Top 10 Most Read Posts of 2020

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As 2020 comes to an end, we look forward to recognizing the year’s top 10 articles! Join me in congratulating this amazing group of authors at all levels of training and from across the United States!

Additionally, I would like to thank each of the AAEM/RSA Modern Resident Blog authors, reviewers, mentors, and editorial staff members for their tireless contributions to the blog. Without all of them, the blog would not be what it is today. Thanks for a successful 2020!

We are currently accepting articles for 2021 and are always looking for additional faculty mentors as well. Feel free to contact us at info@aaemrsa.org with questions.

Sincerely,

Alex Gregory, MD
Editor-in-Chief
AAEM/RSA Modern Resident Blog

Platelet-Lymphocyte Ratio and Neutrophil-Lymphocyte Ratio: Updates in Prognosticating Fournier Gangrene in the Emergency Department

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This post was peer reviewed.
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Authors: Alessandra Della Porta, EMT-B, MSIIIUniversity of Miami School of Medicine

Kasha Bornstein, Msc Pharm, EMT-P, MSIV
AAEM/RSA Modern Resident Blog Copy Editor
University of Miami School of Medicine

Bottom Line Up Front:
Fournier gangrene (FG) is a necrotizing soft tissue infection (NSTI) associated with high mortality rates, particularly when it is not suspected early, or interventions are initiated late in the course. Diagnosis is clinical and challenged by overlap with more superficial skin infections (i.e. cellulitis) and the need for thorough examination of the genital region. Imaging and laboratory analysis are not able to consistently rule out FG. While risk calculators exist, they are also limited in their utility for ruling out severity of illness. This brief article discusses use of the monocyte-lymphocyte ratio, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio; recently innovated, simple, and effective biomarkers for prognosticating NSTIs. 

Optimizing Medical Surge Capacity

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This post was peer reviewed.
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Authors: Mary Unanyan, OMS-I
Gregory Jasani, MD; AAEM/RSA Secretary Treasurer

The coronavirus pandemic has caused many to wonder whether our nation’s healthcare system can properly treat all of the projected critically ill patients. Experts worry that the sudden increase in sick patients may overwhelm existing healthcare resources. One way to determine how well hospitals are able to respond to this pandemic is to look at the “surge capacity” of the health system.

Medical surge capacity is a measure of the ability of a health system to manage care for a sudden increased volume of patients beyond the normal operating capacity.¹ 

 

The Gender Gap in Medical Leadership: Glass Ceiling, Domestic Tethers, or Both?

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Authors: Eveline Hitti, MD MBA FAAEM

Lisa A. Moreno, MD MS MSCR FAAEM FIFEM

Originally published: Common Sense
May/June 2017

The number of women enrolled in medical schools has risen from less than 25% in the 1970s to over 47% today.^1,2 In spite of this, we continue to see striking under-representation of women in leadership positions in academic medicine, professional organizations, and health services in general. Women comprise only 38% of full-time faculty, 21% of full professors, and 30% of new tenures in academic medicine. Only 18% of hospital CEOs are women, and the percentage of female department chairs and deans at US medical schools remains low, at 15% and 16% respectively.^2,3 This leadership gap is not unique to medicine. It mirrors trends in law, where women continue to constitute a disproportionate minority of partners within firms; and business, where women are less likely than men to hold corporate executive positions. In the past this discrepancy could be explained by a higher percentage of male medical and professional school graduates. Yet today, when the percentage of females in medical school, law school, and business school equals or exceeds the percentage of males, a significant leadership gap persists.

From Chaos to Clarity: Leadership in the Resuscitation Bay

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Author: Mary Haas, MD
Originally published: Common Sense
November/December 2016

You are managing a busy emergency department, when you hear via the overhead paging system that a new patient has arrived in your resuscitation bay. You scurry from the farthest corner of your department, where you were evaluating a patient with multiple chronic medical problems and multiple complaints. As you book it to the resuscitation bay, you carry the weight of several sick patients you are managing and the knowledge of several on stretchers waiting to be seen, not to mention the full waiting room. You arrive at the resuscitation bay, where a group of people are bustling around as if a storm is about to hit. You see the ambulance pull up to the doorway with lights flashing. In this moment, as leader of the resuscitation, you have the responsibility to transform chaos into clarity.

Meditation in Medicine

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Author: Puja Gopal, MD
University of Illinois College of Medicine

This post was peer reviewed.
Click to learn more.

Recently when watching the evening news, I came across an interesting segment focusing on how teaching meditation in middle and high schools in San Francisco has led to many positive measurable changes. School officials have noted better attendance, better academic performance, and at least a 75 percent decrease in suspensions over a period of four years.

