Thursday, December 29, 2016

Top 10 Most Read Posts of 2016

Image Credit
We would like to take a moment to recognize our Top 10 articles of 2016 and congratulate the authors (see below).

Additionally, I would like to thank each of the AAEM/RSA Blog authors, reviewers, mentors, and editorial staff members for a wonderful and successful 2016.

We are accepting articles for 2017 and we welcome additional faculty mentors; contact us at with questions. Have a safe and happy holiday season!

1. The Salesman Doctor
Edward Siegel, MD MBA
August 25, 2016
2. From Chaos to Clarity: Leadership in the Resuscitation Bay
Mary Haas, MD
December 8, 2016

3. How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 1
How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 2

Gregory K. Wanner, DO PA-C and Andrew W. Phillips, MD Med
July 21, 2016 and August 4, 2016

4. Digoxin Toxicity: Myths, Truths and Management
Andrew V. Bokarius, MD
May 8, 2016

5. Blakemore, Bleed Less: Massive Upper GI Bleeding and the GEBT Tube
Gregory Wanner, DO PA-C and Dimitrios Papanagnou, MD MPH EdD(c)
July 28, 2016

6. Electrical Storm: Don’t Just “Push Another Milligram of Epi”
Khalid M Miri, OMSIV
May 22, 2016

7. The Proper Start to Your Financial Journey
James M. Dahle, MD
June 12, 2016

8. Ocular Emergency: Chemical Burns, A Non-Ophthalmologist Approach to Initial Treatment and Referral
Fernando Pellerano, MSV
February 7, 2016

9. Drowning in Your Own Blood: Managing Massive Hemoptysis
Jonathan Morgan, MSIV
March 6, 2016

10. Tox Talk: Calcium Channel Blocker Overdose
Erica Schramm, MSIV
October 6, 2016

Thursday, December 22, 2016

There’s a First for Everything: Surviving and Thriving Through Internship and Pregnancy

Author: Faith Quenzer, DO PGY-1
Originally Published: Common Sense November/December 2016

July was a whirlwind. Fresh out of medical school, I moved to the desert in California to a brand new emergency medicine residency. I was one of five interns and the only female in our inaugural class. Five weeks into the program, I felt strangely tired and nauseated every day. The positive pregnancy test confirmed my suspicion. I knew, without a doubt, that being an emergency physician was exactly what I wanted to do — a stroke in one bed, major trauma in another, appendicitis next to that patient, etc. But now I had the internal turmoil of figuring out how to balance working hard and taking advantage of all the learning opportunities presented to me with proper self-care — which really means baby care. Additionally, the anxiety of having to reveal my pregnancy to my program director, coordinator, fellow residents, and the hospital was a heavy burden. I feared this news might be detrimental to the newly minted EM program and to me as a new physician.

The number of women in the physician workforce has increased substantially over the last couple decades. According to a recent survey by the American Medical Association, approximately 48% of those enrolled in medical school are women. The average age of a graduating medical student is 28.[1-2] For those already in their 30s, the pressure to have children increases as advanced maternal age looms. And complications are a reality for pregnant physicians. According to surveys conducted in surgical specialties, high stress levels and long hours increase the risk of preterm labor, pre-eclampsia, and other obstetrical complications.[3]

Sunday, December 18, 2016

Asymptomatic Pediatric Fresh Water Drowning: How Long to Observe?

Image Credit
Author: Megan Litzau, MD
Indiana University Emergency Medicine Resident PGY 2

This post was peer reviewed.
Click to learn more.


A three-year-old female arrives after falling into a swimming pool. The patient did go underwater as witnessed by the patient’s siblings before the siblings pulled the patient out. The period of time underwater is unknown, however, she did not require any resuscitation at the scene. The patient arrived in a private vehicle in no apparent distress with normal vital signs for her age.

In pediatric drownings in which the patient is in cardiopulmonary arrest, the treatment and disposition is very clear as there are algorithms for treatment and the disposition is admission if return of spontaneous circulation (ROSC) is achieved. However, in a patient who presents asymptomatic after a fresh water near drowning incident as described above, what is the best treatment and disposition course for those patients? Do these patients need to be admitted or can they be observed and released from the emergency department? If the patients are going to be observed and released, how long do they need to be observed for in order to release them safely?

Thursday, December 15, 2016

Alcohol Withdrawal: Complications and Treatment

Image Credit
Author: Niklas Eriksson, MS4
Loyola University Chicago Stritch School of Medicine
AAEM/RSA Social Media Committee

This post was peer reviewed.
Click to learn more.

There are roughly eight million Americans who are alcohol-dependent, with 500,000 cases of alcohol withdrawal requiring treatment each year.[1] Being able to recognize and manage alcohol withdrawal is an essential skill for every emergency room physician. Long-term ethanol use causes downregulation of gamma-aminobutyric acid (GABA) receptors causing an increased inhibitory tone, as well as upregulation of glutamate receptors to maintain excitatory pathways. With sudden cessation of ethanol, there is decreased inhibition via GABA receptors and increased excitatory effects from glutamate receptors, causing central nervous system (CNS) excitation and the symptoms of alcohol withdrawal.[2]

