Thursday, November 23, 2017

Non-Invasive Positive Pressure Ventilation in the Treatment of Acute Respiratory Distress in the Emergency Department

Authors: Theodore J Segarra, Lee Grodin, Taylor Conrad, Ray Beyda, Kelly Maurelus, Michael C. Bond
Originally Published: Common Sense September/October 2017

Over the last decade, non-invasive ventilation (NIV), including both bilevel positive airway pressure (BPAP) and continuous positive airway pressure (CPAP) modes, has become an important tool in the management of ED patients with respiratory distress due to acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. Many studies have shown its utility in successfully reducing the need for intubation and reducing length of stay (LOS) in the ICU. Given these positive results, interest in NIV for patients with undifferentiated respiratory distress has increased but very few studies have compared the outcomes of using NIV for other causes of acute respiratory distress, such as asthma, pneumonia, malignancy, or interstitial lung disease. This review aims to discuss the current literature on the non-standard use of NIV for for other causes of respiratory distress in the emergency setting and to identify potential areas for further research.

Sunday, November 19, 2017

Updates in Pharmacology: Interactions and Adverse Effects of Psychiatric Medications

Authors: Erica Bates, MD; Philip Magidson, MD MPH; Robert Brown, MD; Megan Donohue, MD; Akilesh Honosage, MD
Editors: Michael C Bond, MD FAAEM; Kelly Maurelus, MD FAAEM
Originally Published: Common Sense March/April 2017

Over the past decade, the number of psychiatric medications dispensed has increased dramatically and now annually numbers in the tens of millions. As Emergency Physicians now frequently encounter patients on psychiatric medications, understanding potential complications and potentially life threatening reactions is necessary. This journal review covers common potential side effects, adverse reactions, and drug-drug interactions of various psychiatric medications commonly found in the ED.

Thursday, November 16, 2017

Advancing the Need to Reduce Unnecessary Antibiotic Treatment by Using the Biomarker Procalcitonin

Authors: Raymond Beyda, MD; Jackie Shibata, MD; Lee Grodin, MD; and Theodore Segarra, MD
Editors: Kelly Maurelus, MD FAAEM and Michael C. Bond, MD FAAEM
Originally Published: Common Sense January/February 2017

ED physicians frequently treat and admit patients for infectious diseases. Judicious use of antimicrobial therapy is important in order to avoiding the development of antimicrobial resistance and adverse drug effects. Procalcitonin (PCT) is one of several bbiomarkers which may be useful in decreasing unnecessary antibiotic therapy. Specifically, PCT levels should be low for viral, as opposed to bacterial, infections. Procalcitonin has been studied as both a diagnostic and prognostic marker in various types of systemic and organ-specific infections. The potential for PCT to reduce unnecessary antimicrobial therapy has been shown in several observational and randomized controlled trials performed in outpatient, inpatient, and ICU environments. The most robust evidence is in sepsis and pulmonary infections. Here we review some of the evidence behind the use of PCT in acute infectious disease management.

Sunday, November 12, 2017

Acute Heart Failure

Author: Daniel F. Leiva, DO, MS
Baystate Medical Center

Acute heart failure is a common and potentially life-threatening disorder the emergentologist should know well. In 2006 there were 5.1 million people living with heart failure in the United States and an estimated 23 million people worldwide.[1,2] Patients can present to the emergency department as a new, acute failure or an acute-on-chronic exacerbation. They typically complain of dyspnea, fatigue, paroxysmal nocturnal dyspnea, or orthopnea, the latter two of which are highly sensitive and specific.[3] Additional symptoms may include cough, chest pain, palpitations, tachypnea, peripheral edema, weight gain, or decreased exercise tolerance, depending especially on the presence of a precipitant. These can include volume excess, especially in renal or liver failure patients, sudden hypertensive states, acute myocardial infarction, myocarditis, pulmonary embolus, excessive exertion in a deconditioned state, changes to drug therapies, including the addition or removal of drugs or changes in dosages, and substance abuse.[3] The most important piece of history to establish in a patient is a previous diagnosis of heart failure. Consideration should be given to systolic dysfunction/heart failure with reduced ejection fraction (HFrEF) versus diastolic dysfunction/heart failure with preserved ejection fraction (HFpEF); left-sided versus right-sided heart failure; and high-output versus low-output failure, which can change the acute management of the patient.[4] Previous echocardiogram records may be beneficial in making this determination if available.

