Thursday, September 17, 2020

Resident Journal Review: Do Adjunctive Therapies Beyond Infection Control and Appropriate Fluid Resuscitation Change Outcomes in Sepsis and Septic Shock?

Authors: Jordan Parker MD; Sharleen Yuan, MA MD PhD; Megan Donohue, MD; Robert Brown, MD; Mark Sutherland, MD; Hannah Goldberg, MD; Akilesh Honasoge, MD
Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM
Originally published: Common Sense
September/October 2020

Introduction
Septic shock is an illness with complex pathophysiology and few available therapies, beyond infection control and appropriate fluid resuscitation, to reverse the disease state. It is one of the most prevalent and lethal disease states that a physician may manage, with 1.7 million cases of sepsis in the United States per year and a reported mortality rate of up to 34%.1,2 The pathogenesis of septic shock is thought to be driven by a dysregulated host response3 with the role of adjunctive therapies being to assist in reversing this dysregulated response. Treatments that have more recently been a hot topic of debate include vitamin C, corticosteroids and thiamine. Vitamin C (ascorbic acid) a role in numerous physiologic processes including endothelial permeability, micro and macrovascular function, cellular apoptosis, immune system function and endogenous catecholamines.4 Studies have shown that vitamin C deficiency is present in critically ill patients,4 and its role in these essential functions is the basis for its use as a potential treatment in septic shock. Thiamine also plays a role in key metabolic processes, including cellular energy production and generation of cellular antioxidants, and thiamine deficiency has been well-documented in sepsis, with observational studies indicating a signal for improved outcomes with supplementation.4 Steroids have been used in refractory septic shock for almost the past two decades5 but the recent rationale for its use includes its synergism with vitamin C. Glucocorticoids may be able to increase the activity of vitamin C by increasing expression of the transporter involved in its uptake into cells, sodium-vitamin C transporter (SVCT2).4 In return, vitamin C, as an antioxidant, may be able to facilitate the binding of glucocorticoids to their receptor, a coupling impeded by oxidizing molecules. We will review several of the high-profile trials that have attempted to elucidate the effectiveness of utilizing corticosteroids, vitamin C, and thiamine in the management of patients with sepsis and septic shock.

Friday, September 4, 2020

A Medical Student/Paramedic's Perspective on COVID-19

Image credit: Pexels
Author:
Matthew Carvey
Originally published: Common Sense
July/August 2020

Medic-1 is responding to an assault in a rural location. Dispatch notifies EMS that the patient has a fever and was put on mandatory self-isolation for 14 days. On arrival, EMS dons a sterile cap, goggles, an N95 mask, face shield, gown, and gloves. The patient, belligerent and intoxicated on alcohol and psilocybin, yells at EMS ‘I have the COVID!’. She rushes EMS, removes the practitioners mask, and coughs in his face. Police arrest the woman under the Mental Health Act, and EMS transports, only for her to spit and verbally abuse them the entire length of transport. EMS unloads the patient and awaits triage. After handing over care, EMS doffs all used PPE, and don’s new equipment to thoroughly clean the ambulance. One of the practitioner’s displays signs of COVID-19 three days later. This article is a medical student/paramedic’s perspective on COVID-19.

Thursday, August 27, 2020

Resident Journal Review: Available Evidence Regarding Targeted Temperature Management (TTM)

Authors:
Rithvik Balakrishnan MD; Taylor M. Douglas, MD; Taylor Conrad, MD, MS; Theodore Segarra, MD; Christianna Sim, MD, MPH
Editors: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM
Originally published: Common Sense
July/August 2020

Introduction
The ability to obtain good neurological outcomes after cardiac arrest is often limited. Interventions during the acute phase of treatment post return of spontaneous circulation (ROSC) are therefore critical.1 The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. While the utility of therapeutic hypothermia for preservation of neurologic function post-cardiac arrest had been suggested in the early 1950s and 1960s, 2-4 the studies were inconclusive, with high complication rates. It was not until the 1990s that studies showed possible benefits to mild hypothermia in animal models. 5-10 The results of the 2002 trial by the Hypothermia after Cardiac Arrest Study Group were the basis for the inclusion of therapeutic hypothermia in the American Heart Association’s post-cardiac arrest care guidelines.11 Subsequent trials have assessed the difference between therapeutic hypothermia to 33 degrees Celsius (ºC) and “targeted temperature management” (TTM) aiming for 36ºC, the duration of TTM, the method used to achieve and maintain it, and whether TTM confers a similar neurological benefit for cardiac arrests secondary to non-shockable rhythms; some of these trials will be discussed below and will help us answer the question at hand.

