Interview Trailblazing: Resources for Residency Applicants

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Author: Jessica Fujimoto MD
Emergency Medicine Chief Resident
Temple University Hospital AAEM/RSA Vice President

Ah, peak residency interview season. You’re getting tired from all of your travels. You’ve forgotten the components of the PERC rule, but can rattle off your hobbies and interests like nobody’s business. Oh yeah, and your suit is starting to get a bit snug from all the free food and drinks.

Ok fine, maybe that last part was just me...

Phones in Medicine

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Author: MohammedMoiz Qureshi, MD
AAEM/RSA President 2018-2019
Originally Published: November/December Common Sense

List your most intimate relationship. Most of us will list a spouse, parent, sibling, relative, or friend. Most of us however will also forget our most intimate — our beloved phones.

They keep us company when we eat, they’re the last things we see before sleep, and they’re the first things we reach for when we’re stressed. And according to some data, we check them, on average, over 60 times a day. For us in medicine, they serve as a great resource. They allow us to look up new cancer drugs we’ve never heard of, remind ourselves of rates when we forget how to start tube feeds, and of course they serve as the clock we check counting the hours till relief checks in.

Residency Match – In Hindsight

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Author: Jake Toy, DO
Modern Resident Blog Editor-in-Chief 

Publications & Social Media Committee Chair

The February 2019 rank residency list deadline is fast approaching. For some, the process of ranking their chosen emergency medicine programs in order of preference was straightforward. For others, including myself, the process of picking a program that balanced superb training and happiness was stress inducing and anxiety provoking to say the least.

As I ranked my programs, I reached out for advice from faculty advisors, peers, and family, only to discover an endless sea of competing thoughts and ideas. Upon searching in the depths of internet blogs, this only further cast a large shadow of doubt and bias on my own rank list. With each person I spoke with and article I read, I found myself left with more questions than answers. At one point, a TV commercial advertising a hospital I was considering as a “World-Class Research Institution & Top Ranked Hospital” threatened to disrupt an initial draft of my program rank list altogether. 

Marine Envenomations

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Authors: Grant Barker, MS4
University of Miami Miller School of Medicine

Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

Case
While spearfishing for lionfish off the coast of Key West during one of our yearly excursions, my father was unfortunate enough to graze a lionfish’s spines with his thumb. Within the next ten minutes, he was hyperventilating and in extreme pain. On our small boat with just a rudimentary first aid kit, thirty miles from shore, we had minimal interventions at our disposal. What would your next step in treatment?

Rapid Estimation of Left Ventricular Ejection Fraction with Ultrasound

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Author: Bill Christian, MS-4
Ross University School of Medicine
AAEM/RSA Publications and Social Media Committee

Rapid assessment of the left ventricular ejection fraction (LVEF) may be critical for the emergency physician. Imagine a patient comes into your emergency department (ED) with acute dyspnea. He has a history of congestive heart failure, chronic obstructive pulmonary disease and myocardial infarction. Can ultrasound help differentiate between some of the many potential causes of dyspnea? Yes!

FOUR Score for the Evaluation of the Comatose Patient

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Authors: Justin Rafael De la Fuente, MSII
Medical Student
University of Miami Miller School of Medicine

Tim Montrief, MD MPH
Emergency Medicine Resident Physician
Jackson Memorial Health System
AAEM/RSA Publications & Social Media Committee

Jeffrey M Scott, DO
Attending Physician
Jackson Memorial Health System

Case
A 63-year-old man is brought in to the emergency department by ambulance after being found unresponsive at home by his family. He was last seen normal about four hours prior to arrival. En route, the patient was exhibiting irregular respirations with an oxygen saturation of 85% and was intubated by paramedics. On arrival, he is unresponsive with an oxygen saturation of 92%, bradycardic at 55 beats per minute, and hypertensive with a blood pressure of 160/95 mmHg.

Emergency Department Boarding: What Can We Do?