Thursday, November 9, 2017

Spinal Epidural Abscess vs. Cauda Equina Syndrome

This post was peer reviewed.
Click to learn more.
Image Credit: Wikipedia

Author: Patrick Wallace, OMS-IV
Rocky Vista University College of Osteopathic Medicine
AAEM/RSA Education Committee

Spinal Epidural Abscess
Spinal epidural abscess (SEA) is a potentially debilitating and life-threatening cause of low back pain. It occurs in 0.2 to 2 cases per 10,000 hospital admissions.[1-3] However, recent articles note the incidence is increasing as much as five-fold.[4,5] SEA most commonly occurs in the thoracic and lumbar regions.[4,6] The difficulty in diagnosing an SEA is due to the nonspecific symptoms that often mimic the more common benign low back pain complaints seen in the emergency department. Making the diagnosis prior to the development of neurological symptoms is rare, so this cause should always be considered in the differential.

Sunday, November 5, 2017

The Challenge of Identifying a Septic Joint

Authors: Raymond Beyda, MD; Lee Grodin, MD; Jackie Shibata, MD; Ted Segarra MD
Editors: Kelly Maurelus, MD FAAEM and Michael Bond, MD FAAEM 

Originally Published: Common Sense May/June 2017

The ED evaluation of patients with acute monoarthritis is often challenging given the broad differential diagnosis and significant morbidity which can result from missed septic arthritis (SA). The following articles aim to simplify the work-up of the undifferentiated hot and swollen joint.

Thursday, November 2, 2017

Updates in the Emergency Department Management of Acute Liver Failure

Authors: David Bostick, MD MPH; Megan Donohue, MD; Robert Brown, MD; and Nicholas Santavicca, MD
Edited by: Michael C. Bond, MD FAAEM and Kelly Maurelus, MD
Originally Published: Common Sense July/August 2017

Patients with chronic liver disease and acute liver failure have disease specific needs for which Eps must be cognizant. Below we review topics related to acetaminophen hepatotoxicity, use of rifaximin and lactulose in hepatic encephalopathy, and thromboelastography (TEG) directed transfusion in patients with liver disease requiring procedures.

Sunday, October 29, 2017

Communicate Your Way to Better Patient Satisfaction

This post was peer reviewed.
Click to learn more.
Image Credit: Wikimedia
Author: Bill Christian, MS-III
Ross University School of Medicine
AAEM/RSA Social Media Committee

Patient satisfaction has become more important recently for various reasons. Surveys have been developed to measure patients’ perspective of their hospital care. Such surveys ask about patients’ communication with various staff, experience in the hospital, and their overall rating.[1] While certain aspects of patient satisfaction has been studied in the past, performance on the surveys is now being coupled to insurance reimbursements, further encouraging the study of how to please patients.

Thursday, October 26, 2017

Never Trust a Norwood: Emergency Management of the Sickest Congenital Heart Patients

Image Source: Pixabay
This post was peer reviewed.
Click to learn more.
Author: Ashley Grigsby, DO, PGY-4
Indiana University
RSA Social Media Committee Member

For many emergency physicians, the scariest patient to come through the doors is the crashing neonate. But make that same neonate a child with congenital heart disease (CHD) and you have a recipe for the so-called, “Code Brown.” One of the most unstable types of CHD is Hypoplastic Left Heart Syndrome (HLHS), a ductal dependent lesion that can be stabilized in the first few weeks of life with intravenous prostaglandins while awaiting surgical management. All patients with HLHS or single ventricle physiology, will require a stage 1 palliative surgery which is usually the Norwood procedure. Norwood patients are, arguably, the sickest of all CHD kids and are the most vulnerable to sudden death, leading many to live by the mantra, “Never trust a Norwood.”

Sunday, October 22, 2017

Preparing for the Worst

Image Source: Common Sense
Author: Aaron C. Tyagi, MD
Sparrow/Michigan State University
Chair, RSA Social Media Committee
Originally Published: Common Sense July/August 2017

We in the world of emergency medicine like to think of ourselves as ready for anything. I have often heard the mantra that we are ready for anything that “walks, rolls, or crawls through the door.” Our world is one of relatively controlled chaos. That is to say, when we receive the chaos, it has started somewhere else, far off and distant and we receive a microcosm of it in the form of a patient. That patient is delivered (for the most part) calmly to our home base. However, what happens when the chaos starts at our home base?

Code Silver. It’s something no health care provider ever wants or expects to hear in his or her hospital. But it was something that became a reality for the patients and staff of Bronx-Lebanon Hospital at 2:50 PM on June 30th, 2017.[1] A disgruntled employee, a former physician at the hospital no-less, entered his former place of employ, traveled calmly to the 16th and 17th floors with an AR-15 neatly hidden under his coat. He was wearing a white coat, the symbol physicians traditionally wear to signify healing, and opened fire on his former colleagues. His brutal attack left one dead and six wounded requiring various levels of inpatient hospital care.

