Disaster Medicine: Prepare to Get Involved

Author: Gregory K. Wanner, DO, PA-C
Thomas Jefferson University Hospital
Disaster Medical Assistance Team NJ-1

This post was peer reviewed.
Click to learn more.

In emergency medicine we deal with the initial presentation of everything. Fractures, pneumonia, dysuria, and cardiac disease — we see it all. We’re also quite flexible in dealing with a multitude of odd complaints and a packed waiting room. Despite this flexibility we are still accustomed to a relatively comfortable, well-lit, climate-controlled emergency department (ED) with access to a lab, CT scanner, and several consultants. Now consider how your ED would function with flooding, a lack of electricity, or a surge of chemically-contaminated patients. Welcome to the field of disaster medicine.

Researching Osteopathic Emergency Medicine Programs

This post was peer reviewed.
Click to learn more.

Author: Muhammad Alghanem, MSIV
Medical Student
Midwestern University - Chicago College of Osteopathic Medicine

If you’re an osteopathic medical student interested in emergency medicine, you may be wondering where to find information specific to osteopathic residency programs. Some general facts, such as the universal four year length of the residency curriculum, may be common knowledge even to those just starting to explore their interest in emergency medicine. However, more program specific information may be harder to come by.[1] Taking the initiative to learn about the resources and opportunities available to you can help you prepare for the application process. In this post, you’ll find some basic insights into researching osteopathic emergency medicine programs.

Tox Talks: Drug Induced Noncardiogenic Pulmonary Edema

Author: Ashley Grigsby, DO, Indiana University

Noncardiogenic pulmonary edema (NCPE) is a clinical entity consisting of alveolar fluid accumulation without evidence of cardiac cause.[1] Although there are many non-toxicologic causes of NCPE, both opiate overdose and salicylate toxicity are known to cause NCPE and should be part of one's differential diagnoses.

Opiate overdose induced NCPE was first recognized by William Osler in 1880.[2] It can occur with any opioid, including heroin and methadone. Although the pathophysiology of this phenomenon is not yet completely understood, it is believed that both direct drug toxicity and hypoxia induced alveolar permeability play a role in the development of pulmonary edema.[1,2] New users and males are more at risk to develop NCPE than other opiate users. Symptoms become clinically apparent within 24 hours of use, but usually manifest within four hours.[2,3] Treatment for NCPE in these patients is mostly supportive. In one case series, approximately 33% of patients required mechanical ventilation; fortunately, most are able to be extubated within 24 hours as the effects are short lasting.[1] Naloxone may be beneficial in these patients to reverse the opioid toxicity. Patients who present with respiratory failure from opiate overdose should be observed for development of pulmonary edema, even if reversed with naloxone.[2]

Interviewing Tips for Emergency Medicine Residency Positions

Via Flickr - Creative Commons

Authors:
Andrew W. Phillips, MD MEd
Gregory Wanner, DO PA-C

This is not peer reviewed … This is not evidence based … This is based on nothing more than our own meandering experiences that we thought may be helpful at this time of year. We invite comments below the post from everyone — students, residents, and attendings. Share your recommendations and experiences.

1) Research the program ahead of time.
Not just for 10-15 minutes, but for 2-3 hours. Know the programs leadership by their faces. Know the faculty you would seek as mentors based on their posted biographies. When you receive your interview schedule upon arrival, try to step aside during down time and look up information about your interviewers. Most interviewers know what is on their program’s website — so should you.

2) Contact medical school alumni who went into emergency medicine.
Get to know them if you don’t already. You never know what a good word from the inside can do when trying to get an interview or on the wait list. They can also give you a candid perspective on programs and their experiences.

Determining Brain Death: Updated Guidelines and Ancillary Testing

This post was peer reviewed.
Click to learn more.

Author: Sean Weaver, DO MPH
Emergency Medicine Resident
University of Nevada, School of Medicine

The following blog post appeared initially at www.lasvegasemr.com/foam-blog and is reproduced with the permission of the author.



Introduction
Last week we reviewed the original 1995 criteria for declaring brain death. This week we are reviewing updated standards as outlined by the American Academy of Neurologists (AAN). Also, this post reviews some of the ancillary tests that EM physicians may be asked to order in order to evaluate for possible brain death.

Updated Evidence-Based Guideline: Determining Brain Death in Adults[1]
In 2010 the American Academy of Neurology published an evidence-based review of the original 1995 guidelines on determining brain death. They reviewed the existing literature and sought to answer five questions listed below. This is a brief summary of their conclusions.

