Wellness and Resiliency Summit

2017 Wellness and Resiliency Summit

Authors: Ashely Alker, MD, AAEM/RSA President 2017-18 and Robert Lam, MD FAAEM, AAEM Wellness Committee Chair
Originally published: Common Sense May/June 2017

Emergency medicine has historically had the highest rate of reported burnout among all specialties. In the 2017 Medscape Lifestyle Survey, 59% of emergency physicians self-identified as “burned out.” A survey conducted by the University of North Carolina-Chapel Hill showed that approximately 70% of residents met criteria for burnout. In one survey residents were asked about their quality of life, and 15% reported “life is as bad as it could be.”

In January, for the first time ever, all national emergency medicine organizations convened in Dallas for an Emergency Medicine Wellness and Resiliency Summit. In a spirit of collaboration, wellness champions and emergency medicine leaders came together to find solutions for the ongoing crisis in physician wellness and resilience. In attendance were representatives from the Council of Emergency Medicine Residency Directors (CORD), American Academy of Emergency Medicine (AAEM), Society for Academy of Emergency Medicine (SAEM), Association of Academic Chairs of Emergency Medicine (AACEM), American College of Osteopathic Emergency Physicians (ACOEP), Accreditation Council for Graduate Medical Education (ACGME), AAEM Resident Student Association (AAEM/RSA), Emergency Medicine Residents’ Association (EMRA), American College of Emergency Physicians (ACEP), American Board of Emergency Medicine (ABEM), and the American Hospital Association (AHA).

Update on Mechanical Ventilation in the ED

Authors: Robert Brown, MD; Adeolu Ogunbodede, MD; Megan Donohue, MD; Hannah Goldberg, MD; Erica Bates, MD
Editors: Michael C. Bond, MD FAAEM; Kelly Maurelus, MD FAAEM
Originally Published: Common Sense November/December 2017

An increasing number of ED patients require critical care time and ICU admission.1 The ED length of stay for these patients has increased by 60 minutes and the median boarding time is now over five hours with nearly a third of patients waiting more than 6 hours.[1,2] Mortality of critically ill patients, including mechanically ventilated patients, in the ED correlates with increased ED length of stay.[3] Instead of just making the decision to intubate, ED physicians must now manage ventilators for critical hours. This review discusses some of the risks, best practices, and future directions of ED ventilator management.

Young, Black & A Doctor: The Job Search

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Author: Joshua A. Sherman, MD
Clinical Faculty, Department of Emergency Medicine, Advocate Christ Medical Center
Originally published: Common Sense November/December 2017

My story isn’t unique, but that in and of itself makes it worth writing. My name is Joshua Sherman; a New Orleans native, Chicago transplant and newly-minted Attending Emergency Physician in a busy Level 1 Trauma Center on Chicago’s south side. I, like most everyone reading this, spent seemingly endless years, days and hours in pursuit of this career and have yet to stop replaying in my mind the feeling that I felt as I walked across the stage on June 8th, 2017, to receive my final ‘diploma’ (aka residency completion certificate). It was the uncertainty of the months immediately before and after this date, however, that have continually been at the forefront of my thoughts and that, ultimately, contributed to my desire to write this.

Dying to Save Lives

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Author: Ashely Alker, MD MSc, PGY-3
2017-18 AAEM/RSA President
Originally Published: Common Sense November/December 2017

I remember the day I was accepted to medical school. It was one of the happiest days of my life. The first six months of medical school I fought against the imposter syndrome that plagued my incredible reality: I was going to be a doctor. To this day I feel privileged to do my job.

The only match to the privilege of being a physician is the challenge. The immense responsibility for human life, sleep deprivation, and loss of balance are challenges that plague all physicians. I have questioned my career choice and even considered quitting. And just as studies have shown that diabetes, hypertension and hyperlipidemia are risk factors for coronary artery disease, the stress, isolation, and sleep deprivation of the physician lifestyle are a perfect storm of precursors to depression.

Updates in Geriatric Emergency Medicine

Authors: Phillip Magidson, MD MPH; David Bostick, MD MPH; Erica Bates, MD; Robert Brown, MD
Edited by: Jay Khapde, MD FAAEM and Michael C. Bond, MD FAAEM

Between the 2000 and 2010 U.S. Census, the population over age 65 increased at a higher rate that the overall U.S. population. For the purposes of this article, we will use age greater than 65 as the definition of a geriatric patient. By 2050, there will be over 83 million geriatric Americans, double the number from 2012.1 Currently, over 15% of emergency department (ED) visits, equaling 20 million total visits, are from geriatric patients.2 These numbers are certain to increase and will represent a unique challenge to the U.S. health care system, specifically to the ED. In this month’s “Resident Journal Review,” we focus on the evaluation, diagnosis, and treatment of geriatric patients presenting to the ED.

