 = P-wave evolution
    • ~8.0 = wide QRS
    • ~9.0 = sinusoidal appearance
Symptoms
Weakness, confusion, chest pain, nausea and vomiting, palpitations

Management
  1. Calcium
    • Calcium chloride if there is a central venous catheter (CVC), or calcium gluconate if there is peripheral access only.
    • Stabilizes membrane in approximately ten minutes, with EKG returning to normal over several minutes.
  2. Insulin and glucose
    • Ten units of insulin given with dextrose.
    • Works over 30 minutes
  3. Sodium bicarbonate
    • Helps correct acidosis
  4. Albuterol
    • Shown to lower potassium 1 mmol/L in healthy subjects
  5. Dialysis
    • May need emergent dialysis. Remember the AEIOU mnemonic:
      • Acidosis
      • Electrolyte disturbances
      • Ingestion
      • Overload (fluid)
      • Uremia
    • In the above case, the patient may benefit from emergent dialysis.
  6. Furosemide
    • May help if the patient is volume-overloaded, but this is a common disease in end stage renal patients and furosemide may have limited value here.[3]
References:

1. Rodriguez, J., Calvert J. Hyperkalemia. Am Fam Physician. 2006 73(2):283-290

2. Hall, B., Salazar, M., Larison, D. The sequening of medication administration in the management of hyperkalemia. J of Em Nurs. 2009 35:4;339-342

3. Wrenn, K., Slovis, C., Slovis B. The ability of physicians to predict hyperkalemia from the ECG. Annals of Emerg Med. 1992 20:11;1229-1232

Sunday, August 6, 2017

Acute Decompensated Heart Failure: What is the Current Evidence for Intravenous Diuretic Therapy? - Resident Journal Review

Image Credit: Pixabay
Authors: Kaycie Corburn, MD; Lee Grodin, MD; Jackie Shibata, MD; Eli Brown, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM
Originally published: Common Sense May/June 2015

The most common cause of hospitalization in the United States and Europe is acute decompensated heart failure (ADHF). ADHF is associated with high baseline mortality rates that only increase after hospitalization. Unfortunately, there is a paucity of high quality evidence for treating this disease. Both the European Society of Cardiology and the Heart Failure Society of America offer practice guidelines that are mainly based on Class C (consensus opinion) recommendations. The complicated pathophysiology of ADHF adds difficulty to finding treatments with both short and long-term benefits.[1] Currently, over 80% of patients hospitalized for ADHF receive IV diuretic therapy.[2] This article reviews key existing studies to examine the evidence for using IV diuretic therapy for patients with ADHF.

Thursday, August 3, 2017

From Resident to Attending

Image Credit: Pixabay
Author: Meaghan Mercer, DO
AAEM/RSA 2015-2016 Immediate Past President
Originally Published: Common Sense May/June 2015

As residency comes to an end, I realize that although I feel ready for life as an attending from a clinical standpoint, we are provided little education on life outside of academia. Many questions remain, such as: What tests do I have to take, what do I have to do to get credentialed, how do I stay up to date? As we transition back into the “real world” we have to acclimate to managing our own affairs.

ABEM.org

If you haven’t looked at the website, do it now. Initial application for the board exam (Qualifying Exam per ABEM terminology) lasts from May 1-November 5 and costs $960. Yes, you can and should apply prior to finishing residency. The qualifying exam will be administered November 16 - 21, 2015. Plan ahead to have ample time to study and have access to your desired date to take your exam. Once you pass your written exam you will then be given a date in the spring or fall of 2016 to take your oral board exam. After you pass the oral board you will be officially board certified for ten years. However, you are not done. To maintain your certification you must participate in maintenance of certification (MOC). Requirements in the first five full years of certification include the following: Passing four ABEM LLSA tests, one of which must be the patient safety LLSA; completing an average of 25 AMA PRA Category 1 CreditsTM or equivalent, with an average of eight of those credits being self-assessment; completing an Assessment of Practice Performance (APP) patient care practice improvement (PI) activity; and completing an APP patient-centered Communication/Professionalism activity. For more information go to www.abem.org.