Meditation and relaxation techniques have garnered a lot of attention lately and have become the focus of much research. A brief literature overview on the potential impact meditation can have, especially in the field of emergency medicine, follows below. For emergency physicians, who operate in high-stress environments; attend to multiple tasks, often simultaneously; and must manage 'the busy pit', overall wellness becomes especially important. Wellness is reflected in one's even mindedness and control during high stress situations such as coding patients; one’s focus and concentration during shifts of high volume; and one’s resiliency, especially after bad outcomes. Stress reduction techniques are thus essential to maintain wellness and happiness and avoid burn-out.

The Open Door

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Author: Lauren Lamparter – Medical Student Council President

Originally published: Common Sense
September/October 2020

One of the reasons I am drawn to and pursuing a career in emergency medicine is its open-door policy — all are welcome, regardless of their ability to pay, the color of their skin, their legal status, or their sexual orientation. The emergency department (ED) is open 24-hours a day, seven days a week, 365 days a year to serve those in need, no matter their ailment or chief complaint. It is a place where there should be no discrimination based on race, religion, insurance status, or gender. All are welcome and will be taken care of with the priority of receiving the best care we can possibly give. I aspire to be an emergency medicine physician so I too can be a champion of health for all; someone who can set aside my implicit biases and provide for a fellow human who is in need of help. 

Human Trafficking: A Review for Health Care Providers

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Authors: Nicole E. McAmis; Angela C. Mirabella; Elizabeth M. McCarthy; Cara A. Cama, MBA; and Frank H. Netter, MD 
Originally published: Common Sense
September/October 2020

Background
The U.S. Department of State defines human trafficking in The Trafficking Victims Protection Act of 2000 as:

• Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; or
• The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.¹

When Do Things in Medicine Start to Become Common Knowledge?

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Author: Shaughnelene D. Smith, BSc (Hons); Eddie K. Maybury, BSc

Originally published: Common Sense

September/October 2020

Several weeks ago, I finished my first year of medical school and began the arborous drive from Kansas City, Missouri, to California for a summer research position. When I was just six minutes away from my destination, my car of 21 years decided to break down. It is important to note that I am studying in the United States as an international student from Canada, and despite growing up as a neighbor from the north, much of the U.S. and its various systems are foreign to me.

As midnight approached and the smoke started billowing out of the front bonnet, I found myself pulling off to the side of the road in a city unfamiliar to myself. I quickly took all the essential paperwork from my vehicle – F1-student visa, passport, insurance papers – and found a rock a safe distance away, where I proceeded to call my parents and quickly realized how clueless I was in navigating what to do next.

“Zooming” into a New Era of Clinical Education

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Author: Alexandria Gregory, MD 

Originally published: Common Sense
September/October 2020

If your residency is like most programs, your pre-COVID didactics likely consisted of several hours of in-person conference once a week. That common, traditional way of learning has been turned upside down with the need for social distancing, and most programs have transitioned to virtual conferences. As the reality of COVID persists, it is important to continuously evaluate the effectiveness of virtual learning. Furthermore, in planning for a post-COVID era, it will be beneficial to determine whether virtual learning remains a valid, effective teaching technique despite being able to meet in-person.

To understand how virtual learning affects curriculum design, it is important to start by breaking down what, in general, emergency medicine residency curriculum looks like. Most programs include the following in some fashion: 

• Core Topics
• Small-Group Sessions/Problem-Based learning
• Electrocardiogram (EKG)/Radiology Interpretation
• Morbidity and Mortality/Case Presentations
• Journal Club
• Ultrasound
• Grand Rounds
• Simulation/Procedure Lab
• Oral Board Review
• Asynchronous Learning

Resident Journal Review: Do Adjunctive Therapies Beyond Infection Control and Appropriate Fluid Resuscitation Change Outcomes in Sepsis and Septic Shock?

Authors: Jordan Parker MD; Sharleen Yuan, MA MD PhD; Megan Donohue, MD; Robert Brown, MD; Mark Sutherland, MD; Hannah Goldberg, MD; Akilesh Honasoge, MD
Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM
Originally published: Common Sense
September/October 2020

