Thursday, May 16, 2019

Identification of the Hospice vs. Palliative Care Patient in the ED

Image Credit: Pexels
Author: Deniece Boothe, DO
Originally Published: Common Sense March/April 2019

The terms “hospice” and “palliative care” remain synonymous for many health care providers. Despite the intertwined relationship, it is important that we understand the differences in an effort to provide appropriate resources for our patients facing serious, life-limiting illness. Palliative care, also known as palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.[1] Hospice care is designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. Those with a prognosis of six months or less meet criteria for hospice. A Center to Advance Palliative Care survey found that most health care professionals erroneously equated palliative care with end-of-life (EOL) care.[1] This lack of understanding leads to ineffective communication between the provider and patient or health care proxy.

Thursday, May 9, 2019

Size Does Matter…For Your Expense Ratio

Image Credit: Pexels
Author: Joel M. Schofer, MD MBA CPE FAAEM
Commander, Medical Corps, U.S. Navy
Originally Published: Common Sense July/August 2019

I published this article three years ago in Common Sense, but this is such a critical concept that it bears repeating every few years. In addition, the recent price war among investment firms has made it even easier to lower your investment costs.[1] There has never been a better time to take a solid look at the investment costs you are paying.

Whether you are managing your investments by yourself or getting help, you need to understand one critical concept, the expense ratio of your investments. Every mutual fund and exchange-traded fund (ETF) has an expense ratio and keeping it as small as possible is key to your long-term financial success. Size does matter.

Thursday, May 2, 2019

Five Pearls for Using Interpreters Ethically

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This post was peer reviewed.
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Author: Sara Urquhart, RN MA
Medical Student
Michigan State University College of Human Medicine
AAEM/RSA Publications and Social Media Committee

Imagine an unconscious 15-year-old male arrives at a downtown Miami trauma center. Paramedics say that before passing out, he told his Spanish-speaking girlfriend he felt “intoxicado.” “Intoxicated,” they say. The boy is stabilized and admitted to intensive care with a diagnosis of drug overdose. No one called an interpreter to interview his girlfriend. If they had, they would have learned that in Cuban Spanish, intoxicado is a word for nausea and that the boy did not take an overdose. Over 36 hours later, imaging shows a ruptured subarachnoid aneurism on the now paraplegic boy, who survives and later wins a $71 million malpractice lawsuit.[1]

Thursday, April 25, 2019

Books, Blogs, and Podcasts to Check Out in 2019

Image source: Pexels
Author: Joel M. Schofer, MD MBA CPE FAAEM
Commander, Medical Corps, U.S. Navy
Originally published: Common Sense March/April 2019

Whether you like it or not, you have a second job. That second job is managing your personal finances.

Even if you don’t do it yourself and use a financial advisor, you still have to know enough to make sure your advisor is giving you solid advice and not ripping you o!. Many financial advisors are really just financial salesman with a particular set of skills. Those skills are designed to take money from your pocket and put it in theirs. You need to know enough to prevent this. Luckily for us, there are quality blogs that you can read online, podcasts you can listen to while commuting or exercising, and books you can get from your local library. And the best part is that all of these resources are FREE! Here are my personal favorites in 2019. I have read, am reading, or listen to everything on this list.

Thursday, April 18, 2019

Why Did AAEM Take a Stand Against APP Independent Practice?

Author: AAEM APP Task Force

Physician members of the American Academy of Emergency Medicine have voiced concerns about the use of advanced practice providers (APPs) in the emergency department and their push for independent practice without the supervision or even availability of a physician. The task force spent hours discussing the issues, comparing the education of physician assistants, nurse practitioners, and board-certified emergency physicians, speaking to physicians about their concerns, and examining the literature. (J Emerg Med 2004;26[3]:279; Acad Emerg Med 2002;9[12]:1452; J Emerg Med 1999;17[3]:427; Acad Emerg Med 1998;5[3]:247; Ann Emerg Med 1992;21[5]:528.)