As with all emergency department (ED) patients, the first step is to manage ABC’s (airway, breathing, and circulation). Aspiration can occur with withdrawal seizures. Initial symptoms of withdrawal can begin as soon as six hours after the patient’s last drink, so asking for a timeline of the patient’s last alcoholic drink is essential for determining when symptoms can be anticipated. A serum ethanol should also be obtained. Hypoglycemia is commonly associated with alcoholic abuse, so checking serum glucose remains essential. Given alcohol’s association with liver and pancreatic damage, a complete blood count (CBC), basic metabolic panel (BMP), Liver enzymes, and Lipase should be checked if there is suspicion for hepatitis or pancreatitis.[3] For the first 6 to 36 hours after the last drink, symptoms can include tremulousness, anxiety, headache, diaphoresis, palpitations, and gastrointestinal upset.[2] Benzodiazepines (often lorazepam or diazepam) are used for management, as they stimulate GABA receptors to inhibit the increased excitatory CNS effects. Withdrawal seizures can occur within 12 to 48 hours, usually occurring as singular seizures or brief flurries. Benzodiazepines are also the treatment of choice here. Examples of doses are Lorazepam IV 2-4mg every 15-20 minutes, or diazepam IV 5-10mg IV every 5-10 minutes, until symptoms resolve.[3]

Sunday, December 11, 2016

Clinical Pearl: "Light Bulb Sign" in Posterior Shoulder Dislocation

Author: Nathan Haas, MD
University of Michigan
Originally Published: Modern Resident, June/July 2014

Posterior shoulder dislocations are relatively uncommon, comprising only 2-4% of all shoulder dislocations. Thus, posterior dislocations often go undiagnosed, and can lead to severe consequences for both the patient and emergency physician (EP). A high index of suspicion and a firm grasp of associated radiologic findings are key to making the diagnosis.

Posterior shoulder dislocations are classically associated with seizures, electrocution and severe trauma. As a group, the internal rotators of the humerus (teres major, pectoralis major and latissimus dorsi) are more powerful than the external rotators (infraspinatus, posterior deltoid and teres minor), leading to internal rotation during global muscle contraction from electrical activity (seizure, electrocution, electroconvulsive therapy, etc.). This internal rotation is what allows the humeral head to dislocate posteriorly from the glenoid fossa, and also produces the characteristic "light bulb sign" of the humeral head seen in posterior shoulder dislocations.

The AP view of the normal shoulder demonstrates the normal asymmetry of the humeral head in anatomic position. The larger portion is on the medial side, seated in the glenoid fossa. With internal rotation in the setting of a posterior dislocation, this larger portion rotates out of view producing the more round and symmetric "light bulb sign" of the humeral head in the second image. It is important to note that this pertains only to the AP view, and not the axillary or lateral view of the shoulder.

*Image 1: Normal AP view of shoulder
Source: Dr. M Daya;

Reprinted with permission from EB Medicine, publisher of Emergency Medicine Practice, from: Daya M, Nakamura Y. Shoulder girdle fractures and dislocations. Emergency Medicine Practice. 2007; 9(10):4,

*Image 2: Posterior dislocation, "light bulb sign"
Source: Dr. Alexandra Stanislavsky;

While the axillary or scapular Y views often help demonstrate posterior shoulder dislocations, the "light bulb sign" of the humeral head is often present on the AP view. Other signs include the rim sign (>6mm gap between the medial humeral head and anterior glenoid rim), the trough sign/reverse Hill-Sachs lesion (compression fracture of anteromedial humeral head), or fracture of the lesser tuberosity.

  1. Shoulder Girdle Fractures And Dislocations. EB Medicine. Web. 20 May 2014.
  2. Stanislavsky A. Posterior Shoulder Dislocation. Radiopaedia. Web. 20 May 2014.
  3. Tosif, S. Posterior Shoulder Dislocation. Life in the Fast Lane. Web. 20 May 2014.

Thursday, December 8, 2016

From Chaos to Clarity: Leadership in the Resuscitation Bay

Author: Mary Haas, MD
AAEM/RSA President '16-'17
Originally Published: Common Sense November/December 2016

You are managing a busy emergency department, when you hear via the overhead paging system that a new patient has arrived in your resuscitation bay. You scurry from the farthest corner of your department, where you were evaluating a patient with multiple chronic medical problems and multiple complaints. As you book it to the resuscitation bay, you carry the weight of several sick patients you are managing and the knowledge of several on stretchers waiting to be seen, not to mention the full waiting room. You arrive at the resuscitation bay, where a group of people are bustling around as if a storm is about to hit. You see the ambulance pull up to the doorway with lights flashing. In this moment, as leader of the resuscitation, you have the responsibility to transform chaos into clarity.

As I transition into my senior year of residency, this common scenario challenges me to reflect on and improve my leadership and communication skills. What makes a physician a good leader in the resuscitation bay?

Sunday, December 4, 2016

Why is My Arm Swollen?

Image Credit: Flickr
Author: Pollianne Ward, MD
Temple University Hospital
Originally Published: Modern Resident February/March '13

A 16-year-old female presented to a children's hospital emergency department with two weeks of intermittent left shoulder pain. Over the last few days, her left arm had become diffusely swollen and painful with mottling of the skin, coolness of her left hand and paresthesias on the lateral forearm. Exam revealed strong radial and brachial pulses with her arm dependent, and decreased pulses when she raised her arm. She was a competitive swimmer and practiced up to four hours per day and symptoms were worse after exercise.