Determining Brain Death: Legal Definition and Original Guidelines

This post was peer reviewed.
Click to learn more.

Author: Sean Weaver, DO MPH
Emergency Medicine Resident
University of Nevada, School of Medicine

The following blog post appeared initially at www.lasvegasemr.com/foam-blog and is reproduced with the permission of the author.  

 
Introduction
Brain death accounts for 1-2% of all deaths in the United States.[1] Patients will present to your emergency department clinically brain dead. While neurologists, neurosurgeons and intensivists may have more experience in determining brain death, all physicians have the legal authority to determine brain death.[2] As emergency physicians we need to know how to properly evaluate these patients, assess their level of brain function, guide their disposition, and prepare their family or loved ones for the eventual outcome.

Increasing the Paper Speed in Narrow-Complex Tachycardia

Normal paper speed (25mm/s)

Authors: Destinee DeLemos, MD
Nathan Haas, MD
University of Michigan Department of Emergency Medicine





Narrow complex tachycardia often presents a diagnostic and therapeutic dilemma, and one simple trick can help in the correct identification of the underlying rhythm. With increasing heart rates, it becomes quite challenging for the emergency physician to distinguish between sinus tachycardia, paroxysmal supraventricular tachycardia (pSVT), atrial fibrillation and atrial flutter. If the underlying rhythm is not pSVT, an unnecessary adenosine trial can prove quite unpleasant for both the patient and physician.

Increased paper speed (50mm/s)
Images Courtesy of Amal Mattu, MD FAAEM

Standard 12-lead EKGs are printed at 25mm/second. By simply doubling the paper speed to 50mm/second, the printed rhythm strip appears widened and exaggerated, which can aid in identifying finer details of the EKG. The images in this post demonstrate previously hidden flutter waves becoming more apparent at an increased paper speed.

Deep Neck Space Infections

Author: Alexandra Murray, OMSIV
Ohio University Heritage College of Osteopathic Medicine

Since the advent of modern antibiotic use, deep neck space infections have decreased in occurrence; however, when these infections take place, the complications can be life threatening.[1-4] Because of the unique compartments of the cervical fascia, deep neck space infections can range in severity and have the potential to extend into the mediastinum. Based on how the infection propagates, these infections have the potential to cause upper airway edema, airway obstruction, mediastinitis, internal jugular vein septic thrombophlebitis, sepsis and septic embolization.[1,2]

Common Sources
Deep neck space infections can develop from infections of the teeth, salivary glands, nasal cavity, paranasal sinuses, pharynx and adenotonsillar tissues.[1,2] In children, adenoids and tonsillar infections are the most common source as they create a drainage pathway through the retropharyngeal lymph nodes resulting in retropharyngeal, parapharyngeal and peritonisllar space infections.1 In adults, dentoalveolar infections are the most common source of infection. In particular, infections of the lower second and third molars are dangerous because their roots spread directly into the submandibular space.[1] Other causes of deep neck space infections in adults include: pharyngitis, tonsillitis, sialoadenitis, trauma, foreing body ingestion, sinusitis, cervical lymphadenitis, middle ear infections, mastoid infections, and IV drug use.[2]

The Adult Learner: Has Medicine Missed the Mark?

Originally published in
Jul/Aug 2014 Common Sense 

Author: Andrew W Phillips, MD MEd
AAEM/RSA Publications Committee Chair

On a recent whim I searched Google for “emergency medicine education fellowship” and “learning theory.” During this entirely non-rigorous search I found that most of the first forty hits were programs specifically mentioning their emphasis on teaching Adult Learning Theory. In fact, even most non-educators reading this have probably heard of ALT. I would wager, however, that you have not heard of Situated Cognition, Cognitive Apprenticeship, Social Learning Theory, or Sociocultural Theory.

Who cares? Why does this matter to the everyday practitioner? Why does this matter to emergency medicine (EM)? The answer lies in the often gross misinterpretation of Adult Learning Theory and the strong case that it does not qualify as legitimate theory, thus leaving learners and teachers selling each other short of the most effective education. Additionally, the medical education community is beginning to move away from emphasizing Adult Learning Theory, and it is important that EM practices education with the most accurate information possible.

This is a two-part series that will first explore the criticisms of ALT, and later offer a breadth of alternatives that together inform us well about how we (adults and children) learn. 