Most emergency physicians have worked with APPs and appreciate that they are talented clinicians who improve emergency department flow, efficiency, and quality of care under the guidance of the emergency physician-led team. Many emergency physicians are aware of situations that place APPs in clinical environments that are beyond their capabilities, level of training, and even scope of practice. This is not the quality of care our emergency patients deserve.

Thursday, April 11, 2019

Diving Emergencies - What You Need to Know on Your Next Shift

Image Credit: U.S. Central Command
This post was peer reviewed.
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Authors:
Joshua Goldstein, MSIII Medical Student
University of Miami Miller SOM

Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

Introduction
SCUBA (Self Contained Underwater Breathing Apparatus) Diving is becoming increasingly popular, with an estimated 306 million dives made in the United States between 2006 and 2015.[1] During that same time there were 658 diving deaths in the United States and nearly 14,000 emergency department (ED) visits.[1] While the pathophysiology underlying many diving injuries is complex, the basic treatments for many life-threatening diving injuries are the same (Figure 1). It is important to understand the relatively simple therapies that underlie appropriate care for these injuries.[2,3]

Thursday, April 4, 2019

Testicular Torsion: Medicolegal Pitfalls

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This post was peer reviewed.
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Authors: Hannah Clode, MSII, University of Miami Miller SOM
Tim Montrief, MD MPH, Jackson Memorial Health System/University of Miami, AAEM/RSA Publications and Social Media Committee Member

Case
A 16-year-old male is brought to your emergency department complaining of acute-onset right lower quadrant abdominal pain that woke him from sleep two hours ago and is associated with some mild nausea and vomiting. His vitals are stable and his physical exam is unremarkable except for mild tenderness to palpation in the right lower quadrant. Labs show no evidence of leukocytosis, and his c-reactive protein is within normal limits. You order an abdominal ultrasound (US) to evaluate for possible appendicitis which is unremarkable. The patient’s pain improves, and you discharge him home. Unfortunately, the patient returns to the hospital three days later and is found to have a torsed, necrotic testicle which was unable to be salvaged. The patient’s family has decided to sue you for failing to diagnose testicular torsion (TT). How could this outcome have been avoided?

Thursday, March 28, 2019

Code Scooter

Image Credit: Pexels
Author: Jake Toy, DO
AAEM/RSA Publications & Social Media Committee Chair
Originally published: Common Sense March/April 2019

It’s 2:00am on a Friday night in your emergency department. A trauma call goes out. Twenty-four-yearold male with head trauma and multiple extremity abrasions after suspected electric scooter (e-scooter) accident. Agitated. Suspected intoxication… If you’re rotating or working in an urban center, trauma runs with this mechanism may already be a daily norm.

Thursday, March 21, 2019

Anatomical Review of Jugular Central Line Placement

Image Source: Wikipedia
This post was peer reviewed.
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Authors:
Benjamin Mogni, MS-IV
Medical Student
University of Kentucky College of Medicine

Terren Trott, MD
Critical Care Fellow
Cooper Hospital University

Jugular venous catheters allow for central administration of medications, frequent blood draws and central venous sampling. While standard of care for placement of central venous catheters (CVCs) involves ultrasound guidance, physicians should be aware of the traditional landmark approach to line placement. This means having a detailed knowledge of the anterior and posterior triangles of the neck, specifically the division of the sternocleidomastoid into the clavicular and sternal heads, as shown in Figure 1 and Figure 2. This review will summarize the anatomy involved in the placement of a jugular venous catheter and possible complications.

Thursday, March 14, 2019

2018-19 AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Jordan Neichelle Powell
University of Rochester School of Medicine and Dentistry

RSA is proud to share the following essay from one of the 2018-2019 Medical Student Scholarship winners, Jordan Neichelle Powell. We felt this essay best exemplified why she is choosing EM as a specialty. Congratulations, Jordan!