Introduction
Septic shock is an illness with complex pathophysiology and few available therapies, beyond infection control and appropriate fluid resuscitation, to reverse the disease state. It is one of the most prevalent and lethal disease states that a physician may manage, with 1.7 million cases of sepsis in the United States per year and a reported mortality rate of up to 34%.^1,2 The pathogenesis of septic shock is thought to be driven by a dysregulated host response³ with the role of adjunctive therapies being to assist in reversing this dysregulated response. Treatments that have more recently been a hot topic of debate include vitamin C, corticosteroids and thiamine. Vitamin C (ascorbic acid) a role in numerous physiologic processes including endothelial permeability, micro and macrovascular function, cellular apoptosis, immune system function and endogenous catecholamines.⁴ Studies have shown that vitamin C deficiency is present in critically ill patients,⁴ and its role in these essential functions is the basis for its use as a potential treatment in septic shock. Thiamine also plays a role in key metabolic processes, including cellular energy production and generation of cellular antioxidants, and thiamine deficiency has been well-documented in sepsis, with observational studies indicating a signal for improved outcomes with supplementation.⁴ Steroids have been used in refractory septic shock for almost the past two decades⁵ but the recent rationale for its use includes its synergism with vitamin C. Glucocorticoids may be able to increase the activity of vitamin C by increasing expression of the transporter involved in its uptake into cells, sodium-vitamin C transporter (SVCT2).⁴ In return, vitamin C, as an antioxidant, may be able to facilitate the binding of glucocorticoids to their receptor, a coupling impeded by oxidizing molecules. We will review several of the high-profile trials that have attempted to elucidate the effectiveness of utilizing corticosteroids, vitamin C, and thiamine in the management of patients with sepsis and septic shock.

A Medical Student/Paramedic's Perspective on COVID-19

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Author: Matthew Carvey

Originally published: Common Sense

July/August 2020

Medic-1 is responding to an assault in a rural location. Dispatch notifies EMS that the patient has a fever and was put on mandatory self-isolation for 14 days. On arrival, EMS dons a sterile cap, goggles, an N95 mask, face shield, gown, and gloves. The patient, belligerent and intoxicated on alcohol and psilocybin, yells at EMS ‘I have the COVID!’. She rushes EMS, removes the practitioners mask, and coughs in his face. Police arrest the woman under the Mental Health Act, and EMS transports, only for her to spit and verbally abuse them the entire length of transport. EMS unloads the patient and awaits triage. After handing over care, EMS doffs all used PPE, and don’s new equipment to thoroughly clean the ambulance. One of the practitioner’s displays signs of COVID-19 three days later. This article is a medical student/paramedic’s perspective on COVID-19.

Resident Journal Review: Available Evidence Regarding Targeted Temperature Management (TTM)

Authors: Rithvik Balakrishnan MD; Taylor M. Douglas, MD; Taylor Conrad, MD, MS; Theodore Segarra, MD; Christianna Sim, MD, MPH
Editors: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM
Originally published: Common Sense
July/August 2020

Introduction
The ability to obtain good neurological outcomes after cardiac arrest is often limited. Interventions during the acute phase of treatment post return of spontaneous circulation (ROSC) are therefore critical.¹ The primary goal of cardiopulmonary resuscitation (CPR) is to optimize coronary perfusion pressure and maintain systemic perfusion in order to prevent neurologic and other end-organ damage while working to achieve ROSC. While the utility of therapeutic hypothermia for preservation of neurologic function post-cardiac arrest had been suggested in the early 1950s and 1960s, ^2-4 the studies were inconclusive, with high complication rates. It was not until the 1990s that studies showed possible benefits to mild hypothermia in animal models. ^5-10 The results of the 2002 trial by the Hypothermia after Cardiac Arrest Study Group were the basis for the inclusion of therapeutic hypothermia in the American Heart Association’s post-cardiac arrest care guidelines.¹¹ Subsequent trials have assessed the difference between therapeutic hypothermia to 33 degrees Celsius (ºC) and “targeted temperature management” (TTM) aiming for 36ºC, the duration of TTM, the method used to achieve and maintain it, and whether TTM confers a similar neurological benefit for cardiac arrests secondary to non-shockable rhythms; some of these trials will be discussed below and will help us answer the question at hand.

New Florida Law Requiring Written Consent for Pelvic Exams: Stumbling Towards Trauma-Informed Care

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Authors:Emily Lara S. Dawra, BS, MSII

University of Miami Miller School of Medicine MD Program
AAEM/RSA Member

Kasha Bornstein, MSc Pharm, EMT-P, MSIV
University of Miami Miller School of Medicine MD/MPH Program
AAEM/RSA Modern Resident Blog Copy Editor

Introduction
On June 18, 2020, Florida Governor Rick DeSantis approved Florida Senate Bill 698, which strictly prohibited and criminalized the non-emergent use of pelvic examinations without written consent of either the patient or legal guardian.¹ The new measure has particular implications for the flow of operations in emergency departments across Florida, as the requirements are a potential source of confusion, additional legal jeopardy, and increased bureaucratic workload. Effective as of July 1, 2020, this legislation has already garnered strong reactions from medical professionals, including the American College of Obstetrics and Gynecology, who believe this serves a “gross intrusion in the patient-physician relationship,” and whose statement is further endorsed by the Florida Medical Association.^2,3 This article describes and expands on the spoken concerns surrounding this bill as they may apply to the emergency clinician. 