Anaphylaxis in a Nutshell

Authors: Eli Brown, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD; Lee Grodin, MD
Edited by: Jay Khadpe, MD FAAEM; Michael Bond, MD FAAEM
Originally Published: Common Sense January/February 2015

The emergency department (ED) is the most common place for treatment of anaphylaxis. While epinephrine is clearly indicated, the Emergency Medicine Practice Update Guidelines of 2011 state, “Despite a unified consensus around epinephrine as first-line treatment, patients are more likely to receive corticosteroids and antihistamines.” Prospective randomized controlled trials comparing medications for the treatment of anaphylaxis in humans are lacking, thus guidelines are based primarily on theory and anecdotal evidence. This summary examines various therapies and evaluates recommended ED observation times and dispositions.

The Adult Learner Part 2: Where the Mark is Moving

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Author: Andrew Phillips, MD
Originally Published: Common Sense September/October 2017

Last month we explored the arguments for and against adult learning theory. We began with medical educators’ attraction to the subject, evaluated the philosophical and psychological concepts behind it, and concluded that it is unlikely that there is a difference in how adults and children learn, making learning theories specific to adults unproductive for learner and educator alike. In this article we will evaluate the alternatives that are most popular and best supported in cognitive and educational psychology, and that have early support in medical education literature.

Toxicodendron Dermatitis

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Authors: Taraneh Matin, DO & Daniel Leiva, DO
Larkin Community Hospital and Baystate Medical Center

Exposure to species in the genus Toxicodendron accounts for the most common cause of plant-induced allergic contact dermatitis in the United States and more plant-dermatitides than all of the other families of dermatitis-causing plants combined.[1,2] This exposure is a common complaint seen in the emergency department with an estimated 25-40 million people affected every year.[3] Of note, Rhus dermatitis is an antiquated term for these dermatitides; members of the genus Rhus do not cause dermatitis.

The significant members of the Toxicodendron genus include poison ivy, poison oak, and poison sumac.[4] While it is possible to find these in many areas of the United States, they are not found in deserts, rainforests, or at altitudes higher than 1500 meters.

International Emergency Medicine

Image Source: Pixabay

Author: Ryan Shanahan, MD
2010-2011 AAEM/RSA President
Originally Published: Common Sense Spring 2011

I recently returned from a trip to Haiti with a group of pediatric residents from Johns Hopkins. The person who runs the trip is a pediatric emergency medicine attending, and she invites the
emergency medicine residents along. It was, in short, an eye-opening trip. It also caused me
to reflect on the fledgling field of international emergency medicine and, in doing so, I want to
highlight some of the efforts of the Academy in this regard.

To say that Haiti has a health care system is to stretch the definition of those words. To say that they have an emergency medical system would simply be false.

Joint Statement from the Emergency Medicine Community on the Loss of Dr. Kevin Rodgers

FOR IMMEDIATE RELEASE
November 27, 2017

Contact: Kay Whalen (kwhalen@aaem.org)
Executive Director
Phone: 800-884-2236


Milwaukee, WI - The following joint statement was released today by the American Academy of Emergency Medicine (AAEM), the AAEM Resident and Student Association (AAEM/RSA), the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the American College of Osteopathic Emergency Physicians (ACOEP), the Council of Emergency Medicine Residency Directors (CORD), and the Society for Academic Emergency Medicine (SAEM).

The emergency medicine community would like to offer our heartfelt condolences to the family, friends, and colleagues of Dr. Kevin Rodgers.

Dollars & Sense - Financial Planning for EM Residents

Author: Joel M. Schofer, MD MBA RDMS FAAEM
2014 Secretary-Treasurer, AAEM
2013-2014 President, Virginia AAEM
Commander, U.S. Navy Medical Corps
Originally Published: Common Sense July/August 2014

Dr. Schofer offers some excellent advice below, and his ongoing series on basic personal finance for emergency physicians is shaping up to be one of the best things Common Sense has published under my editorship. I hope all our residents and new attendings read it carefully.

Although I have done more things right than wrong, I have made a few painful financial mistakes in my 55 years. One of the two worst mistakes I made was buying "variable universal" life insurance rather than term insurance — one of the topics Dr. Schofer mentions below. The other was trading in an overseas wine futures market. That ended badly...

There is one other thing I feel compelled to mention. While most families ought to have 3-6 months of income saved for emergencies, as Dr. Schofer says, I believe emergency physicians should have 6-12 months of income saved in a fairly liquid, easily accessible form. Every single emergency physician is virtually guaranteed to lose at least one job unexpectedly, and most of us will lose more than one. Be prepared.