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Authors: Tyler Ericson, MS3
University of Miami Miller School of Medicine

Tim Montrief, MD MPH
Emergency Medicine Resident
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

Jeffrey M Scott, DO FACEP EDIC
Assistant Professor of Clinical Medicine, Division of Pulmonary, Critical Care, and Sleep
Medicine, University of Miami Miller School of Medicine

Many emergency departments (EDs) often experience critical overcrowding and heavy demand on scarce emergency resources, hampering the delivery of high-quality medical care and compromising patient safety.[1] The primary cause of overcrowding is boarding—the practice of holding patients in the ED after they have been admitted to the hospital because no inpatient beds are available. Boarding is a prevalent practice in EDs across the country, with nine out of ten hospitals reporting some degree of boarding.[2] Boarding times may vary depending on many factors, including hospital size, time of day, and patient population. Some studies have shown the median boarding time to be 79 minutes, with 32% of admitted patients boarding for longer than two hours.[3]

Lay Corporations Running Residency Programs

Author: Gabe Stahl, MD
AAEM/RSA Advocacy Committee Co-Chair

Most of you who are reading this are here because you live, breathe, and bleed emergency medicine. EM offers the perfect mix of medicine, procedures, and adrenaline. Unfortunately, not all parties involved do it for the love of emergency medicine. While EM may be one of the youngest specialties, its short history is rife with conflict pitting hospitals against Emergency Medicine practitioners in the form of lay entities incorporated to manage emergency departments even though there are statutes against this practice in many states, and some even run residency programs.[1] A lay entity means that a non-physician owns and operates the emergency department. For an excellent history lesson as told by James Keaney, MD MPH FAAEM, the first president of AAEM, we highly suggest that every medical student and resident interested in EM read The Rape of Emergency Medicine.[2]

AAEM/RSA FIX Scholarship Winner - Aaryn Hammond

Name: Aaryn Hammond, MD
Residency Program: Johns Hopkins University
Graduation Date: June 2019

RSA is proud to share the following essay from one of the 2017 FemInEM Idea Exchange (FIX) Scholarship winners, Aaryn Hammond, MD. Congratulations, Dr. Hammond! 
 
“Just go so you can say you went.” I can still hear my mother’s advice echoing in my head 4 years later. Specifically, this was the advice my mom gave me as I contemplated cancelling my interview for residency at Johns Hopkins, as I explained to her all the reasons it wouldn’t be a good fit and therefore a waste of time. I’ve since discovered that my “reasons” were actually disguises for what I now consider to be my personal version of “imposter syndrome” ...the very syndrome that plagued me with thoughts of inadequacy in the face of accomplishments that almost prevented me from achieving my dreams. In considering all the ways the “imposter syndrome” has reared its ugly head, I think back to the high school student that considered forensic science because as a doctor I could potentially hurt someone...the medical student who loved but yet feared Emergency Medicine because I could never be a “Master of all trades”, and finally to the graduate of two historically black universities afraid to interview at Johns Hopkins because why would they want me? This photo reminds me of all that I can do and be when I push myself to persist beyond my fears. This photo, taken on the final day of my intern year, is a constant reminder of what it means to be a black female emergency physician. It is evidence of the victory over fear and a testament of overcoming in pursuit of one’s destiny.

RSA FIX18 Scholarship Winner - Heather Boynton

Name: Heather Boynton, MD
Residency Program: University of California San Diego Medical Center
Graduation Date: June 2019

RSA is proud to share the following essay from one of the 2018 FemInEM Idea Exchange (FIX) Scholarship winners, Heather Boynton, MD. Congratulations, Dr. Boynton! 

Photo Title: Where My Witches At

On Halloween nine years ago I met my fake husband. I showed up at my best friend’s house dressed as Accident Prone. I had been working at an orthopedic clinic and used the time to craft a costume that included a full leg cast, two short arm casts and a cast hat. Who needs a cast hat? A 30-year-old who had an early midlife crisis, quit her life in foreign policy, broke her clavicle skiing, got out of a terrible relationship and was now going to a Halloween party. It got hot at the party and I took off and lost the cast hat. My fake husband was my best friend’s idea. Long story short, I told her the only not-insulting time I had been hit on was in Germany, when men asked me what books I was reading. She produced a German for the Halloween party. He wore a strange costume. We took a picture with Jesus and Mary, and I thought that was the end of that. Now he’s my fake husband. “Fake” because we never got married. “Husband,” because we have a nice life together, and a 7-year-old daughter who thinks of my EM colleagues as her friends, not mine. Last Halloween my daughter and I dressed as witches. You’d think it would get old, to keep saying, Where my witches at? It doesn’t. It’s the best. It’s like code, for strong and powerful lady people. We were and we are. Wiiiitches.

