Top 10 Most Read Posts of 2016

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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 info@aaemrsa.org 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

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]

Asymptomatic Pediatric Fresh Water Drowning: How Long to Observe?

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

This post was peer reviewed.
Click to learn more.

Case:
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.


Introduction:
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?

Alcohol Withdrawal: Complications and Treatment

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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]

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; ebmedicine.net

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, www.ebmedicine.net

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

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.

References:

1. Shoulder Girdle Fractures And Dislocations. EB Medicine. Web. 20 May 2014. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=120&seg_id=2471
2. Stanislavsky A. Posterior Shoulder Dislocation. Radiopaedia. Web. 20 May 2014. http://radiopaedia.org/cases/posterior-shoulder-dislocation
3. Tosif, S. Posterior Shoulder Dislocation. Life in the Fast Lane. Web. 20 May 2014. http://lifeinthefastlane.com/posterior-shoulder-dislocation/

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?

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.

Decreasing Door to Doc Time: The Online Waiting Room

Image Credit: Flickr

This post was peer reviewed.
Click to learn more.

Author: 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]