Sunday, July 30, 2017

Fever in Returning Traveler - Resident Journal Review

Image Credit: Pixabay
Authors: Megan Donohue, MD MPH; Phil Magidson, MD MPH; Erica Bates, MD; Adeolu Ogunbodede, MD; Mark Sutherland, MD; Akilesh Honasoge, MD
Editors: Michael C. Bond, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally Published: Common Sense November/December 2016

With increasing frequency of international travel, EMPs often find themselves caring for travelers who return ill. According to the International Society of Travel Medicine global surveillance network, fever was the chief complaint in approximately one third of ill travelers. The care of these patients may be challenging given the broad differential diagnosis that must be considered, including many illnesses that are uncommon in the US. This article provides a review of the literature on the epidemiology of febrile illness in the returning traveler and offers an approach to the initial evaluation, management, and diagnosis.

Thursday, July 27, 2017

Tox Talks: A Case of (Very) Long QT

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Image Source: Wikipedia
Author: Ashley Grigsby, DO
Indiana Univeristy
AAEM/RSA Social Media Committee

Case
A 42-year-old female presented to the emergency department with her husband for new episodes of apnea that had been occurring over the last few days. She currently felt well and review of systems was negative except for possible jerking movements that had been occurring prior to the apneic episodes. She had no history of seizures. Past medical history included untreated Graves’ disease. She was not on any prescription medications. Physical exam was unremarkable, including a normal neurologic exam. Laboratory evaluation was significant only for hypokalemia of 2.9 mEq/L, ionized calcium of 1.1 mg/dL, and low thyroid stimulating hormone (TSH). Electrocardiogram (EKG) was obtained and is shown below.


The patient’s QTc was greater than 700 msec on initial EKG and QRS was widened at 126 msec. On further questioning, the patient admitted to taking 160 mg of loperamide daily to treat her opioid addiction. She was admitted to the intensive care unit (ICU) for cardiac monitoring, electrolytes were aggressively replaced, and loperamide was held. Her QTc decreased from greater than 700 msec to 520 msec and she was discharged home in good condition.

Sunday, July 23, 2017

How to Be an Effective Leader in the ED

Image Credit: Pixabay
Author: Meaghan Mercer, DO
2013/2014 AAEM/RSA President
Originally Published: Common Sense November/December 2013

Leadership is creating a way for people to contribute to making something happen, developing an environment that allows cohesion and a drive toward a common goal. Leadership affects our lives on a constant basis and our role in the hierarchy changes as we shift from one environment to another: parent, boss, teacher, mentor. Leadership is a skill and learned behavior that becomes second nature over time and is important to cultivate, especially when working in the emergency department. In the ED we orchestrate the movement and flow of patients, staff, and resources, in a delicate yet chaotic balance. As we progress through residency, we gain the leadership skills to manage all the pieces until we unconsciously and fluidly become leaders in the field.

Thursday, July 20, 2017

Putting the Focus Back on Diagnosis

Image Credit: Pixabay
Author: Leana S. Wen, MD MSc
AAME/RSA 2010 Resident Editor
Originally Published: Common Sense September/October 2010

Last week, Jerry got the scare of his life. Jerry is a 48-year old mechanic who is in good health. His parents are healthy, and he recently got a “clean bill of health” during his annual check-up. Over the weekend, he helped his brother move across town. Monday morning, he woke with tightness in his chest. He described it as a “spasm” and thought that he might have pulled something while he was lifting the sleeper sofa. But someone in his neighborhood had a heart attack recently, and Jerry’s wife persuaded him to go to the ED to get it checked out.

Sunday, July 16, 2017

Getting the Most Out of Residency

Image Credit: Pixabay
Author: Meaghan Mercer, DO
2014-2015 RSA President
Originally Published: Common Sense September/October 2014

As I enter my third year of residency, the end of training is becoming more of a reality every day. I have received many pearls of wisdom along my path from medical students to residents to soon-to-be-attendings. With less than a year to go, I remind myself every day that I should make the most of each day of my education — and I hope you will do the same. A huge thank you to the members of AAEM/RSA, who really have been with me all the way. Reflecting on these past few years, I want to share some advice that has helped me succeed.

Thursday, July 13, 2017

Haney Mallemat on Technology’s Role in EM Education and Training

Image Credit: Pixabay
Author: Ali Farzad, MD, AAEM/RSA Publications Committee Chair
Author: Linda J. Kesselring, MS, ELS, Copyeditor
Originally published: Common Sense July/August 2013

This article marks the last of a series that has aimed to highlight how you can use simple technology to make your learning more efficient and effective. In previous interviews with leaders in emergency medicine (EM) education — Drs. Mel Herbert, Amal Mattu, and Scott Weingart — we learned the value using free websites, blogs, podcasts, and ECG videos to stay current with medical information and save more lives. Continuing that theme, I recently had the pleasure of interviewing Haney Mallemat, MD FAAEM (@criticalcarenow), an EM/IM-trained critical care specialist who works in the adult emergency department at the University of Maryland Medical Center as well as the critical care ICUs in the R Adams Cowley Shock Trauma Center in Baltimore, Maryland.

