Peds Tox Talk: Liquid Nicotine

Photo by Lindsay Fox

Author: Ashley Grigsby, DO PGY-1
Indiana University Emergency Medicine/Pediatrics

Originally Published: Modern Resident, June/July 2015 

Nicotine toxicity is a well-described clinical entity that often occurs in children who accidentally ingest cigarette buds or nicotine patches. However, a new form of nicotine has the potential to cause serious clinical symptoms, including death.

E-cigarettes use a form of liquid nicotine of varying concentrations that come in individual vials. E-cigarette use is on the rise across the United States, and unfortunately, the liquid nicotine is both easily accessible and appealing to young children. These liquid cartridges are often packaged in a tempting way, with one such cartridge described as having a cartoon monkey holding grapes on the front. The packaging is not regulated by the FDA and therefore has no child proof regulations for packaging. The liquid itself is also appealing for young children, and flavors include cotton candy, bubble gum, fruit, mint and chocolate.[1,2]

The CDC reported a significant increase from 2010 to 2014 of calls to poison centers regarding nicotine exposure. They also reported that e-cigarette exposure compared to regular cigarette exposure was about 1.5 times more likely to cause an adverse health effect.[1] Among the calls to poison centers during this time period, 51% involved young children.[2]

Resident Rules of the Road: Chapter 11 Summary: "Wellness"

Originally Published: AAEM's Rules of the Road for Emergency Medicine Residents, 7th Ed. Chief Editors: Tom Scaletta, MD FAAEM; Michael Ybarra, MD FAAEM; Leana Wen, MD MSc. AAEM and AAEM/RSA. Milwaukee, WI. 2010. http://www.aaem.org/publications/aaem-book-store

Chapter Summary Edited By: Andrew W Phillips, MD MEd, Stanford/Kaiser Emergency Medicine Residency Program  

Summary Series Editors: Muhammad Alghanem, BS and Andrew W Phillips, MD MEd

Physician—heal thyself.

It is difficult to estimate exactly the burnout rate in emergency medicine (EM) since it is a relatively young specialty, but there is no denying that it is a stressful specialty prone to burnout. Here, we provide some tips for preventing burnout.

Shift Work/Sleep
Dealing with night shifts: If you move to a regular night schedule, keep that schedule even on days off whenever possible to keep your circadian rhythm. Be cautious that day sleepers often do not get as good of sleep as night sleepers and will lean toward using stimulants and sedatives. Scattered, single night shifts may be preferable. A third alternative is a forward-moving schedule: day to evening to night to break. Shorter shifts (8hr) and 30-45 minute power naps before night shifts are helpful to remain alert. Experts also recommend sleeping as soon as possible after a night shift.

Save a Life: Know the Precious P’s of Rapid Sequence Intubation

Photo: Wikimedia Commons

Author: Valery Victoria Rivas Cuesta, MSVI
Medical Student
Universidad Iberoamericana (UNIBE) School of Medicine

An emergency physician’s failure to secure the airway can rapidly lead to death or disability. In the emergency setting, patients are assumed to have a full stomach and be at risk for aspiration. Often, rapid-sequence intubation (RSI) represents the preferred method to secure the airway in the ED setting, as it results in unconsciousness (induction) and neuromuscular blockade (paralysis) rapidly thereafter.[1]

This post was peer reviewed.
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The procedure has the following main goals: prevention of hypoxia, shortening the time between induction and intubation, minimizing aspiration risk, and improving first pass success.[1] This is achieved by the “ritual of the P’s”:[2]

Resident Rules of the Road: Chapter 10 Summary: "The First Year Out"

Originally Published: AAEM's Rules of the Road for Emergency Medicine Residents, 7th Ed. Chief Editors: Tom Scaletta, MD FAAEM; Michael Ybarra, MD FAAEM; Leana Wen, MD MSc. AAEM and AAEM/RSA. Milwaukee, WI. 2010. http://www.aaem.org/publications/aaem-book-store.

Chapter Summary Edited By: Andrew W Phillips, MD MEd, Stanford/Kaiser Emergency Medicine Residency Program

Summary Series Editors: Muhammad Alghanem, BS and Andrew W Phillips, MD MEd

There’s a light! Do you see it? The end of the tunnel! Except … wait — it’s fading as you realize that now your name is at the bottom of the chart, that utopic emergency department staff doesn’t actually exist, you still have disrespectful consultants, the boards are approaching, and Press Ganey now applies to YOU!

Never fear — your AAEM and AAEM/RSA colleagues are here, just as they always have been!

Standardized Sign-Outs in the ED: An Opportunity to Improve Patient Safety

Image Credit: Flickr

Authors: Peter Malamet, OMS-IV, Philadelphia College of Osteopathic Medicine
Andrew W. Phillips, MD MEd, Stanford/Kaiser Emergency Medicine Residency Program
Sarah Williams, MD, Stanford University, Division of Emergency Medicine

Originally Published: Common Sense, January/February 2015


The Importance of Sign-outs
Emergency physicians routinely perform sign-outs, both at shift change and during consultations and admissions. Sign-out, also known as a hand-off or turnover, is a time to summarize information about current patients and transition their care from one provider to the next. This sign-out can be between emergency physicians (EPs) or between EPs and other health care providers. However, despite being so common in everyday practice, sign-outs continue to be cited as a large source of medical error in the emergency department (ED).[1] It is critical for patient safety that this process is optimized.