Thoracic outlet syndrome (TOS) is an uncommon condition with varying presentations and a constellation of signs and symptoms that make diagnosis very tricky. It is characterized by compression of the neurovascular bundle exiting the thoracic outlet, involving the subclavian artery, vein and Brachial plexus. Historically, it was categorized by the anatomic abnormality causing the compression, such as cervical or first rib, scalene muscle hypertrophy, costoclavicular and hyperabduction syndrome.

Thursday, December 1, 2016

Decreasing Door to Doc Time: The Online Waiting Room

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

Christine Au
Medical Student- OMS-II
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific
AAEM/RSA Social Media Committee

While the demand for emergency medical service has dramatically increased throughout the last five years, patients are finding that they are spending a great deal of time waiting to be seen.[1] In fact, emergency department (ED) visits have doubled the increase in population rates from 1997-2007.[2] On average, patients wait for two hours and 15 minutes from the time of arrival to the time they are admitted, or to the time of discharge.[2] However, this data point varies depending on the state the patient is being seen in, patient demographic, as well as the complexity of a patient’s case. In some of the more extreme cases, patients may wait an average of four hours or more before being seen by any healthcare professional.[1]

Sunday, November 27, 2016

Toxicology Review: Chronic Salicylate Poisoning

Image Credit: Flickr
Author: Pollianne Ward, MD
Temple University Hospital
Originally Published: Modern Resident January 2013

A 46-year-old female presented to an urban emergency department with complaints of a fall and altered mental status per family. It was reported that the patient had begun to experience nausea and vomiting followed by somnolence one day prior. She had no medical problems and did not take any medications regularly. Vital signs were heart rate 125, BP 130/86, temperature 99.6˚ F, respiratory rate 22 and oxygen saturation 99% on room air. The patient had some minor facial fractures from a fall, but no other injuries after trauma evaluation. EKG showed a sinus tachycardia with a widened QRS and peaked T waves. Basic metabolic panel revealed creatinine 8.5, potassium 7.3, and an anion gap metabolic acidosis. Treatment of hyperkalemia was initiated. A comprehensive drug screen was sent, which showed a salicylate level of 75mg/dl.

Salicylate overdose is a not uncommon chief complaint that emergency physicians encounter. Either intentional or accidental, acute toxicity is usually easily recognizable with symptoms of nausea, vomiting, tinnitus, tachypnea and lethargy in a known or suspected ingestion. However, chronic toxicity can often be indolent and present with non-specific symptoms.

Thursday, November 24, 2016

Six Clinical Pearls from Intern Year

Image Credit: Flickr
Author: Casey Grover, MD
Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident October/November 2011

Looking back after finishing a year as an emergency medicine intern, the lessons that I remember the most come from the mistakes that I have made. I had one particularly rough month late in my internship that was filled with bounce backs and mismanaged cases. I learned six important lessons that will hopefully help to avoid another such month in the future.

  1. Review every study that you order. While you may have ordered a chemistry panel just to check the creatinine, it's embarrassing to miss a sodium of 121.
  2. Document your discharge decision process. If a patient has a problem or bounces back, it is extremely helpful to have documented everything (i.e., normal vitals, well appearance, consultant recommendations) that you considered when sending that patient home.
  3. Review discharge vital signs. Vital signs are actually important – they reflect the patient's underlying physiology. Document normal vital signs when sending patients home; and when discharging someone with abnormal vitals, document your rationale and plan.
  4. Document your discussions with consultants. Record at what time and to whom you spoke, as well as what they recommended. This allows others to see the basis of your decisions, which is essential if an adverse outcome occurs.
  5. Be suspicious of patients signed out to you. Review the labs and vital signs of the patient you will be taking care of, and address all of their medical issues. Approach the case with fresh eyes and be willing to consider other diagnoses than those billed to you in sign out.
  6. Approach procedures carefully. While it's fun to do procedures, be aware that complications may arise – particularly in a patient who is high risk for bleeding. Review labs and history, particularly for things like coagulopathy, that may make procedures difficult.

Sunday, November 20, 2016

Tox Talks: Bath Salts

Author: Meaghan Mercer, MSIV
Western University of Health Sciences
AAEM/RSA Medical Student Council President '11-'12

Originally Published: Modern Resident October/November 2011

Walking onto my shift a few days ago, I heard shrieking coming from my pod, and I knew this would be an interesting night. I rushed over to find a female restrained by four police officers screaming that demons were out to get her. Witnesses reported that after snorting an unknown substance, the patient began running down the street, topless, yelling that something was after her. It required all four officers to control her and get her to the ED. She was agitated and combative, unwilling to answer questions, with a HR: 130, RR: 20, BP: 190/115, temp: 103, and an O2 saturation of 95% on room air. This was it, what I have been hearing so much about ... a bath salt ingestion.

