Friday, November 22, 2019

Resident Journal Review: Diagnosis and Treatment of Cellulitis in the Emergency Department

Authors: Taylor M. Douglas MD, Taylor Conrad, MD, Ted Segarra, MD, Rithvik Balakrishnan MD, Christianna Sim, MD, MPH
Editors: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM
Originally published: Common Sense
November/December 2019

Skin and soft tissue infections (SSTIs) result in over two million visits to the emergency department (ED) every year. While this term encompasses infections ranging from erysipelas to necrotizing fasciitis, this article focuses on superficial cellulitis. Due to the lack of good data, there is no true consensus in the medical community regarding standard of care, i.e. whether intravenous (IV) antibiotics are required or what clinical presentations mandate admission. The Infectious Disease Society of America (IDSA) makes recommendations for treatment duration (five days), when to cover methicillin-resistant Staphylococcus aureus (MRSA) [penetrating wounds, intravenous drug use, systemic inflammatory response syndrome (SIRS), nasal colonization, evidence of other MRSA infection] and outpatient management (for those without SIRS, altered mental status, or hemodynamic instability) 1. Most of these guidelines, however, are based on retrospective studies. Studies in the surgical field have attempted to identify grading systems to help guide management without success.2 Without consensus, emergency physicians are left with the following questions on how to best treat and disposition our patients with cellulitis to ensure their infection resolves.

Thursday, November 14, 2019

The Future of Wellness

Authors: Andrea Purpura, MD; Robert Lam, MD; and Ryan DesCamp, MD
AAEM/RSA Wellness Committee
Originally published: Common Sense September/October 2019


If you feel like you are suffering symptoms of burnout, you are not alone. Most prevalence studies show that more than 65% of all emergency physicians are experiencing symptoms of burnout.1 Most physicians find they are no longer able to mitigate the challenges of an increasingly frustrating work environment with individual resilience practices alone. This frustration mirrors the shift in our current understanding of burnout and physician well-being.


Thursday, November 7, 2019

Thriving in Third Year

Image credit: Pexels
Author: David Fine, Medical Student Council President
Originally published: Common Sense  September/October 2019


The beginning of the year brings new residents and medical students to the floors. A question that all new learners have on their minds is, “How can I succeed?” Personally, I can’t speak to the resident experience, but any medical student knows that there is not just a single way to do well. Over the course of the year you will be challenged with new concepts, different practicing styles, and inconsistent expectations. There is not just a single method that will be successful in your unique training environments, but I believe that there are a few key pieces of advice that will help you thrive and adapt throughout the year.

Monday, November 4, 2019

Becoming a Night Shift Jedi: Do or Do Not, There is No Try.

Image credit: Pexels
Author: Patrick Wallace, DO
AAEM/RSA Education Committee 
Originally published: Common Sense
September/October 2019


Emergency medicine (EM) physicians will inevitably work night shifts during their career. With transitions of days and nights occurring as frequently as once a week, it is imperative to maximize the quality of sleep and recovery time. Abundant research has been done on various aspects of sleep hygiene and effective techniques to combat difficulties surrounding night shift-work. This article will address some of those key factors including napping, caffeine, sleep environment, and long-term health consequences.




1. Preparing
Acquisition of sleep debt during the transition to and from night shift often arises from staying awake the entire day leading up to the first night.1 By minimizing sleep debt going into night shift, performance can be improved and recovery hastened.2


Thursday, October 24, 2019

An Argument for the Enforcement of Electronic Health Record Cross-Communication

Image credit: Pexels
Author: Haig Aintablian, MD
AAEM/RSA President
Originally published: Common Sense September/October 2019


A 77-year-old patient comes into the ED for a complaint of shortness of breath x 6 months. This is the first time the patient has come to this hospital and there are no medical records in the EHR. The patient doesn’t remember what problems they have, but they know they’re on some sort of medication for their heart. They deny any kidney problems. You optimize the patient in the ED, see no acute ECG changes, no troponin elevations, but a creatinine of 2.3 and a BNP that is mildly elevated. You admit for heart failure and AKI. Multiple renal and cardiac studies are done in house because his records can’t be retrieved. Once they are retrieved you see that his BNP and Cr are within baseline and the patient did not require admission.