Pre-intubation Optimization of the Neurocritical Care Patient

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Author: Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

The catastrophic neurologic emergency remains one of the most challenging presentations managed by emergency physicians. Stress, diagnostic uncertainty, and time-sensitive nature lead to challenging management decisions. Likewise, the intubation of the neurocritical care patient provides many challenges, and requires a modified technique to avoid the harmful consequences of intubation, including an exaggerated reflex sympathetic response to laryngoscopy, hypotension due to induction agents, and exacerbation of elevated intracranial pressure (ICP). Additionally, maximizing first past success and minimizing hypoxia is especially important in patients with central nervous system (CNS) pathology, in particular, unsecured aneurysmal subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), and stroke. Optimization of the neurocritical care patient is of upmost importance, and many of the techniques are familiar to the emergency physician. For instance, apneic oxygenation via a nasal cannula on the patient at 15 L/min maximizes oxygenation prior to intubation. Additionally, one may raise the head of the bed, which decreases ICP and has a ben­eficial effect on oxygenation. While ninety degrees is the ideal angle, elevation of the head of bed to thirty degrees is also an option. Finally, if faced with an agitated, combative patient, delayed sequence intubation (read more about it here) may be an option to optimize preoxygenation.

ECMO in the Adult ED

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Author: Tim Montrief, MD, MPH
Emergency Medicine Resident, PGY-2
Jackson Memorial Hospital

Extra Corporeal Membrane Oxygenation (ECMO), more accurately known as Extracorporeal Life Support (ECLS) is a type of prolonged mechanical cardiopulmonary support that began in the 1970s. Its technology, indications, and usage have rapidly evolved over the last two decades; it has now become an essential tool in the care of critically ill adults and children refractory to conventional management who have potentially reversible causes of respiratory/cardiac failure. With the development of ECMO programs across the nation, this technology is making its way to an emergency department (ED) near you.

The Cruelty of Depression

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Author: Becky Lee, MS4
University of Maryland School of Medicine
AAEM RSA Wellness Committee

In the middle of a hot August day, excited chatter echoed inside the dome of the columned, 200-year-old medical school building. It was our first day of medical school, and my classmates and I were eager to get started on our long-held dreams of becoming doctors. The next few days of orientation were a blur of information and optimism, all leading up to the first day of anatomy lab, where we paused in solemn silence to thank the donors and their families. I let this feeling sink in – the feeling that I was exactly where I was supposed to be. I had no idea that the next few months would be my darkest days of medical school. By the time winter break loomed around the corner, I couldn’t sleep, I no longer felt like eating, and I stopped talking to my friends and family. I stopped running and reading. In fact, I stopped going outside altogether. I spent most of my time in bed, staring at the ceiling, wondering if things would ever get better, and questioning how I ended up here. Sometimes, the thought occurred to me that I wouldn’t mind if I didn’t wake up the next day.

Carotid Doppler Ultrasound and Passive Leg Raise to Predict Fluid Responsiveness

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Author: Jake Toy, DO
PGY1 Emergency Medicine, Harbor UCLA Medical Center
Modern Resident Blog Editor-in-Chief

Background
The management of intravascular volume in critically ill patients is a challenge we face daily in the emergency department (ED). Since the beginning of our training, hypotension and shock have often been synonymous with rapid fluid resuscitation. Yet at present, fluid resuscitation remains largely empiric in nature.

Be Aware of the Stoic Man

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Author: Taylor Brittan, MSIV
University of Queensland-Ochsner Clinic
AAEM/RSA Education Committee

Introduction
There are several patient populations to which we are attentive so as not to miss a diagnosis in the context of an atypical presentation. Typical cases include the elderly, female, diabetics, or those with HIV.[1,2,3] I contend that there is another group which we should assess with even more caution—the stoic man.

Burning Both Ends of the Candle

Image Credit: Common Sense

Author: Faith Quenzer, DO
AAEM/RSA At-Large Board Member
Originally Published: Common Sense July/August 2018

I wasn’t out of the woods yet. After the birth of my first child, my son would keep me up every two to three hours a night. This was not what I imagined life to be as a mother. Additionally, I was out of the department for several months taking time off and doing outside rotations. However, I was struggling to keep things together at home and in the emergency department during shifts. Balancing life inside and outside the home was difficult until my working husband and I got extra help. My mom helped watched my son until he was 10 months old. My husband worked from home two days of the week, but his work was based primarily in San Diego. This still was too much for everyone. So we decided to use my residency income to pay for daycare five days per week. “Finally, a break.” I thought to myself.

