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
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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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     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.

Sunday, April 23, 2017

Pediatric Breath Holding Spells

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Author: Christine Au
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific

In the world of emergency medicine, it is prudent to be trained and adept at handling the worse case scenario. Breath holding spells are a pediatric phenomenon that affects 5% of children from six months to four years where an involuntary pause in breathing occurs. This may lead to a patient becoming unconscious; however, these routine episodes are far from life-threatening.[1] Breath holding spells can be a result of various situations, such as a frightening or painful event, or can be linked to excessive anger in a child. Goldman defined this as a “benign paroxysmal non-epileptic disorder occurring in healthy children 6 to 48 months of age”.[2] There are two main types of spells: cyanotic and pallid. Cyanotic is much more common compared to the pallid type. These spells are a result of a decrease in heart rate, low oxygen, and high carbon dioxide in the system that may precipitate a loss of consciousness.

Thursday, April 20, 2017

Scapulothoracic Disassociation: A Rare and Devastating Injury

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Image Credit: Emergency Medicine: Open Access











The Case
Trauma Activation: A 25-year-old motorcyclist traveling approximately 75 miles per hour lost control and the motorcycle slid from underneath him. His entire right side made primary contact with the road. Upon arrival, he was awake and able to participate in his examination. His left upper extremity was pulseless with a complete loss of motor function and sensation. 

Diagnosis
Left Scapulothoracic Dissociation - a traumatic disruption of the scapulothoracic articulation often associated with:
  • other orthopedic injuries including those to the acromioclavicular joint, clavicle, scapula, and sternoclavicular joint,
  • vascular injuries particular to the subclavian and axillary arteries,
  • neurologic injuries especially to the ipsilateral brachial plexus.[1,2] 

Sunday, April 16, 2017

An Electronic Resource Guide to the EM Clerkship

Image Credit: Pixabay
Author: Stephanie Cihlar
AAEM/RSA Medical Student Council President (2016-2017)

Smartphones and tablets have changed the way we practice medicine. They help us make informed medical decisions and offer a practical way to keep us up to date on the latest research. Apps and podcasts are increasingly popular tools used to help us achieve these goals, both inside and outside of the ED. For students striving to do well in EM clerkships, the ability to stay organized and access to the right resources is critical for success. However, in this rapidly changing world of medical apps, podcasts, and seemingly endless amounts of available information, it can be difficult to know where to begin. After evaluating some popular EM resources, I developed this guide of apps and podcasts to help students ensure success in their EM clerkships.

Thursday, April 13, 2017

Personal Learning Networks

Image Credit: Pixabay
Author: Mary Haas, MD (PGY-3)
University of Michigan

Over the past year I have come to appreciate the importance of concepts from sociology, psychology, and education theory on my development as a physician and educator. I recently had the pleasure of working with Drs. Felix Ankel, Anand Swaminathan, and Sally Santen on a lecture for the CORD Academic Assembly in Nashville, called Personal Learning Networks. This launched me on a study of personal learning networks and their impact on my own development so far.

A personal learning network refers to a dynamic group of connections that allow individuals to both teach and learn, share ideas and collaborate. Each individual or organization within a network is referred to as a “node.” These networks reflect our values, goals and interests. They include a mixed level of expertise: peers, novices, and experts can all serve as nodes. The most effective personal learning networks include connections outside one’s immediate institution and area of expertise, called “weak ties.”

Sunday, April 9, 2017

Point-of-Care Ultrasound

Image Credit: Flickr
Author: Aaron C. Tyagi, MD
Vice-Chair, RSA Social Media Committee
Originally Published: Common Sense March/April 2017

It is the start of your shift. You are just starting to get settled in after taking sign-out, when one of the nurses comes over and says he needs a physician in room 22 immediately!

You enter the room to find a patient in obvious distress, diaphoretic, tachypnic, sitting straight up in the bed. You immediately assess his ABCs. He exhibits severe dyspnea but his airway is intact. He has a generous amount of soft-tissue for a neck, so it is difficult to assess his trachea. You move on to his breath sounds. They are somewhat decreased on the right compared to the left, but there are some audible breath sounds on the right — though they may be transmitted sounds. No adventitious sounds. Peripheral pulses are palpable and fast. Vital signs show a heart rate of 112, a respiratory rate of 29, blood pressure in the 140s/90s, and a SpO2 of 94% on room air.