There has been a recent insurgency of patients presenting to emergency departments across the country in an agitated delirium caused by a new designer drug called bath salts. On October 21st, the DEA issued a temporary one-year ban on methylenedioxypyrovalerone (MDPV), the main component of bath salts, classifying it as a schedule 1 substance. Manufacturers evade the restriction with minor alterations in the chemical structure, and bath salts are still available in gas stations, head shops and online.[1]

Thursday, November 17, 2016

Board Review: Toxic Alcohols

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

Authors: Gregory Wanner, DO
Emergency Physician/Clinical Faculty
Christiana Care Health System

Paul Kolecki, MD
Associate Professor, Emergency Medicine
Medical Toxicologist
Thomas Jefferson University

An 18-year-old male presents to the emergency department (ED) stating, “Doc, I’m really drunk.” He and a friend were drinking in the friend’s garage. The patient drank one “very strong” sweet-smelling drink, which was prepared by his friend. He began to feel sick and nauseated and rode his bike home (with difficulty due to this intoxication, but without any falls or trauma). He vomited twice and his mother referred him to the ED. Attempts to contact the friend were unsuccessful.

How would you evaluate this patient? 

Several intoxicants can cause similar symptoms. While ethanol is the most likely cause, in patients with unclear ingestions other alcohols should be considered as well. The following is a brief summary of the alcohols often tested on in-service and board exams; a summary table is included at the end:

Sunday, November 13, 2016

Board Review: Heat-Related Illnesses

Image Credit: Flickr
Author: Kaitlin Fries, DO PGY-1
Doctors Hospital
Originally Published: Modern Resident June/July 2015

Heat-related illnesses are responsible for approximately 400 U.S. deaths each year.[4] Drastic spikes in mortality can be seen during severe droughts and heat waves, the latter of which is defined as temperatures greater than 90°F for three or more consecutive days.[3,4] Those at greatest risk for heat-related emergencies are children, the elderly, people with certain predisposing medical conditions and those taking medications that interfere with the body’s thermoregulatory center.[3,4] The spectrum of heat-related illnesses ranges from cramps, syncope and heat exhaustion to more serious conditions such as heat stroke. All of these conditions are easily preventable with public education and adequate access to hydration and cool shelters.

The main two cooling mechanisms used by the human body are radiation and evaporation.[2,3,4] Radiation can account for up to 65% of total heat loss.4 However, radiation can only occur in a cool environment. Patients who do not have access to air-conditioning must rely on evaporation to dissipate heat by producing sweat, which then evaporates from the skin’s surface due to body heat.[2] However, as atmospheric humidity increases, the effectiveness of evaporation decreases.[2] Below is a brief review of the minor presentations of heat-related complaints.

Thursday, November 10, 2016

Sex-Specific Differences of Myocardial Infarction Presentation in the ED

Image Credit: Pixabay
Author: Jake Toy, MS3
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA
AAEM/RSA Publications Committee '16-'17

This post was peer reviewed.
Click to learn more.

Heart disease is the leading cause of morbidity and mortality among women in the United States and accounts for approximately 1 in 4 deaths among women­.[1] Unfortunately, society fails to recognize this burden, often labeling heart disease as a “male problem”. In the past decade, only 54% of women recognized heart disease as a number 1 cause of mortality.[2] Exacerbating this issue further, the “classic” symptoms of myocardial infarction (MI) were historically based off studies analyzing MI in men.[3] Additionally, women often experience greater delays in care during an MI and have higher associated mortality rates when compared to men.[4, 5]

A significant body of literature exists describing sex-specific differences in MI presentation and outcomes. In the emergency department (ED), awareness of these variances in MI presentation is crucial toward providing timely and effective care to women presenting with an acute MI.

Typical vs. Atypical Chest Pain

The textbook symptoms of “typical” chest pain are well-defined – (1) precordial chest discomfort, pain, heaviness, or fullness, possibly radiating to the arm, shoulder, back, neck, jaw, or epigastrium; (2) symptoms worsened by stress or activity; (3) symptoms relieved by rest or medications, such as nitroglycerin; (4) associated symptoms that include shortness of breath, diaphoresis, weakness, nausea, vomiting, or lightheadedness.[3]

In comparison, “atypical” chest pain does not present in the aforementioned classic pattern. Signs may include: burning, sharp, pleuritic, or positional chest pain or discomfort; chest pain that is localized by one finger and reproducible; pain only in the arm, shoulder, back, neck, jaw, or epigastrium, or pain concentrated in regions of the body other than the chest, arm, shoulder, back, neck, jaw, or epigastrium.[3]

Sunday, November 6, 2016

A Crash Course in Sports-Related Concussions

Image Credit: Flickr
Author: Jennifer Reink, MSIV
Ohio University Heritage College of Osteopathic Medicine
AAEM/RSA Social Media Committee '16-'17

This post was peer reviewed.
Click to learn more.

With school back in session and autumn just around the corner, the fall sports season is upon us, and where there are athletic competitions, there are bound to be concussions. Nearly half of all emergency department (ED) visits for concussions are sports related, with 4 in 1000 children ages 8 to 13 and 6 in 1000 children ages 14 to 19 presenting to the ED each year for a concussion sustained during an organized team sport.[1] Furthermore, sports are second only to motor vehicle accidents as the leading cause of traumatic brain injury among people ages 15 to 24.[2] From football and cheerleading, to swimming and basketball, each sport has its own risk for head injury. For those of us who find ourselves caring for these young beaten warriors, here is what you need to know about what makes sports-related concussions such a challenging diagnosis.

1) Clinical symptoms are often subtle and may manifest with immediate or delayed onset.