Thursday, October 19, 2017

The Pulseless Extremity: An Approach to Acute Ischemic Limb

Image Source: Wikimedia
This post was peer reviewed.
Click to learn more.

Authors: Benjamin Mogni, MS-3
University of Kentucky
RSA Wellness Committee Member

Terren Trott, MD, Assistant Professor
University of Kentucky

A 55-year-old man with a past medical history of atrial fibrillation and aortic atherosclerosis presents to your emergency room with numbness, tingling, and pain in his left lower extremity below the knee. A tech is pushing him in a wheelchair because the pain is too great and he cannot move his foot. His foot appears pale in comparison to the other. The patient writhes uncomfortably in bed. Brief examination of the leg demonstrates a cold extremity with no posterior tibial or dorsalis pedis pulses.

Sunday, October 15, 2017

Management Strategies for Acute Atrial Fibrillation in the Emergency Department - Resident Journal Review

Authors: Eli Brown, MD; Allison Regan, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD
Edited by: Jay Khadpe, MD, FAAEM; Michael C. Bond, MD, FAAEM
Originally Published: Common Sense September/October 2013

Atrial fibrillation (AF) and atrial flutter (AFL) are the most commonly occurring arrhythmias in the United States. Management strategies for AF and AFL emphasize ventricular rate control, cardioversion to normal sinus rhythm and long-term interventions such as anticoagulation to reduce the risk of stroke. In patients in whom cardioversion is an option, either pharmacological or electrical cardioversion may be considered. While there is a significant amount of literature comparing the effectiveness and safety of pharmacologic versus electrical cardioversion in acute AF, studies which analyze discharge rates and hospital length of stays are becoming more frequent due to concerns over rising healthcare costs and ED overcrowding. This review focuses on treatment strategies for patients presenting to the ED with acute atrial fibrillation; in particular, rate control versus cardioversion, options for cardioversion (chemical versus electrical) and the safety of these strategies when used in the ED.

Thursday, October 12, 2017

Preserving the Humanity of Our Patients and Fostering Our Own

Image Credit: Pixabay
Author: Leana S. Wen, MD MSc
2012-2013 AAEM/RSA President
Originally Published: Common Sense March/April 2013

We EPs know that life in the ED is fast-faced, extremely busy, and ever-challenging. When things get crazy, it becomes habit to see our patients as “the chest pain in room 6” or “the lac in the hallway.” We turn people with their amazing lives and fascinating stories into chief complaints and tiles on our electronic tracking board.

It’s a practice that’s easy to justify. After all, taking a long time with one patient can delay care for all the other people who are waiting to see us. However, the patient's story and the context of his illness are important to him — and critical to the care we render.

Sunday, October 8, 2017

Development in Clinical Toxicology: Use of Intralipid Emulsion and High-Dose Insulin Therapy

Authors: Allison Regan, MD; Eli Brown, MD; Jackie Shibata, MD; Kaycie Corburn, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM

There are few antidotes in clinical toxicology, especially with regards to some of the most commonly used medications including calcium channel blockers, beta-blockers, and peripheral anesthetics. Morbidity and mortality rates are high and supportive care is often ineffective. Intralipid and high-dose insulin therapy are two exciting developments in clinical toxicology. This review of the literature explores the evidence behind these new treatment options for beta-blocker and calcium channel blocker toxicity, as well as anesthetic overdoses.

Engebretsen, K, et al. High-dose insulin therapy in beta-blocker and calcium-channel-blocker poisoning. Clinical Toxicology. 2011;49,277-283.

Beta-blocker and calcium channel blockers are common medications that can result in both intentional, and unintentional, overdoses. The high morbidity and mortality associated with these overdoses is largely secondary to cardiovascular toxicity. Recent data suggests that early use of high dose insulin (HDI) may be an effective treatment strategy for beta-blocker and calcium channel blocker poisonings.

Thursday, October 5, 2017

Resident Journal Review: Mechanical Ventilation in the Emergency Department

Image Credit: Flickr
Authors: Michael Allison, MD; Kami Hu, MD; David Bostick, MD MPH; Phil Magidson MD MPH; and Michael Scott, MD
Edited by: Michael C. Bond, MD FAAEM and Jay Khadpe, MD FAAEM

Originally Published: Common Sense March/April 2014

Patients with respiratory failure are commonly encountered in the emergency department (ED), and many of these patients progress to require endotracheal intubation and mechanical ventilation. Mechanical ventilation strategies were the focus on a recent Annals of Emergency Medicine Clinical Controversy.1,2 Since its publication, there have been a number of newer studies suggesting that perhaps ventilation with low tidal volume can improve outcomes for many ED patients with respiratory failure, not just those with the acute respiratory distress syndrome (ARDS). This “Resident Journal Review” goes through the pertinent recent literature on low tidal volume ventilation.