Thursday, August 20, 2020

New Florida Law Requiring Written Consent for Pelvic Exams: Stumbling Towards Trauma-Informed Care

Image credit: Flickr

Authors:Emily Lara S. Dawra, BS, MSII
University of Miami Miller School of Medicine MD Program
AAEM/RSA Member

Kasha Bornstein, MSc Pharm, EMT-P, MSIV
University of Miami Miller School of Medicine MD/MPH Program
AAEM/RSA Modern Resident Blog Copy Editor


Introduction
On June 18, 2020, Florida Governor Rick DeSantis approved Florida Senate Bill 698, which strictly prohibited and criminalized the non-emergent use of pelvic examinations without written consent of either the patient or legal guardian.1 The new measure has particular implications for the flow of operations in emergency departments across Florida, as the requirements are a potential source of confusion, additional legal jeopardy, and increased bureaucratic workload. Effective as of July 1, 2020, this legislation has already garnered strong reactions from medical professionals, including the American College of Obstetrics and Gynecology, who believe this serves a “gross intrusion in the patient-physician relationship,” and whose statement is further endorsed by the Florida Medical Association.2,3 This article describes and expands on the spoken concerns surrounding this bill as they may apply to the emergency clinician. 

Thursday, August 13, 2020

Lightning Strike Emergencies Part 2: Trauma Approach

Image Credit: Piqsels
Author:
Vivek Abraham, MD
PGY-1, Orthopedic Surgery

Additional Authors:
Ivan Yue, MD
PGY-1, Emergency Medicine
Naval Medical Center San Diego
AAEM/RSA Publications and Social Media Committee

Alexander Li, MD
PGY-1, Orthopedic Surgery
Naval Medical Center Portsmouth

Introduction
Lightning strike triage and cardiac resuscitation was previously covered in part 1. Abnormal cardiac rhythms are the most common fatal complications of lightning strikes, but other complications of lightning strikes can cause high morbidity and mortality if left untreated. This article will go over injury patterns that may be seen and diagnosed in the emergency room.

Thursday, August 6, 2020

Lightning Strike Emergencies Part 1: Triage and Cardiac Emergency



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

Author:
Vivek Abraham, MD
PGY-1, Orthopedic Surgery

Additional Authors:
Alexander Li, MD
PGY-1, Orthopedic Surgery
Naval Medical Center Portsmouth

Ivan Yue, MD
PGY-1, Emergency Medicine
Naval Medical Center San Diego
AAEM/RSA Publications and Social Media Committee
 
Introduction
Lightning strikes occur commonly, with an estimated global incidence of 240,000 worldwide per year with deaths numbering 24,000.[1] As more people embark on expeditions and explore the outdoors, they are putting themselves at risk of these strikes. Due to the prevalence and mortality of lightning strikes, emergency medicine physicians and other healthcare providers should be adept in treating these life-threatening injuries. This article reviews the guidelines for triage and management of cardiac emergencies due to lightning. 

Saturday, July 11, 2020

Medical Student Experiences with Ethical and Legal Cases

Image credit: Pexels
Author: David Fine, Medical Student Council President
Originally published: Common Sense
May/June 2020

The purpose of medical education is to train future providers to be prepared for the multitude of patients, presentations, and complications that they might face in their future careers. Ethical and legal dilemmas are incredibly complicated and vary based on where you practice, so they are often less discussed than our essential medical fundamentals. Being somewhat familiar with common problems, however, is relevant not only to your future career but your rotations as well. I aim to share a few of the complex situations that I faced, which may apply to your rotations in the emergency department or on the floors.

Dilemma 1: A patient who was frustrated with long wait times starts the patient interview by stating that they are recording the conversation. 

Sunday, July 5, 2020

Should ST elevation in lead aVR with concern for acute coronary syndrome prompt emergent coronary angiography?

Authors: Akilesh Honasoge, MD, Robert Brown, MD, Samantha Yarmis, MD, Mark Sutherland, MD, Megan Donohue, MD, Hannah Goldberg, MD

Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM

Originally published: Common Sense
May/June 2020


Thursday, June 25, 2020

Nine Steps to The Best Medical Notebook You'll Ever Use

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

Author: Philip A Castrovinci MD
Undersea Medical Officer
US Navy

While a medical student, I remember a fourth-year emergency medicine resident with a notebook of his own creation. We did not see a single patient over a dozen shifts that he didn't pull out the notebook to extract some high-yield crucial information about the variety of conditions we came across. It was like a clown car of medical knowledge. He let me look at it. It was glorious. What I found was, and subsequently copied, was the best medical notebook I have ever seen. I forget what I learned during those dozen shifts, but the organization of the medical notebook will stay with me for the rest of my career.

Sunday, June 21, 2020

A Message to Students in these Uncertain Times

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








Author: David Fine, MD
AAEM/RSA Board Members, Liaison to the AAEM/RSA Education Committee, and AAEM/RSA Medical Student Council

Medical school is undoubtedly a stressful time, but studying medicine in the context of a pandemic is a challenge that brings about additional stressors, anxiety, and uncertainty. The changes that have been implemented are a result of safety being a number one priority. I also feel it is important to recognize the difficult situation that students are facing.