Thursday, October 17, 2019

Resident Journal Review: Neurologic Complications of Correction for Hyperglycemic Hyperosmolar State in the Emergency Department


Authors: Mark Sutherland, MD, Megan Donohue, MD, Caleb Chan, MD, Robert Brown, MD
Editors: Kami M. Hu, MD FAAEM; Kelly Maurelus, MD FAAEM
Originally published: Common Sense September/October  2019






Questions
  1. What is the preferred therapy for correction of hyperglycemic hyperosmolar states (HHS) in the emergency department, and what potential adverse neurologic effects of these corrective therapies should be considered?
  2. What is the incidence of osmotic demyelination syndrome (ODS) or cerebral edema when aggressively correcting hyperglycemic states?
  3. Who is at greatest risk for ODS and what can be done to reduce their risk?
  4. Who is at greatest risk for cerebral edema and what can be done to reduce their risk?

Friday, October 11, 2019

Case report: A rare case of acute lumbar paraspinal compartment syndrome in a military trainee

Image by: Airman st Class Janelle Patio
This post was peer reviewed.
Click to learn more.








Author: Conner Murphy, MSIV, Ivan Yue, MSIV, and Vivek Abraham, MSIV
Uniformed Services University School of Medicine
AAEM/RSA Publications and Social Media
Committee

INTRODUCTION
Acute lumbar paraspinal compartment syndrome is a rare injury, occurring primarily in male patients and often related to overhead weight lifting activities.[1] It has also been reported following skiing, surfing, blunt trauma, and as the result of reperfusion injury following abdominal aortic procedures.[2] The syndrome occurs when the enclosed fibro-osseous space of the lumbar paraspinal compartment increases in pressure beyond perfusion pressure, leading to ischemia, intractable pain and eventually tissue necrosis if left untreated.[1] Patients generally present with intense acute pain after exercise, physical exam revealing swollen and tense lumbar paraspinal muscles, and laboratory abnormalities including high creatine kinase levels and myoglobinuria, often appearing like or in conjunction with rhabdomyolysis.[2] Muscle tissue may remain viable for up to four hours without irreversible damage, while eight hours of ischemia has been known to cause irreversible necrosis.[3] Early recognition and orthopedic consultation for surgical management decreases prolonged suffering and neurovascular compromise, allowing resolution of rhabdomyolysis and pain, as well as return to baseline athletic activity.[4] In this case report, we present a case of acute lumbar compartment syndrome in a young athletic male in the context of intense military training.

Thursday, October 3, 2019

CPR Induced Consciousness – An Important Phenomenon to be Aware Of

Image credit: Pexels
Author: Jake Toy, DO
Harbor UCLA Medical Center
Originally published: Common Sense July/August 2019

In a recent resuscitation of an unconscious elderly woman in ventricular fibrillation, my team observed that upon initiation of cardiopulmonary resuscitation (CPR), she began to make purposeful movements with her arms and legs. During compressions, she batted at the mechanical CPR device and reached for her endotracheal tube. When attempting to place a femoral line, she withdrew to pain from the needle on that side. Through these periods of seemingly purposeful movements, her eyes remained closed and she was not responsive to voice commands. Upon pulse checks, these movements abruptly ceased. Many questions arose during this resuscitation for my team: Should we physically restrain the patient? Should we chemically sedate? What was the level of the patient’s awareness?

Thursday, September 26, 2019

The Power of Mentorship

Image credit: Pexels
Author: Alexandria Gregory, MD
AAEM/RSA Social Media & Publications Committee Chair
Originally published: Common Sense
July/August 2019 

I fell in love with emergency medicine before medical school. Truth be told, I had been hooked on EM since the first time I watched “ER” when I was ten years old. But as I entered college and became pre-med in earnest, I started to wonder if perhaps another specialty might be right for me. That was until I started working as a scribe in the ED. It was there that I fell in love with emergency medicine all over again, and this time for better reasons than I had seen on television. Above all, though, were the people.