Ocular Ultrasound: Unavoidably Essential

Author: Peter Malamet OMS- IV
Philadelphia College of Osteopathic Medicine

This post was peer reviewed. Click to learn more.

Recently, I heard a quote that has summarized a large part of the emergency medicine practice I have experienced thus far. My attending said, “In a few years, ultrasound will be the new stethoscope.” What he was referring to is not only how popular ultrasound is becoming, but the necessity for physicians to be able to use ultrasound correctly. Ultrasound can help keep certain patients right where we want them, not in a CT scanner, but in our emergency room where we can adequately diagnose and treat them. Ask any physician in the hospital, the last place they want an unstable (or potentially unstable) patient is in the radiology suite. From the Focused Assessment with Sonography in Trauma (FAST) exam to a simple post void residual, ultrasound is a fantastic tool. In this article I will present a relatively newer type of ultrasound technique as an example showing how important this tool can be.

New Peer Review System for Original Articles

Andrew W. Phillips, MD, MEd
AAEM/RSA Blog Editor-in-Chief

Gregory K. Wanner, DO, PA-C
AAEM/RSA Blog Deputy Editor

Meaghan Mercer, DO
AAEM/RSA President



The American Academy of Emergency Medicine Resident and Student Association is pleased to present a new peer review process for original articles. As the FOAMED movement continues to expand and becomes more accepted, we aim to provide trusted, pertinent information to our blog readers[1-3]. Whether clinical, departmental processes, medical education, tips for success, or any other researchable topic, the article will be peer reviewed and be noted as such with a symbol.

This notably excludes Modern Resident and Common Sense articles that are highlighted on the blog, and they will not bear the peer reviewed symbol.

Although there exists some controversy at this time about formally peer reviewing FOAMED versus simply allowing freely entered comments on the page[4], we do not view these review formats as mutually exclusive. Although articles need to be pertinent to emergency medicine, the blog accepts articles based on merit, not space restrictions, so the formal peer review portion can only enhance what is published. Comments will still be permitted on the site.

This is a limited peer review process since it is performed by residents and students. On the one hand, one could argue that a student or resident is not yet ready to be a peer reviewer. However, since these are all review articles, no primary research methods are employed. The reviewers are tasked with reviewing the references to ensure appropriate interpretation by the author. Moreover, AAEM-RSA is a resident and student organization, so we are exercising reviews among, truly, our peers. Nonetheless, our hope is to eventually develop a mentoring program for our reviewers, and we invite interested attendings to contact us at info@aaemrsa.org.

The peer review form was created by the Publications Committee to embody the essentials of a quality paper while leaving flexibility for articles to discuss cutting edge ideas and creatively share information with readers. It is attached below to provide full disclosure of the process that vets the materials you read on our site.

The AAEM/RSA Board of Directors and Publications Committee are pleased to provide this even more rigorous process to help you provide the very best care to your patients and successfully navigate emergency medicine.

If you are interested being a peer reviewer, please contact us at info@aaemrsa.org.


References:

1. Duffy M. Have you FOAMed? Am J Nurs. 2014 Apr;114(4):59–63.

2. Hoffman L. The Problem With FOAMed. Emergency Medicine News. 2013 Mar 15.

3. Lex J. PRO/CON: Why #FOAMed is Essential to EM Education. epmonthlycom. 2014 Apr 7.

4. Thoma B, Chan T, Desouza N, Lin M. Implementing peer review at an emergency medicine blog: bridging the gap between educators and clinical experts. CJEM. 2014 Apr 1;16(0):1–4. 

AAEM/RSA Blog

Blog Submission Evaluation Form

Manuscript Title:

Peer Reviewer’s Name/Title:

Instructions for peer reviewers:

Note that reviewing is not blinded. Save the form to your computer before filling it out. Submit the completed form to the AAEM-RSA staff via email at info@aaemrsa.org.

I. Rate the quality of the manuscript.

Please indicate your agreement (+) or disagreement (-) with each question. (Note: A submission must receive a (+) for every category to be published.)

___ The topic is appropriate for emergency medicine students, residents, and attendings.

___ The paper references credible peer-reviewed sources accurately. (Textbook references are acceptable but must not constitute the majority of references.)

___ References are formatted correctly in AMA citation format (examples below).

___ The content is evidence-based and appears accurate.

___ The paper is well written. Headings and subheadings are used well. Ideas are coherent and flow between paragraphs.

II. Positive Comments. Please remark as appropriate on particularly exceptional portions of the submission.

III. Areas Needing Improvement. Please remark as appropriate on areas needing improvement prior to publication (include specific recommendations for improvement and refer to the paragraph and/or line numbers).

