Sunday, March 29, 2020

Own Your Worth

Image Credit: Pexels
Author: Adriana Coleska, MD
AAEM/RSA Board of Directors
Originally published: Common Sense
March/April 2020

As emergency medicine (EM) physicians, we use humor as a way to cope with a difficult diagnosis, patient loss, or an uncomfortable consultant interaction. While those who have worked with me in the emergency department know that I thrive on a relaxed and joking environment to make the shifts go by, I want to shed light on a worrisome trend that I have noticed. I want to talk about the overuse of self-deprecating humor by physicians in our specialty. I have only been in the field of emergency medicine for 2.5 years, and I cannot count how many times I’ve heard my co-residents, friends in EM, even attendings end a story or consultation with the phrase “but what do I know, I am just an emergency room doctor.” Some physicians have even gone so far as coining the term “JAFERD” (just another f****** emergency room doctor).

Though jokes, even self-deprecating ones, can quickly diffuse a tense situation, my sense is that sometimes the “just an ER doc” phrase comes from a place of insecurity. I’ve witnessed residents and attendings give thorough explanations regarding their thought process and reason for a consult, only to end with the wobbly “but I’m not sure, I am only an ER doc.” Using this statement in a professional setting diminishes the validity of your question and possibly the consultant’s opinion of your clinical knowledge and reliability. Why use language that can negatively impact your intelligence? Have you ever heard a surgeon say “I am JUST a surgeon?” We all went to medical school and matched in a competitive field, trust in your knowledge and hard work, be confident in your exam and thought process. We are not perfect. We are allowed to get things wrong; it’s hard to keep up with new literature and new protocols on all of medicine. But when speaking to a consultant who is questioning your management, don’t shy away and hide behind the phrase JAFERD. Explain to them where you are coming from and eagerly ask to be educated on the new literature that consultant is guiding their treatment off of. And while some may use JAFERD as an inside joke, when heard by outsiders the “just” portion of the phrase can be misconstrued as lacking confidence or as excusatory.

Thursday, March 12, 2020

Letter to Our Emergency Medicine Residents and Medical Students

Image Credit: CDC
Dear Emergency Medicine Residents and Students,

We have reached a critical time in modern medicine with the pandemic of Coronavirus (COVID-19). Today, I wanted to take a minute to remind you just how important you are in this fight against COVID-19.

Over the coming days and weeks, your efforts will be critical in helping to manage large numbers of critically ill patients and to help stifle the spread of this deadly virus. As emergency medicine residents and medical students you are the front-line, at all times. You are the engine of the emergency department - arguably the most essential department for containing and treating this virus. Every single patient you see, every treatment you administer, every intubation you perform, is one further step in gaining control against COVID-19.

Friday, March 6, 2020

What is Happening to Our Specialty? An Open and Honest Look at the Chaos in Our Trade.

Image credit: Pexels
Author: AAEM/RSA News
Originally published: Common Sense January/February 2020

As physicians, we all subscribe to the four tenets of medical ethics: autonomy, justice, beneficence, and non-maleficence. These ideals are integral in providing ethical care to all our patients, from the weakest and most vulnerable, to the most astute and medically literate. Our patients deserve these moral characteristics in their physician in order to get the best care possible. But what do physicians deserve?

If we were to apply these factors to ourselves as EM physicians, we’d see a grim trend of unethical practices occurring in our own specialty. Corporate greed, poor educational transparency, loss of autonomy – and the illegitimization of the emergency physician.


Friday, February 28, 2020

Resident Journal Review: Utility of Ultrasound Measurements in Assessing Fluid Responsiveness

Authors: Samantha J. Yarmis, MD; Robert Brown, MD; Jordan Parker, MD; Caleb Chan, MD; Akilesh Honasoge, MD
Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM
Originally published: Common Sense January/February 2020

Clinical Question
How can we utilize ultrasound measurements to accurately determine which patients are fluid responsive? Does any single ultrasound measurement accurately predict fluid responsiveness?

Introduction
Volume expansion is a cornerstone of resuscitation in the ED and is currently one of the main recommended components of septic shock management. The ability to predict fluid responsiveness has been a highly debated issue within emergency and critical care medicine. Early studies found inferior vena cava (IVC) diameter and variability could predict fluid responsiveness in intubated, mechanically-ventilated septic patients.1,2 The applicability of these findings to other populations is unknown and subsequent studies have called these findings into question.3 At the other end of the spectrum, the existence of a volume overloaded state may be detected by measuring indices in the liver and kidneys such as portal vein pulsatility,4,5 hepatic venous flow velocity,6 and intrarenal venous flow.7 Confirmation of increased stroke volume with passive leg raise or a small fluid challenge is currently one of the better, albeit imperfect, existing methods to ensure true volume responsiveness.8,9,10

Friday, February 21, 2020

Tranexamic Acid (TXA) in Obstetric Hemorrhage

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







Authors: Patrick Wallace, DO, MS
Emergency Medicine Resident, PGY-2
University Nevada Las Vegas
AAEM/RSA Publications and Social Media Committee, and AAEM/RSA Education Committee

Laurie Bezjian Wallace, DO
Family Medicine Resident, PGY-2
Mike O’Callaghan Military Medical Center

Bottom Line Up Front: Tranexamic Acid (TXA) reduces postpartum hemorrhage with no major adverse events. There is some evidence to suggest routine use of TXA in all vaginal deliveries.

Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal deaths with over 100,000 deaths per year. It occurs in 3-15% of deliveries, making up about 25% of all maternal deaths worldwide.[1-5] The three most common causes of PPH can be remembered as the three T’s: tone, tissue, and trauma. Tone refers to uterine atony, tissue referrers to retained placental tissue, and trauma refers to cervical or perineal lacerations. Uterine atony is the most common cause of PPH and can be treated with bimanual massage and uterotonics such as oxytocin, methergine, or misoprostol.[2,5] American College of Obstetrics and Gynecology (ACOG) and World Health Organization (WHO) currently recommend routine prophylaxis with the administration of oxytocin during the third stage of labor.[2,5]


Friday, February 14, 2020

My First "Sick" Patient

Image credit: Pexels
Author: Alexandria Gregory, MD
AAEM/RSA Publications & Social Media Committee Chair
Originally published: Common Sense January/February 2020

Everyone knows the most fundamental part of emergency medicine residency is learning how to determine “sick versus not sick,” which is often easier said than done. One night, at the end of my shift, a nurse grabbed me, saying the patient in room six needed a doctor now. The patient was a young asthmatic who had apparently walked into the emergency department minutes earlier, but was now unresponsive, gray, and with an oxygen saturation in the 50s. I had no trouble determining she was sick; as a relatively new intern, the bigger problem was figuring out what to do next. To quote Michael Scott from The Office episode “Stress Relief,” in that moment, “I knew exactly what to do, but in a much more real sense I had no idea what to do.” I knew I needed to focus on the ABCs and I knew what medications the patient needed in terms of asthma management, but in the acuity of that moment, it all jumbled together. I quickly grabbed an attending and we worked through the ABCs together as the proper medications were administered and the patient stabilized.

That patient taught me several important lessons about intern year and residency as a whole:


Thursday, February 6, 2020

Sex Sent Her to the Emergency Department: A Rare Case of Postcoital Hemoperitoneum

This post was peer reviewed. Click to learn more.
Image credit: Pxfuel







Author: Christina Schramm, MSIV Medical Student
St. George’s University School of Medicine
AAEM/RSA Social Media Committee

CASE PRESENTATION
A 31-year-old gravida 0, para 0 female patient presented to the emergency department with lower abdominal pain that started during sexual intercourse three days prior. She presented with abdominal distension, diffuse, constant, and cramping bilateral lower abdominal pain, referred pain to her shoulders, exertional dyspnea, orthostatic hypotension, and near-syncopal episodes. The patient reported constipation that turned to loose stools on day three. The patient denied fevers, vomiting, vaginal discharge or foul odor, vaginal bleeding, and dysuria. The patient had a past medical history of anemia and stated that her hemoglobin was within normal limits during her last routine blood draw. The patient had Mirena intrauterine device (IUD) inserted three years prior, and her last menstrual period was unknown. The patient had been in a mutually monogamous relationship with a male partner and stated no concern for sexually transmitted infection (STI). Differential diagnosis included IUD displacement, ectopic pregnancy, pelvic inflammatory disease, ovarian cyst rupture, ovarian torsion, and appendicitis.

Thursday, January 30, 2020

Board Review: Debunking Dysbarism

This post was peer reviewed. Click to learn more.

Image credit: Brett Seymour








Authors: Patrick Wallace, DO PGY-2
Emergency Medicine Resident
University of Nevada Las Vegas
AAEM/RSA Education Committee

Laurie Bezjian Wallace, DO PGY-2
Family Medicine Resident
Mike O’Callaghan Military Medical Center

Intro
“Dysbarism” collectively refers to diving-related disorders. These disorders are relatively common and range in severity. This topic is high yield on board exams and is also important for emergency medicine providers to recognize so as to administer timely interventions. This article differentiates and categorizes disorders by those occurring with descent, at depth, and with ascent (Table 1).


DISORDERS OF DESCENT
Facial Barotrauma (Mask Squeeze)
Negative pressure within the mask and over the eyes must be equalized. This is often done by exhaling through the nose. Failure to equalize leads to a negative pressure effect on the periorbital and ocular vessels, resulting in edema and subconjunctival hemorrhage.[1,2] Emergent complications are rare but may include hyphema, subperiosteal orbital hemorrhage, and intraorbital hematoma. In these cases, emergent ophthalmology consultation should be obtained as surgery or needle aspiration may be required.[3,4] However, the majority of facial barotrauma cases are benign and do not require treatment.[1,3,4]
Key Phrases: Conjunctival edema, subconjunctival hemorrhage, and petechial hemorrhage after diving.