Thursday, September 19, 2019

SVI: The Next Step 2 CS

Image credit: Pexels
Author: Haig Aintablian, MD
AAEM/RSA President
Originally published: Common Sense July/August 2019

I did great on my SVI. The day of, I had just gotten a haircut and shaved my beard. My top half was covered by a nicely pressed navy blue suit jacket my mom bought me 4 years ago but that I hadn’t touched since my undergrad graduation. Under the blazer, a white shirt I’d worn twice that week already, and a baby blue tie I’m pretty sure I’ve had since high school. Best of all though, my bottom half was covered with a pair of stereotypical grey Hanes boxers – the type you buy in a 6+1 pack because you get one for free. I sat behind a desk in the middle of my half disastrous room (the side not covered by the camera), prayed an Our Father, and I said what had become my motivational slogan at this point, “**** it, we’re almost done.” I looked great on camera. My upper body displaying a professional, well-groomed student against a clean room backdrop with undergraduate degrees newly hung on the wall. There were no tight pants to hold me back (away rotations made me gain weight like a CHFer off Lasix). Regardless of how I looked on camera, I felt a deep helplessness. During the hardest half year of medical school trying to prove myself on away rotation after away rotation, devoid of family, friends, and proper sleep or nutrition, I was expected to be a robot in front of a video camera for reasons no medical student understood, no administrator could directly answer, and almost no PD would actually care about (let alone watch).

Thursday, September 5, 2019

FIX Scholarship Winner - Valerie Pierre

Name: Valerie Pierre, MD
Residency Program: Brookdale University Hospital and Medical Center
Graduation Date: June 2021

This photo highlights the importance of mentorship - an integral aspect of my journey in emergency medicine. As I reflect on my matriculation into emergency medicine residency, and the successes, triumphs and failures during my training, I can truly say that my mentors’ support has been a source of encouragement for me. More specifically, I have been fortunate to have strong female mentors who came before me. They continually share their wisdom and experience gained in overcoming the many barriers throughout their journeys in emergency medicine and encourage me to persevere in a primarily male-dominated field. This knowledge that my story is not unique serves as daily inspiration for me.

Thursday, August 29, 2019

FIX Scholarship Winner - Natassia Buckridge

Name: Natassia Buckridge, MD
Residency Program: SUNY Downstate Medical Center
Graduation Date: June 2023

There is something so exciting about sizing up a tree, mastering the climb, and looking out at the landscape from atop it. I like to envision my journey to emergency medicine as the ascent up a large, complex, identity-shaping tree. Reflecting on my first few days of elementary school as a new immigrant in New York City, I stood at the base of this tree. I was uncertain about this climb. I remember feeling that sense of otherness too, with my thick Jamaican accent and thrifted clothing. I became a U.S citizen some ten years later and a physician eight years after that. I didn’t always know where the next step up the tree would lead me. I did pick up gear along the way that makes the climb easier– rope (mentors), harnesses (colleagues and friends), and spurs (resilience and grit).

Thursday, August 22, 2019

Does Albumin as Resuscitative Fluid in Sepsis Improve Mortality When Compared to Crystalloid?

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








Authors: Laurie Bezjian Wallace, DO
Mike O’Callaghan Military Medical Center

Bottom Line Up Front
Utilizing albumin as resuscitative fluid in patients with sepsis demonstrated no difference in all-cause mortality when compared to crystalloid (System of Record ((SOR)) A: meta-analysis of randomized controlled trials [RCTs]). Administration of 300mL of 20% albumin did not significantly lower mortality rates at 28 days or 90 days post-administration (SOR B: single unblinded RCT).

Introduction
Crystalloid versus colloid fluid resuscitation in septic patients remains a topic of discussion within the critical care community. This article details a meta-analysis and RCT which address the outcomes of utilizing albumin as a resuscitative fluid in patients with sepsis.

