Sunday, August 28, 2016

Ocular Emergency: Retinal Artery Occlusion (RAO), A Non-Ophthalmologist Approach to Initial Treatment and Referral

Image Credit: Flickr

This post was peer reviewed.
Click to learn more.

Author: Fernando Pellerano, MS-V
Universidad Iberoamericana (UNIBE) School of Medicine

Retinal artery occlusion (RAO) is considered a true ophthalmic emergency requiring immediate assessment and initiation of treatment. Appropriate initial emergency management may be the most important factor in determining visual outcome.[1]

RAO can either be central or branch. Central retinal artery occlusion (CRAO) results from a blockage anywhere between the origin of the artery (off the ophthalmic artery), to its first branch at the entry to the retina.[2] The site of obstruction is therefore not generally visible on ophthalmoscopy and in most cases the entire retina is affected. Branch retinal artery occlusion (BRAO) occurs when the blockage is distal to the optic nerve, within the visible vasculature of the retina. A BRAO can involve as large an area as three quarters of the retina, or as small an area as just a few micrometers.[1]

Epidemiology and Etiology
Incidence of RAO is approximately one per 100,000 per year and increases with age, peaking in the sixth and seventh decades. The central retinal artery is more commonly blocked than the branch retinal artery. [1] Although many systemic diseases are associated with RAO, more than 50 % of all affected patients will manifest no apparent systemic or local causes for the retinal disease.[2] Possible Etiology and Risk Factors for both CRAO and BRAO are listed in Table 1 and Table 2.[3, 4]

Thursday, August 25, 2016

The Salesman-Doctor

Image Credit: Flickr
Author: Edward Siegel, MD MBA
RSA Secretary-Treasurer '13-'14
Originally Published: Common Sense March/April 2014

I remember one of the early classes at my business school, when the lecturer asked how many of the students had been in sales prior to starting their MBA. I was one of the minority of students who raised their hands, as most of my classmates were in fields like engineering, consulting, and finance before starting their MBA program. Then the lecturer asked how many of us thought we would be in sales after graduating with our new degree. Though my memory is hazy, I think I was the only person to raise his hand. The lecturer asked me why I wanted to be in sales, and I told her that it wasn’t because I wanted to be in sales, but that I was going to be required to be in sales — that all of us, no matter what our background, skills, or abilities — were at one point going to have to sell ourselves to get jobs, convey the value of our ideas, and work with others. I went on to say that I had been working in sales in one form or another since I was a teenager, and that being a salesman was nothing to be ashamed of.

Sunday, August 21, 2016

Bradykinin-mediated Angioedema

Image Credit: Wikimedia Commons
This post was peer reviewed.
Click to learn more.
Authors: Samuel Bergin, MD, University of Nevada School of Medicine

Davis Erickson MD, San Antonio Military Medical Center

The emergent management of angioedema presents as a challenge in the emergency department (ED). While the vast majority of cases are histamine-mediated allergic reactions, there remains a portion of cases mediated by bradykinin, which, do not respond to epinephrine, antihistamines, and steroids. Bradykinin-mediated angioedema broadly divides into three types: hereditary angioedema (HAE), angiotensin-converting enzyme inhibitor induced (ACEI-AAE), and acquired angioedema (Figure 1).[1-3]

Thursday, August 18, 2016

Making the Most of Third Year

Image Credit: Flickr
Author: Mary Calderone, MS3
AAEM/RSA Medical Student Council President '13-'14

Originally published: Common Sense January/February 2013

Aside from intern year, the third year of medical school is traditionally considered one of the most formative experiences in a physician’s life. Suddenly, we’re propelled from passively sitting in a lecture hall to thinking on our feet. Our thought process now has the potential to impact how we care for a patient, rather than just how we answer an exam question. Just as we impact the lives of patients, patients also impact us in powerful ways. We begin to make decisions about the future of our medical careers, ruling out certain specialties and exploring others further. As we navigate these new challenges, we gain an increasingly keen sense of self-awareness. Our strengths and weaknesses stare us straight in the eyes, whether we realize them through self-reflection, hear about them from one of our senior colleagues, or experience some combination of the two. We start to contemplate our life goals and our requirements for happiness and well-being. By the time we’re fourth years, we’re expected to have decided upon an area of medicine after a whirlwind of speed-dating with different specialties.

While many students enter medical school with some idea as to their future specialty, studies have shown that the majority of students change their minds. I entered my M1 year with a passion for emergency medicine that has only continued to grow as I’ve gained more clinical experience. Entering medical school with relative confidence in the area of medicine you wish to practice has its advantages and disadvantages. On one hand, you can direct your efforts toward a concrete goal. You can lay the foundation for pursuing a career in a given area of medicine early in your training. You can participate in activities and opportunities that prepare you well. You can find the right mentors. On the other hand, you may fail to consider all of the exciting possibilities for your career, thereby prematurely closing your mind to an area of medicine that you might otherwise have loved. Your bias toward one specialty may cloud your judgment of whether or not you actually fit well into its culture. You may even disregard the importance of a clerkship because you think it won’t ultimately be relevant to the type of medicine you plan to practice, thereby cheating yourself of a fulfilling and valuable experience.

