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.

What does the aforementioned data suggest? Cancer patients that present to the ED have a high mortality rate and should be considered sick until proven otherwise. Treat the symptoms and have a low threshold to admit.

Cancer is the second leading cause of death after cardiovascular disease, and because of the improvement of novel therapies these patients are living longer.[2] Lung (32.5%), gastrointestinal (25%), and breast (9%) were the most common malignancies presenting in the ED. It was then determined that progressive disease (42%), chemotherapy side effects (21%), and infections (17%) were the most common causes for presentation to the ED.[1]  Important recognition of these symptoms and determining the cause is crucial for helping these potentially critically-ill patients extend their lives.

Fever and infections were found to be the most life threatening and a common cause of hospitalization and death among chemotherapy patients.[3] Furthermore, so much of chemotherapy is done as an outpatient-patient basis, it is not uncommon for these patients to present to the ED after hours due to their oncologist’s office being closed.

The moral of this post, cancer patients are sick until proven otherwise. They may present with any host of symptoms, such as shortness of breath, fever, and pain. Due to the high morbidity and mortality associated with cancer-associated illnesses it is on us as emergency providers to treat these patients as we would any other critically ill patient.

References


1. Sadik M, Ozlem K, Huseyin M, AliAyberk B, Ahmet S, Ozgur O. Attributes of cancer patients admitted to the emergency department in one year. World Journal of Emergency Medicine. 2014;5(2):85-90. doi:10.5847/wjem.j.issn.1920-8642.2014.02.001.

2. Swenson K, Rose M, Ritz L, Murray C, Adlis S. Recognition and evaluation of oncology-related symptoms in the emergency department. Annals of Emergency Medicine. 1995;26(1):12-17. Doi:http://dx.doi.org/10.1016/s0196—0644(95)70231-8


3. Escalante C, Weiser M, Manzullo E, et al. Outcomes of treatment pathways in outpatient treatment of low risk febrile neutropenic cancer patients. Support Care Cancer2004;12(9):657-662 doi:10.1007/s00520-004-0613-6

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