Friday, August 16, 2019

Resident Journal Review: Update on Attitudes Towards Patients with Sickle Cell Disease and Effects on the Provision of High-Quality Care in the Emergency Department

Authors: Hannah Goldberg, MD; Sharleen Yuan, MD PhD; Samantha Yarmis, MD
Editors: Kami M. Hu, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally published: Common Sense January/February 2019

Question
Do emergency physicians have biases towards patients with sickle cell
disease and do biases affect the delivery of appropriate care?

Introduction
Many patients with sickle cell disease (SCD) have disease that is well managed in the outpatient setting. However, among patients with severe symptoms of SCD, there is a high recidivism rate in the emergency department (ED).[1] Care of patients with sickle cell disease with vasoocclusive crises (VOC) can often elicit frustration on the part of both the patient and the emergency physician due to many factors. These patients tend to have pain that is difficult to assess, as well as a high opiate tolerance requiring large doses to control pain. Additionally, physicians can have negative feelings about patients with sickle cell disease, with hesitancy regarding redosing of parental opioids due to concerns about opiate addiction and drug-seeking behavior.[2] These exist despite evidence that patients with sickle cell generally present with less outward distress or vital sign abnormality despite sincere pain and that lab-work does not correlate to presence of VOC or severity of associated discomfort.[3] We attempt to discern how pervasive these negative biases may be and whether or not they affect patient care.

Friday, August 9, 2019

Be Alert to Potential Loperamide Abuse and Resulting Cardiotoxicity

Originally published: Common Sense November/December 2018

This article was contributed by LoperamideSafety.org which is maintained by Consumer Healthcare Products Association (CHPA). They are an advocacy group for the consumer healthcare products industry (https://www.chpa.org/About.aspx).
 

A small, but growing, number of people are intentionally misusing loperamide (also sold
under the brand name Imodium®). Approved by the U.S. Food and Drug Administration (FDA) to relieve the symptoms of diarrhea. This overthe- counter (OTC) and
prescription medication is safe and effective when used as directed. Some individuals are consuming very high doses of loperamide to self-manage their opioid withdrawal or to achieve a euphoric high, putting them at risk for cardiotoxicity.

It is important to recognize the signs and symptoms associated with loperamide abuse and address them appropriately with patients who may be abusing or at risk for abusing loperamide.

Thursday, August 1, 2019

Why We Shouldn’t Teach Doctors to be Well

Image Credit: Pexels
Author: Arlene Chung, MD MACM FAAEM
Originally published: Common Sense May/June 2019

My nightmare is waking up to a phone call in the middle of the night with a frantic chief resident telling me that one of our residents is dead.

We shouldn’t be teaching our doctors how to be well. Teaching the individual resident or physician is the easy way out, and as an educator, I do not say that lightly. Culture change is harder, but critical to protecting the wellness of our residents and physicians. Individual wellness education has a place, but increasingly our focus needs to be turned outward toward the places where we can make the greatest impact for both the individual and the system. We must be proactive, not reactive. Once a resident or physician is dead, no amount of after-the-fact education or policy change will bring her back.

Thursday, July 25, 2019

Cancer Sucks

Image Credit: Pixabay
Author: Nick Pettit, DO PhD
2018-2019 AAEM/RSA Board Liaison to the Publications and Social Media Committee
Originally published: Common Sense May/June 2019

Cancer sucks! This is the proverbial phrase that unites all cancer survivors, cancer fighters, and cancer victims. It allows unity among the terrifying cancer experience, allowing us to bond and empathize over the seriousness that is a cancer diagnosis. Clinical experience suggests that cancer is frequently diagnosed in the emergency department (ED). Anecdotally, in three years of residency I have seen a whopping two STEMI’s between my two large academic EDs, whereas, maybe monthly I worry about a new cancer diagnosis.