IV. Accessories. Please list any accessory tables, figures, etc. that you feel would improve the submission.(Note that copyright permission will have to be obtained.)

V. Final Recommendation.

___Accept manuscript without revisions (as is)

___Ask author to revise and resubmit

___Reject manuscript (The article is not suitable for the blog, either because the topic is not suitable or manuscript quality is too poor.)

ARDS: Early Ventilator Settings Matter

Author: Sean Weaver, DO MPH
Emergency Medicine Resident
University of Nevada, School of Medicine

The following blog post appeared initially at www.lasvegasemr.com/foam-blog and is reproduced with the permission of the author.

A 40y/o male with no known significant PMH presents with non-productive cough, SOB, DOE, diarrhea, and possibly fever though he is not sure. He has not had a similar illness in the past, denies any recent travel, no sick contacts and denies ever smoking.

Vitals: HR 102, RR 20, O2 sats: 90% on RA, BP: 116/56, Temp: 98ºF

Physical exam reveals an ill appearing male in mild distress. Mucous membranes are dry with a thrush like appearance isolated to the soft palate. Pulmonary exam reveals equal breath sounds bilaterally with some scattered rhonchi, dry crackles and occasional wheeze. ECG was unremarkable. Two view chest x ray was positive for diffuse prominence of the interstitium with interstitial infiltrates vs interstitial edema.

While awaiting admission patient becomes tachypneic and requires NRB mask. Patient stated that he was having difficulty breathing, felt tired and agreed to intubation.

Vitals: HR 103, RR 40, O2sats: 94 % on NRB, BP: 124/86

The patient is successfully intubated, placed on AC/VC w/ PEEP of 10, TV 500, RR 14 and FiO2 of 100% with orders to titrate to O2 sats >90%. An ABG was ordered for two hours post intubation.

Representative post intubation chest X-ray:

Chest x ray is representative of the patient’s portable chest X-ray after intubation.
This image is freely available on-line, courtesy the University of Washington (2004) copyright policy at the following link: http://courses.washington.edu/med620/mechanicalventilation/case3answers.html

Post intubation ABG: pH: 7.39; PCO2: 29; PO2: 112; FiO2: 100; SO2: 98

What is your diagnosis?

What interventions, specifically regarding the ventilator settings, could dramatically reduce the mortality risk in this patient?

Analgesia for Acute Abdominal Pain in the ED

Author: Ken Young, MS4
Loyola Stritch School of Medicine

While this post may involve less new information and more beating of dead horses, two recent experiences have reminded me of what I found to be an interesting concept in medicine — the belief that pain medications interfere with diagnosis in acute abdominal pain.

Recently, a friend of mine had a case of appendicitis, presented to his local ED, and was promptly told he could not be given any pain medication because it would “mask his abdominal exam.” Shortly after this, while studying for my final exam of medical school, I read the following in a case study on abdominal pain:

Be a Non-Terrible Medical Student in Ten Easy Steps

Author: Gregory Wanner, DO PA-C

Thomas Jefferson University Hospital

As the year moves on there is excitement in the air. Birds are chirping, flowers blooming, and second-year medical students are getting ready for clinical rotations. There are many ways to be a terrible student on rotations, but terribleness should probably be avoided. A better plan involves learning some methods of being a good clinical student. I’ll share some hints.

Acute Severe Upper Airway Obstruction in Children

Author: Shane R. Sergent, DO

Upper airway obstruction (UAO) is potentially problematic in any population, but the incidence is more common in children given that they have small compliant airways. UAO in newborns is frequently from congenital abnormalities. In contrast, infants and young children have a spectrum of differentiated causes, the most common being acute infectious etiology. It is essential to recognize UAO early since increased work of breathing in these patients rapidly progresses to respiratory failure. This is because children have a decreased respiratory reserve patients. Therefore it is time critical to identify the cause and treatment.

Tips for Research

Author: Shane R. Sergent, DO

Research is fundamental to medicine. The future of medicine relies on scientific developments and, as such, clinical physicians should be at the forefront of such scientific progress. Research is defined by Merriam-Webster as an investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or laws in the light of new facts, or practical application of such new or revised theories or laws. Although many of us feel that research is a term reserved for PhD students, it should be a critical part of all of our thought processes and delivery of patient care.

