Friday, October 16, 2020

When Do Things in Medicine Start to Become Common Knowledge?

Image credit: Pexels
Author: Shaughnelene D. Smith, BSc (Hons); Eddie K. Maybury, BSc
Originally published: Common Sense
September/October 2020

Several weeks ago, I finished my first year of medical school and began the arborous drive from Kansas City, Missouri, to California for a summer research position. When I was just six minutes away from my destination, my car of 21 years decided to break down. It is important to note that I am studying in the United States as an international student from Canada, and despite growing up as a neighbor from the north, much of the U.S. and its various systems are foreign to me.

As midnight approached and the smoke started billowing out of the front bonnet, I found myself pulling off to the side of the road in a city unfamiliar to myself. I quickly took all the essential paperwork from my vehicle – F1-student visa, passport, insurance papers – and found a rock a safe distance away, where I proceeded to call my parents and quickly realized how clueless I was in navigating what to do next.

Thursday, October 1, 2020

“Zooming” into a New Era of Clinical Education

Image credit: Pexels
Author: Alexandria Gregory, MD 
Originally published: Common Sense
September/October 2020

If your residency is like most programs, your pre-COVID didactics likely consisted of several hours of in-person conference once a week. That common, traditional way of learning has been turned upside down with the need for social distancing, and most programs have transitioned to virtual conferences. As the reality of COVID persists, it is important to continuously evaluate the effectiveness of virtual learning. Furthermore, in planning for a post-COVID era, it will be beneficial to determine whether virtual learning remains a valid, effective teaching technique despite being able to meet in-person.

To understand how virtual learning affects curriculum design, it is important to start by breaking down what, in general, emergency medicine residency curriculum looks like. Most programs include the following in some fashion: 

  • Core Topics
  • Small-Group Sessions/Problem-Based learning
  • Electrocardiogram (EKG)/Radiology Interpretation
  • Morbidity and Mortality/Case Presentations
  • Journal Club
  • Ultrasound
  • Grand Rounds
  • Simulation/Procedure Lab
  • Oral Board Review
  • Asynchronous Learning

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

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
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)

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

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.