Lightning Strike Emergencies Part 2: Trauma Approach

Image Credit: Piqsels

Author:

Vivek Abraham, MD
PGY-1, Orthopedic Surgery

Additional Authors:

Ivan Yue, MD

PGY-1, Emergency Medicine
Naval Medical Center San Diego
AAEM/RSA Publications and Social Media Committee

Alexander Li, MD
PGY-1, Orthopedic Surgery

Naval Medical Center Portsmouth

Introduction
Lightning strike triage and cardiac resuscitation was previously covered in part 1. Abnormal cardiac rhythms are the most common fatal complications of lightning strikes, but other complications of lightning strikes can cause high morbidity and mortality if left untreated. This article will go over injury patterns that may be seen and diagnosed in the emergency room.

Lightning Strike Emergencies Part 1: Triage and Cardiac Emergency

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This post was peer reviewed.
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Author:

Vivek Abraham, MD
PGY-1, Orthopedic Surgery

Additional Authors:

Alexander Li, MD
PGY-1, Orthopedic Surgery

Naval Medical Center Portsmouth

Ivan Yue, MD

PGY-1, Emergency Medicine
Naval Medical Center San Diego
AAEM/RSA Publications and Social Media Committee

 

Introduction
Lightning strikes occur commonly, with an estimated global incidence of 240,000 worldwide per year with deaths numbering 24,000.[1] As more people embark on expeditions and explore the outdoors, they are putting themselves at risk of these strikes. Due to the prevalence and mortality of lightning strikes, emergency medicine physicians and other healthcare providers should be adept in treating these life-threatening injuries. This article reviews the guidelines for triage and management of cardiac emergencies due to lightning. 

Approaching Away Rotations

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This post was peer reviewed.
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Author: Taylor Petrusevski, MS4
Loyola Stritch School of Medicine
AAEM/RSA Social Media Committee

For emergency medicine (EM)-bound third-year medical students, exciting times are quickly approaching, including starting to think about your away rotations. Away rotations are a crucial component of an EM application, as studies consistently note that the away Standardized Letter of Evaluation (SLOE) and grade have the highest values in selecting prospective EM residents.¹ One year ago, my fellow EM-bound classmates and I began to have similar questions around away rotations: primarily, how many and where? I’d like to pass along notable conclusions from recent studies around this topic as well as some advice I received from mentors that helped me along the way.

Medical Student Experiences with Ethical and Legal Cases

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Author: David Fine, Medical Student Council President

Originally published: Common Sense
May/June 2020

The purpose of medical education is to train future providers to be prepared for the multitude of patients, presentations, and complications that they might face in their future careers. Ethical and legal dilemmas are incredibly complicated and vary based on where you practice, so they are often less discussed than our essential medical fundamentals. Being somewhat familiar with common problems, however, is relevant not only to your future career but your rotations as well. I aim to share a few of the complex situations that I faced, which may apply to your rotations in the emergency department or on the floors.

Dilemma 1: A patient who was frustrated with long wait times starts the patient interview by stating that they are recording the conversation. 

Should ST elevation in lead aVR with concern for acute coronary syndrome prompt emergent coronary angiography?

Authors: Akilesh Honasoge, MD, Robert Brown, MD, Samantha Yarmis, MD, Mark Sutherland, MD, Megan Donohue, MD, Hannah Goldberg, MD

Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM

Originally published: Common Sense

May/June 2020

Nine Steps to The Best Medical Notebook You'll Ever Use

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This post was peer reviewed.
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Author: Philip A Castrovinci MD
Undersea Medical Officer
US Navy

While a medical student, I remember a fourth-year emergency medicine resident with a notebook of his own creation. We did not see a single patient over a dozen shifts that he didn't pull out the notebook to extract some high-yield crucial information about the variety of conditions we came across. It was like a clown car of medical knowledge. He let me look at it. It was glorious. What I found was, and subsequently copied, was the best medical notebook I have ever seen. I forget what I learned during those dozen shifts, but the organization of the medical notebook will stay with me for the rest of my career.

A Message to Students in these Uncertain Times

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Image Credit: Needpix

Author: David Fine, MD

AAEM/RSA Board Members, Liaison to the AAEM/RSA Education Committee, and AAEM/RSA Medical Student Council

Medical school is undoubtedly a stressful time, but studying medicine in the context of a pandemic is a challenge that brings about additional stressors, anxiety, and uncertainty. The changes that have been implemented are a result of safety being a number one priority. I also feel it is important to recognize the difficult situation that students are facing.