Management of Hemophilia Patients in the Emergency Department

Original Author: Nayma Casamayor, MSII, Universidad Iberoamericana (UNIBE)

Submitted by: Sepi Jooniani, MD, MPH (Blog Editor for the month)

Introduction to Hemophilia
The term Hemophilia encompasses a group of hereditary genetic disorders that alter homoeostatis, wherein to due certain deficiencies in the clotting cascade, the human body is rendered inept at controlling bleeding from an ulcerated blood vessel. Depending on the subtype and severity of the disease, as well as the presence of trauma, hemophilia can cause severe hemorrhage, anemia, and possibly even death if left untreated. Although hemophilia is seen in both

How to Make Your Residency Rank Order List

Author: Sepi Jooniani, MD MPH

Interview season is usually a whirlwind of traveling, navigating your way around too
many new cities to count, and meeting so many people that you tend to lost track of the
details along the way. Programs may start seeming more alike than different to you after
a certain point. In making your rank list, my best advice is to follow your instincts. Your
heart usually knows what will make you the happiest before your brain does. But for
those of you who like more concrete facts, here is some actual data that shows what
factors applicants value the most in making their rank list decisions.


In the largest study of its kind, performed in 2004, all medical students registered with
ERAS that year were surveyed to assess exactly what about a program mattered to them
most. Receiving over 7,000 responses, the top five factors that students considered were
the following (please note these are in no particular order):[1]

10 Tips for the Interview Trail

Author: Sepi Jooniani, MD MPH

As you prepare for interview season, here are ten tips to help you along the way. Most of this advice is purely common sense, and after going on your first few interviews, it will become a routine that is second nature to you. However, if the anticipation of your first interview overwhelms you with pre-interview jitters, it might help to mentally prepare yourself by reading over some pointers.

The Epidemic of Prescription Drug Abuse

Photo Attribution:
By J. Troha (Photographer)
[Public domain or Public domain],
via Wikimedia Commons

Originally published: Dr. Wen’s blog: http://whendoctorsdontlisten.blogspot.com/

Original author: Leana Wen, MD MSc

Recently, I learned of some shocking statistics:

• Every year, pharmacies dispense 257 million prescriptions for opioid painkillers — one for every adult American.
• While the U.S. makes up less than 5 percent of the world's population, Americans consume 80 percent of its total opiate supply.
• 1/3 of people who used illicit drugs for the first time start by using a prescription drug.
• Prescription narcotics kill 6 times more people per year than heroin.

As an emergency physician, I prescribe narcotic drugs for pain every day. I began to wonder how complicit doctors are in furthering this epidemic of prescription drug abuse.

My recent article in NPR explores this struggle, between relieving people's pain, and possibly fueling this worsening epidemic.

Proper Adult Lumbar Puncture Technique

Author: Nick Pettit, OMS 2
Ohio University Heritage College of Osteopathic Medicine


Proper Lumbar Puncture (LP) technique is critical for both obtaining a pure CSF sample as well as minimizing patient discomfort and post LP side effects. Herein, a summary of the proper technique will be described.

Smoking Cessation in the ED

Author: Nick Pettit, Ph.D. OMS-II
Ohio University Heritage College of Osteopathic Medicine

Patients present to the emergency department (ED) at some of the lowest points in their lives, and in many cases their visits can be directly attributed to the chronic use of tobacco products. Having a history of tobacco consumption increases the risk of coronary artery disease, stroke, lung cancer, gastrointestinal cancer, genitourinary cancer, and chronic obstructive pulmonary disease, and accounts for 430,000 deaths annually. (1)

OUCH! Forearm Fractures Board Review

Author: Meaghan Mercer, DO; AAEM/RSA President

Galeazzi Fractures: A typically isolated radial fracture with subluxation or dislocation of the ulnar head.

• Injury to a division of the median nerve known as the anterior interosseous nerve (AIN) can occur.

• AIN palsy can cause paralysis of the flexor pollicis longus and flexor digitorum profundus muscles.
      o Clinical manifestations: loss of the pinch mechanism between the thumb and index finger, ability to pronate forearm, and the ability to flex the thumb, index, and middle fingers.
• Requires open reduction and internal fixation (ORIF) in adults

Understanding the Urgent Care Clinic

Originally Published: Common Sense, Nov/Dec 2013

Original Author: Edward Siegel, MD MBA; AAEM/RSA Publications Committee Chair

Recently a family member tried to call me regarding a minor medical problem. Unfortunately I was working at the time, and our emergency department is the place where cell phone reception goes to die.