— Common Sense Editor

Non-Invasive Positive Pressure Ventilation in the Treatment of Acute Respiratory Distress in the Emergency Department

Authors: Theodore J Segarra, Lee Grodin, Taylor Conrad, Ray Beyda, Kelly Maurelus, Michael C. Bond
Originally Published: Common Sense September/October 2017

Over the last decade, non-invasive ventilation (NIV), including both bilevel positive airway pressure (BPAP) and continuous positive airway pressure (CPAP) modes, has become an important tool in the management of ED patients with respiratory distress due to acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. Many studies have shown its utility in successfully reducing the need for intubation and reducing length of stay (LOS) in the ICU. Given these positive results, interest in NIV for patients with undifferentiated respiratory distress has increased but very few studies have compared the outcomes of using NIV for other causes of acute respiratory distress, such as asthma, pneumonia, malignancy, or interstitial lung disease. This review aims to discuss the current literature on the non-standard use of NIV for for other causes of respiratory distress in the emergency setting and to identify potential areas for further research.

Updates in Pharmacology: Interactions and Adverse Effects of Psychiatric Medications

Authors: Erica Bates, MD; Philip Magidson, MD MPH; Robert Brown, MD; Megan Donohue, MD; Akilesh Honosage, MD
Editors: Michael C Bond, MD FAAEM; Kelly Maurelus, MD FAAEM
Originally Published: Common Sense March/April 2017

Introduction
Over the past decade, the number of psychiatric medications dispensed has increased dramatically and now annually numbers in the tens of millions. As Emergency Physicians now frequently encounter patients on psychiatric medications, understanding potential complications and potentially life threatening reactions is necessary. This journal review covers common potential side effects, adverse reactions, and drug-drug interactions of various psychiatric medications commonly found in the ED.

Advancing the Need to Reduce Unnecessary Antibiotic Treatment by Using the Biomarker Procalcitonin

Authors: Raymond Beyda, MD; Jackie Shibata, MD; Lee Grodin, MD; and Theodore Segarra, MD
Editors: Kelly Maurelus, MD FAAEM and Michael C. Bond, MD FAAEM
Originally Published: Common Sense January/February 2017

ED physicians frequently treat and admit patients for infectious diseases. Judicious use of antimicrobial therapy is important in order to avoiding the development of antimicrobial resistance and adverse drug effects. Procalcitonin (PCT) is one of several bbiomarkers which may be useful in decreasing unnecessary antibiotic therapy. Specifically, PCT levels should be low for viral, as opposed to bacterial, infections. Procalcitonin has been studied as both a diagnostic and prognostic marker in various types of systemic and organ-specific infections. The potential for PCT to reduce unnecessary antimicrobial therapy has been shown in several observational and randomized controlled trials performed in outpatient, inpatient, and ICU environments. The most robust evidence is in sepsis and pulmonary infections. Here we review some of the evidence behind the use of PCT in acute infectious disease management.

Acute Heart Failure

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Image Credit: Pixabay

Author: Daniel F. Leiva, DO, MS
Baystate Medical Center

Acute heart failure is a common and potentially life-threatening disorder the emergentologist should know well. In 2006 there were 5.1 million people living with heart failure in the United States and an estimated 23 million people worldwide.[1,2] Patients can present to the emergency department as a new, acute failure or an acute-on-chronic exacerbation. They typically complain of dyspnea, fatigue, paroxysmal nocturnal dyspnea, or orthopnea, the latter two of which are highly sensitive and specific.[3] Additional symptoms may include cough, chest pain, palpitations, tachypnea, peripheral edema, weight gain, or decreased exercise tolerance, depending especially on the presence of a precipitant. These can include volume excess, especially in renal or liver failure patients, sudden hypertensive states, acute myocardial infarction, myocarditis, pulmonary embolus, excessive exertion in a deconditioned state, changes to drug therapies, including the addition or removal of drugs or changes in dosages, and substance abuse.[3] The most important piece of history to establish in a patient is a previous diagnosis of heart failure. Consideration should be given to systolic dysfunction/heart failure with reduced ejection fraction (HFrEF) versus diastolic dysfunction/heart failure with preserved ejection fraction (HFpEF); left-sided versus right-sided heart failure; and high-output versus low-output failure, which can change the acute management of the patient.[4] Previous echocardiogram records may be beneficial in making this determination if available.

Spinal Epidural Abscess vs. Cauda Equina Syndrome

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Image Credit: Wikipedia

Author: Patrick Wallace, OMS-IV
Rocky Vista University College of Osteopathic Medicine
AAEM/RSA Education Committee

Spinal Epidural Abscess
Spinal epidural abscess (SEA) is a potentially debilitating and life-threatening cause of low back pain. It occurs in 0.2 to 2 cases per 10,000 hospital admissions.[1-3] However, recent articles note the incidence is increasing as much as five-fold.[4,5] SEA most commonly occurs in the thoracic and lumbar regions.[4,6] The difficulty in diagnosing an SEA is due to the nonspecific symptoms that often mimic the more common benign low back pain complaints seen in the emergency department. Making the diagnosis prior to the development of neurological symptoms is rare, so this cause should always be considered in the differential.