Fast forward a year, my father goes to see a cardiologist for his persistent dyspnea he has had for several months. I had bugged him about it for a while and he agreed to see someone at the hospital where I work. Finally, we figure it out; his heart has an ejection fracture of 15%. My hopes could not sink any further than the depths of the sea. The cardiologist decided to take him to cardiac cath lab and I, as the both daughter and the doctor in the family, took a deep breath and braced myself. I noticed the cold temperature of the cardiac cath suite as the cardiologist prepped and draped. Dad is out with a touch of Versed and the dye squirted in and very slowly trickled through the brittle appearing arteries.

Find Your Power Ballad

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Author: Aaron C. Tyagi, MD
Originally Published: Common Sense July/August 2018

The ED is a naturally stressful environment, where sensory overload is the norm. At any given moment, you can simultaneously be handed two stat EKGs while receiving an EMS refusal and have a consultant return a page. As a senior resident, I have taken to reflecting on this and how I will approach this in my own independent practice going forward. In doing so, I have found that I have already subconsciously been finding my own ways of mitigating my own stress. One of my favorite methods of doing this on-shift is music.

Punjab’s Opioid Crisis

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Author: Hunter Singh Lau
University of Wisconsin School of Medicine and Public Health
AAEM/RSA International Committee

With the rapidly increasing number of opioid overdoses, increasing public recognition, and subsequent pressure for action, the opioid crisis has become a prominent issue.[1-5] However, I am not referring to the opioid epidemic in the United States (U.S.), rather, the lesser-known opioid crisis in the North Indian state of Punjab. Though these two opioid epidemics appear distinct from one another, they are deeply entangled, and Americans would benefit from examining how Punjab is reacting to their crisis and whether their recently enacted policies prove to be efficacious.

Legal Implications of Responding to In-flight Medical Emergencies

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Author: Ali Bacharouch, MSIII
University of Michigan
AAEM/RSA Education Committee

Imagine boarding your flight to Fort Lauderdale after a hectic few months at the hospital. As the plane takes off you begin to think about how relaxing your trip is going to be. As you are trying to sleep, you hear some sounds coming from the back of the plane that give you flashbacks of the emergency department. You then hear an announcement the intercom system: “A fellow passenger needs medical attention; if you are a medical professional please identify yourself to a cabin crew member.” You quickly spring into action and attend to an elderly woman who reports new-onset lightheadedness. After ruling out life threatening conditions, you provide reassurance and head back to your seat as the woman expresses her gratitude.

Update on Direct Oral Anticoagulants in the Emergency Department

Authors: Megan Donohue MD, MPH, Erica Bates MD, Robert Brown MD, Christine Carter MD, Hannah Goldberg MD.
Editors: Kami M. Hu MD FAAEM, Kelly Maurelus, MD FAAEM
Originally Published: Common Sense May/June 2018

Questions: What new information do we have regarding direct oral anticoagulants (DOACs), specifically:

1. What is the most recent safety data?
2. Do our standard coagulation assays provide an accurate measure of anticoagulant activity?
3. Where do we stand with reversal agents?

The Unfortunate Case of the Costa Rican Colles’ Fracture: An Up-Close case study of Costa Rica’s Emergency Department

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Author: Kayla King
Originally published: Common Sense May/June 2018

Picture this: you’re on a study abroad in beautiful, picturesque Costa Rica, in between your first and second year of medical school, learning about their health care system and practicing medical Spanish. You’re traveling to volcanoes, beaches, national parks, and national sloth reserves, taking pictures for every social media account possible, with six classmates. Seems glorious, right? Now, imagine that you’re doing all this, except you have a bright blue cast on your dominant wrist.

… What?

In Vitro Fertilization: Complications and Special Considerations in the Emergency Department

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Authors: Alexandria Gregory, MS-4
Medical Student Saint Louis University School of Medicine
AAEM/RSA Social Media Committee

Eric Goedecke, DO
Milford Regional Medical Center

Overview
A 41-year-old female presented to the emergency department (ED) with a several-day history of abdominal pain, nausea, vomiting, and lightheadedness. She reported that she was currently five weeks pregnant after having in vitro fertilization (IVF) in which two embryos were implanted. She had a history of one prior miscarriage, but no other pregnancies. She reported that she was followed by an obstetrician (OB) and had had two normal ultrasounds during this pregnancy. The patient had no vaginal bleeding, vaginal discharge, fever, or chills.