Sunday, July 9, 2017

A Real Case of Broken Heart: Takotsubo Cardiomyopathy

This post was peer reviewed.
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Image Credit: Flickr

Author: Alexandria Gregory, MS3
Saint Louis University School of Medicine
AAEM/RSA Social Media Committee 
Author: Eric Goedecke, DO  
Milford Regional Medical Center

Overview
An 80-year-old female with a history of chronic obstructive pulmonary disease (COPD), high cholesterol, and hypertension presented to the emergency department (ED) with a two-day history of shortness of breath. She also reported mild left-sided chest pain, but had no cough, fever, or calf pain. She had no history of deep vein thrombosis (DVT) or pulmonary embolism (PE), though she recently traveled from Massachusetts to Florida via airplane, and returned on the day her symptoms began. The patient had quit smoking over ten years prior to her presentation in the ED. She had been using her inhalers, prescribed for COPD, frequently with minimal improvement.

Thursday, July 6, 2017

Board Review: Rabies Exposure

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Image Credit: Flickr










Author: Alexandria Gregory, MS-3
Saint Louis University School of Medicine
AAEM/RSA Social Media Committee

A 16-year old male presents to the emergency department (ED) after a potential exposure to a bat while sleeping in a barn. He believes his friend may have been bitten by the bat, but did not have any known contact with the bat himself. The bat could not be found after the incident. The patient has not noticed any skin changes and has no other physical complaints.

Thursday, June 29, 2017

Recognizing and Treating Exertional Heat Stroke

Image Credit: Pixabay
This post was peer reviewed.
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Author: Patrick M. Brown, MSIV
Western University of Health Sciences College of Osteopathic Medicine of the Pacific

Case

An otherwise healthy 25 year old male is brought to the emergency department (ED) by emergency medical services (EMS) after witnesses saw him collapse while hiking in Arizona on a humid 38.3°C (101°F) summer day. His friends state that he was feeling well and behaving normally before hiking and add that they found his full water bottle in the car on the way to the ED. On physical exam, his temperature is 40.6°C (105.2°F), pulse is 134, blood pressure is 82/60, O2 saturation is 88% on room air and respirations are 21 breaths/min and labored. BMI is 29.3. He currently is unable to answer questions appropriately and appears restless. He is diaphoretic and hot to the touch. Eye exam reveals pupils that are 3mm and reactive to light bilaterally. Crackles are heard bilaterally on lung auscultation. Neurological exam reveals no abnormalities in tone or reflexes and the neck is supple. There are no obvious signs of trauma. His friends state that he is a regular smoker, social drinker and smokes marijuana recreationally. Labs significant for hemoglobin of 17.2, hematocrit of 51.0, WBC of 16.9, BUN of 43, creatinine of 0.9, and 2+ ketones in urine.

Sunday, June 25, 2017

Critical Care Pearl: Metabolic Acidosis: Bicarbonate Drips and Alternative Options

Image Credit: Pixabay
Authors: Victoria Weston, MD; Kevin Bajer, PharmD; and Randy Orr, MD
Northwestern University
Originally Published: Modern Resident, June/July 2013

The focus of this critical care pearl is to discuss the use of bicarbonate drips for severe metabolic acidosis, as well as alternative options, which are available. Given the current nature of medication shortages, it is valuable to learn about the alternative options available for use in some of our most critically ill patients.

When approaching a patient with metabolic acidosis, it is important to consider the cause of their acidosis (e.g., increased generation of acids as in lactic acidosis, ketoacidosis and ingestions vs. loss of bicarbonate or decreased acid excretion). As this is a relatively broad topic, this critical care pearl will focus on the treatment of lactic acidosis, as treatment of ingestions may vary with the substance ingested.

Thursday, June 22, 2017

Image of the Month (From August/September 2011 Issue of Modern Resident)

Author: Casey Grover, MD
Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident August/September 2011

A 17 month old female is brought to the ED by her mother for emesis and fever. The mother thinks that her daughter may have swallowed something last night because the child had made a "wheezing sound" while breathing and appeared uncomfortable. There was no witnessed ingestion. The child appears well with normal vital signs and is playful and interactive. Her physical exam, including pulmonary examination, is normal.

