Sunday, January 25, 2015

The Sculptor’s Compass — A Diagnostic Paradigm

Originally Published in
Nov/Dec 2014 Common Sense
Author: Darshan Thota, MD FAWM
Naval Medical Center San Diego

As a new resident in the emergency department, I am starting to learn that serious and life-threatening conditions require rapid identification and intervention. Response time is often lengthened due to ancillary services, existing policies, overcrowding and cost of care. The most efficient emergency medicine (EM) physicians have a mental model or road map to guide them through the uncertainty of pathology. I call my EM diagnostic paradigm the Sculptor’s Compass. My mental model frames medicine as a sea of uncertainty where physicians are captains sailing through stormy conditions of disease and pain trying to avoid hitting the icebergs of death and suffering. In sailing, we reach for a compass to help aid in navigation. In this model, my schema for how to approach the undifferentiated patient is my compass. In my short time within this fast paced, quick thinking and amazingly fun field, I noticed that our paradigm in the ED is completely different than the rest of the hospital. For example, a friend who is a urology resident asked me to explain how ED personnel approach patient care. This resident couldn’t follow the thought process of consultations from the ED. I initially tried to use a metaphor of playing with a box of Legos. I said that the diagnostic process in the emergency department is a lot like assembling a structure using Lego pieces. You take data points and put them together to see which pieces fit correctly in order to build a stable structure. That logical structure will hopefully form some foundation for a reasonable diagnosis.

Sunday, January 18, 2015

Management of Open Fractures in the Emergency Department

This post was peer reviewed.
Click to learn more.

Author: Bill Mulkerin, MD
Stanford/Kaiser Emergency Medicine Residency

Open fractures often result from high-energy impacts, such as motorcycle crashes, motor vehicle collisions, and pedestrians being struck by motor vehicles.[1,2] These injuries are usually associated with poly-trauma.[1] Up to 9% of open fractures result in compartment syndrome.[3] Open fractures are most commonly classified by the Gustilo classification:

  • Type I – clean wound less than 1cm
  • Type II – laceration more than 1cm long, without extensive soft tissue damage, flaps, or avulsions 
  • Type IIIA – adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound 
  • Type IIIB – extensive soft tissue injury with periosteum stripping and bony exposure. This is usually associated with massive contamination. 
  • Type IIIC – Exposed fracture with arterial damage that requires repair[4,5]

Sunday, January 11, 2015

Updates on LBBB and STEMI

This post was peer reviewed.
Click to learn more.
Author: Meaghan Mercer, DO
Emergency Medicine Resident
University of Nevada School of Medicine
AAEM/RSA President

I recently attended the #Resus14 conference in Las Vegas and Dr. Amal Mattu asked the audience how many felt comfortable with the Sgarbossa criteria. I was surprised at how few hands went up. Repetition is the key, but if you think you had Sgarbossa down there are some changes!

New LBBB is no longer a STEMI equivalent *UNLESS*
a. The patient has new heart failure
b. The patient is unstable
c. The EKG meets Sgarbossa A or B criteria

Thursday, January 1, 2015

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