A concussion is defined as a disturbance in brain function caused by a direct or indirect force to the brain resulting in a disruption of neural membranes.[1,3] This leads to a variety of non-specific signs and symptoms. Although symptoms typically present immediately after injury, some may not appear until several hours following impact. There are even patients who present days later with delayed or worsening symptoms. Common manifestations of concussions include:[2,3]

Thursday, November 3, 2016

Patient Satisfaction

Image Credit: Flickr
Author: Victoria Weston, MD
AAEM/RSA President '15-'16
Originally Published: Common Sense March/April 2016

Patient satisfaction. It feels like sometimes the concept is overemphasized, yet another addition to the countless expectations and constraints placed on doctors. I have felt this way at times, but recently my thinking has shifted. Instead of trying to meet arbitrary Press Ganey requirements, I have focused on trying to understand patients' wants and needs in order to better connect with them.

I recently had a shift with what seemed an unusually high number of patients with difficult personalities and “supratentorial pathology.”At times it was exceptionally frustrating, and although I started the shift feeling positive, by midway through the morning I could feel my spirits sinking. People had psychosomatic complaints. Some were drug-seeking and negotiating for narcotics. Some were demanding inappropriate care or tests. Some acted entitled and were rude to staff. I took this as a challenge, and tried to reframe my mind to see it as a learning experience in how to deal with difficult patients.

Sunday, October 30, 2016

Bronchiolitis: Updated Guidelines

Image Credit: Wikipedia
Author: Ashley Grigsby, DO
Indiana University
Emergency Medicine/Pediatrics Residency

Originally Published: Modern Resident December 2014/January 2015

It’s that time of year again. Snow is starting to fall, holiday lights are going up and little babies are showing up wheezing in your emergency department. While babies sometimes make emergency physicians nervous, the treatment for bronchiolitis just got a little easier. The American Academy of Pediatrics recently updated their clinical practice guidelines; the last update prior to this was in 2006. These guidelines were updated to provide clinicians with the most recent evidence based management strategies.

Bronchiolitis is a viral illness caused by multiple viruses and occurs in 90% of children before the age of two. Bronchiolitis is a clinical diagnosis and as such, it does not require any testing to confirm diagnosis. Illness usually starts with rhinitis and cough, but can progress to respiratory distress.1 Exam frequently reveals tachypnea, mild retractions and expiratory wheezing.[2] Patients with more severe disease can have grunting, nasal flaring or severe retractions.[1] Assessment of these patients should include evaluation of hydration status, respiratory status, history of apnea, behavior changes and history of cyanosis.[2]

Thursday, October 27, 2016

Standardized Residency Video Interviews: Benefit or Burden?

Author: Mike Wilk, MD
PGY-1, Brown EM

Forward: Please note that after submission of this article, the Standardized Video Interview Project was put on hold this year for further review by the AAMC. However, its implementation remains expected at a later date.

We are trained as emergency physicians to start evaluating patients from the moment we lay eyes on them. Sometimes referred as the “door test,” we assess, determine workups and consider possible dispositions from the moment we step through the door to lay eyes on our patient. Much like assessing patients, EM residency programs are looking for more efficient ways to rapidly evaluate future residents even before they are invited for an in-person interview. This year, medical students bound for an EM residency will have a new option to complete on their residency applications: the AAMC Standardized Video Interview.

What exactly will this video interview involve? When I first heard of the concept, I initially envisioned it to be a “personal branding” video where each student would have a minute or two to sell themselves. While this idea is exciting, I also envisioned medical students spending many hours perfecting this video, and even more burdensome, spending hundreds of dollars for professional videography. Basically, I imagined something similar to YouTube high school football recruiting videos, complete with pump-up music and special effects.

Sunday, October 23, 2016

When Pneumothoraces Become Cyclic

Image Credit: Wikimedia Commons
Author: Kaila Pomeranz, OMSIV
Midwestern University, Arizona College of Osteopathic Medicine

This post was peer reviewed.
Click to learn more.

A 34-year-old Caucasian female presents to the emergency department with acute onset breathing difficulty and right-sided, stabbing chest pain. Physical exam reveals decreased breath sounds over the right hemithorax and chest x-ray confirms a right pneumothorax. This is her third occurrence of right-sided pneumothoraces.

What can be considered a cause of recurrent pneumothoraces?
Upon further questioning, the patient’s past medical history consists of clinically diagnosed endometriosis treated with NSAIDs. She has no history of asthma, COPD, chest injury, or history of smoking. The patient has no history of Marfan’s syndrome, which may increase the risk of pneumothoraces due to apical blebs or bullae.

Thursday, October 20, 2016

Evaluation of an Ankle Injury in the Emergency Department

Image Credit: Flickr
Authors: Sachin Allahabadi, MSIV
Jorge Louis Aceves, MSIV
Joseph Nathaniel Chorley, MD
Veronica Tucci, MD JD
Baylor College of Medicine; Houston, TX

This post was peer reviewed.
Click to learn more.

An 18-year-old male presents to the emergency department after a fall and painful, twisting right ankle injury during a soccer game. The patient is unable to bear weight, and denies numbness and tingling. Initial exam reveals generalized ankle swelling and ecchymosis, with intact and equal sensation to light touch in bilateral lower extremities, brisk capillary refill, and a 2+ dorsalis pedis pulse. The patient is non-tender to palpation of bilateral malleoli, but has exquisite bony tenderness over his distal fibula. The proximal fibula is non-tender to palpation. There is also tenderness over the medial joint line. Ankle range of motion is limited due to pain, but the patient is able to wiggle his toes.