The Changing Landscape of Pre-clinical Medical Education

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Author: Alexandria Gregory, MD
AAEM/RSA Editor

Originally published: Common Sense
May/June 2020

In mid-February, the National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) announced that the United States Medical Licensing Examination (USMLE) Step 1 scoring would be changed to pass/fail as early as 2022.1 Many rejoiced about the potential for residency programs to emphasize other parts of applications rather than a test that does not evaluate the most clinically-relevant medical knowledge, while others expressed concern about the logistics of the decision and whether it would truly have its intended effect. Regardless of where you stand on the issue, it is important to recognize the implication this has regarding how preclinical education may change in upcoming years in medical schools across the country.

Intractable hiccups: a presentation of COVID-19

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This post was peer reviewed.
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Author: Jaclyn H. Jansen, MD MS
Emergency Medicine Resident

Department of Emergency Medicine, Indiana University School of Medicine 

Indianapolis, Indiana

ABSTRACT

BACKGROUND: 

While patients with COVID-19 infection most frequently present with fever, dry cough, and dyspnea, other symptoms have been associated with viral infection. This case report describes a patient presenting without respiratory complaints, initially screened as low-risk for COVID-19. With known communal spread, it is paramount to recognize unusual presentations of COVID-19 infection including hiccups and gastrointestinal complaints. Early recognition and isolation of patients with possible infection while in the emergency department improves provider safety and patient care.

The Moral Dilemma of COVID-19

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Author: Andy Mayer, MD FAAEM
Editor-in-Chief Common Sense
Originally published: Common Sense

May/June 2020

Certainly, there is only one issue which is dominating all thoughts, prayers, and efforts on our planet right now and it is COVID-19. Hopefully where you are, your life and practice will only be incredibly inconvenienced and that your family, your community, and your hospital will be spared the worst of this pandemic. Many areas may be relatively spared by early social distancing and the shutdown of many aspects of daily life which until last month we took for granted. This crisis has brought to the forefront many ethical and moral dilemmas which our society and world need to face with open eyes and minds. Our medical capabilities in our modern prosperous society are currently been taxed past the breaking point in the hotspots of the COVID-19 pandemic. We need as a profession and as a society to consider the correct response to the complex and difficult decisions which physicians on the frontlines are now making or may eventually be facing where conditions are worse. Even if we manage to make it through this pandemic without running out of ventilators and do not lose too many talented and selfless healthcare professionals there may be a next time.

Avalanche Resuscitation in the Emergency Department

Image Credit: Wikipedia

This post was peer reviewed.
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Authors: Vivek Abraham, MS4

Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Ivan Yue, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine
AAEM/RSA Publications and Social Media Committee

Alexander Li, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Introduction
Avalanches are among the most feared events to occur in mountainous areas. Although the morbidity and mortality statistics are underreported worldwide, in North America and Europe combined there are roughly 140 avalanche-related deaths per year.[1,2] The majority of victims include snowboarders, skiers, mountaineers, and snowmobilers. With more people seeking to participate in snow sports or explore the mountains as part of expeditions, preparing to treat avalanche-related injuries is essential for an emergency physician working or traveling near a mountainous area. This article details the resuscitation guidelines that physicians can implement for those who fall victim to an avalanche as well as recommendations for mitigating avalanche exposure risk.

Considerations for Your Social Media Presence

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Author: David Fine 

Medical Student Council President 

Originally published: Common Sense
March/April 2020

Should you create a professional social media account? What are the benefits and risks associated with this commitment? When applying for medical school, residency, or jobs are people searching for you on the internet? How do HIPPA, professionalism, and unspoken rules factor into your social media presence? My search for information has shown that many people are asking the same questions. There are a plethora of different resources that can help you make informed decisions.

The American Medical Student Association (AMSA) has created a set of 10 social media guidelines: be professional, be responsible, maintain separation, be transparent/use disclaimers, be respectful, follow copyright laws, avoid politics, protect client/patient information, comply with all legal restrictions and obligations, and be aware of risks to privacy and security (Keating 2016). These guidelines are vague, but this speaks to the potential for problems that you might face and the importance of thoughtful posting. Even on private accounts, posts that violate HIPAA and professionalism can result in punitive actions from your home institutions. There is often this discussion about ways that these forums can be negative, but there is a massive potential benefit that is much less often explained. 