On exam, the patient’s initial vital signs were as follows: temperature 97.3° F, pulse 60 bpm, blood pressure 58/32 mmHg, respiratory rate 19, and oxygen saturation 98% on room air. The patient was in severe distress. Abdomen was diffusely tender and distended with guarding. Skin was pale and clammy.

Delayed Sequence Intubation

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Image Source: Wikimedia

Author: Timothy Montrief, MD MPH
Jackson Memorial Hospital

Case
A 55-year-old man is brought in to the emergency department by ambulance with a chief complaint of shortness of breath with associated fevers, chills, and productive cough over the past three days. On arrival, he is agitated, anxious, and repeatedly takes off his non-rebreather, stating that he is becoming increasingly dyspneic. He has an oxygen saturation (SpO2) of 85%, is tachycardic to 115 beats per minute, tachypneic to 24 respirations per minute, and has a blood pressure of 145/90 mm Hg.

Applications, Barriers, and Future of Point of Care Ultrasound in Limited Resource Communities

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Author: Janette Magallanes, MS4
Medical Student
Indiana University School of Medicine

The most common use of point-of-care ultrasound (PoCUS) in the emergency department (ED) is in evaluating trauma patients by assessing for pericardial effusion, pneumothorax, and intra-abdominal hemorrhage. The advantage in such acute settings primarily lies in ultrasound’s ability to minimize delays and quickly narrow down a differential diagnosis. Although there is minimal data on the impact of ultrasound (US) findings on patient outcomes in underserved rural communities, there is data showing that portable ultrasound findings have led to changes in patient management in up to 70% of cases.[1]

Applications of PoCUS
Other relevant applications have been found for PoCUS throughout the world. It has been found to have utility in diagnosing empyema, intussusception, retinal detachment, and fractures, as well as in verifying endotracheal tube placements in neonates and in cardiopulmonary resuscitation.[1] More relevant to developing countries, protocols have been developed to include PoCUS in risk stratifying patients with malaria, predicting progression of dengue fever, and even assessing lymphatic filariasis.[1] There is no question that there is enormous potential in the utility of PoCUS all over the world.

Emergency Departments: Primary Care of the New Century?

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Author: Kenneth K. Chang, MS III
Western University of Health Sciences
AAEM/RSA Education Committee

As aspiring emergency medicine (EM) physicians, what is it that motivates us? Perhaps it was from working as a first responder or in emergency medical services? Or maybe even from shadowing at a busy trauma center or watching a TV show come to life as the ED team rush to diagnose a complex pediatric poisoning? Or maybe, it was a poignant personal experience with serious disease or injury? While these challenging and adrenaline-rush cases provide variety and excitement to the profession, one must always remember that the core of EM is often times primary care medicine. According to the 2014 CDC data, while there were 141.4 million ED visits in the year, only 7.9% of those were critical cases requiring hospital admission.[3] As many as one-third of ED visits are thought to be for primary care complaints.[5] Although there is not a set definition, most of these are defined as non-urgent ED visits, conditions in which a delay of several hours of care would not increase the likelihood of adverse outcomes. In retrospective medical record reviews, non-urgent visits were defined by diagnoses, whether hospital admission was an endpoint, symptoms, and vital signs to name a few. However perceived seriousness of condition by the patient may also be a subjective factor. With changing healthcare policies of our new era, it is inevitable that access to healthcare, especially primary care, will be a significant concern for the younger uninsured and Medicaid population.[4] It is evident that the greatest increase in ED visits between 2006 and 2014 were from the Medicaid population. In that time period, with the exception of injury as the first-listed diagnosis, there has been an increased percentage in medical, mental health/substance abuse, and maternal/neonatal conditions that were managed on an outpatient disposition. From the EM profession’s standpoint, the questions arises: should there be more policy changes and interventions to decrease use of the already overextended ED’s? Or should the EM profession embrace this inevitable change and adapt to care for primary care issues?

EKG Case Study: Is There More to This Chest Pain?