Sunday, October 16, 2016

Reflections on Mentorship

Author: Mary Haas, MD
AAEM/RSA President '16-'17
Originally Published: Common Sense September/October 2016

Mentorship has played a crucial role in my brief EM career. Perhaps, more importantly, it has also contributed to my personal and professional wellness. Realizing this, I asked myself a few questions. Why does mentorship matter? What makes a good mentor?

The term mentor originated from Homer’s Odyssey, as the name of the man entrusted by Odysseus, the king of Ithaca, to care for his son and household while he fought in the Trojan War. Following that example, a mentor is one who guides a junior colleague. Specifically a mentor should teach, advise, and share wisdom with their colleague. A mentor may provide personal advice, professional advice, or both. One useful definition of mentorship is “a process for the informal transmission of knowledge, social capital, and psychosocial support perceived by the recipient as relevant to career or personal development.”[1]

Thursday, October 13, 2016

The Poor Porphyrias Don’t Get Enough Respect in the Emergency Department

Image Credit: Wikimedia Commons
Authors: Kristen Pena, DO; Nicholas Mota, DO; Terrance McGovern, DO MPH
Emergency Medicine Resident Physicians
St. Joseph’s Regional Medical Center, Paterson, NJ

This post was peer reviewed.
Click to learn more.

All emergency physicians have had patients that arrive at the emergency department with 10/10 abdominal pain, coming in like a screaming banshee from the waiting room. We pursue and rule out the dangerous diagnoses that we don’t want to miss: abdominal aortic aneurysm, pneumoperitoneum, appendicitis, ischemic bowel, etc., but what happens when all the labs and imaging you ordered are normal? Perhaps it is a not so uncommon case of hypodilaudidemia, but is there something else more sinister that we should have in the back of our minds with these patients?

The eight-step process that is required for the biosynthesis of heme is something we rarely think of in emergency medicine, but can be the source of great concern for patients that suffer from one of the many porphyrias. There is a wide range of clinical entities that can manifest by a defect or absence of the multiple enzymes within this pathway; luckily, there are only four inherited and one acquired subtype that present acutely.

Acute intermittent porphyria (AIP) is the most common of these acute porphyrias occurring in 1-2/10,000 people, and most commonly in those of northern European descent.[1] Variegate porphyria (VP), hereditary coproporphyria (HCP), and aminolevulinic acid dehydratase deficient porphyria (ALAD-P) constitute the remaining inherited acute porphyrias; whereas, Plumboporphyria (also known as lead poisoning) is the only acquired form and acts at the same catalytic step as the ALAD-P porphyria.[1] The biochemical differences between the different acute porphyrias are not essential to know as they are not distinguishable in their clinical presentations, and the treatment is uniform for all of them.

Sunday, October 9, 2016

Maybe Grandma Was Right: Dilute Apple Juice for Pediatric Oral Rehydration

Image Credit: Pixabay
Author: Ashley Grigsby, DO PGY-3
Indiana University
Emergency Medicine/Pediatrics Residency

This post was peer reviewed.
Click to learn more.

Acute gastroenteritis is a common diagnosis for pediatric patients in emergency departments across the country. Although the cause is usually viral, successful treatment consists of adequate fluid hydration and supportive care through the course of the child’s illness.[1] The ability to keep a child hydrated through the illness is a major contributor to the successful outpatient management of these patients. There are oral rehydration solutions (ORS) available that have been recommended due to their ideal electrolyte concentrations, however, some children refuse to drink them because of the taste.[1] High sugar drinks, such as sports drinks, have also been thought to induce osmotic diarrhea and therefore have not been previously recommended for gastroenteritis.[1] Throughout my short career, I’ve had many parents tell me they give watered-down juice because “that’s what Grandma told me to do.” A recent study published in JAMA attempted to determine if half-dilute apple juice would be an acceptable oral rehydration option, and perhaps prove that grandmas sometimes do know best.

Thursday, October 6, 2016

Tox Talk: Calcium Channel Blocker Overdose

Image Credit: Flickr
Author: Erica Schramm, MS4
Cooper Medical School of Rowan University
Originally Published: Modern Resident April/May 2016

Calcium channel blockers (CCBs) are used to treat a variety of common conditions such as hypertension, cardiac dysrhythmias and headaches. But use of CCBs is not without risk, particularly in cases of toxicity and overdose. CCBs are the ninth most widely prescribed class of drugs in the United States, accounting for an estimated 92 million prescriptions filled per year. The American Association of Poison Control Centers’ 2008 data noted over 10,000 human exposures to CCBs and 60 deaths associated with CCB overdose.[1]

What are the signs of CCB overdose?
The most common signs of CCB overdose are hypotension, sinus bradycardia, and shock. Other associated signs of overdose are hyperglycemia, pulmonary edema, myoclonus, dizziness, syncope, seizures, nausea, vomiting and acute kidney injury. Sustained release formulations can cause initial signs of overdose up to 12 hours post-ingestion. Diagnosis is clinical and thorough history taking is key to identifying CCB overdose. Patients taking CCBs who present with signs of toxicity should be questioned about intentional or unintentional overdose. Physicians should also inquire about details of how and when the patients take their medication to identify potential overdose.[1]

Sunday, October 2, 2016

SCUBA and Diving Injuries

Image Credit: Flickr
Author: Daniel F. Leiva, MS OMSIV
Nova Southeastern University
Originally Published: Modern Resident, December/January 2015-2016

SCUBA, an acronym for self-contained underwater breathing apparatus, is a system for recreational diving practiced by hundreds of thousands of people across the world, but is not without its risks. In 2012, the incidence of SCUBA-related injuries ranged from seven to 35 per 10,000 divers and from five to 152 injuries per 100,000 dives. Insufficient training and preexisting medical conditions were common factors that played a role in injury, and drowning was the most common cause of death.[1] While risks of trauma, hypothermia and submersion injury also exist, those more specific to diving including barotrauma, decompression sickness and nitrogen narcosis will be discussed in this piece and the next.