You order a PA and lateral chest X-ray. What does it show?

 
Image Credit: Modern Resident
  1. A coin in the esophagus
  2. A coin in the trachea
  3. A bottle cap in the esophagus
  4. A button battery in the esophagus
Click here for the answer.

Sunday, June 18, 2017

Tell Me More: The Basics of Child Forensic Interviewing

Image Credit: Pixabay
This post was peer reviewed.
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Author: Michelle Mitchell, MD, PGY-1
Duke University Medical Center

Posterior rib fractures in infants. Burns on the buttocks and legs. Mechanism of injury that is not consistent with developmental age. Most physicians will recognize these potential red flags of child abuse. However, many emergency medicine physicians have received little training on how to interview children who present with injuries concerning for child abuse. As physicians, we are not expected to definitively determine if child abuse has occurred. Instead, we often report suspected cases and leave the investigation to the authorities. It is thus important to obtain and document a thorough history in the medical record as it may be used in future court proceedings.

It is imperative that physicians have general knowledge about forensic child interviewing, as the method of interviewing may greatly impact the information that a child provides. Most models of child forensic interviewing have three stages.

Thursday, June 15, 2017

Unexpected Patient Demise in the Emergency Department

Image Credit: Pixabay
Author: Victoria Weston, MD
2015-2016 RSA President
Originally published: Common Sense January/February 2016

I could hear the wails of grief coming from our trauma bay. It was the start of my shift, and the prior team had recently terminated an unsuccessful resuscitation. The patient had been chronically ill and had collapsed while checking in at our triage desk. Although the patient had cancer and had been unwell for years, his family was shocked and devastated by their sudden, unexpected loss.

Sunday, June 11, 2017

Image of the Month (From August/September 2013 Modern Resident)

Author: Michael Gottlieb, MD
Cook County Emergency Medicine Residency
Originally Published: Modern Resident August/September 2013

An 81-year-old man with PMHx of HTN, DM, HL and OA s/p right hip replacement presents to the ED with acute onset CP and SOB x 1 day. While watching TV earlier, he developed a sudden inability to catch his breath, as well as some poorly localized, pleuritic chest tightness on the right side of his chest. He initially attributed this to reflux, but when it did not improve he drove himself to the ED.

His initial vitals are: Temp: 98.2, HR: 56, BP: 132/78, RR: 28, O2 Sat: 89%. Upon examination, he is in moderate distress, appreciably tachypneic and has to stop halfway through his sentences to catch his breath. The remainder of his exam is significant only 2+ pitting edema bilaterally. Labs are pending, a chest X-ray is ordered and his ECG is shown below.

Thursday, June 8, 2017

Photo of the Month (From Apr/May 2013 Issue of Modern Resident)

Author: ENS Dylan Hendy, MSIV
Arizona College of Osteopathic Medicine
Author: LT Christopher D. Helman, DO
Naval Medical Center Portsmouth
Originally Published: Modern Resident, April/May 2013

Patient Vignette
Twenty-nine-year-old male was sent to the ED by a community clinic for a syncopal episode. The patient originally visited the clinic for a headache that resulted from a shelf falling on the back of his head while working in his garage two days earlier. The patient denies losing consciousness, amnesia, disorientation or N/V. However, upon further questioning the patient described an unwitnessed episode of “blacking out” while sitting in his car today. He states this episode may have lasted for 30-60 minutes. The clinic subsequently sent the patient to the ED for further workup. In the ED the patient explained that he has a history of chronic headaches and that his headache at present is similar with regards to onset, location and duration. However, to the best of his knowledge, today’s unwitnessed syncopal episode was a first time occurrence. Further ROS were negative. The patient has no other pertinent PMH and is taking no medications. Complete physical exam was unremarkable. A workup for a closed head injury and syncopal episode was performed. Laboratory data was WNL. Non-contrast CT head and CXR were both unremarkable. The following ECG was obtained:

Image Credit: Modern Resident

Thursday, June 1, 2017

Bark Scorpion Stings

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Author: Ashley Grigsby, DO, PGY-3
Indiana University combined Emergency Medicine/Pediatrics

Centruroides sculpturatus, also known as the bark scorpion, is a type of venomous scorpion found in the Southwestern United States, i.e. Arizona, Nevada, New Mexico and Texas. The majority of these stings occur in Arizona, with a reported 3,498 emergency department (ED) visits in 2010.[1] The bark scorpion’s venom is a neurotoxin that works at axonal sodium channels causing excessive acetylcholine release in the neuromuscular junction. The clinical syndrome is most pronounced in young children, especially under 10 years old, who are most susceptible to the toxin. From 2005-2015, there were 185,000 scorpion calls to the poison centers nationally, 68% from Arizona.[1] Multiple other southwestern states were included in these calls; however, Arizona had the highest rate of neurologic and respiratory symptoms, and hospital admission.