The Challenge of Identifying a Septic Joint

Authors: Raymond Beyda, MD; Lee Grodin, MD; Jackie Shibata, MD; Ted Segarra MD
Editors: Kelly Maurelus, MD FAAEM and Michael Bond, MD FAAEM 
Originally Published: Common Sense May/June 2017

The ED evaluation of patients with acute monoarthritis is often challenging given the broad differential diagnosis and significant morbidity which can result from missed septic arthritis (SA). The following articles aim to simplify the work-up of the undifferentiated hot and swollen joint.

Updates in the Emergency Department Management of Acute Liver Failure

Authors: David Bostick, MD MPH; Megan Donohue, MD; Robert Brown, MD; and Nicholas Santavicca, MD
Edited by: Michael C. Bond, MD FAAEM and Kelly Maurelus, MD
Originally Published: Common Sense July/August 2017

Introduction
Patients with chronic liver disease and acute liver failure have disease specific needs for which Eps must be cognizant. Below we review topics related to acetaminophen hepatotoxicity, use of rifaximin and lactulose in hepatic encephalopathy, and thromboelastography (TEG) directed transfusion in patients with liver disease requiring procedures.

Communicate Your Way to Better Patient Satisfaction

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Author: Bill Christian, MS-III
Ross University School of Medicine
AAEM/RSA Social Media Committee

Patient satisfaction has become more important recently for various reasons. Surveys have been developed to measure patients’ perspective of their hospital care. Such surveys ask about patients’ communication with various staff, experience in the hospital, and their overall rating.[1] While certain aspects of patient satisfaction has been studied in the past, performance on the surveys is now being coupled to insurance reimbursements, further encouraging the study of how to please patients.

Never Trust a Norwood: Emergency Management of the Sickest Congenital Heart Patients

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Author: Ashley Grigsby, DO, PGY-4
Indiana University
RSA Social Media Committee Member

For many emergency physicians, the scariest patient to come through the doors is the crashing neonate. But make that same neonate a child with congenital heart disease (CHD) and you have a recipe for the so-called, “Code Brown.” One of the most unstable types of CHD is Hypoplastic Left Heart Syndrome (HLHS), a ductal dependent lesion that can be stabilized in the first few weeks of life with intravenous prostaglandins while awaiting surgical management. All patients with HLHS or single ventricle physiology, will require a stage 1 palliative surgery which is usually the Norwood procedure. Norwood patients are, arguably, the sickest of all CHD kids and are the most vulnerable to sudden death, leading many to live by the mantra, “Never trust a Norwood.”

Preparing for the Worst

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Author: Aaron C. Tyagi, MD
Sparrow/Michigan State University
Chair, RSA Social Media Committee
Originally Published: Common Sense July/August 2017

We in the world of emergency medicine like to think of ourselves as ready for anything. I have often heard the mantra that we are ready for anything that “walks, rolls, or crawls through the door.” Our world is one of relatively controlled chaos. That is to say, when we receive the chaos, it has started somewhere else, far off and distant and we receive a microcosm of it in the form of a patient. That patient is delivered (for the most part) calmly to our home base. However, what happens when the chaos starts at our home base?

Code Silver. It’s something no health care provider ever wants or expects to hear in his or her hospital. But it was something that became a reality for the patients and staff of Bronx-Lebanon Hospital at 2:50 PM on June 30th, 2017.[1] A disgruntled employee, a former physician at the hospital no-less, entered his former place of employ, traveled calmly to the 16th and 17th floors with an AR-15 neatly hidden under his coat. He was wearing a white coat, the symbol physicians traditionally wear to signify healing, and opened fire on his former colleagues. His brutal attack left one dead and six wounded requiring various levels of inpatient hospital care.

The Pulseless Extremity: An Approach to Acute Ischemic Limb

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Authors: Benjamin Mogni, MS-3
University of Kentucky
RSA Wellness Committee Member

Terren Trott, MD, Assistant Professor
University of Kentucky

A 55-year-old man with a past medical history of atrial fibrillation and aortic atherosclerosis presents to your emergency room with numbness, tingling, and pain in his left lower extremity below the knee. A tech is pushing him in a wheelchair because the pain is too great and he cannot move his foot. His foot appears pale in comparison to the other. The patient writhes uncomfortably in bed. Brief examination of the leg demonstrates a cold extremity with no posterior tibial or dorsalis pedis pulses.