Boyle’s law describes the relationship between pressure and volume of a system: as pressure increases (for example: descent), the volume of gas decreases. The opposite occurs during ascent. An example of this mechanism is the discomfort felt by divers and swimmers within their ears when descending and ascending in water. During descent, the increase in external water pressure causes a decrease in middle ear volume, a space enclosed by the tympanic membrane and the Eustachian tube. This causes pain in the form of middle ear squeeze or otic barotrauma, and is why divers and swimmers must frequently perform maneuvers to open their Eustachian tube. This is done by yawning, swallowing, jaw thrusting, head tilting and performing the Valsalva maneuver. For people who have trouble achieving equilibrium, advanced techniques employing a combination of moves may be necessary. Without equalization divers run the risk of tympanic membrane rupture or inner ear barotrauma leading to a perilymph fistula, which requires a referral to an otolaryngologist.

Thursday, September 29, 2016

The Dying Gut: Identifying Patients with Intestinal Ischemia

Image Credit: Flickr
Author: Ashley Grigsby, DO PGY-1M
Indiana University
Originally Published: Modern Resident, February/March 2015

Intestinal ischemia is a serious illness with severe and life threatening complications. The likelihood of developing complications improves with earlier diagnosis. However, early diagnosis can be difficult, especially in the setting of no known risk factors.

Acute mesenteric ischemia is any process that causes hypoperfusion to the small intestine. The large intestine can also become ischemic from hypoperfusion, usually referred to as ischemic colitis.[1] Intestinal hypoperfusion can be due to arterial or venous obstruction from acute embolism, thrombosis or low-flow states.

We all learned in medical school, “abdominal pain out-of-proportion to physical exam” means acute mesenteric ischemia. However, in real-life situations, many emergency department patients presenting with abdominal pain would fit into this category. The question becomes, who gets a workup and who does not? First, a careful history should be performed; about one third of patients with acute intestinal ischemia will have a previous history of embolic event.[1] Patients with peripheral vascular disease, cardiac disease, atrial fibrillation, hypercoaguable states and hypovolemic states are all at increased risk of developing intestinal ischemia.[1]

Sunday, September 25, 2016

Shiitake Mushroom Dermatitis: A Case Report

Image Credit: Wikimedia Commons
This post was peer reviewed.
Click to learn more.
Megan Litzau, MD
Emergency Medicine Resident
Indiana University
AAEM/RSA Social Media Committee

A 31-year-old African American male presented with an erythematous rash of 8 days duration. The patient had been seen in the emergency department one week prior for the rash. At that time, he was given Eucerin cream, prednisone taper, and diphenhydramine. The patient returned one week later as the rash had not improved. Upon examination, the patient had a violaceous, linear rash across his torso and all of his extremities. The linear lesions appeared as though the patient had been scratching. However, he adamantly denied scratching and was unable to reach several of the lesions on examination. Upon further questioning, the only recent change in the patient’s habits was consuming a large amount of uncooked shiitake mushrooms 9 days prior. Approximately 12 hours after consuming the mushrooms, the rash appeared. Since that time, the rash had persisted. The rash was initially erythematous and had faded to a violaceous color during the course of the rash. The patient noted the rash to be constantly pruritic, which prompted his return visit to the emergency department. The patient also noticed that the rash and itching got worse when he was working outdoors. 

Thursday, September 22, 2016

When Back Pain is More Than Musculoskeletal: The Red Flags of Spinal Epidural Abscesses

Image Credit: Flickr
Author: Kaitlin M. Fries, OMSIV
Ohio University Heritage College of Osteopathic Medicine

Originally Published: Modern Resident April/May 2015

As an emergency medicine physician it is important to always think about the worst-case scenario. What is the worst thing that could explain this patient’s symptoms? What could potentially kill this patient if not quickly identified and appropriately managed? For common complaints such as back pain, this mindset can easily be over looked. No matter how simple and straightforward a case of back pain may seem, it is still important to ensure there are no red flags. One of the most concerning worst-case scenarios of low back pain is that of a spinal epidural abscess.