One cold winter night during a pediatric emergency medicine (EM) shift I had the pleasure of taking care of a nine-year-old girl with what I thought would be a typical sick visit during the winter season. Upon informing the parent and the child that she would soon be discharged, she stopped me before leaving the room. She informed me that she had a secret to tell me. As I approached her bedside, she timorously shared that she has never seen someone that looked like her take care of her. I remained silent since the words that so easily flowed from her mouth were not what I was expecting. She then shared that she wanted to be a doctor just like me one day. Experiencing sudden shock, I also felt a sense of humbling warmth. Before I left her I hugged her and whispered back in her ear that she could be anything that she wanted to be. That moment, is one of many that constantly remind me of why I went into medicine and decided to pursue Emergency Medicine as my specialty. This specialty not only allows me to be a positive influence on those underrepresented in the community but has also been an opportunity to learn from and advocate for patients as well. It can be something as small as representation and letting a little girl know that she too can be whatever she wants to be; or, on a larger scale, making sure that a patient knows that they are safe, heard, and cared for.

Thursday, March 7, 2019

2018-19 AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Abdullah Faiq
Howard College of Medicine

RSA is proud to share the following essay from one of the 2018-2019 Medical Student Scholarship winners, Abdullah Faiq. We felt this essay best exemplified why they are choosing EM as a specialty. Congratulations, Abdullah!

As I stitched my patient’s last sutures, drawing his eyebrows back into alignment, I turned my attention to his visibly relieved wife. “Don’t worry, he’ll be as handsome as he was yesterday.” She laughed, complimented my work, and insisted her husband take a selfie for the kids. A few hours earlier, he had been in a life-threatening car accident, arriving as a code yellow with 1.5L of blood loss. I lifted the suture mat off his face and saw him smile for the first time. It was 3AM, I felt present and focused, and there was no place I would rather have been.

Thursday, February 28, 2019

The Light at the End of the Tunnel

Image Credit: Pexels
Author: MohammedMoiz Qureshi, MD
AAEM/RSA President
Originally published: Common Sense March/April 2019

As of January 1, 2019, current second year residents in three year programs have officially completed half their residency! Just under 18 months away from completing a long and grueling journey. It’s remarkable how much you grow from a fourth year med student to a semi-competent senior resident in the ED. As we look forward to the second half and start looking at the next stage in our careers there is an overwhelming feeling of unease in terms of where to begin the “grown-up” job search and what to assess and prioritize.

Thursday, February 14, 2019

A Life Almost Saved

Image Credit: Common Sense
Author: Nick Pettit, DO PhD
Originally published: Common Sense January/February 2019

Very few jobs, let alone, medical specialties have the potential to encounter death on a daily basis. With this comes responsibility, honor, reward, pride, but also despair, death, and failure. Politics and biases aside, as clinicians, it is engrained early in our training that we are present to aid, cure, educate, and comfort the patient. The patient is the focus of everything, patient satisfaction, outcomes, money, litigation, politics, and this is so true when we as a health care team almost save a life. Imagine Billy, a 12 year old boy riding his bicycle on a sidewalk and is struck by a drunk driver. EMS arrives and finds a child as a GCS 3. Intubated and sent to local ED, where thorough radiographic imaging demonstrates diffuse axonal injury, possible cervical spine injury, bilateral hemopneumothoraces, etc., and clinically has experienced a nonsurvivable event. After being admitted to the pediatric intensive care unit, and after numerous consultations with subspecialists, the parents do the most heroic thing of all and consent to organ donation.

Thursday, February 7, 2019

Three vs. Four and Everything in Between


Image Credit: Pexels
Author: MohammedMoiz Qureshi, MD
AAEM/RSA President
Originally published: Common Sense January/February 2019

As interview and rank season comes to an end and the ever-anticipated Match is just a few short months away, I thought it would be a good time to reach out to our medical students who have questions and concerns regarding the variations in residency training programs. Emergency medicine programs are abundant nationwide and vary in length between three and four years. Students are often confused whether the extra year makes a difference in overall training or ability to pass board certification and it remains one of the most commonly asked questions on the interview trail.