Thursday, January 23, 2020

Case Report: Detecting an Occult Open Globe Laceration with Pneumotonometry

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







Author: Conner Murphy, MSIV
Medical Student
Uniformed Services University School of Medicine

Additional Authors:
Ivan Yue, MSIV
Medical Student
Uniformed Services University School of Medicine
AAEM/RSA Publications and Social Media Committee

Melisa Walsh, MSIII
Medical Student
Uniformed Services University School of Medicine


David Supinski, DSc EMPA-C
Emergency Medicine PA
Fort Belvoir Community Hospital Emergency Department

Grigory Charny, MD MS FAAEM
Assistant Professor
Department of Military and Emergency Medicine, Uniformed Services University School of Medicine

Introduction
An open globe laceration is defined as a full-thickness penetration of the eye by a sharp object.[1] Observational studies suggest that male patients ages 10-19 are at highest risk for this type of injury due to types of sports they participate in, occupations, and involvement in physical altercations.[2,3] Obvious signs of trauma are not always apparent, and a negative Seidel’s test does not rule out an occult intraocular foreign body as the wound may temporarily seal itself if small enough.[4] Decreased visual acuity, chemosis, hypotony, and pain are often the only clues that the patient has an open globe injury.[5] Early diagnosis and evaluation by an ophthalmologist are crucial to preserving vision.[6] In this case report we present an atypical case of a 24-year-old male patient with penetrating eye trauma to his right eye that was not apparent on physical exam or computed tomography.

Friday, January 17, 2020

How to Approach Third Year (M3) as an EM-bound Medical Student

Image credit: Wikimedia
Author: Taylor Petrusevski, MS4
Loyola Stritch School of Medicine
AAEM/RSA Publications & Social Media Committee

You made it through the seemingly endless lectures and question blocks that consume the pre-clinical years of medical school. In third year, it’s time to bring your classroom knowledge to the bedside. It is an exciting and overwhelming transition, but it is such a transformative year and a pivotal point in your training. You are building the foundation of your clinical skills and the formulation of your practice patterns start now. Among many variables, including Standard Letters of Evaluation (SLOEs), performance on the emergency medicine (EM) clerkship, interviews, and Step scores, third year clerkship performance continues to be an important parameter that program directors use when evaluating candidates.[1] While some studies note that your third year clerkship grades do not carry as much statistical weight as these aforementioned application components, your third year clerkships serve as the foundation of clinical skills that will allow you to succeed on your EM rotations, which is heavily weighted.[2] There are several methods to successfully navigate this transition. Different learning models emphasize the best cognitive practices to bridge this transition, noting that active reflection is just as important as preparing and actually getting the clinical experience.[3] Ultimately, do what works for you. Here are some suggestions on how to approach M3 as an emergency medicine (EM) bound student:

Tuesday, January 14, 2020

Ketamine for Acute Pain Relief in the Emergency Department

Image credit: Flickr
Author: Kasha Bornstein, MSc EMT-P MSIII
University of Miami Miller School of Medicine MD/MPH Program, AAEM/RSA Modern Resident Blog Copy Editor

Bottom Line Up Front:
In comparison to 0.1mg/kg intravenous morphine, multiple studies demonstrated 0.3-0.5mg/kg ketamine was as effective in short term management of acute pain, without any increased risk of severe adverse effects. In addition to primary analgesia, ketamine may be effective as an analgesic adjunct in situations where opioids are contraindicated or for patients who have pain refractory to conventional pharmacologic approaches.

Introduction:
In the setting of the contemporary opioid epidemic, use of opioids for pain relief in the emergency department (ED) has been scrutinized. Opioid prescription presents increased risk for development of opioid use disorder and presents challenges for attainment of adequate pain control in opioid tolerant patients. Alternatives to opioids are an important topic of discussion in emergency medicine as well as in pain management subspecialties. Many institutions are adopting ketamine for analgesic use based on observational data and/or provider choice, but until recently, the high-quality evidence validating ketamine using randomized controlled trials (RCTs) has been limited. This article details a meta-analysis of RCTs comparing low-dose ketamine (LDK) to morphine for analgesia.


Thursday, January 2, 2020

Top 10 Most Read Posts of 2019

Image Source: Pexels
As 2019 comes to an end, 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 2019!

We are currently accepting articles for 2020 and are always looking for additional faculty mentors as well. Feel free to contact us at info@aaemrsa.org with questions.

Sincerely,

Alex Gregory, MD
Editor-in-Chief
AAEM/RSA Modern Resident Blog