The ideal sign-out happens in a quiet area with no distractions, with sufficient time to discuss pertinent aspects of patient care.[2] This may be possible on a medicine floor, although even here there are challenges. However, this is particularly difficult to achieve in the ED.[3,4] Nonetheless, recent research shows that a standardized sign-out process can reduce medical errors.[3]

Resident Rules of the Road: Chapter 9 Summary: "Job Search"

Originally Published: AAEM's Rules of the Road for Emergency Medicine Residents, 7th Ed. Chief Editors: Tom Scaletta, MD FAAEM; Michael Ybarra, MD FAAEM; Leana Wen, MD MSc. AAEM and AAEM/RSA. Milwaukee, WI. 2010.

http://www.aaem.org/publications/aaem-book-store.


Chapter Summary By: Aga De Castro, MPH, MA, MSIV Medical Student, Georgetown University School of Medicine


Summary Series Editors: Muhammad Alghanem, BS, and Andrew W Phillips, MD, MEd


Finding employment after residency can be a stressful period but maintaining an organized yet flexible approach can lead to finding that first job as an independent emergency physician. A few things to consider when going on the job hunt:

1. State licensures can often take months to process. Starting up to a year ahead of your desired start date will allow you appropriate time.
2. Know your priorities. Do you have a geographic area in mind? Or are you looking for opportunities only in academic centers?
3. Finding a job is easy but finding the perfect job requires more time and effort. Invest the energy if you want your job out of residency to be the most ideal.
4. Know your network. Often, the best job opportunities are not advertised and only known through the grapevine. People associated with your residency program such as the leadership and alumni can be helpful contacts for potential job opportunities.

Calling Consultations from the Emergency Department

Photo by NEC Corporation:
https://flic.kr/p/nJ7P9M

Author: Andrew W Phillips, MD MEdStanford/Kaiser Emergency Medicine Residency Program

You will be judged by your consultations. Period.

The best evidence we have for handling emergency department (ED) consultations supports the use of the “5 C’s of consultation,” which was shown to be helpful in a randomized, controlled trial.[1]

1) Contact: start with an introduction between you and the consultant.
2) Communicate: provide a concise story.
3) Core question: have a specific question or request for the consultant (“What do you think is wrong?” is unacceptable).
4) Collaboration: create agreement between you and the consultant about further management by the emergency department and the consulting team.
5) Closing the loop: ensure you and the consultant have the same plan.

Within the core question components, it is also important to know and express to the consultant the goal of the consultation. There is a taxonomy of consultations with differing goals, which can be divided into: [2]

Resident Rules of the Road: Chapter 8 Summary: "Curriculum Vitae"

Originally Published: AAEM's Rules of the Road for Emergency Medicine Residents, 7th Ed. Chief Editors: Tom Scaletta, MD FAAEM; Michael Ybarra, MD FAAEM; Leana Wen, MD MSc. AAEM and AAEM/RSA. Milwaukee, WI. 2010. http://www.aaem.org/publications/aaem-book-store.

Chapter Summary By: Aga De Castro, MPH, MA, MSIV Medical Student, Georgetown University School of Medicine

Summary Series Editors: Muhammad Alghanem, BS, and Andrew W Phillips, MD, MEd

The curriculum vitae (CV) is an important component of one’s professional career since it is an organized representation of a person’s education, work history and job qualifications. The CV must be detailed, yet concise enough for a future employer to get a good grasp of an applicant’s professional accomplishments. Having a CV that is well organized will ensure that a candidate is worthy of further consideration.

The CV has several components that are considered essential. It should have the appropriate contact information displayed at the top of the page including name, mailing address, phone number and email information. A training subsection should follow to outline an applicant’s residency and/or fellowship experience. An education subsection typically follows, highlighting all higher academic institutions from which the applicant received a degree. High school education or earlier are typically not included in this subsection. An experience and skills subsection should describe any current or prior experiences as they would relate to a prospective job. Each of these subsections should be in reverse chronological order with the most recent experience listed first.

Meditation in Medicine

Photo Credit: “Meditation” by Sebastian Wiertz:
https://flic.kr/p/aht7Wt.

Author: Puja Gopal, MSIV
University of Illinois College of Medicine

Recently when watching the evening news, I came across an interesting segment focusing on how teaching meditation in middle and high schools in San Francisco has led to many positive measurable changes. School officials have noted better attendance, better academic performance, and at least a 75 percent decrease in suspensions over a period of four years.

This post was peer reviewed.
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Meditation and relaxation techniques have garnered a lot of attention lately and have become the focus of much research. A brief literature overview on the potential impact meditation can have, especially in the field of emergency medicine, follows below. For emergency physicians, who operate in high-stress environments; attend to multiple tasks, often simultaneously; and must manage 'the busy pit', overall wellness becomes especially important. Wellness is reflected in one's even mindedness and control during high stress situations such as coding patients; one’s focus and concentration during shifts of high volume; and one’s resiliency, especially after bad outcomes. Stress reduction techniques are thus essential to maintain wellness and happiness and avoid burn-out.