Thursday, April 6, 2017

Lessons from My First Lobbying Experience

L-R: Matt Hoekstra, Williams & Jensen;
Mary Haas, MD;
Brian Potts, MD MBA FAAEM;
Kevin Rodgers, MD FAAEM
Author: Mary Haas, MD, AAEM/RSA President
University of Michigan
Originally Published: Common Sense March/April 2017

In December I traveled to D.C. with the AAEM Board of Directors, for my first Advocacy Day. I admit I did not know what to expect, and although I looked forward to actively advocating for our specialty, the idea of lobbying intimidated me. Would I know how to “speak the language?” How would I make Congressional staffers understand the importance of our cause, let alone care about it? I was both excited and nervous for this new and very important experience.

It was eye-opening and incredibly educational. On the morning of our visit to Capitol Hill we reviewed our big issue, due process, one of critical importance for emergency physicians. “Due process” refers to a fair hearing in front of peers on the hospital medical staff, prior to the termination of a physician's privilege to practice there.

Sunday, April 2, 2017

AAEM/RSA 2017 Award Winners

RSA Secretary-Treasurer, Philip Dixon, MD (left) with AAEM/RSA Program Director of the Year Award recipient,
Jonathan S. Jones, MD FAAEM (center), and AAEM/RSA Resident of the Year Award recipient,
Mary Haas, MD (right)
Author: Michael Wilk, MD

Congratulations to our AAEM/RSA award and scholarship winners from this past year! All of them have made outstanding contributions to their programs and/or RSA over the past year and we are pleased to recognize them.

AAEM/RSA Program Director of the Year Award
Jonathan S. Jones, MD FAAEM, Mississippi University

To nominate your program director next year: http://www.aaemrsa.org/get-involved/residents/program-director-of-the-year-award


AAEM/RSA Program Coordinator of the Year Award
Krista Fukumoto, Stanford University

AAEM/RSA Resident of the Year Award
Mary Haas, MD, AAEM/RSA President, PGY3, University of Michigan

AAEM/RSA Committee Member of the Year AwardJake Toy, MS3, Copy Editor, Social Media Committee.

AAEM/RSA Medical Student “Why EM?” Essay Scholarship Winners:

For information for medical students to apply next year visit: (http://www.aaemrsa.org/get-involved/students/medical-student-scholarship)

Thursday, March 30, 2017

Palliative Care Myth Busters

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Author: Michelle Mitchell, MS-IV
Geisinger Commonwealth School of Medicine

Palliative care concepts have increasingly become integrated into care in the emergency department (ED). As the health of patients with advanced and end-stage disease continues to decline, they often present to the ED for symptom management and pain relief. Therefore, emergency medicine physicians should be knowledgeable about basic palliative care treatments, as well as some common myths surrounding palliative care.

Sunday, March 26, 2017

Needle Thoracostomy: Is it Time to Switch to a Longer Needle?

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Author: Jake Toy, MSIII
Western University of Health Sciences


Needle thoracostomy (NT) is a lifesaving procedure often utilized in pre-hospital settings and emergency departments (ED), and is indicated in cases of tension pneumothorax. Placement of a needle catheter into the pleural space allows for emergent decompression, resulting in restored and/or increased venous return to the right atrium.[1] Placement of a chest tube is the definitive management of a tension pneumothorax following both a successful or failed needle placement. Advance Trauma Life Support (ALTS) guidelines recommend the use of a 14-gauge 5 cm (approx. 2 in) angiocatheter placed in the 2nd intercostal space, midclavicular line (ICS-MCL), inserted at a perpendicular angle to the skin.[2]

Thursday, March 23, 2017

No But Really…How Much Weed Do You Smoke?

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Image Credit: Flickr

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

Case
A 21-year-old female presented with epigastric abdominal pain and severe vomiting for the last three days. She has had similar vomiting episodes before and has had a large workup that was unremarkable for the etiology. She was unable to stay hydrated during this latest episode so she presented to the emergency department (ED). She stated that the only thing that helped her vomiting has been a hot shower. Her vitals were normal except for a heart rate of 112 beats per minute; her exam was unremarkable except for mild epigastric tenderness to palpation. The patient was questioned multiple times alone in the room and denied, multiple times, any marijuana use or other drug use. She was treated symptomatically and improved. On discharge, she was again questioned about drug use and admitted to twice daily marijuana use for the past several years. She was diagnosed with cannabinoid hyperemesis syndrome, counseled on the importance of marijuana cessation, and discharged home in good condition.