Thursday, June 4, 2020

The Changing Landscape of Pre-clinical Medical Education

Image credit: Pexels
Author: Alexandria Gregory, MD
AAEM/RSA Editor
Originally published: Common Sense
May/June 2020

In mid-February, the National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) announced that the United States Medical Licensing Examination (USMLE) Step 1 scoring would be changed to pass/fail as early as 2022.1 Many rejoiced about the potential for residency programs to emphasize other parts of applications rather than a test that does not evaluate the most clinically-relevant medical knowledge, while others expressed concern about the logistics of the decision and whether it would truly have its intended effect. Regardless of where you stand on the issue, it is important to recognize the implication this has regarding how preclinical education may change in upcoming years in medical schools across the country.

Thursday, May 28, 2020

Intractable hiccups: a presentation of COVID-19

Image credit: Flickr

This post was peer reviewed.
Click to learn more.

Author:
Jaclyn H. Jansen, MD MS
Emergency Medicine Resident
Department of Emergency Medicine, Indiana University School of Medicine 
Indianapolis, Indiana

ABSTRACT

BACKGROUND: 
While patients with COVID-19 infection most frequently present with fever, dry cough, and dyspnea, other symptoms have been associated with viral infection. This case report describes a patient presenting without respiratory complaints, initially screened as low-risk for COVID-19. With known communal spread, it is paramount to recognize unusual presentations of COVID-19 infection including hiccups and gastrointestinal complaints. Early recognition and isolation of patients with possible infection while in the emergency department improves provider safety and patient care.

Thursday, May 21, 2020

The Moral Dilemma of COVID-19

Image Credit: Pexels
Author: Andy Mayer, MD FAAEM
Editor-in-Chief Common Sense
Originally published: Common Sense
May/June 2020

Certainly, there is only one issue which is dominating all thoughts, prayers, and efforts on our planet right now and it is COVID-19. Hopefully where you are, your life and practice will only be incredibly inconvenienced and that your family, your community, and your hospital will be spared the worst of this pandemic. Many areas may be relatively spared by early social distancing and the shutdown of many aspects of daily life which until last month we took for granted. This crisis has brought to the forefront many ethical and moral dilemmas which our society and world need to face with open eyes and minds. Our medical capabilities in our modern prosperous society are currently been taxed past the breaking point in the hotspots of the COVID-19 pandemic. We need as a profession and as a society to consider the correct response to the complex and difficult decisions which physicians on the frontlines are now making or may eventually be facing where conditions are worse. Even if we manage to make it through this pandemic without running out of ventilators and do not lose too many talented and selfless healthcare professionals there may be a next time.

Friday, May 8, 2020

Avalanche Resuscitation in the Emergency Department


Image Credit: Wikipedia
This post was peer reviewed.
Click to learn more.
Authors: Vivek Abraham, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Ivan Yue, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine
AAEM/RSA Publications and Social Media Committee

Alexander Li, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Introduction
Avalanches are among the most feared events to occur in mountainous areas. Although the morbidity and mortality statistics are underreported worldwide, in North America and Europe combined there are roughly 140 avalanche-related deaths per year.[1,2] The majority of victims include snowboarders, skiers, mountaineers, and snowmobilers. With more people seeking to participate in snow sports or explore the mountains as part of expeditions, preparing to treat avalanche-related injuries is essential for an emergency physician working or traveling near a mountainous area. This article details the resuscitation guidelines that physicians can implement for those who fall victim to an avalanche as well as recommendations for mitigating avalanche exposure risk.

Sunday, April 26, 2020

Considerations for Your Social Media Presence

Image Credit: Pexels
Author: David Fine 
Medical Student Council President 
Originally published: Common Sense
March/April 2020

Should you create a professional social media account? What are the benefits and risks associated with this commitment? When applying for medical school, residency, or jobs are people searching for you on the internet? How do HIPPA, professionalism, and unspoken rules factor into your social media presence? My search for information has shown that many people are asking the same questions. There are a plethora of different resources that can help you make informed decisions.

The American Medical Student Association (AMSA) has created a set of 10 social media guidelines: be professional, be responsible, maintain separation, be transparent/use disclaimers, be respectful, follow copyright laws, avoid politics, protect client/patient information, comply with all legal restrictions and obligations, and be aware of risks to privacy and security (Keating 2016). These guidelines are vague, but this speaks to the potential for problems that you might face and the importance of thoughtful posting. Even on private accounts, posts that violate HIPAA and professionalism can result in punitive actions from your home institutions. There is often this discussion about ways that these forums can be negative, but there is a massive potential benefit that is much less often explained. 