Management Strategies for Acute Atrial Fibrillation in the Emergency Department - Resident Journal Review

Authors: Eli Brown, MD; Allison Regan, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD
Edited by: Jay Khadpe, MD, FAAEM; Michael C. Bond, MD, FAAEM
Originally Published: Common Sense September/October 2013

Introduction
Atrial fibrillation (AF) and atrial flutter (AFL) are the most commonly occurring arrhythmias in the United States. Management strategies for AF and AFL emphasize ventricular rate control, cardioversion to normal sinus rhythm and long-term interventions such as anticoagulation to reduce the risk of stroke. In patients in whom cardioversion is an option, either pharmacological or electrical cardioversion may be considered. While there is a significant amount of literature comparing the effectiveness and safety of pharmacologic versus electrical cardioversion in acute AF, studies which analyze discharge rates and hospital length of stays are becoming more frequent due to concerns over rising healthcare costs and ED overcrowding. This review focuses on treatment strategies for patients presenting to the ED with acute atrial fibrillation; in particular, rate control versus cardioversion, options for cardioversion (chemical versus electrical) and the safety of these strategies when used in the ED.

Preserving the Humanity of Our Patients and Fostering Our Own

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Author: Leana S. Wen, MD MSc
2012-2013 AAEM/RSA President
Originally Published: Common Sense March/April 2013

We EPs know that life in the ED is fast-faced, extremely busy, and ever-challenging. When things get crazy, it becomes habit to see our patients as “the chest pain in room 6” or “the lac in the hallway.” We turn people with their amazing lives and fascinating stories into chief complaints and tiles on our electronic tracking board.

It’s a practice that’s easy to justify. After all, taking a long time with one patient can delay care for all the other people who are waiting to see us. However, the patient's story and the context of his illness are important to him — and critical to the care we render.

Development in Clinical Toxicology: Use of Intralipid Emulsion and High-Dose Insulin Therapy

Authors: Allison Regan, MD; Eli Brown, MD; Jackie Shibata, MD; Kaycie Corburn, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM

Introduction
There are few antidotes in clinical toxicology, especially with regards to some of the most commonly used medications including calcium channel blockers, beta-blockers, and peripheral anesthetics. Morbidity and mortality rates are high and supportive care is often ineffective. Intralipid and high-dose insulin therapy are two exciting developments in clinical toxicology. This review of the literature explores the evidence behind these new treatment options for beta-blocker and calcium channel blocker toxicity, as well as anesthetic overdoses.

Engebretsen, K, et al. High-dose insulin therapy in beta-blocker and calcium-channel-blocker poisoning. Clinical Toxicology. 2011;49,277-283.

Beta-blocker and calcium channel blockers are common medications that can result in both intentional, and unintentional, overdoses. The high morbidity and mortality associated with these overdoses is largely secondary to cardiovascular toxicity. Recent data suggests that early use of high dose insulin (HDI) may be an effective treatment strategy for beta-blocker and calcium channel blocker poisonings.

Resident Journal Review: Mechanical Ventilation in the Emergency Department

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Authors: Michael Allison, MD; Kami Hu, MD; David Bostick, MD MPH; Phil Magidson MD MPH; and Michael Scott, MD
Edited by: Michael C. Bond, MD FAAEM and Jay Khadpe, MD FAAEM

Originally Published: Common Sense March/April 2014

Introduction
Patients with respiratory failure are commonly encountered in the emergency department (ED), and many of these patients progress to require endotracheal intubation and mechanical ventilation. Mechanical ventilation strategies were the focus on a recent Annals of Emergency Medicine Clinical Controversy.1,2 Since its publication, there have been a number of newer studies suggesting that perhaps ventilation with low tidal volume can improve outcomes for many ED patients with respiratory failure, not just those with the acute respiratory distress syndrome (ARDS). This “Resident Journal Review” goes through the pertinent recent literature on low tidal volume ventilation.

We begin with an investigation regarding the use of low tidal volume ventilation in the ED among patients with and without ARDS. The investigators found that low tidal volumes are infrequently used in both scenarios. The impact of this becomes clearer, as the following three articles note a variety of improvements in patients ventilated with lower tidal volumes. There is a suggestion that even a 1mL/kg difference from a lung-protective strategy can worsen clinical outcomes.

Serious Bacterial Infections in the Febrile Infant

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Authors: Kaycie Corburn, MD; Jacqueline Shibata, MD; Lee Grodin, MD; Raymond Beyda, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM
Originally Published: Common Sense September/October 2015

Pediatric fever, especially in infants, is often a challenging and nerve-racking presentation to evaluate in the ED. The prevalence of serious bacterial infections (SBI) in young infants range from 8-20%.[1] There is no clear cut consensus on how to work-up these patients in the ED.[2] As a result, many infants are subjected to invasive, unnecessary, and costly procedures or needlessly treated with empiric antibiotics and hospitalizations. In this edition of the Resident Journal Review, we review the literature on this topic in an effort to give more clarity on how to approach the febrile infant.

