Palliative Care Myth Busters

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Author: Michelle Mitchell, MS-IV
Geisinger Commonwealth School of Medicine

Palliative care concepts have increasingly become integrated into care in the emergency department (ED). As the health of patients with advanced and end-stage disease continues to decline, they often present to the ED for symptom management and pain relief. Therefore, emergency medicine physicians should be knowledgeable about basic palliative care treatments, as well as some common myths surrounding palliative care.

Needle Thoracostomy: Is it Time to Switch to a Longer Needle?

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Author: Jake Toy, MSIII
Western University of Health Sciences


Needle thoracostomy (NT) is a lifesaving procedure often utilized in pre-hospital settings and emergency departments (ED), and is indicated in cases of tension pneumothorax. Placement of a needle catheter into the pleural space allows for emergent decompression, resulting in restored and/or increased venous return to the right atrium.[1] Placement of a chest tube is the definitive management of a tension pneumothorax following both a successful or failed needle placement. Advance Trauma Life Support (ALTS) guidelines recommend the use of a 14-gauge 5 cm (approx. 2 in) angiocatheter placed in the 2nd intercostal space, midclavicular line (ICS-MCL), inserted at a perpendicular angle to the skin.[2]

No But Really…How Much Weed Do You Smoke?

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Image Credit: Flickr

Author: Ashley Grigsby, DO, PGY-3
Indiana University, Emergency Medicine/Pediatrics

Case
A 21-year-old female presented with epigastric abdominal pain and severe vomiting for the last three days. She has had similar vomiting episodes before and has had a large workup that was unremarkable for the etiology. She was unable to stay hydrated during this latest episode so she presented to the emergency department (ED). She stated that the only thing that helped her vomiting has been a hot shower. Her vitals were normal except for a heart rate of 112 beats per minute; her exam was unremarkable except for mild epigastric tenderness to palpation. The patient was questioned multiple times alone in the room and denied, multiple times, any marijuana use or other drug use. She was treated symptomatically and improved. On discharge, she was again questioned about drug use and admitted to twice daily marijuana use for the past several years. She was diagnosed with cannabinoid hyperemesis syndrome, counseled on the importance of marijuana cessation, and discharged home in good condition.

The Waiting Game

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Author: Victoria Weston, MD
Originally Published: Common Sense November/December 2015

I could feel her eyes on me, burning with anger. It was a hot July day and she had been waiting for hours in our crowded waiting room, and then waited even longer in our ENT room in an upright, unforgiving chair as our team cared for multiple unstable patients who had been roomed shortly after sign-out. The ED was packed with patients, new interns, and other new learners — and everything seemed to be moving so much more slowly than just a few weeks before.

When I walked into her room, I entered with a smile, made eye contact, introduced myself, and made my apologies: I am so sorry for the wait. I am glad that you came in today and appreciate your patience. I know that it has been a long wait, but I am here now and am totally focused on you. How can I help you today?

All I Really Need to Know — Still — I Learned in Kindergarten

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Author: Andrew W Phillips, MD Med
Originally Published: Common Sense July/August 2015

While still being far from hitting my full stride as a “real” emergency physician, I feel that I’ve come a long way now that I’m finally finishing residency. And while I’m cautious of being overly nostalgic or simplistic at this point, I find myself reflecting that life’s core lessons change very little. The medicine changes every five to 10 years, but certain constants never change, and they all have to do with playing together well in the sandbox.

Reflections of a Third-Year Resident

Author: Meaghan Mercer, DO
Originally Published: Common Sense March/April 2015

Writing this around New Year's Day makes me nostalgic. There is a contagious sense of hope and excitement this time of year. Fourth-year medical students are thrilled that interviews have come to a close, rank lists are in, and Match Day looms around the corner. Interns are feeling comfortable in their shoes, seasoned residents are in the groove, graduating residents are applying for licensure, and nervous excitement accompanies the end of residency. Each New Year's Day I write a letter to myself that includes what I expect from the year and what I hope to achieve. I then seal it, and one year later open it and read it. As I reflect back on the last seven years, I want to leave you my experience and advice.

Clinical Pearl: A Parent’s Kiss for Nasal Foreign Body Removal

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Author: Ashley Grigsby, DO PGY-1
Indiana University Emergency Medicine/Pediatrics
Originally published: Modern Resident April/May 2015

Every little boy knows the best place for anything is up your nose. That is, until they show up in your emergency department (ED).

The Case:
Three-year-old previously healthy male presents after he put his older sister’s jewelry bead up his right nostril two hours ago. Vitals are normal. As you walk in the room, he is breathing comfortably and appears well, but his big brown eyes see you coming and immediately start welling up with tears. He’s sitting in his mom’s lap; he’s anxious and wants no part of you coming near him.

Lean, Mean, ED Resident Machine: Resident Application of Lean Tools

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Author: Thomas Damiano, MD
Christiana Care Health System
Originally Published: Modern Resident February/March 2013

One of the first responses when asked what field of medicine I practice following "that must be interesting work," undoubtedly becomes "the waits are awfully long." The demand for emergency services has far outpaced supply over the last two decades. Administrators across the country are looking to the Lean philosophy to help deal with ED operational improvement. From a Lean perspective, resident involvement in advancing ED operations is essential.

If one were to search "Lean," results mentioning Toyota, various courses offering black belts and attempts at definitions may quickly confuse the inquirer. Lean has nothing to do with sticking accelerator pedals (too soon?). Courses are not taught by Chuck Norris (although I would be the first to sign up). Rather, Lean is a term for a production philosophy with the central concept that the expenditure of resources for any goal other than adding value for the customer is wasteful and should be minimized. Lean involves various tools for operational improvement and seeks to foster "a community of scientists" to employ these tools.

Family Presence During Cardiopulmonary Resuscitation – What’s the Policy at Your Hospital?

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Author: Jake Toy MSIII

Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA

The upper gastrointestinal bleed patient that I had been following since admission was in cardiac arrest in the intensive care unit. The resuscitation effort was routine; however, the presence of his family at bedside was new to me.

One initial concern lay with the patient’s observing family members in regards to the possibility of psychological trauma due to a limited capacity to understand or comprehend the resuscitation events. These concerns have been documented among the medical community and further include the potential for family member disruption and delay of resuscitation efforts, which may directly or indirectly influence treatment outcomes, and the notion of an increased frequency of litigation following family presence during resuscitation (FDPR).[1-3] However, little evidence substantiates these concerns.[1] Current literature suggests FDPR during both out-of-hospital and in-hospital cardiac arrest confers psychological benefits for family members regardless of treatment outcome.[4, 5] What’s more, multiple cohorts of surveyed patients wished their family member(s) to be at bedside should they need to be resuscitated.[6, 7]