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Author: Ashley Grigsby, DO, PGY-4
Combined Emergency Medicine/Pediatrics
Indiana University

Case
A 32-year-old previously healthy African American male presents via emergency medical services (EMS) for evaluation of chest pain. An ST elevation myocardial infarction (STEMI) code had been activated by EMS based on pre-hospital electrocardiogram (EKG) that had been interpreted as ST elevation in the anterior leads with reciprocal ST depression in the lateral leads. On arrival to the emergency department (ED), the patient appears ill and reports severe crushing chest pain radiating to the arm and down into the abdomen. He is diaphoretic and clutching his chest. His heart rate is 123 beats per minutes, respiratory rate 16 breaths per minute, and blood pressure 210/110 mmHg. He is afebrile. Initial ED EKG is shown below.

Just a Nick?: Mitigating and Identifying Paracentesis Complications

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Author: Mitchell Zekhtser, MS III
Western University of Health Sciences
AAEM/RSA Vice-Chair of Education Committee

Case
A 60-year-old female with a past medical history of alcoholic cirrhosis presented to the emergency department (ED) with abdominal pain and distension seven hours after undergoing a paracentesis. The patient noted that she routinely had the procedure done at her primary care office, but today she started feeling distended again at an accelerated rate. On exam, the patient was hypotensive with a pressure of 98/57, tachycardic with a heart rate of 110, and had diffuse abdominal tenderness worst in the left lower quadrant (LLQ). A computed tomography (CT) scan revealed blood between the abdominal wall and parietal peritoneum, and complete blood count (CBC) showed an acute drop in hemoglobin. Several hours after presentation, the patient underwent an emergent exploratory laparotomy, which revealed a lacerated left inferior epigastric artery (IEA), likely a result of her recent paracentesis. The patient lost four liters of blood throughout the operation. During her stay, she received a total of five units of packed red blood cells and three units of fresh frozen plasma. While the patient survived the surgery, unfortunately, she passed away two weeks later due to exacerbation of her chronic conditions.

Resident Journal Review: Inflammatory Bowel Disease

Authors: Erica Bates, MD and Adeolu Ogunbodede, MD
Editors: Michael Bond, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally Published: Common Sense March/April 2018

Introduction
Inflammatory bowel disease (IBD), which includes both Crohn’s disease (CD) and ulcerative colitis (UC), is a potentially debilitating chronic inflammatory condition of the digestive tract that affects over one million Americans.[1] Individuals with IBD are at risk for a number of potentially serious complications which emergency physicians must be able to recognize and manage. Here we review several articles relevant to the care of this patient population.

Top Ten Things I Have Learned Along the Interview Trail

Author: Chris Ryba, MS4
Loyola Stritch School of Medicine
AAEM/RSA Medical Student Council President

As my interview season comes to a close and Match Day now awaits on the horizon, I thought now would be the perfect opportunity to list the top ten things I have learned along the interview trail:

1. The Interview Trail is TIRING
Long days, long travel times across the country, early morning starts, and the constant goal of always trying to look your best during months of interviews can take a major toll on the body.

My advice: Rest up and keep a good sleep schedule, maintain a healthy lifestyle, pack meals for road trips, and take advantage of hotel perks.

Chief Complaint: I Feel Like I’m About to Have a Seizure

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Author: Elaine Holtzman Brown, MD
University of Mississippi Medical Center
Board Liaison to the RSA Social Media Committee
Originally Published: Common Sense March/April 2018

Your patient is a 69-year-old female with a past medical history significant for seizure disorder, hypothyroidism, anxiety, and frequent urinary tract infections. She presents with a four-day history of generalized weakness to the point where she can no longer walk without assistance. Additionally, she has shortness of breath that worsens with exertion. She is anxious, and feels like she is about to have a seizure. You hear her say, “I have this feeling of impending doom.” And there it is. This lady has a PE. You nailed it!

Evaluation of Syncope in the Emergency Department

Authors: Theodore Segarra, MD; Lee Grodin, MD; Taylor Conrad, MD; Raymond Beyda, MD
Editors: Michael C. Bond, MD FAAEM and Kelly Maurelus, MD
Originally Published: Common Sense January/February 2018

As syncope is a common yet nebulous complaint, evaluation of the patient with syncope presents a unique challenge. Syncope is defined as a brief loss of consciousness and postural tone with rapid return to baseline mentation. Yet, rather than having a single underlying cause, syncope itself is a syndrome with many potential etiologies. Some identified causes are arrhythmia, myocardial infarction (MI), cerebrovascular accident (CVA), hemorrhage, and pulmonary embolism (PE).[1] In this edition of RJR, we review the potential etiologies of syncope, the utility of risk stratification tools in the workup of syncope, and the prevalence of atypical causes of syncope.