Literature Update in Pneumonia

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Authors: David Bostick, MD MPH; Phil Magidson, MD MPH; Carina Sorenson, MD; Neil Christopher, MD; Kami M. Hu, MD; David Wacker, MD PhD
Editors: Michael C. Bond, MD FAAEM; Jay Khadpe, MD FAAEM
Originally Published: Common Sense March/April 2015

Patients with community-acquired pneumonia (CAP) are frequently seen in the emergency department (ED). According to the National Hospital Ambulatory Medical Care Survey (NHAMCS), pneumonia is the third most common principal ED discharge diagnosis in the United States.[1] In this literature update, we examine: use of point-of-care ultrasound to diagnose pneumonia, obtaining routine blood cultures, risk factors for multi-drug resistant organisms and the efficacy of antibiotic monotherapy versus combination therapy in moderately severe pneumonia.

Updates in Prehospital Emergency Medical Service Care - Resident Journal Review

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Authors: Phillip Magidson, MD MPH; David Bostick, MD MPH; Kami Hu, MD; Carina Sorenson, MD; David Wacker, MD PhD
Editors: Michael C. Bond, MD FAAEM; Jay Khadpe, MD FAAEM
Originally Published: Common Sense Nov/Dec 20147

Over 15% of all patients seen in the emergency department (ED) arrive via emergency medical services (EMS).1 This represents over 20 million visits annually. For this reason, improvement and expansion of evidence based interventions within the prehospital setting should continue to be explored. In this month’s “Resident Journal Review,” we focus on diagnostic, therapeutic, and logistical updates within prehospital EMS care.

Approach to the Dizzy Patient - Resident Journal Review

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Authors: Eli Brown, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD; Lee Grodin, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM
Originally Published: Common Sense September/October 2014

Dizziness, often a challenging presentation, refers to a variety of vague sensations including lightheadedness, disequilibrium, and vertigo. Life-threatening disorders, such as stroke, are easily mistaken for benign illnesses, such as acute vestibular syndrome (AVS). This review focuses on recent developments in the evaluation of dizzy patients including some bedside tests which may improve diagnostic accuracy and reduce the cost and time of the ED evaluation.

Calling Back, Checking Up, Finding Out

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Author: Edward Siegel, MD MBA
2014-2015 AAEM/RSA Publications Committee Chair
Originally Published: Common Sense May/June 2014

With the exception of occasional resident research projects, most RSA members are insulated from efforts to improve efficiency, patient satisfaction, and the other dollars-and-cents concerns of running an emergency department (ED) that dog administrators. There is, however, a team in almost every ED that is focused solely on those things. These teams are constantly trying new innovations, methods, and systems to gain efficiency and improve (or reach) profitability.

Our hospital recently initiated a patient call-back system, following in the footsteps of many other EDs nationwide. This system was implemented with several goals in mind, with improved patient care chief among them. Our program is young, but it may interest those looking for ways to improve their own emergency departments.

Consider an Away Elective. Now is Your Chance!

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Author: Teresa M. Ross, MD
2011-2012 AAEM/RSA President
Originally Published: Common Sense March/April 2014

If the only medical world you’ve ever known is the infinite connecting hallways of a classic teaching hospital, you’re not alone. Medical school and residency naturally bring us to these oldies but goodies as the epicenter of our academic and clinical training.

But step away for a while – imagine a world where emergency docs come to work in jeans, know their colleagues (and their families) by name, and can’t count on off-hours, in-house consultants except medicine and pediatrics. There is an exciting world out there beyond formal department conferences and journal-quoting consultants.

World Suicide Prevention Day 2017

September 10, 2017 is World Suicide Prevention Day and the AAEM Resident and Student Association (RSA) is asking everyone to Take 5 to Save Lives! Take 5 to Save Lives is a public awareness campaign started by the National Council for Suicide Prevention in support of World Suicide Prevention Day. The campaign provides prevention-focused tools to help keep yourself and others safe from suicide. What does it mean to Take 5 to Save Lives? Head to www.take5tosavelives.org to learn 5 steps you can take in just 5 minutes. The steps include:

Teen Suicide in the United States: What Every Emergency Physician Should Know

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Authors: Casey Grover, MD; David M. Carreon, MSIV; Michael K. Hole, MSIV
Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident August/September 2013

A 14-year-old boy is brought to the ED with a wrist laceration. Accident or suicide attempt?

