Thursday, July 25, 2019

Cancer Sucks

Image Credit: Pixabay
Author: Nick Pettit, DO PhD
2018-2019 AAEM/RSA Board Liaison to the Publications and Social Media Committee
Originally published: Common Sense May/June 2019

Cancer sucks! This is the proverbial phrase that unites all cancer survivors, cancer fighters, and cancer victims. It allows unity among the terrifying cancer experience, allowing us to bond and empathize over the seriousness that is a cancer diagnosis. Clinical experience suggests that cancer is frequently diagnosed in the emergency department (ED). Anecdotally, in three years of residency I have seen a whopping two STEMI’s between my two large academic EDs, whereas, maybe monthly I worry about a new cancer diagnosis.

Thursday, July 18, 2019

Dip, Chew, and Snuff: A Case of Nicotine Toxicity

Authors: Tim Montrief, MD MPH and Mehruba Anwar Parris, MD FAAEM
AAEM/RSA Publications & Social Media Committee and Common Sense Assistant Editor 
Originally published: Common Sense May/June 2019

A 25-year-old Caucasian male with no significant known past medical history presented to a community emergency department via EMS with palpitations and altered mental status while on vacation at a friend’s bachelor party. Per the patient’s friend, he had been drinking alcohol all day and accidentally ingested a large amount of smokeless tobacco one hour prior to arrival, with subsequent nausea, vomiting, and excessive salivation. His friend denied any co-ingestions or drug use. The patient was found to be somnolent but arousable to voice, without any focal neurologic deficits and normal point of care blood glucose. The initial physical exam was remarkable for new-onset atrial fibrillation with a heart rate in the 160’s, blood pressure of 102/56 mmHg, respiratory rate of 16 breaths per minute, and saturating 100% on room air. Aside from atrial fibrillation with rapid ventricular response, the electrocardiogram was unremarkable (Figure 1). Additionally, the chest X-ray showed no evidence of cardiopulmonary pathology. Further testing revealed normal troponin, T4, and TSH levels. He had an elevated serum alcohol level of 191 mg/dL, and a negative urine drug screen. Initial cotinine and nicotine levels were not available. The patient was given a diltiazem bolus and drip, as well as four liters of lactated ringers, with subsequent heart rates in the low 100’s, with corresponding blood pressures in the 120’s/80’s. The patient was admitted to the ICU, and spontaneously converted back to a normal sinus rhythm within 24 hours of his initial presentation. The patient was discharged the next day with close outpatient follow-up.

Thursday, July 11, 2019

The Last Lecture to the Newly Graduating Emergency Medicine Residents

Author: James Keaney, MD MPH MAAEM FAAEM
First President of AAEM
Originally published: Common Sense May/June 2019

The Current Climate of EM – How Did We Get Here?
There are several recurrent phrases making their way into the vernacular of emergency medicine including transmutation, Joe the Plummer, the Leviathan Levy, and tumbleweed doctors.

The transmutation of clinically generated fees into management money is the theme of this talk revolving around the misallocation of Medicare-approved, clinically generated fees by practicing doctors into administrative wealth. The premise of the talk is this transmutation not only provides zero-point-zero real benefit to the physician, possibly even has negative effects, but also represents a public health detriment to the communities in which the hospitals are located.

Thursday, July 4, 2019

The Role of High Sensitivity Troponin Pathways in the Emergency Department

Authors: Akilesh Honasoge, MD MA; Robert Brown, MD; Sharleen Yuan, MD PhD MA
Editors: Kami M. Hu, MD FAAEM and Kelly Maurelus, MD FAAEM
Originally Published: Common Sense May/June 2019

Clinical Question:
Can high sensitivity troponin meaningfully contribute to an acute coronary syndrome evaluation?

Traditional 4th-generation troponin assays are part of the standard cardiac evaluation when there is suspicion of acute coronary syndrome (ACS). Patients presenting to emergency departments with chest pain are typically risk stratified using a combination of historical risk factors, electrocardiogram (ECG) findings, troponin testing, and clinical suspicion. Patients are discharged from the emergency department if their risk is determined to be low while higher risk patients are usually admitted for further observation or testing. Recent data suggests, however, that high sensitivity troponin (hsTrop) testing could supplement or even replace current methods such as clinical risk scores when used in specific protocolized serial testing pathways. High sensitivity troponins first became available in the United States in 2017, but their use has not yet reached widespread acceptance. The test offers detection of cardiac troponin approximately 1,000 times more sensitive than standard 4th-generation cardiac troponin testing. With this higher sensitivity come questions regarding reliability and specificity in certain comorbidities such as chronic kidney disease and underlying coronary artery disease. Some studies also explore the use of computed tomography (CT) coronary angiography when used in conjunction with hsTrop. Here we explore a few studies that evaluate the role of hsTrop in the evaluation of potential ACS.