Thursday, July 18, 2019

Dip, Chew, and Snuff: A Case of Nicotine Toxicity

Authors: Tim Montrief, MD MPH and Mehruba Anwar Parris, MD FAAEM
AAEM/RSA Publications & Social Media Committee and Common Sense Assistant Editor 
Originally published: Common Sense May/June 2019

Case
A 25-year-old Caucasian male with no significant known past medical history presented to a community emergency department via EMS with palpitations and altered mental status while on vacation at a friend’s bachelor party. Per the patient’s friend, he had been drinking alcohol all day and accidentally ingested a large amount of smokeless tobacco one hour prior to arrival, with subsequent nausea, vomiting, and excessive salivation. His friend denied any co-ingestions or drug use. The patient was found to be somnolent but arousable to voice, without any focal neurologic deficits and normal point of care blood glucose. The initial physical exam was remarkable for new-onset atrial fibrillation with a heart rate in the 160’s, blood pressure of 102/56 mmHg, respiratory rate of 16 breaths per minute, and saturating 100% on room air. Aside from atrial fibrillation with rapid ventricular response, the electrocardiogram was unremarkable (Figure 1). Additionally, the chest X-ray showed no evidence of cardiopulmonary pathology. Further testing revealed normal troponin, T4, and TSH levels. He had an elevated serum alcohol level of 191 mg/dL, and a negative urine drug screen. Initial cotinine and nicotine levels were not available. The patient was given a diltiazem bolus and drip, as well as four liters of lactated ringers, with subsequent heart rates in the low 100’s, with corresponding blood pressures in the 120’s/80’s. The patient was admitted to the ICU, and spontaneously converted back to a normal sinus rhythm within 24 hours of his initial presentation. The patient was discharged the next day with close outpatient follow-up.

Thursday, July 11, 2019

The Last Lecture to the Newly Graduating Emergency Medicine Residents

Author: James Keaney, MD MPH MAAEM FAAEM
First President of AAEM
Originally published: Common Sense May/June 2019

The Current Climate of EM – How Did We Get Here?
There are several recurrent phrases making their way into the vernacular of emergency medicine including transmutation, Joe the Plummer, the Leviathan Levy, and tumbleweed doctors.

The transmutation of clinically generated fees into management money is the theme of this talk revolving around the misallocation of Medicare-approved, clinically generated fees by practicing doctors into administrative wealth. The premise of the talk is this transmutation not only provides zero-point-zero real benefit to the physician, possibly even has negative effects, but also represents a public health detriment to the communities in which the hospitals are located.

Thursday, July 4, 2019

The Role of High Sensitivity Troponin Pathways in the Emergency Department

Authors: Akilesh Honasoge, MD MA; Robert Brown, MD; Sharleen Yuan, MD PhD MA
Editors: Kami M. Hu, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally Published: Common Sense May/June 2019

Clinical Question:
Can high sensitivity troponin meaningfully contribute to an acute coronary syndrome evaluation?

Introduction:
Traditional 4th-generation troponin assays are part of the standard cardiac evaluation when there is suspicion of acute coronary syndrome (ACS). Patients presenting to emergency departments with chest pain are typically risk stratified using a combination of historical risk factors, electrocardiogram (ECG) findings, troponin testing, and clinical suspicion. Patients are discharged from the emergency department if their risk is determined to be low while higher risk patients are usually admitted for further observation or testing. Recent data suggests, however, that high sensitivity troponin (hsTrop) testing could supplement or even replace current methods such as clinical risk scores when used in specific protocolized serial testing pathways. High sensitivity troponins first became available in the United States in 2017, but their use has not yet reached widespread acceptance. The test offers detection of cardiac troponin approximately 1,000 times more sensitive than standard 4th-generation cardiac troponin testing. With this higher sensitivity come questions regarding reliability and specificity in certain comorbidities such as chronic kidney disease and underlying coronary artery disease. Some studies also explore the use of computed tomography (CT) coronary angiography when used in conjunction with hsTrop. Here we explore a few studies that evaluate the role of hsTrop in the evaluation of potential ACS.