Sunday, March 19, 2017

The Waiting Game

Image Credit: Pixabay
Author: Victoria Weston, MD
Originally Published: Common Sense November/December 2015

I could feel her eyes on me, burning with anger. It was a hot July day and she had been waiting for hours in our crowded waiting room, and then waited even longer in our ENT room in an upright, unforgiving chair as our team cared for multiple unstable patients who had been roomed shortly after sign-out. The ED was packed with patients, new interns, and other new learners — and everything seemed to be moving so much more slowly than just a few weeks before.

When I walked into her room, I entered with a smile, made eye contact, introduced myself, and made my apologies: I am so sorry for the wait. I am glad that you came in today and appreciate your patience. I know that it has been a long wait, but I am here now and am totally focused on you. How can I help you today?

Thursday, March 16, 2017

All I Really Need to Know — Still — I Learned in Kindergarten

Image Credit: Pixabay
Author: Andrew W Phillips, MD Med
Originally Published: Common Sense July/August 2015

While still being far from hitting my full stride as a “real” emergency physician, I feel that I’ve come a long way now that I’m finally finishing residency. And while I’m cautious of being overly nostalgic or simplistic at this point, I find myself reflecting that life’s core lessons change very little. The medicine changes every five to 10 years, but certain constants never change, and they all have to do with playing together well in the sandbox.

Sunday, March 12, 2017

Reflections of a Third-Year Resident

Author: Meaghan Mercer, DO
Originally Published: Common Sense March/April 2015

Writing this around New Year's Day makes me nostalgic. There is a contagious sense of hope and excitement this time of year. Fourth-year medical students are thrilled that interviews have come to a close, rank lists are in, and Match Day looms around the corner. Interns are feeling comfortable in their shoes, seasoned residents are in the groove, graduating residents are applying for licensure, and nervous excitement accompanies the end of residency. Each New Year's Day I write a letter to myself that includes what I expect from the year and what I hope to achieve. I then seal it, and one year later open it and read it. As I reflect back on the last seven years, I want to leave you my experience and advice.

Thursday, March 9, 2017

Clinical Pearl: A Parent’s Kiss for Nasal Foreign Body Removal

Image Credit:flickr
Author: Ashley Grigsby, DO PGY-1
Indiana University Emergency Medicine/Pediatrics
Originally published: Modern Resident April/May 2015

Every little boy knows the best place for anything is up your nose. That is, until they show up in your emergency department (ED).

The Case:
Three-year-old previously healthy male presents after he put his older sister’s jewelry bead up his right nostril two hours ago. Vitals are normal. As you walk in the room, he is breathing comfortably and appears well, but his big brown eyes see you coming and immediately start welling up with tears. He’s sitting in his mom’s lap; he’s anxious and wants no part of you coming near him.

Sunday, March 5, 2017

Lean, Mean, ED Resident Machine: Resident Application of Lean Tools

Image Credit: Pixabay
Author: Thomas Damiano, MD
Christiana Care Health System
Originally Published: Modern Resident February/March 2013

One of the first responses when asked what field of medicine I practice following "that must be interesting work," undoubtedly becomes "the waits are awfully long." The demand for emergency services has far outpaced supply over the last two decades. Administrators across the country are looking to the Lean philosophy to help deal with ED operational improvement. From a Lean perspective, resident involvement in advancing ED operations is essential.

If one were to search "Lean," results mentioning Toyota, various courses offering black belts and attempts at definitions may quickly confuse the inquirer. Lean has nothing to do with sticking accelerator pedals (too soon?). Courses are not taught by Chuck Norris (although I would be the first to sign up). Rather, Lean is a term for a production philosophy with the central concept that the expenditure of resources for any goal other than adding value for the customer is wasteful and should be minimized. Lean involves various tools for operational improvement and seeks to foster "a community of scientists" to employ these tools.

Thursday, March 2, 2017

Family Presence During Cardiopulmonary Resuscitation – What’s the Policy at Your Hospital?



Image Credit: Wikipedia
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Author: Jake Toy MSIII
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA

The upper gastrointestinal bleed patient that I had been following since admission was in cardiac arrest in the intensive care unit. The resuscitation effort was routine; however, the presence of his family at bedside was new to me.