Recent studies have shown that the number of cases of spinal epidural abscesses is rising due to an increase in IV drug abuse and spinal surgeries.[2,3] If overlooked, this infection can cause a rapid decline and lead to sepsis, meningitis and permanent paralysis.[3] With a mortality rate as high as 20%, it is vital to catch this infection on the patient’s first presentation.[2,3] Diagnostic delays are far too common in these patients. In 2003, a retrospective study looked at 63 cases of spinal epidural abscesses. It was found that 75% of these cases had multiple ED visits or were admitted without a clear diagnosis.[1]

Sunday, September 18, 2016

More Than Meets the Eye: The Subtle Presentation of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) in the Emergency Setting

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

Authors: Taraneh Matin, OMS-IV MA; Victoria Comeau, DO; Daniel F. Leiva, DO, MS
Nova Southeastern University

Rashes in the emergency department can often be overlooked as benign skin conditions. Being able to differentiate between life-threatening and non-life-threatening rashes is vital for the emergency physician. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) comprise a spectrum of the same subset of vesiculobullous diseases with an incidence that ranges from 0.4 to 7 per million per year, with a mortality that ranges from 1-5% for SJS and 25-40% for TEN.[1,2] The majority of cases are caused by medications while a lesser extent are caused by infections.[1] Typical causative agents include allopurinol, antibiotics, nonsteroidal anti-inflammatory drugs, and anticonvulsants.

Although it is a fatal condition with serious systemic complications, SJS presents with very subtle and often times overlooked or misdiagnosed prodromal symptoms including fever, painful eyes, or pain with swallowing. These are often mistaken for a benign viral illness. When evaluating a patient with these findings, obtaining a thorough history is important due to the high correlation of these symptoms with the onset of a new medication. The cutaneous manifestations present within days of the initial symptoms as ill-defined, erythematous macules or purpura beginning on the trunk and spreading outward. The oral, genital, and/or ocular mucosa are involved in 90% of cases as well as frequent involvement of the palms and soles.[3] With progression, vesicles and bullae form and the skin begins to slough leading to a positive Nikolsky sign on examination.[5-7] Ocular involvement can present as erythema, conjunctivitis, keratitis, and endophthalmitis and has been seen in 50-80% of cases. One-third of these cases can lead to vision impairing ocular sequelae.[8] Other organ systems including the gastrointestinal or pulmonary systems may be involved. It is important when evaluating these patients to note the body surface area (BSA) involved. SJS has a BSA involvement of <10% while TEN has a BSA involvement of >30%. Risk factors include co-morbid HIV infection or an immunocompromised state.[6]

Thursday, September 15, 2016

Drug Choice for Procedural Sedation: Propofol vs. Ketamine

Image Credit: Flickr
Author: Randy Kring, MSIV
Tufts University School of Medicine

Procedural sedation is frequently performed in the emergency department, whether it is for electrical cardioversion, closed joint reduction or abscess incision and drainage. Although the focus in these cases is often on the procedure, smart preparation for procedural sedation and an understanding of the different strategies that can be used is vitally important.

The goal of procedural sedation is to provide moderate sedation and analgesia while preserving the patient’s protective airway reflexes, adequate ventilation and cardiovascular function. Relative contraindications for procedural sedation may include advanced age, significant medical comorbidities such as CHF or COPD or signs of a difficult airway.[1] Recent food intake is not a contraindication for procedural sedation, but aspiration risk should be assessed and minimized whenever possible.[2] Many drugs can be used for procedural sedation, including midazolam, etomidate, propofol and ketamine. Which drug is “the best?”

Propofol, a sedative and amnestic, has onset in about 40 seconds and duration of action of about six minutes. Common side effects include pain at the injection site, hypotension and respiratory depression.[3] Ketamine, a dissociative anesthetic that provides sedation, amnesia and analgesia, has onset in about 30 seconds and duration of action of about 10 to 20 minutes. Common side effects include agitation on emergence, nausea and (rarely) tachycardia and hypertension.[4]

Sunday, September 11, 2016

Clinical Pearl: Procalcitonin and Lower Respiratory Tract Infections

Image Credit: Flickr
Author: Jordan Kaylor, MD PGY4
Northwestern/McGaw Medical Center

Procalcitonin (PCT) is a serum biomarker that, when paired with clinical judgment, may help guide management of lower respiratory tract infections (LRTIs) in the emergency department (ED). Procalcitonin levels can help clinicians distinguish between bacterial and viral infections and might subsequently guide decisions to initiate or discontinue antibiotics. Procalcitonin is a prohormone of calcitonin. It is an acute-phase reactant synthesized in many tissues and released in response to cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-α.1 Normal serum concentrations are <0.05ng/mL, but in bacterial infections, PCT increases to detectable levels within three to four hours (earlier than ESR or CRP).[1] Elevations are not seen in noninfectious inflammatory conditions or viral infections, but are possible in Addisonian crises, malaria, severe fungal infections and medullary thyroid carcinoma.[1] In viral infections, interferon (INF)-ɣ probably decreases PCT release, leading to lower or undetectable serum levels.[2]

Thursday, September 8, 2016

Exploring an interest in Wilderness Medicine

Image Credit: Flickr
This post was peer reviewed.
Click to learn more.
Author: Josh Symes, MD
University of Mississippi Medical Center

Wilderness Medicine affords the opportunity to combine passion for the outdoors with passion for medicine. Many people pursue wilderness medicine to be better equipped to use their medical training and expertise in medical situations they may encounter outside the hospital such as fishing, backpacking, mountain biking, etc. Others apply the training in lower resource settings on medical service trips abroad. Some make it a significant part of their career in medicine. It also provides an excellent teaching platform (ex. making the physiology of altitude more interesting). WM can provide opportunities for team building exercise through scenario-based training in medical school or residency. Some medical schools and residency programs have wilderness medicine built into the curriculum, but many do not. This blog entry aims to provide a primer of ways to explore an interest in wilderness medicine.