Thursday, June 27, 2019

How to Teach in the Midst of the Crazy

Image Credit: Common Sense
Author: Molly Estes, MD FAAEM
YPS Board of Directors
Originally published: Common Sense January/February 2019

We’ve all seen our waiting rooms on an “average day.” And we’ve all read the studies about annual census numbers. And we all dread every approaching flu season with increasing levels of anxiety as we try to imagine seeing even more patients with no beds or room to speak of. And in the middle of the administration meetings about flow, setting up tents and triage units in parking lots and hallways, and trying to prevent patients from dying in the waiting room, those of us who work at academic institutions are also expected to impart our hard-fought knowledge onto the next generation. Now how in the world is that possible?

Thursday, June 20, 2019

Building Resilience Through Food

Image Source: Pexels
Author: Madhu Hardasmalani, MD FAAEM
AAEM Physician Wellness and Burnout Prevention Committee
Originally Published: Common Sense November/December 2017

Resilience is the ability to bounce back from an adverse life situation. Some individuals are born with this trait and we are all envious. However, the majority of us need a little help. Even those individuals with the inborn resilience trait, need help maintaining it.

Now having and maintaining this trait is not very simple — there is no magic “resilience pill.” The key is lifestyle changes, which may initially be a bit daunting, but can better equip us to meet life’s challenges head on without breaking down.

Thursday, June 13, 2019

The Wonder Women of WiEM: Why Do Female Superheroes Still Need Support Organizations?

Image Credit: Common Sense
Author: Ashely Alker, MD MSc
AAEM/RSA 2017-2018 President

Whether it is Women in EM (WiEM), AWAEM, FeminEM or Shemergency, women in emergency medicine are uniting to advance shared goals, including equal pay and access to leadership opportunities. This comes at a time when women across many disciplines, from Hollywood actors to D.C. politicians, are standing up against inequality.

Women have been undervalued since before they entered the workplace. A Washington Post article determined that the value of a homemaker’s labor is equivalent to an annual salary of $96,261.[1] This is not an inconsequential sum, as the United States Census Bureau quotes the median household income as $55,322.[2] Meanwhile, a woman with an advanced degree earns $65,000, which is $30,000 less than the median income of a man with the same degree.[3]

Thursday, June 6, 2019

Tattered Tarp or New Roof: Who Gets Included in Disaster Recovery?

Image Credit: Heather Star Krause, MD MPH(c)
Author: Heather Star Krause, MD MPH(c), 2019 EM Residency Candidate
AAEM Diversity and Inclusion Committee
Originally Published: Common Sense November/December 2018

In the bend of the south Texas coast, a community comes together to reflect on a year gone by since
many lost everything. We danced in the streets, honored one another’s hardships and congratulated each other’s resilience, and I reflect on my own experience.

The last move my husband and I made before evacuating with our toddler and seven-month-old was to throw an anchor from our sailboat, sitting on its trailer, in the front yard, a hundred feet from the water’s edge. “Maybe that will keep her from surfing into the neighbor’s second story living room,” my husband half-heartedly joked as he climbed into our small RV, wet from the first bands of the storm blowing ashore. At 5:30am, we left our home, driving in 20-minute shifts, exhausted from a day and a night of increasingly frantic preparation. Less than 12 hours later, the eye-wall of Hurricane Harvey made landfall directly on our small hometown of Rockport, Texas.

Saturday, June 1, 2019

Blog Staff, Reviewers, & Mentors

Thank you to our 2019-2020 peer review & editorial team!

