With You All the Way

Image Credit: Pixabay

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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Image Credit: Pixabay

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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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

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This post was peer reviewed.
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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

Acute Decompensated Heart Failure: What is the Current Evidence for Intravenous Diuretic Therapy? - Resident Journal Review

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Authors: Kaycie Corburn, MD; Lee Grodin, MD; Jackie Shibata, MD; Eli Brown, MD
Edited by: Jay Khadpe, MD FAAEM; Michael C. Bond, MD FAAEM
Originally published: Common Sense May/June 2015

The most common cause of hospitalization in the United States and Europe is acute decompensated heart failure (ADHF). ADHF is associated with high baseline mortality rates that only increase after hospitalization. Unfortunately, there is a paucity of high quality evidence for treating this disease. Both the European Society of Cardiology and the Heart Failure Society of America offer practice guidelines that are mainly based on Class C (consensus opinion) recommendations. The complicated pathophysiology of ADHF adds difficulty to finding treatments with both short and long-term benefits.[1] Currently, over 80% of patients hospitalized for ADHF receive IV diuretic therapy.[2] This article reviews key existing studies to examine the evidence for using IV diuretic therapy for patients with ADHF.

From Resident to Attending

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Author: Meaghan Mercer, DO
AAEM/RSA 2015-2016 Immediate Past President
Originally Published: Common Sense May/June 2015

As residency comes to an end, I realize that although I feel ready for life as an attending from a clinical standpoint, we are provided little education on life outside of academia. Many questions remain, such as: What tests do I have to take, what do I have to do to get credentialed, how do I stay up to date? As we transition back into the “real world” we have to acclimate to managing our own affairs.

ABEM.org
If you haven’t looked at the website, do it now. Initial application for the board exam (Qualifying Exam per ABEM terminology) lasts from May 1-November 5 and costs $960. Yes, you can and should apply prior to finishing residency. The qualifying exam will be administered November 16 - 21, 2015. Plan ahead to have ample time to study and have access to your desired date to take your exam. Once you pass your written exam you will then be given a date in the spring or fall of 2016 to take your oral board exam. After you pass the oral board you will be officially board certified for ten years. However, you are not done. To maintain your certification you must participate in maintenance of certification (MOC). Requirements in the first five full years of certification include the following: Passing four ABEM LLSA tests, one of which must be the patient safety LLSA; completing an average of 25 AMA PRA Category 1 CreditsTM or equivalent, with an average of eight of those credits being self-assessment; completing an Assessment of Practice Performance (APP) patient care practice improvement (PI) activity; and completing an APP patient-centered Communication/Professionalism activity. For more information go to www.abem.org.