Sunday, August 14, 2016

Reanimare: View from a Romanian Resuscitation Bay

Author: Wit Davis, DO MS MPH
PGY2 Baystate Medical Center
Board Member of Equal Health

Your three-person resuscitation bay has four boarding intubated patients when the woman that you just stabilized becomes tachypneic to the 70’s with an O2 sat of 65% on non-rebreather. As you get her onto CPAP ventilation, the overhead alert announces that the helicopter has landed with a trauma arrest. That’s when you hear someone yelling from the adjacent CT scanner, “Ajuta! Ajuta-ma!”

At least that’s what you think they said. After all, the cries of a CT tech when a patient codes in their scanner is universally understood, and you’re in Romania.

Thursday, August 11, 2016

End of Life Care in the Emergency Department

Image Credit: Flickr
Author: Andrew W Phillips, MD MEd
Clinical Fellow, Division of Critical Care
Stanford University

We’ve all been there too many times: A terminally ill patient is rushed to the emergency department (ED) by ambulance in distress, either missing the Physician Orders for Life Sustaining Treatment (POLST) or the family instructs EMS to “do everything.” The ED staff begins to stabilize the patient: inotropes and pressors, central line, intubation, arterial line, pressure bagging, fluids — and then they are told to stop.

Now what? How do you allow the acutely ill patient to pass comfortably with dignity after you just did so many invasive, painful procedures? If there is no other place for the patient but the ED, here are some recommendations, based on literature and my personal experience, to make the patient’s final moments as comfortable as possible.

Preparation [1]
  • Put the patient in a private room. The resuscitation bay is not the place to transition a patient to comfort care.
  • Get social work, the chaplain, and/or palliative care involved to help with the “small” things that are meaningful (water, chairs for the family, calling family members, etc.) so you can focus on the patient.
  • Determine what the most life-threatening physiology is for that patient – it is usually hypotension versus hypoxemia.

Sunday, August 7, 2016

Reversible Posterior Leukoencephalopathy Syndrome

Author: Robert Adams OMSIII and Wayne Lindsay OMSIII
Campbell University School of Osteopathic Medicine

A 24-year-old African American female with a history of polysubstance abuse presented to the emergency department in status epilepticus. The patient was given Midazolam by EMS. She arrived unable to protect her airway and was therefore intubated and sent for a non-contrast head CT. The patient’s mother denied a history of seizures, but reported her daughter complained of a headache earlier that afternoon. Past medical history was significant for SLE, depression, fibromyalgia, and medication non-compliance. Initial vitals revealed she was afebrile, pulse of 87, blood pressure of 150/96, and respiratory rate of 30. Within the first hour, her blood pressure climbed to 167/120 and her pulse to 153. Her initial CT scan is shown below:

Image: Radiopedia

Which of the following treatments will most likely improve the clinical outcome in this patient?

A. Tissue plasminogen activator

B. 325 mg Aspirin and physical therapy consult when stable

C. Immediate blood pressure lowering

D. Broad spectrum IV antibiotics with lumbar puncture

Thursday, August 4, 2016

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

Originally Published: Common Sense, March/April 2016

Author: Gregory K. Wanner, DO PA-C
Senior Emergency Medicine Resident, Thomas Jefferson University

Author: Andrew W. Phillips, MD Med
Critical Care Fellow, Stanford University, Division of Critical Care
Staff Emergency Physician, The Permanente Group

In “Improving Efficiency for Residents, Part 1” (Common Sense, Mar/Apr 2016), we discussed patients per hour (pt/hr), factors influencing efficiency, and the value of efficiency. In this article we will share advice on how to safely improve efficiency.

Recap of Part 1
Our review showed that PGY-1 residents average between 0.73 and 1.06 pt/hr, PGY-2 residents range from 0.85 to 1.33 pt/hr, and senior residents see between 1.05 and 1.41 pt/hr.1 These numbers may seem a little low, but they are averages across several studies that include different shift lengths and practice environments. Some of the factors that influence efficiency are shift length (longer shifts appear to reduce productivity) and distractions (emergency physicians are interrupted every 5.8 minutes and are required to unexpectedly switch tasks every 8.7 minutes).2,3

Speed versus Efficiency
Learning to be efficient is more important than learning to be fast, and there is a difference. The number of patients seen per hour, while important, does not tell the whole story. Avoiding discussions with patients, minimal documentation, and hurrying through procedures are not appropriate ways to increase patients per hour. Efficiency, however, makes use of all available resources to help move patients through the ED without cutting corners. It takes practice — lots of practice. As residents, we can all improve our efficiency.