Blog Staff, Reviewers, & Mentors

Thank you to our 2017-2018 peer review & editorial team!

AAEM/RSA Leadership:

Ashely Alker, MD
AAEM/RSA President
University of California San Diego Medical Center

Mike Wilk, MD
AAEM/RSA Vice President
Brown University

Michael Hight, MD
AAEM/RSA Secretary-Treasurer
Naval Medical Center San Diego

Mary Haas, MD
AAEM/RSA Immediate Past President
University of Michigan

AAEM/RSA Blog Leadership:

Aaron Tyagi, MD
Blog Editor-in-Chief
Social Media Committee Chair
Michigan State University - ‎Sparrow Health System

Alex Gregory, MS3
Copy Editor
Saint Louis University School of Medicine

Elaine H. Brown, MD
RSA Board Liaison to the Social Media Committee
Thomas Jefferson University Hospital

Janet Wilson, CAE
Executive Director, AAEM/RSA

Laura Burns, MA

Senior Communications Manager, AAEM

Cassidy Davis
Communication Manager, AAEM


Madeleine Hanan, MSM
Administrative Manager, AAEM/RSA

Publications Mentors:

Attending physicians or fellows who have agreed to help authors and reviewers learn about and navigate the publications process. Interested attendings/fellows can contact info@aaemrsa.org.

Michael Epter, MD
Laleh Gharahbaghian, MD
Nikita Joshi, MD
Arayel Osborne, MD
Andrew Phillips, MD MEd
Loice Swisher, MD

Peer Reviewers:

David C. Adams, MD
Elaine H. Brown, MD
Bill Christian
Alex Gregory
Ashley Grigsby, MD
Zachary J. Kosak
Caleb Larsen
Daniel F. Leiva, DO
Christopher J. Nash, MD
Nicholas R. Pettit, DO PhD
Jennifer Reink, MD
Jake Toy
Aaron C. Tyagi, MD


Sunday, May 28, 2017

TXA Literature Review

Author: Alexandra Murray
Mercy St. Vincent Medical Center Emergency Medicine
Originally Published: Modern Resident December/January 2016

What is tranexamic acid (TXA)?
When the body experiences vascular injury, the hemostatic system tries to maintain circulation by balancing the formation and degradation of blood clots. In response to severe blood loss, this balance is challenged and hyper-fibrinolysis can occur. The conversion of plasminogen to plasmin plays a large role in fibrin binding and degradation. Tranexamic acid is a synthetic derivative of lysine that reversibly blocks binding sites on plasminogen and inhibits fibrinolysis.[1] TXA has been approved by the FDA since 1986 as an antifibrinolytic and has been marketed for menorrhagia (Lysteda) and dental hemorrhage in hemophiliacs (Cyklokapron).[2,3] More recently, TXA has been investigated as a treatment for posttraumatic hemorrhage, postpartum hemorrhage and prevention of surgical blood loss.

Thursday, May 25, 2017

Interstitial versus Cornual Pregnancies: There is a Difference

Image Credit: Pixabay
Author: Megan Litzau, MD
Indiana University
Originally Published: Modern Resident April/May 2016

Commonly the terms interstitial and cornual pregnancies are used interchangeably. However, these are two distinct entities, and are managed differently.[1] An interstitial pregnancy occurs when there is implantation in the proximal intramural portion of the fallopian tube. A cornual pregnancy is when there is implantation in the lateral portion of the uterus.

Thursday, May 18, 2017

Case Report: Hypopharyngeal Burns Secondary to Hot Potato Ingestion


Image Credit: Pixabay
This post was peer reviewed.
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Author: Alexandria Gregory, MS-2
Saint Louis University School of Medicine AAEM/RSA Social Media Committee

Eric Goedecke, DO
Milford Regional Medical Center

Overview

A 59-year-old male presented to the emergency department (ED) with a food bolus sensation several hours after eating hot potatoes for breakfast. Since then, he had been able to tolerate coffee, scrambled eggs and handle his secretions without difficulty. He was feeling well otherwise and denied any recent illness.