Self-harm is the third leading cause of death in this age category behind violence and motor vehicle accidents.[3] One nationally representative sample suggests 7% of U.S. teens have attempted suicide in the last year, and 2% have made attempts serious enough to require medical attention.[2]

Synthetic Cathinones (“Bath Salts”) and Gerbal Marijuana Alternatives – Resident Journal Review

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Authors: Susan Cheng, MD MPH; Jonathan Yeo, MD; Eli Brown, MD; Allison Regan, MD
Edited by: Michael C. Bond, MD FAAEM and Christopher Doty, MD FAAEM
Originally Published: Common Sense April/May 2012

This resident Journal review focuses on two popular designer drugs that have made their way into the media as well as our emergency departments: synthetic cathinones, also known as “bath salts,” and herbal marijuana alternatives. Due to the relative novelty of these drugs, not much literature or research exists to help ED physicians manage patients who come in with these acute intoxications. The pharmacology, clinical symptoms and management options, as well as a few case reports, will be discussed in this review.

With You All the Way

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Author: Meaghan Mercer, MD
2014-2015 RSA President
Originally Published: Common Sense May/June 2014

Emergency medicine is a specialty known for high burnout. Professional burnout is described and measured in many different ways, but it encompasses a loss of enthusiasm for work, emotional exhaustion, disparagement, depersonalization, a loss of empathy, and feeling a lack personal accomplishment. A study done in the 1990s showed that, of surveyed emergency physicians, 77-80% of physicians said that EM had met or exceeded their career expectations but 31-33% still noted that burnout was a significant problem in their work life. We have a dichotomous emotional response to our work: a love of what we do and a component of exhaustion from it. We can have large swings of daily highs and lows, or a day full of benign abdominal pains. We often present ourselves as emotionally open and able to look at all things objectively, but with burnout we can become emotionally blunted. How do we prevent this? There have been many proposals on how to prevent burnout, but fundamentally the answer is in rediscovering what drew us to EM initially and letting that continue to motivate us day to day.

Thiamine Repletion in Alcohol Abuse

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Author: Alexandria Gregory, MS-3
Saint Louis University School of Medicine
AAEM/RSA Social Media Committee

Thiamine deficiency is commonly seen in patients with a history of chronic alcohol use and can have significant consequences if untreated. Therefore, repletion of thiamine in these patients is crucial, and appropriate administration should begin in the emergency department (ED).

AAEM/RSA FIX Scholarship Winners - Women in EM: Essay Two

Kimberly M. Brown, MD

Author: Kimberly M. Brown, MD
University of Tennessee Health Science Center (Memphis)

RSA is proud to share the following essay from one of the 2017 FemInEM Idea Exchange (FIX) Scholarship winners, Kimberly Brown, MD. Congratulations, Dr. Brown! 

Author Bio: Kimberly M. Brown, MD is a senior emergency medicine resident at the University of Tennessee Health Science Center in Memphis, TN. She was born and raised in Milwaukee, WI, then left the Midwest to complete her BA in Biology from Fisk University in Nashville, TN. Loving the warm weather, she moved to Gainesville, FL and completed a Master in Public Health from the University of Florida. She completed her medical education at Ross University School of Medicine. After completing residency, she will start a fellowship in neurocritical care at the University of Tennessee.

“YOU’RE Doctor Brown?” my elderly patient incredulously asks. I turn my badge around to squint at it and then look at my embroidered scrubs to double check. “That’s what it says on here!” My patient and her family members laugh. My patient touches my hand and tells me, “I am so proud of you.” Being black and female, I'm no stranger to a surprised reaction to my initial introduction. However, this time was different.

Combat and Cruise Ships: Reviving the Practice of Fresh Whole Blood Transfusion in Remote Environments

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Image Credit: Pixabay

Author: Scott Bland, MSIV
Campbell University School of Osteopathic Medicine

Whole blood was the only available transfusion product prior to the development of Cohn’s plasma fractionation process in 1947.[1] However, with advances in laboratory technology and more targeted therapies in hospital settings, the medical community has greatly increased the use of individual blood components, including red blood cells, platelets, and plasma. These components allow for more specific treatment effects, fewer unintended effects, potentially longer shelf life, and more uses per donation than whole blood.[2] In optimal situations, the contemporary choice of processed and screened donations is clearly the safest, but there are uses for fresh whole blood that merit consideration.

AAEM/RSA FIX Scholarship Winners - Women in EM: Essay One

Trisha Morshed, MD

Author: Trisha Morshed, MD
UCSD Department of Emergency Medicine

RSA is proud to share the following essay from one of the 2017 FemInEM Idea Exchange (FIX) Scholarship winners, Trisha Morshed, MD. Congratulations, Dr. Morshed!