One initial concern lay with the patient’s observing family members in regards to the possibility of psychological trauma due to a limited capacity to understand or comprehend the resuscitation events. These concerns have been documented among the medical community and further include the potential for family member disruption and delay of resuscitation efforts, which may directly or indirectly influence treatment outcomes, and the notion of an increased frequency of litigation following family presence during resuscitation (FDPR).[1-3] However, little evidence substantiates these concerns.[1] Current literature suggests FDPR during both out-of-hospital and in-hospital cardiac arrest confers psychological benefits for family members regardless of treatment outcome.[4, 5] What’s more, multiple cohorts of surveyed patients wished their family member(s) to be at bedside should they need to be resuscitated.[6, 7]

Sunday, February 26, 2017

Cancer in the ED

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Author: Nicholas Pettit, DO, PhD
Indiana University

Next up on the board, a 55-year-old male with a temperature of 102.3, heart rate of 119, and blood pressure of 89/50. Sick versus not sick? Clearly sick.

After that, 45-year-old male, with a temperature of 100.1, heart rate of 110, and blood pressure of 120/80, and who is also a cancer patient. Sick versus not sick? Hard to tell, right?

Cancer is a frequent comorbid condition that presents to the emergency department (ED), and researchers are just now starting to demonstrate the association between emergency medicine and the outcomes for cancer patients. The most common symptoms that are brought through our doors are shortness of breath (23%), pain (18%), fever (14%), and nausea/vomiting (14%).[1] From the same study, the investigators found out that approximately 60% of the patients were admitted, 47% of patients subsequently died after admission to the ED, and the 1-year overall survival of all patients seen in the ED was 7.3 months.

Thursday, February 23, 2017

Acute Limb Ischemia: A Literal Case of Cold Feet

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Author: Jennifer Reink, MSIV
Ohio University Heritage College of Osteopathic Medicine

Case
A 58-year-old Caucasian male was brought into a community emergency department via ambulance for evaluation of sudden onset left leg pain and right leg numbness. He stated that about five hours earlier, he had begun to experience severe sharp pains shooting down the entire length of his left leg. His right leg had initially felt like pins and needles, but prior to arrival had gone completely numb, to the point that he was unable to lift it. He denied recent trauma, back or abdominal pain, or urinary or stool incontinence. Upon further review, we learned that he had a history of stroke, abdominal aortic aneurysm with graft repair, hypertension, and diabetes. He was taking the associated medications for these conditions, which did not include an anticoagulant. He had no prior history of tobacco, alcohol, or drug use.

Sunday, February 19, 2017

Necrotizing Fasciitis: A Dermatologic Emergency

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Author: Lauren Van Woy, OMS III
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific

Introduction
Necrotizing fasciitis is a rare but potentially fatal dermatologic infection that emergency physicians must be able to promptly recognize and treat. Misdiagnosis of necrotizing fasciitis is common, with 41% to 96% of cases falsely identified as a less serious soft tissue infection (such as cellulitis or an abscess).[1] Failure to treat necrotizing fasciitis can lead to sepsis, organ failure, and death.[2] Therefore, it is imperative to have a low threshold for diagnosis.

Thursday, February 16, 2017

AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Hannah Wolsiefer-Leak, MSIV
Indiana University
 

RSA is proud to share the following essay from one of the 2016-2017 Medical Student Scholarship winners, Hannah Wolsiefer-Leak. We felt this essay best exemplified why she is choosing EM as a specialty. Congratulations, Hannah!

It was day six and we had hardly seen another human. We were surrounded by a desolate, moon-like environment. No trees, no grass, no signs of life – just boulders of rock on one side and a 600-foot drop on the other. “The world’s most dangerous road” we had been told. We drove for days across this landscape to reach vulnerable populations high in the Indian Himalayas to provide medical care of which they were otherwise devoid. I always knew I was passionate for medicine and adventure, but having the opportunity to combine the two pushed me over the edge of enjoyment and into the depths of euphoria.

Sunday, February 12, 2017

AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Yasmeen Elmelige, MSIV
Morehouse School of Medicine

RSA is proud to share the following essay from one of the 2016-2017 Medical Student Scholarship winners, Yasmeen Elmelige. We felt this essay best exemplified why she is choosing EM as a specialty. Congratulations, Yasmeen! 

Lights flashed and sirens blared as we sped through downtown Atlanta, Georgia. We were responding to a call for a “74 year-old sick male.” My heart pounded as I pulled on my gloves, grabbed equipment, and jumped out of the truck. Within minutes of our arrival, the patient’s heart stopped and I was directed to start CPR. Within a minute, I was sweating and my muscles were already exhausted, but all I could think of was “hard and fast, 30 to 2.” Still, no pulse. We loaded him onto the ambulance and raced towards Grady Memorial Hospital where the Emergency Department (ED) staff began pushing medications and trying to resuscitate him. I stood back watching, absorbing everything. “We have a heartbeat,” someone yelled and I sighed in relief. Suddenly I heard “V-fib, begin CPR!” Five minutes later, the attending physician called time of death. I stood frozen, speechless, and numb. One minute he was here, and the next, he was gone. I watched helplessly as the deceased man’s wife received the news of her husband’s death and tears flooded her eyes. I could only imagine how she felt as even I, a first responder with no relation to this man, felt the stinging, heart-wrenching pain of his passing. I knew that her grieving and healing processes were just beginning.