Resuscitation Guidelines Updates: What You Need to Know

Image Credit: Wikimedia

Author: Kasha Bornstein, MSc Pharm, EMT-P, MSIII
University of Miami Miller School of Medicine MD/MPH Program
AAEM/RSA Modern Resident Blog Copy Editor

Introduction

In late 2019, the International Liaison Committee on Resuscitation (ILCOR) released its updated guidelines for adult and pediatric resuscitation, informing the United States-based American Heart Association (AHA)/Advanced Cardiac Life Support (ACLS) focused protocol update.[1]

Significant changes this year in ILCOR recommendations focus on:

- Vasopressor use
- Advanced airway interventions and extracorporeal cardiopulmonary resuscitation (ECPR) in adult and pediatric cardiac arrest
- Targeted temperature management (TTM) in pediatric cardiac arrest This short article will address the salient details regarding each of these updates. Vasopressor Use Epinephrine, the old standby for the all-cause pulseless patient, has undergone significant review in recent years. Multiple large-scale retrospective and placebo-controlled randomized-controlled prospective studies have probed the efficacy and safety of epinephrine in cardiac arrest.[2,3] The majority of these studies find that while epinephrine may increase return of spontaneous circulation (ROSC), the effect size is small versus placebo and no difference is seen in favorable neurologic outcome. Many aspects surrounding best practices in epinephrine use remain unknown. These include optimal timing for administration in patients with shockable rhythms, efficacious dosing, and dose/effect relationships. However, alternative interventions are limited, overall survival for patients with non-shockable rhythms (asystole, pulseless electrical activity) is low, and no other pharmacologic intervention has demonstrated improved ROSC in these cases.

Human Trafficking: Identification and Treatment Tools for the Emergency Physician

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Authors: Maryam Hockley, MD MPH, Erin Hartnett, BS BA, Gregory Jasani, MD

Originally published: Common Sense

March/April 2020

Human trafficking (HT) affects over 21 million people worldwide¹, with 600,000-800,000 persons being trafficked annually across international borders, approximately half of whom are younger than 18 years old.² Closer to home, roughly 18,000-20,000 trafficking victims are brought into the United States every year, and this number does not count victims already within our borders.³ Its victims are not confined to a certain age, race, gender, sexual orientation, or socioeconomic level, and it is this level of pervasiveness that makes signs of HT difficult to identify. Vulnerable populations include those in the child welfare and juvenile justice systems, runaway and homeless youth, unaccompanied children, American Indians/Alaska Natives, migrant laborers including undocumented workers and temporary workers on visas, foreign national domestic workers in diplomatic homes, those with limited English proficiency and low literacy, disabled peoples, LGBTI, and those in court-ordered substance use programs.⁴ The International Labor Office estimates that 44% of all HT victims worldwide had migrated either within or across international borders prior to being put into forced labor.¹ The nature of human trafficking often leads to both physical and emotional harm for the victims, as it relies upon the coercion of a person into such an exploited role. As a result, an article by emDocs estimates that as many as 88% of victims will seek medical care during the time that they are being trafficked, oftentimes in an emergency department. However, their studies have also shown that as few as 5% of emergency medicine providers feel comfortable identifying and treating victims of HT.⁵ This unique encounter, however, offers emergency medicine physicians an invaluable opportunity to intervene in these victims’ lives. Improving this statistic represents a crucial opportunity to increase awareness and understanding of the potential role we can play in these patients’ lives.

Resident Journal Review: Assessing Fluid Responsiveness in the Emergency Department Part II

Authors: Taylor Conrad, MD MS, Taylor M. Douglas MD, Ted Segarra, MD, Rithvik Balakrishnan MD, Christianna Sim, MD MPH Editor: Kelly Maurelus MD FAAEM, Kami Hu MD FAAEM

Originally published: Common Sense

March/April 2020

Clinical Question
What methods are most effective at determining if a patient will be fluid responsive?

The most recent Common Sense Resident Journal Review article looked at the utility of ultrasound to accurately assess fluid responsiveness in the Emergency Department (ED). In this article, we attempt to look at other modalities that ED physicians may use to quickly determine how patients with various etiologies of hypotension and shock respond to fluid. Initial intervention often involves a fluid bolus of varying amounts to determine if increasing preload can improve the patient’s hemodynamic status along the Frank-Starling curve^1,2. Other factors affect the patient's hemodynamics, however, including systemic vascular resistance and the contractility of the myocardium. Vital signs and the rest of the physical exam are inadequate in determining response to fluid and persistent hypotension may represent alterations in these other factors³. Invasive measurements of a patient's hemodynamic status can be performed with insertion of Swan-Ganz catheter but its lack of proven benefit in the ED and associated potential complications has led to a decline in its use⁵. As such, patients often receive varying amounts of fluid by ED providers, which often comprises a large amount of the initial resuscitation volume. As it has also been established that a positive fluid balance is associated with a variety of negative effects and worsened patient outcomes, identifying means to help avoid unnecessary fluid administration is crucial.^2,6

Own Your Worth

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Author: Adriana Coleska, MD
AAEM/RSA Board of Directors

Originally published: Common Sense

March/April 2020

As emergency medicine (EM) physicians, we use humor as a way to cope with a difficult diagnosis, patient loss, or an uncomfortable consultant interaction. While those who have worked with me in the emergency department know that I thrive on a relaxed and joking environment to make the shifts go by, I want to shed light on a worrisome trend that I have noticed. I want to talk about the overuse of self-deprecating humor by physicians in our specialty. I have only been in the field of emergency medicine for 2.5 years, and I cannot count how many times I’ve heard my co-residents, friends in EM, even attendings end a story or consultation with the phrase “but what do I know, I am just an emergency room doctor.” Some physicians have even gone so far as coining the term “JAFERD” (just another f****** emergency room doctor).