Risk Management Monthly / Emergency Medicine - Case of the Month, February 2018

Seward v Metrolina Medical Associates (South Carolina) – A patient presented with shortness of breath and chest pressure after a lengthy airplane flight. He was accompanied by his wife. The chief complaint on the ED chart listed “cough and shortness of breath.” A chest x-ray was reported as negative for pneumonia, and the patient was discharged with a diagnosis of bronchitis. He died the following day. The autopsy listed pulmonary embolism as the cause of death. At the malpractice proceeding, the plaintiff’s attorney pointed out that the diagnosis was missed despite the presence of classic PE symptoms after a longplane flight. The defendant falsified the records after the fact (indicating that the patient had declined an ECG, reported productive cough, and had a negative calf exam for tenderness and swelling). The defendant claimed that this documentation was completed in the presence of the patient and his wife, but examination of the EHR showed that this documentation occurred after the diagnosis was known. The case was settled for $3 million.

The RMM panel notes that:

• In the age of electronic medical records, it’s easy to determine the timing of documentation. Be aware that juries are likely to come down hard on you if you are dishonest in your testimony.
• In Dr. Henry’s experience, he is unaware of a single case in which the defendant has prevailed after it is demonstrated that he/she has charted something that was not actually done or said something that was later found to be untrue.

2017-18 AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Tamathor Abughnaim
University of Illinois College of Medicine

RSA is proud to share the following essay from one of the 2017-2018 Medical Student Scholarship winners, Tamathor Abughnaim. We felt this essay best exemplified why she is choosing EM as a specialty. Congratulations, Tamathor!

2017-18 AAEM/RSA Medical Student Scholarship Winners Share Why They Are Choosing EM

Author: Michael Lauria
Dartmouth Geisel School of Medicine

RSA is proud to share the following essay from one of the 2017-2018 Medical Student Scholarship winners, Michael Lauria. We felt this essay best exemplified why he is choosing EM as a specialty. Congratulations, Michael!

Exhaustion had never felt so good. Many of the other details surrounding that rescue operation in the middle of the Iraqi desert were a blur, a shadowy haze of blood, twisted metal, and wind-driven dust. Just hours before, our combat search and rescue team had managed to triage, treat, and transport seven critically injured soldiers involved in a catastrophic helicopter crash. As the team sat back, relaxed, and watched the sun rise over the desert, I quietly reflected on the night's events. I realized that I truly loved being there to provide emergency medical care to those soldiers when they needed it most. Now, eight years later, I recognize that I want to dedicate my career as a physician to that same purpose.

The Opioid Epidemic: Where Are We Now?

Image Credit: Pixabay

Author: Aaron C. Tyagi, MD
Chair, RSA Social Media Committee
Originally Published: Common Sense January/February 2018

We have seen the rate of overdose mortality in general and mortality of overdoses related to opioids continue to rise.[1,2] As a society, we were slow to recognize this problem, for a number of reasons. Now it is incumbent upon us to respond appropriately and in a timely manner. But our opportunity in which to do that in is quickly shrinking. It seems the executive branch and President Trump have recognized this.[3] But let’s actually take closer look at what we’ve done and what we’re doing currently.

Drug overdose and opioid overdose continues to be a problem in the United States. According to a 2016 report by the CDC, of the 47,055 deaths from drug overdoses that occurred in 2014, 28,647 (60.9%) involved an opioid. The following year (2015), the number of deaths from overdoses rose to 52,404 with 33,091 (63.1%) from opioids.[4] We are constantly exposed to this in the ED. We (the ED and our EMS colleagues in the field) are the frontlines when these patients come in dead or near-dead and need to be resuscitated. We know first-hand the potentially devastating effects of these medications.

A Racing Heart and Seeing Stars: Pre-excitation and Syncope in a Young Adult

This post was peer reviewed.
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Author: Eric Sulava, MD
Emergency Medicine Resident
Naval Medical Center Portsmouth
AAEM Education Committee

Author: Hannah Harris MD
Student Naval Flight Surgeon
Naval Aerospace Medical Institute

Author: Katrina Destree, MD
Staff Physician
Naval Medical Center Camp Lejeune

Chief Complaint
“My heart was racing and then everything went grey”