Thursday, February 9, 2017

Balance

Image Credit: Pixabay
Author: Thomas Hull, MSIV
Medical Student
Loyola University Chicago SSOM
AAEM/RSA Social Media Committee

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The eyes do not see what the mind does not know,” a common saying many of us have come to hear in medicine. A simple and powerful aphorism illustrating the fundamental connection between awareness and intelligence; it urges us to keep reading and expanding our education. The connection between study and clinical success may seem obvious, and even elementary, but one cannot dismiss it as reductive. A deeper proverb is speaking here about the connection between mind-body, or more specifically, consciousness and well-being. We all know the feeling after a long day, with energy running low and emotional barriers wearing thin, of being “brain-dead.” The medical community has been forced to deal with this in recent decades, most prominently and publicly with residency duty restrictions. Now this November with conclusions by the Accreditation Council on General Medical Education (ACGME) task force that 24-hour call (with 4 additional hours allowed for transition) for first-year residents does not affect patient care,[1] it’s even more relevant. Their recommendation has found support in the idea that increasing number of handoffs and transitions of care could result in an actual rise in medical errors. A 24-hour shift may also be desirable to some, as one long shift with a day off after may seem better than to two rigorous 16-hour shifts abutted. Though the ACGME has requested public discourse on this topic before making its official 2017-2018 recommendations on December 19th, it’s likely these changes will take affect and highlights the importance of maintaining healthy balance heading into residency. After all, these hours are already the standard for PGY2 and beyond, thus it’s only a matter of time.

Sunday, February 5, 2017

Case Presentation: 53 Year-Old Female with Neck Stiffness

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Author:
Michelle Mitchell, MS-IV
Geisinger Commonwealth School of Medicine
AAEM/RSA Social Media Committee Member


53 year-old female presents with chief complaint of neck stiffness. She states that while rolling cigarettes the previous day, she had an abrupt onset of a headache, which she describes as diffuse, dull, and of moderate intensity. She denies a thunderclap headache, but states it is “different” than her typical headaches. The pain continues to radiate down the posterior aspect of her neck, and while her headache has improved since yesterday, her neck pain has worsened. She has a significant past medical history of diabetes mellitus type 2, hypertension, morbid obesity, bipolar disorder, and previous deep vein thrombosis (DVT), and takes insulin, metformin, lisinopril, aripiprazole, fluoxetine, and buproprion for her conditions. Family history is remarkable for her maternal grandmother dying from a cerebral aneurysm.

On physical exam, she has a blood pressure of 116/65, heart rate of 100, respiratory rate of 18, and temperature of 36° Celsius. The patient does not appear to be in any apparent distress and is sitting comfortably on the edge of the bed. Her physical exam reveals decreased range-of-motion on lateral neck flexion, and tenderness to palpation along her cervical spine, primarily in the C2 dermatome. The rest of her physical exam, including an in-depth neurological exam, is normal.

Thursday, February 2, 2017

Case Report: Antrochoanal Polyp

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Authors: Alexandria Gregory, MS-2 
Saint Louis University School of Medicine
AAEM/RSA Social Media Committee

Eric Goedecke, DO
Milford Regional Medical Center

Overview
A 22-year-old female with a history of nasal polyps presented to the emergency department (ED) reporting a polyp in her nose that she noticed several days prior, as well as a growth in her throat that appeared approximately eight hours prior to evaluation. She also reported chills earlier in the week as well as a sore throat. The patient had a history of nasal polyp removal several years prior, but was not currently being followed by Otolaryngology.

On exam, there was a mass adjacent to the left lateral uvula, approximately 1.5-2 cm in length and 1 cm in width, appearing to originate from the palate. The mass was purple in color with some areas of scattered opacity. Tonsillar pillars and uvula were normal. There was a clear nasal polyp in the anterior left nare. The patient had bilateral submandibular adenopathy.