Though jokes, even self-deprecating ones, can quickly diffuse a tense situation, my sense is that sometimes the “just an ER doc” phrase comes from a place of insecurity. I’ve witnessed residents and attendings give thorough explanations regarding their thought process and reason for a consult, only to end with the wobbly “but I’m not sure, I am only an ER doc.” Using this statement in a professional setting diminishes the validity of your question and possibly the consultant’s opinion of your clinical knowledge and reliability. Why use language that can negatively impact your intelligence? Have you ever heard a surgeon say “I am JUST a surgeon?” We all went to medical school and matched in a competitive field, trust in your knowledge and hard work, be confident in your exam and thought process. We are not perfect. We are allowed to get things wrong; it’s hard to keep up with new literature and new protocols on all of medicine. But when speaking to a consultant who is questioning your management, don’t shy away and hide behind the phrase JAFERD. Explain to them where you are coming from and eagerly ask to be educated on the new literature that consultant is guiding their treatment off of. And while some may use JAFERD as an inside joke, when heard by outsiders the “just” portion of the phrase can be misconstrued as lacking confidence or as excusatory.

Letter to Our Emergency Medicine Residents and Medical Students

Image Credit: CDC

Dear Emergency Medicine Residents and Students,

We have reached a critical time in modern medicine with the pandemic of Coronavirus (COVID-19). Today, I wanted to take a minute to remind you just how important you are in this fight against COVID-19.

Over the coming days and weeks, your efforts will be critical in helping to manage large numbers of critically ill patients and to help stifle the spread of this deadly virus. As emergency medicine residents and medical students you are the front-line, at all times. You are the engine of the emergency department - arguably the most essential department for containing and treating this virus. Every single patient you see, every treatment you administer, every intubation you perform, is one further step in gaining control against COVID-19.

What is Happening to Our Specialty? An Open and Honest Look at the Chaos in Our Trade.

Image credit: Pexels

Author: AAEM/RSA News

Originally published: Common Sense January/February 2020

As physicians, we all subscribe to the four tenets of medical ethics: autonomy, justice, beneficence, and non-maleficence. These ideals are integral in providing ethical care to all our patients, from the weakest and most vulnerable, to the most astute and medically literate. Our patients deserve these moral characteristics in their physician in order to get the best care possible. But what do physicians deserve?

If we were to apply these factors to ourselves as EM physicians, we’d see a grim trend of unethical practices occurring in our own specialty. Corporate greed, poor educational transparency, loss of autonomy – and the illegitimization of the emergency physician.

Resident Journal Review: Utility of Ultrasound Measurements in Assessing Fluid Responsiveness

Authors: Samantha J. Yarmis, MD; Robert Brown, MD; Jordan Parker, MD; Caleb Chan, MD; Akilesh Honasoge, MD
Editors: Kami M. Hu, MD FAAEM, Kelly Maurelus, MD FAAEM
Originally published: Common Sense January/February 2020

Clinical Question
How can we utilize ultrasound measurements to accurately determine which patients are fluid responsive? Does any single ultrasound measurement accurately predict fluid responsiveness?

Introduction
Volume expansion is a cornerstone of resuscitation in the ED and is currently one of the main recommended components of septic shock management. The ability to predict fluid responsiveness has been a highly debated issue within emergency and critical care medicine. Early studies found inferior vena cava (IVC) diameter and variability could predict fluid responsiveness in intubated, mechanically-ventilated septic patients.^1,2 The applicability of these findings to other populations is unknown and subsequent studies have called these findings into question.³ At the other end of the spectrum, the existence of a volume overloaded state may be detected by measuring indices in the liver and kidneys such as portal vein pulsatility,^4,5 hepatic venous flow velocity,⁶ and intrarenal venous flow.⁷ Confirmation of increased stroke volume with passive leg raise or a small fluid challenge is currently one of the better, albeit imperfect, existing methods to ensure true volume responsiveness.^8,9,10

Tranexamic Acid (TXA) in Obstetric Hemorrhage

This post was peer reviewed. Click to learn more.

Image Credit: Wikimedia

Authors: Patrick Wallace, DO, MS
Emergency Medicine Resident, PGY-2
University Nevada Las Vegas
AAEM/RSA Publications and Social Media Committee, and AAEM/RSA Education Committee

Laurie Bezjian Wallace, DO
Family Medicine Resident, PGY-2
Mike O’Callaghan Military Medical Center

Bottom Line Up Front: Tranexamic Acid (TXA) reduces postpartum hemorrhage with no major adverse events. There is some evidence to suggest routine use of TXA in all vaginal deliveries.