We begin with an investigation regarding the use of low tidal volume ventilation in the ED among patients with and without ARDS. The investigators found that low tidal volumes are infrequently used in both scenarios. The impact of this becomes clearer, as the following three articles note a variety of improvements in patients ventilated with lower tidal volumes. There is a suggestion that even a 1mL/kg difference from a lung-protective strategy can worsen clinical outcomes.

Sunday, October 1, 2017

Serious Bacterial Infections in the Febrile Infant

Image Credit: Pixabay
Authors: Kaycie Corburn, MD; Jacqueline Shibata, MD; Lee Grodin, MD; Raymond Beyda, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM
Originally Published: Common Sense September/October 2015

Pediatric fever, especially in infants, is often a challenging and nerve-racking presentation to evaluate in the ED. The prevalence of serious bacterial infections (SBI) in young infants range from 8-20%.[1] There is no clear cut consensus on how to work-up these patients in the ED.[2] As a result, many infants are subjected to invasive, unnecessary, and costly procedures or needlessly treated with empiric antibiotics and hospitalizations. In this edition of the Resident Journal Review, we review the literature on this topic in an effort to give more clarity on how to approach the febrile infant.

Friday, September 29, 2017

Literature Update in Pneumonia

Image Credit: Flickr
Authors: David Bostick, MD MPH; Phil Magidson, MD MPH; Carina Sorenson, MD; Neil Christopher, MD; Kami M. Hu, MD; David Wacker, MD PhD
Editors: Michael C. Bond, MD FAAEM; Jay Khadpe, MD FAAEM
Originally Published: Common Sense March/April 2015

Patients with community-acquired pneumonia (CAP) are frequently seen in the emergency department (ED). According to the National Hospital Ambulatory Medical Care Survey (NHAMCS), pneumonia is the third most common principal ED discharge diagnosis in the United States.[1] In this literature update, we examine: use of point-of-care ultrasound to diagnose pneumonia, obtaining routine blood cultures, risk factors for multi-drug resistant organisms and the efficacy of antibiotic monotherapy versus combination therapy in moderately severe pneumonia.

Sunday, September 24, 2017

Updates in Prehospital Emergency Medical Service Care - Resident Journal Review

Image Credit: Pixabay
Authors: Phillip Magidson, MD MPH; David Bostick, MD MPH; Kami Hu, MD; Carina Sorenson, MD; David Wacker, MD PhD
Editors: Michael C. Bond, MD FAAEM; Jay Khadpe, MD FAAEM
Originally Published: Common Sense Nov/Dec 20147

Over 15% of all patients seen in the emergency department (ED) arrive via emergency medical services (EMS).1 This represents over 20 million visits annually. For this reason, improvement and expansion of evidence based interventions within the prehospital setting should continue to be explored. In this month’s “Resident Journal Review,” we focus on diagnostic, therapeutic, and logistical updates within prehospital EMS care.

Thursday, September 21, 2017

Approach to the Dizzy Patient - Resident Journal Review

Image Credit: Pixabay
Authors: Eli Brown, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD; Lee Grodin, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM
Originally Published: Common Sense September/October 2014

Dizziness, often a challenging presentation, refers to a variety of vague sensations including lightheadedness, disequilibrium, and vertigo. Life-threatening disorders, such as stroke, are easily mistaken for benign illnesses, such as acute vestibular syndrome (AVS). This review focuses on recent developments in the evaluation of dizzy patients including some bedside tests which may improve diagnostic accuracy and reduce the cost and time of the ED evaluation.

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
Originally Published: Common Sense May/June 2014

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
Originally Published: Common Sense March/April 2014

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 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

This post was peer reviewed.
Click to learn more.
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

This post was peer reviewed.
Click to learn more.
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.
Click to learn more.
Author: Alfred Morrobel, M.D
Universidad Iberoamericana

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

This post was peer reviewed.
Click to learn more.
Image Credit: US Air Force

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

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.

  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]
  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
Weakness, confusion, chest pain, nausea and vomiting, palpitations

  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]

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.

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

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

This post was peer reviewed.
Click to learn more.
Image Source: Wikipedia
Author: Ashley Grigsby, DO
Indiana Univeristy
AAEM/RSA Social Media Committee

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.