Figure 1: Oropharyngeal exam
Image Credit: Eric Goedecke, DO


Sunday, January 29, 2017

Medical Students and Nurses Can Make a Great Team

Image Credit: Flickr
Author: Scott Bland, MSIII Campbell University School of Osteopathic Medicine
AAEM/RSA Medical Student Council Southern Region Representative '16-'17

This post was peer reviewed.
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In the medical realm, it is hard to go five minutes without hearing terms like “interprofessional,” “collaborative,” or “team based.” Many schools offer seminars intended to teach medical students how to interact with other professions. However, when we hit the floor for rotations, we sometimes struggle in our interactions with the largest of the health professions.[1] But nurses can be great allies in patient care and can really help a medical student transition into their clinical education. So here are a few tips on how to be a good team member with your nursing staff.

1. Treat others the way you want to be treated: If you are intentional about the quality of your work interactions, they will improve. Try to address people by their name. Be forgiving if they make a mistake. Say “please” and “thank you”.[2] If you ask a nurse to do something for your patient and they are busy, offer to help. One tip for how to phrase things is, “Mrs. Smith soiled her linens and needs them changed. If you are busy, I can go get the new linens and help you once I bring them to the room.” If the task is important, demonstrate that you are willing to get involved.

Thursday, January 26, 2017

Management of Atrial Fibrilation with Rapid Ventricular Response — Choosing Rate Control Wisely

Image Credit: Pixabay
Author: Nathan Haas, MD
University of Michigan Department of Emergency
Originally Published: Modern Resident October/November 2014

Atrial fibrillation (AF) with rapid ventricular response (RVR) is relatively commonplace in the ED, and practice patterns vary in how rate control is achieved. Presented below are different approaches to accomplishing rate control, broken down by medication class and clinical situation.


Big Picture: Calcium Channel Blocker Versus Beta Blocker
The mainstays for rate control agents include calcium channel blockers (CCBs), such as verapamil or diltiazem, or beta blockers (BBs), such as esmolol or metoprolol. Recent literature has trended towards favoring CCB from an overall standpoint, although the difference between the two classes is far from clear-cut.[1]

Sunday, January 22, 2017

Delivering Bad News

Image Credit: Pixabay
Author: Niklas Eriksson, MSIV
Loyola University Chicago Stritch School of Medicine
AAEM/RSA Social Media Committee

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A variety of patients present in the emergency department (ED), and every ED physician, resident, and even student will encounter patients in critical condition or life-threatening injuries. As a result, it is an essential skill for an ED clinician to be able to give bad news. One of the more helpful mnemonics I have learned and been able to apply when having to break bad news to patients or their families is SPIKES. This mnemonic is often used by oncologists, but can apply equally well in the more acute ED setting.[1,2]

S: Setting. Make sure you are in an appropriate setting to deliver the news. A private room with minimal noise interference is preferable. A recent study showed that there is a discrepancy between patient and physician perspective on the level of privacy achieved during these conversations, indicating that more emphasis could be placed on finding an appropriate setting. [2,3] Also recognize the importance of introducing yourself and your role.[3,4]

P: Perception. Ask the patient and/or their family what their understanding of the transpired events has been thus far. It may be that the patient has been suffering from a chronic disease and they have been preparing for their eventual death for a long time, or this may be a sudden and unexpected occurrence. Many times it may be better to be direct. Overall, keep in mind that every family has different experiences with their loved ones and their diseases that makes each encounter different.

Thursday, January 19, 2017

Residency Work Hour Restrictions: Is the Pendulum Swinging Back?

Author: Mike Wilk, MD
PGY-1, Brown EM
Originally Published: Common Sense January/February 2017

“I walked into the hospital on my first day of residency and didn’t walk out until 36 hours later. Those were the darkest days of my life, but I am the doctor that I am today because I went through that,” I still distinctly remember these words from one of my more senior physician mentors when our discussion turned to work hour restrictions. As I wondered how it was possible to physically stay awake for so long, there was no doubt in his mind that work hour restrictions were dampening the training experience of newly minted residents.

First instituted in 2003 and revised again in 2011, interns now “enjoy” an 80-hour work week restriction with a maximum shift length of 16 hours (PGY-2s and above are still allowed to work up to 28 consecutive hours). However, the pendulum may be swinging back on strict work hour restrictions as new research on the topic becomes available.

The event that led to work hour restrictions was the death of Libby Zion in 1984. An overworked medical intern on a 36-hour shift prescribed meperidine to the 18-year-old patient, who was on an antidepressant, the MAO inhibitor phenelzine. This drug combination is thought to have caused the serotonin syndrome, leading to Zion's death.