Author bio: Trisha Morshed is an Emergency Medicine Resident at UC San Diego. She is originally from Portland, Oregon and went to undergraduate and medical school in Arizona. Her professional interests include a passion to make a difference both locally and globally. She is the Resident representative on the Board of Delegates of the San Diego County Medical Society, a physician group that meets regularly with local legislators for medical advocacy. She is also excited about global health and has been involved in international collaborative research as well as overseas projects to improve access to healthcare in resource limited settings. Trisha is a strong advocate for work/life balance and physician wellness-- on her downtime, she can be found traveling, playing outdoors, and practicing partner acrobatics.

When I was growing up, I was always told by my parents that with hard-work and perseverance, I could make my dreams a reality. I realized my passion for emergency medicine during third year of medical school during a shadowing experience, and feel so fortunate to find a field where I look forward to going to work most days and can’t imagine myself doing anything else. I have never felt that my gender hindered me at any point previously in my life; however, was surprised when I entered my residency at a place which is predominantly male, at how much I noticed the difference between how I was perceived differently from my male colleagues.

Acute Management in Pediatric Congestive Heart Failure

Image Credit: Wikimedia

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Author: Alfred Morrobel, M.D
Universidad Iberoamericana

Epidemiology
Congestive heart failure (CHF) in children is diverse due to the myriad underlying etiologies that can occur from birth to adolescence. In the United States, CHF is estimated to affect 12,000 to 35,000 children below the age of 19 years and there are approximately 11,000 to 15,000 heart failure-related hospitalizations in children per year.[1]

Board Review: Making Decisions Based on the EKG

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Image Credit: US Air Force

Author: Nick Pettit, DO PhD, PGY-2
Indiana University
AAEM/RSA Social Media Committee

Case
The setting is a busy shift in your high-acuity pod of your emergency department. You just walked out of room 1 after resuscitating a tricyclic antidepressant (TCA) overdose. Then overhead you hear, “trauma 1 here, room 4,” and at the same time your nurse hands you the below electrocardiogram (EKG).

As you are walking toward room 4 and scribble “non-ST-elevation myocardial infarction (non-STEMI),” she gives a quick history about this patient. The patient is a 77-year-old male with a past medical history of some kidney and heart issues, and he now has fatigue, shortness of breath, and bilateral lower extremity edema. Just as you pop into the trauma in room 4, you tell your nurse you will be right over, but to please draw a rainbow of labs and:

1. Administer 40 mL/kg 0.9% NaCl bolus.
2. Administer 3 g calcium gluconate.
3. Administer 6 vials of digi-bind.
4. Administer 40 mEQ of potassium chloride
5. Place pads and pull up ketamine for procedural sedation and immediate cardioversion.
6. Call poison control.

Correct answer
B. Administer 3 g calcium gluconate. This patient has hyperkalemia, and based on the EKG, it should not be surprising if their potassium returns at greater than 9.0.

This review will focus on the causes of hyperkalemia, its identification, and its immediate treatment.

Causes

1. Decreased excretion, such as in renal failure (as in this case)
2. Excessive potassium intake
3. Increased production of potassium (rhabdomyolysis, tumor lysis, trauma)
4. Redistribution (digoxin, acidosis)[1]

Identification

1. Basic metabolic panel (BMP). Be sure to watch for hemolysis, which can cause pseudohyperkalemia.
2. EKG. Different levels of potassium elevation can cause unique EKG findings:[2]
• ~6.0 = peaked T waves
• ~7.0 = P-wave evolution
• ~8.0 = wide QRS
• ~9.0 = sinusoidal appearance

Symptoms
Weakness, confusion, chest pain, nausea and vomiting, palpitations

Management

1. Calcium
• Calcium chloride if there is a central venous catheter (CVC), or calcium gluconate if there is peripheral access only.
• Stabilizes membrane in approximately ten minutes, with EKG returning to normal over several minutes.
2. Insulin and glucose
• Ten units of insulin given with dextrose.
• Works over 30 minutes
3. Sodium bicarbonate
• Helps correct acidosis
4. Albuterol
• Shown to lower potassium 1 mmol/L in healthy subjects
5. Dialysis
• May need emergent dialysis. Remember the AEIOU mnemonic:
• Acidosis
• Electrolyte disturbances
• Ingestion
• Overload (fluid)
• Uremia
• In the above case, the patient may benefit from emergent dialysis.
6. Furosemide
• May help if the patient is volume-overloaded, but this is a common disease in end stage renal patients and furosemide may have limited value here.[3]

References:

1. Rodriguez, J., Calvert J. Hyperkalemia. Am Fam Physician. 2006 73(2):283-290

2. Hall, B., Salazar, M., Larison, D. The sequening of medication administration in the management of hyperkalemia. J of Em Nurs. 2009 35:4;339-342

3. Wrenn, K., Slovis, C., Slovis B. The ability of physicians to predict hyperkalemia from the ECG. Annals of Emerg Med. 1992 20:11;1229-1232