Friday, April 17, 2020

Resuscitation Guidelines Updates: What You Need to Know

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


Introduction
In late 2019, the International Liaison Committee on Resuscitation (ILCOR) released its updated guidelines for adult and pediatric resuscitation, informing the United States-based American Heart Association (AHA)/Advanced Cardiac Life Support (ACLS) focused protocol update.[1]

Significant changes this year in ILCOR recommendations focus on:

- Vasopressor use
- Advanced airway interventions and extracorporeal cardiopulmonary resuscitation (ECPR) in adult and pediatric cardiac arrest
- Targeted temperature management (TTM) in pediatric cardiac arrest This short article will address the salient details regarding each of these updates. Vasopressor Use Epinephrine, the old standby for the all-cause pulseless patient, has undergone significant review in recent years. Multiple large-scale retrospective and placebo-controlled randomized-controlled prospective studies have probed the efficacy and safety of epinephrine in cardiac arrest.[2,3] The majority of these studies find that while epinephrine may increase return of spontaneous circulation (ROSC), the effect size is small versus placebo and no difference is seen in favorable neurologic outcome. Many aspects surrounding best practices in epinephrine use remain unknown. These include optimal timing for administration in patients with shockable rhythms, efficacious dosing, and dose/effect relationships. However, alternative interventions are limited, overall survival for patients with non-shockable rhythms (asystole, pulseless electrical activity) is low, and no other pharmacologic intervention has demonstrated improved ROSC in these cases.

Friday, April 10, 2020

Human Trafficking: Identification and Treatment Tools for the Emergency Physician

Image Credit: Pexels
Authors: Maryam Hockley, MD MPH, Erin Hartnett, BS BA, Gregory Jasani, MD
Originally published: Common Sense
March/April 2020

Human trafficking (HT) affects over 21 million people worldwide¹, with 600,000-800,000 persons being trafficked annually across international borders, approximately half of whom are younger than 18 years old.² Closer to home, roughly 18,000-20,000 trafficking victims are brought into the United States every year, and this number does not count victims already within our borders.³ Its victims are not confined to a certain age, race, gender, sexual orientation, or socioeconomic level, and it is this level of pervasiveness that makes signs of HT difficult to identify. Vulnerable populations include those in the child welfare and juvenile justice systems, runaway and homeless youth, unaccompanied children, American Indians/Alaska Natives, migrant laborers including undocumented workers and temporary workers on visas, foreign national domestic workers in diplomatic homes, those with limited English proficiency and low literacy, disabled peoples, LGBTI, and those in court-ordered substance use programs.⁴ The International Labor Office estimates that 44% of all HT victims worldwide had migrated either within or across international borders prior to being put into forced labor.¹ The nature of human trafficking often leads to both physical and emotional harm for the victims, as it relies upon the coercion of a person into such an exploited role. As a result, an article by emDocs estimates that as many as 88% of victims will seek medical care during the time that they are being trafficked, oftentimes in an emergency department. However, their studies have also shown that as few as 5% of emergency medicine providers feel comfortable identifying and treating victims of HT.⁵ This unique encounter, however, offers emergency medicine physicians an invaluable opportunity to intervene in these victims’ lives. Improving this statistic represents a crucial opportunity to increase awareness and understanding of the potential role we can play in these patients’ lives.

Friday, April 3, 2020

Resident Journal Review: Assessing Fluid Responsiveness in the Emergency Department Part II

Authors: Taylor Conrad, MD MS, Taylor M. Douglas MD, Ted Segarra, MD, Rithvik Balakrishnan MD, Christianna Sim, MD MPH Editor: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM
Originally published: Common Sense
March/April 2020

Clinical Question
What methods are most effective at determining if a patient will be fluid responsive?
The most recent Common Sense Resident Journal Review article looked at the utility of ultrasound to accurately assess fluid responsiveness in the Emergency Department (ED). In this article, we attempt to look at other modalities that ED physicians may use to quickly determine how patients with various etiologies of hypotension and shock respond to fluid. Initial intervention often involves a fluid bolus of varying amounts to determine if increasing preload can improve the patient’s hemodynamic status along the Frank-Starling curve1,2. Other factors affect the patient's hemodynamics, however, including systemic vascular resistance and the contractility of the myocardium. Vital signs and the rest of the physical exam are inadequate in determining response to fluid and persistent hypotension may represent alterations in these other factors3. Invasive measurements of a patient's hemodynamic status can be performed with insertion of Swan-Ganz catheter but its lack of proven benefit in the ED and associated potential complications has led to a decline in its use5. As such, patients often receive varying amounts of fluid by ED providers, which often comprises a large amount of the initial resuscitation volume. As it has also been established that a positive fluid balance is associated with a variety of negative effects and worsened patient outcomes, identifying means to help avoid unnecessary fluid administration is crucial.2,6

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