Thursday, January 24, 2019

Intravenous Fluid Therapy in the Emergency Department and Critical Care Setting


Authors: Raymond Beyda, MD; Taylor Conrad, MD; Rithvik Balakrishnan, MD; Ted Segarra, MD; Taylor M. Douglas, MD

Editors: Kami Hu, MD FAAEM and Kelly Maurelus, MD FAAEM

Originally published: Common Sense
November/December 2018

Intravenous fluid (IVF) therapy is one of the most common therapies employed during the care and resuscitation of patients in the emergency, acute, and critical care settings. With several available IVF options such as balanced crystalloids, normal saline (NS), albumin, and other colloid solutions, it is clear that choosing the best solution, the optimal volume, and the appropriate rate of administration is an ever-present clinical challenge. In this review we attempt to address the following questions using recently published literature on the topic:

  1. Does the use of balanced crystalloids (BC) in the resuscitation of patients confer a mortality/morbidity benefit when compared with NS?
  2. Does the use of BC decrease the risk of acute kidney injury (AKI) in the acute setting?

D Annane, et al. Effects of Fluid Resuscitation With Colloids versus Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock, The CRISTAL Randomized Trial. JAMA. 2013;310(17):1809-1817.
Crystalloids, including Lactated Ringers (LR), NS, and hypertonic saline, are thought to work based on the osmotic pressure of their contents. Colloids such as albumin, hydroxyethyl starch (HES), and gelatins, on the other hand, act on oncotic pressures to keep fluid in the intravascular space. The authors of the Colloids Versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial sought to compare the efficacy of these two large classes of fluids in acute hypovolemic shock without making specific comments on the above subtypes.

Thursday, January 17, 2019

Geriatric Trauma: Not Just Older Adults, An Interview with Christopher Colwell, MD

This post was peer reviewed.
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Christopher Colwell, MD FACEP








Author: M. Kaitlin Parks, MSIV
Medical Student
Oklahoma State University COM
AAEM/RSA Publications and Social Media Committee

Interviewee: Dr. Christopher Colwell, MD FACEP
Chief of Emergency Medicine
San Francisco General Hospital and Trauma Center, Professor, UCSF

Just as any pediatrician would tell you, “a child is not just a small adult”. The same goes for the geriatric population. There are many physiologic differences in the geriatric population that are important to understand in order to deliver the best and most tailored care. An area where this is especially pertinent to the emergency physician is in the setting of trauma. A lot of what we know about trauma has come from military medicine, which sees a strong bias towards the young and healthy. As our population ages, we are seeing an increasing number of geriatric trauma patients in the emergency department (ED).[1,2] Older patients have higher morbidity and mortality in the setting of trauma.[3] Our geriatric patients are also more likely to have comorbidities and medications that both worsen their response (such as anti-coagulation and clotting) or blunt their capacity to compensate (such as beta-blockers and heart rate).[4] Age has been integrated into Trauma Triage criteria but many criteria are based on vitals that may not adequately measure the severity of select trauma cases in the geriatric population.[5]

Thursday, January 10, 2019

Tumor Lysis Syndrome

Image Credit: Pixabay
This post was peer reviewed.
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Author: Nick Pettit, DO PhD
Resident Physician, Indiana University
AAEM/RSA At-Large Board Member

Malignancy is the second leading cause of mortality, and scarily, retrospective studies have demonstrated that the projected five-year survival once someone receives a diagnosis of cancer is approximately 50%. The National Cancer Institute recently expanded its research agenda to better understand cancer care in the ED. Studies have shown that cancer patients make up about 3% of emergency department (ED) visits and Medicare data has demonstrated that in the last six months of life, cancer patients utilize the ED significantly more.[1]

Thursday, January 3, 2019

Top 10 Most Read Posts of 2018

Image Source: Wikimedia
As December comes to a close, we look forward to recognizing the year’s top 10 articles! Join me in congratulating this amazing group of authors at all levels of training and from across the USA!

Additionally, I would like to thank each of the AAEM/RSA Modern Resident Blog authors, reviewers, mentors, and editorial staff members for their tireless contributions to the blog. Without all of them, the blog would not be what it is today. Thanks for a successful 2018!

We are currently accepting articles for 2019 and are always looking for additional faculty mentors as well. Feel free to contact us at info@aaemrsa.org with questions. Have a safe and happy holiday season!

Sincerely,

Jake Toy, DO
Editor-in-Chief
Modern Resident Blog