AAEM/RSA Leadership:

Haig Aintablian, MD
AAEM/RSA President
UCLA Medical Center

Crystal Bae, MD MSc
AAEM/RSA Vice President
Temple University

Joshua Elliott Novy, MD MBA MS
AAEM/RSA Secretary-Treasurer
Northwell Health

MohammedMoiz Qureshi, MD
AAEM/RSA Immediate Past President
Penn State

AAEM/RSA Blog Leadership:

Alex Gregory, MD
Blog Editor-in-Chief
Social Media Committee Chair
University of Massachusetts

Kasha Bornstein
Copy Editor
University of Miami

Adriana Coleska, MD
RSA Board Liaison to the Social Media Committee
University of Chicago

Cassidy Davis
Communications Manager, AAEM

Yeimidy Lagunas
Communications Manager, AAEM

Publications Mentors:

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

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

Peer Reviewers:

Mary Blaha, DO
Kasha Bornstein
Jonathon R. Burns
Adriana Coleska, MD
David F. Fine
Alexandria Gregory, MD
Kaitlin Parks, DO
Taylor A. Petrusevski
Christina Schramm
Ivan Yue

Thursday, May 30, 2019

The Utility of Intravenous Lipid Emulsion Therapy in the Management of Acute Calcium Channel Blocker Overdose

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








Author: Mary E. Blaha, DO
Indiana University School of Medicine
AAEM/RSA Publications and Social Media Committe

Calcium channel blocker (CCB) overdose is a potentially lethal toxicity with multiple management options available. Intravenous lipid emulsion (ILE) therapy is a potential treatment that is being used with more frequency. This review will discuss the management of CCB overdose focusing on the available ILE literature.

CCB Toxicity Overview
CCBs are commonly prescribed to manage hypertension and arrhythmias. When implicated in accidental or intentional overdose, CCBs carry a high potential for toxicity that can ultimately lead to severe cardiovascular injury.[1,2] Specificlly, dihydropyridine CCBs, which include amlodipine and nicardipine, act primarily on arterial smooth muscle L-type calcium channels, which can lead to reflex tachycardia. Nondihydropyridine CCBs, which include diltiazem and verapamil, act primarily on cardiac myocyte L-type calcium channels, which can lead to cardiogenic shock.

Thursday, May 23, 2019

Resident Journal Review: Bedside Ultrasound for the Diagnosis of Pneumonia

Authors: Ted Segarra, MD; Taylor Conrad, MD; Rithvik Balakrishnan, MD; Taylor M. Douglas, MD
Editors: Kami Hu, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally published: Common Sense March/April 2019

Respiratory distress is a common presentation in both the pediatric and adult emergency department (ED). Community acquired pneumonia (CAP) is a common cause for this distress, and carries the potential for high morbidity and mortality if inadequately treated. In a fast-moving and potentially resource-limited ED, however, it can sometimes be difficult to decide which patients require further imaging to differentiate CAP from the myriad of other potential etiologies for respiratory distress such as bronchiolitis, asthma, chronic obstructive pulmonary disease (COPD), heart failure, and pulmonary embolism. Although both the British Thoracic Society (BTS) and Infectious Disease Society of America (IDSA) state that bacterial CAP is a clinical diagnosis based on persistent fever, retractions, and tachypnea, they agree that radiographic imaging should be obtained in any patient requiring hospital admission or with significant clinical uncertainty.[1,2] Unfortunately, even if the ED provider decides to pursue chest X-ray (CXR) imaging, he or she may still miss the diagnosis, as CXR has been shown in several studies to have a notable false negative rate (FNR) and high inter-observer variability in the diagnosis of CAP.[3,4,5,6] The limitations and inherent radiation exposure of CXR, in combination with the increasing availability of and familiarity with bedside lung ultrasound (LUS) imaging, have prompted many ED physicians to begin looking to LUS as a potential alternative in the evaluation of patients with suspected CAP.
  1. What is the level of sensitivity and specificity of LUS compared to traditional CXR and clinical findings in the diagnosis of CAP?
  2. Do other aspects of bedside LUS (i.e. lack of ionizing radiation, speed of assessment, easy repeatability, ability to monitor progression of disease, cost) make LUS a more feasible alternative in resource-limited environments?

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

Image Source: Defense Visual Information Distribution Services
This post was peer reviewed.
Click to learn more.








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

Image Credit: Wikimedia
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