On exam, the patient was well-appearing and in no respiratory distress. There was no wheezing or stridor. Oropharyngeal exam showed no edema, lesions, burns, or visible foreign body. The remainder of the physical exam was unremarkable.

Sunday, May 14, 2017

Button Batteries

Image Credit: Flickr
Author: Phillip Fry, MSIV
Midwestern University - Arizona College of Osteopathic Medicine
Originally Published: Modern Resident February/March 2017

Patients presenting to the emergency department after ingesting a button or cylindrical battery typically warrant prompt foreign body removal. The majority of battery ingestion cases involves button batteries and occurs in children younger than six years of age.[1] However, there is also a growing number of ingestions in the elderly with hearing aid batteries being mistaken for pills.

Thursday, May 11, 2017

Eyelid Lacerations

Image Source: Flickr
Author: Kaitlin Fries, DO
Doctors Hospital
Originally Published: Modern Resident February/March 2016

Eyelids are often one of the more complex locations for providers to perform laceration repairs. The eye has many important neighboring structures that can often be damaged by even minor trauma to the eye. As with any wound, it is important to start by doing a thorough exam of the tissue involved, being sure to assess for the possibility of a retained foreign body. Once the area has been evaluated it is time to ensure that a few critical nearby anatomical structures are still intact.

Sunday, May 7, 2017

Chilaiditi’s Syndrome

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Image Credit: Wikipedia








Author: Megan Litzau, MD
Indiana University Emergency Medicine Residency

A previously healthy 29-year-old male arrived with right upper quadrant pain for approximately six hours prior to arrival. On examination, the patient appeared uncomfortable. Vital signs were remarkable for mild tachycardia with an afebrile patient. Labs were obtained including a complete metabolic panel, complete blood count, lipase and urinary analysis. All of the lab values returned within normal limits. Given the patient’s persistent abdominal discomfort, computed tomography (CT) imaging of the abdomen was also obtained. On CT imaging, a segment of his transverse colon was located in an abnormal position between his liver and his diaphragm, which was in the correct location for the patient’s discomfort.

Thursday, May 4, 2017

Did You Know? Broselow Pediatric Emergency Tape

Image Credit: Wikimedia Commons
Author: Jenna Erickson, MD
Phoenix Children's Hospital/Maricopa Medical Center
Originally Published: Modern Resident August/September 2015

In a pediatric trauma, one of the initial treatment steps is determination of a child’s “color.” This is referencing the Broselow Pediatric Emergency Tape, an old but widely accepted method of estimating a child’s weight based on length. Pediatric drug dosing is based on weight, therefore a fast, efficient way to calculate dosing is essential to reduce medical error and optimize patient outcomes. The Broselow Tape is a color-coded tape measurer consisting of nine color zones that group together pediatric medication doses and equipment sizes. When a child first arrives in a trauma bay he is measured with the tape from crown to heel. The color that is reached by the child’s heel indicates a weight estimate; this color is then used for a quick reference sheet of pre-calculated medication doses, voltages and equipment sizes. Resuscitation carts with color-coded drawers further simplify the process of selecting the correct supplies for pediatric patients, thus expediting treatment and minimizing error.

Sunday, April 30, 2017

The Difficult Situation

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Image Credit: Flickr











     Author: Thomas Hull, MSIV
     Loyola University Chicago SSOM

I remember trying to take my first history and physical as a first-year medical student when a middle-aged man came into the emergency department (ED) with transient ischemic attack-like symptoms. With the encouragement of my preceptor, who was the attending emergency physician, I went to do a full interview history and physical. After spending almost 45 minutes learning about this man and his life in friendly conversation, I exited the room to see my preceptor with a somber face. The patient’s head computed tomography revealed numerous scattered round tumors at the gray-white junction, likely metastases from melanoma, which I’d just heard had been treated years ago and he considered “past” medical history. My preceptor apologized for such a first encounter, though confessed she was relieved to have a partner in delivering the news. I welcomed the role, willing to employ whatever emotional capital I’d just established, and confidently planted myself at his bedside as she began to tell him. But when he started crying, I knew that there was no good response – I stood there speechless.