Introduction: Postpartum hemorrhage (PPH) is the leading cause of maternal deaths with over 100,000 deaths per year. It occurs in 3-15% of deliveries, making up about 25% of all maternal deaths worldwide.[1-5] The three most common causes of PPH can be remembered as the three T’s: tone, tissue, and trauma. Tone refers to uterine atony, tissue referrers to retained placental tissue, and trauma refers to cervical or perineal lacerations. Uterine atony is the most common cause of PPH and can be treated with bimanual massage and uterotonics such as oxytocin, methergine, or misoprostol.[2,5] American College of Obstetrics and Gynecology (ACOG) and World Health Organization (WHO) currently recommend routine prophylaxis with the administration of oxytocin during the third stage of labor.[2,5]

My First "Sick" Patient

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Author: Alexandria Gregory, MD

AAEM/RSA Publications & Social Media Committee Chair
Originally published: Common Sense January/February 2020

Everyone knows the most fundamental part of emergency medicine residency is learning how to determine “sick versus not sick,” which is often easier said than done. One night, at the end of my shift, a nurse grabbed me, saying the patient in room six needed a doctor now. The patient was a young asthmatic who had apparently walked into the emergency department minutes earlier, but was now unresponsive, gray, and with an oxygen saturation in the 50s. I had no trouble determining she was sick; as a relatively new intern, the bigger problem was figuring out what to do next. To quote Michael Scott from The Office episode “Stress Relief,” in that moment, “I knew exactly what to do, but in a much more real sense I had no idea what to do.” I knew I needed to focus on the ABCs and I knew what medications the patient needed in terms of asthma management, but in the acuity of that moment, it all jumbled together. I quickly grabbed an attending and we worked through the ABCs together as the proper medications were administered and the patient stabilized.

That patient taught me several important lessons about intern year and residency as a whole:

Sex Sent Her to the Emergency Department: A Rare Case of Postcoital Hemoperitoneum

This post was peer reviewed. Click to learn more.

Image credit: Pxfuel

Author: Christina Schramm, MSIV Medical Student

St. George’s University School of Medicine

AAEM/RSA Social Media Committee

CASE PRESENTATION
A 31-year-old gravida 0, para 0 female patient presented to the emergency department with lower abdominal pain that started during sexual intercourse three days prior. She presented with abdominal distension, diffuse, constant, and cramping bilateral lower abdominal pain, referred pain to her shoulders, exertional dyspnea, orthostatic hypotension, and near-syncopal episodes. The patient reported constipation that turned to loose stools on day three. The patient denied fevers, vomiting, vaginal discharge or foul odor, vaginal bleeding, and dysuria. The patient had a past medical history of anemia and stated that her hemoglobin was within normal limits during her last routine blood draw. The patient had Mirena intrauterine device (IUD) inserted three years prior, and her last menstrual period was unknown. The patient had been in a mutually monogamous relationship with a male partner and stated no concern for sexually transmitted infection (STI). Differential diagnosis included IUD displacement, ectopic pregnancy, pelvic inflammatory disease, ovarian cyst rupture, ovarian torsion, and appendicitis.

Board Review: Debunking Dysbarism

This post was peer reviewed. Click to learn more.

Image credit: Brett Seymour

Authors: Patrick Wallace, DO PGY-2

Emergency Medicine Resident

University of Nevada Las Vegas

AAEM/RSA Education Committee

Laurie Bezjian Wallace, DO PGY-2

Family Medicine Resident

Mike O’Callaghan Military Medical Center

Intro
“Dysbarism” collectively refers to diving-related disorders. These disorders are relatively common and range in severity. This topic is high yield on board exams and is also important for emergency medicine providers to recognize so as to administer timely interventions. This article differentiates and categorizes disorders by those occurring with descent, at depth, and with ascent (Table 1).


DISORDERS OF DESCENT
Facial Barotrauma (Mask Squeeze)
Negative pressure within the mask and over the eyes must be equalized. This is often done by exhaling through the nose. Failure to equalize leads to a negative pressure effect on the periorbital and ocular vessels, resulting in edema and subconjunctival hemorrhage.[1,2] Emergent complications are rare but may include hyphema, subperiosteal orbital hemorrhage, and intraorbital hematoma. In these cases, emergent ophthalmology consultation should be obtained as surgery or needle aspiration may be required.[3,4] However, the majority of facial barotrauma cases are benign and do not require treatment.[1,3,4]
Key Phrases: Conjunctival edema, subconjunctival hemorrhage, and petechial hemorrhage after diving.