AAEM Resident and Student Association : Peer Reviewed

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Sunday, November 8, 2020

Meditation in Medicine

Image credit: Pexels

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

This post was peer reviewed.
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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.

Blog Staff, Reviewers, & Mentors

Thank you to our 2019-2020 peer review & editorial team!

AAEM/RSA Leadership:

Haig Aintablian, MD
AAEM/RSA President
UCLA Medical Center

Crystal Bae, MD MSc
AAEM/RSA Vice President
Temple University

Joshua Elliott Novy, MD MBA MS
AAEM/RSA Secretary-Treasurer
Northwell Health

MohammedMoiz Qureshi, MD
AAEM/RSA Immediate Past President
Penn State

AAEM/RSA Blog Leadership:

Alex Gregory, MD
Blog Editor-in-Chief
Social Media Committee Chair
University of Massachusetts

Kasha Bornstein
Copy Editor
University of Miami

Adriana Coleska, MD
RSA Board Liaison to the Social Media Committee
University of Chicago

Cassidy Davis
Communications Manager, AAEM

Yeimidy Lagunas
Communications Manager, AAEM

Publications Mentors:

Attending physicians or fellows who have agreed to help authors and reviewers learn about and navigate the publications process. Interested attendings/fellows can contact info@aaemrsa.org.

Michael Epter, MD
Laleh Gharahbaghian, MD
Nikita Joshi, MD
Arayel Osborne, MD
Andrew Phillips, MD MEd
Loice Swisher, MD

Peer Reviewers:

Mary Blaha, DO
Kasha Bornstein
Jonathon R. Burns
Adriana Coleska, MD
David F. Fine
Alexandria Gregory, MD
Kaitlin Parks, DO
Taylor A. Petrusevski
Christina Schramm
Ivan Yue

Sunday, January 1, 2017

Guidelines for Reviewers

Thank you for your contribution to the AAEM/RSA blog as a reviewer. The goal of the blog is not only to hone writers’ skills, but also reviewers’ skills so you are prepared to be a valuable asset to the scientific community. Your role as a reviewer is more like a coach than anything else, and we provide tips on how to be the best coach possible.

Your Role (Expectations):

The AAEM/RSA blog accepts topic summary manuscripts on any topic related to medicine, from clinical care, to administration, to teaching techniques. The editor will screen article topics and type for you.

Sunday, July 31, 2016

The Case of the Buffalo Chest

Image Credit: Flickr

This post was peer reviewed.
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Author: Jeffrey Chen, MSIII
UCSF School of Medicine

Case:
A 73-year-old man with a history of severe multi-vessel CAD status post CABG surgery 9 weeks ago presents after a high-speed motor vehicle collision with worsening SOB and chest pain. On exam, he is in acute distress, with a pulse of 102, blood pressure of 129/64, respiratory rate of 28, and saturating at 91% on 100% Oxygen NRB. The left chest has decreased breath sounds and is hyperresonant to percussion. Trachea is midline. A rapid chest X-ray shows a fractured left 7th rib and a corresponding large pneumothorax on the left with no evidence of tension. A chest tube is placed without any complications and connected to suction; his oxygen saturation improves to 98%, and his other vitals stabilize. A repeat CXR confirms successful placement of the tube, mild reinflation of the left lung, and a small pneumothorax on the right side that was not noted on the previous X-ray.

Diagnosis and Management:
In this gentleman who suffered a blunt traumatic pneumothorax on the left, there are a few possibilities to explain why he subsequently developed a pneumothorax on the right. First is a small traumatic pneumothorax that was already there on the right that was not visualized on the first film. Next is mediastinal damage during the placement of the left-sided chest tube, though there were no complications described in this case.

Blakemore, Bleed Less: Massive Upper GI Bleeding and the GEBT Tube

Image Credit: Gregory Wanner, DO PA-C

This post was peer reviewed.
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Author: Gregory Wanner, DO PA-C
Emergency Medicine Resident, PGY-3
AAEM/RSA Publications Committee Chair '16-'17

Author: Dimitrios Papanagnou, MD, MPH, EdD(c)
Assistant Professor, Emergency Medicine

A version of this article was previously published on the Jefferson Emergency Medicine Residency Blog (www.jeffem.org), March 2016.

It’s 3 am on a Saturday and you’re covering the emergency department at a community hospital. You hear a nurse’s firm but slightly nervous-sounding voice from down the hall say, “Umm, I need some help in here.”

You enter the room and find a geyser of blood erupting from the mouth of a middle-aged, male patient. His family informs you that he is a heavy drinker and has “liver problems”.

What do you do?
After applying triple-G protection (gown, gloves, and goggles), you slide towards the patient and begin to perform the critical actions associated with establishing large bore IV access, securing the airway, transfusing blood, starting octreotide, and calling GI. The patient keeps bleeding. He is severely hypotensive and GI is unavailable.

Tips for Tackling the Pediatric Trauma

Image: Bigstock

Author: Shyam Sivasankar, MD
Emergency Medicine Resident
Stanford-Kaiser Emergency Medicine
AAEM/RSA Publications Committee Member

This post was peer reviewed.
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I am very fortunate to train at a facility with a child life specialist present in the emergency department. Their presence has helped me learn a lot about running pediatric trauma surveys and resuscitations, and I have picked up a few pearls along the way. The following are some of their tips, tricks, and suggestions.

1. Calming Distractions

A trauma resuscitation can be quite overwhelming for an adult, let alone for a child. Use age appropriate interventions for each child including, but not limited to:

Infants and Toddlers:

Stuffed animals (for comfort)

Bubbles (to encourage deep breathing and relaxation)

Elmo Calls (Facetime™ with Elmo, a fun game for distraction)

School Age/ Teens:

iPads (or smart phones for distraction and teaching moments with patients)

Simply Sayin’ (a smart phone application, created in part by Phoenix Children’s Hospital. This application provides illustrations, a free-draw option, and video clips to help both patients and their parents understand what is happening while simultaneously lowering the anxiety level in the room.)

Stress ball for relaxation and stress management

Deep breathing techniques to support relaxation

Electrical Storm: Don’t Just “Push Another Milligram of Epi”

Bigstock

This post was peer reviewed.
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Author: Khalid M Miri, OMSIV
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific

"Are you ready to call it?" "Not yet, let’s push one more of epi." Sound familiar? Despite doing proper CPR, defibrillating, and pushing all the ACLS meds, you know deep down that after the first few rounds of chest compressions, your cardiac arrest patient has a tiny chance of surviving to discharge in good neurological condition. You have seen too many codes that go on too long and all you know to do is keep pushing epinephrine and hope that your patient is that one rare case that will achieve sustained ROSC. Have you ever wished you had another option, something that might work when epinephrine and amiodarone do not? Well, an additional option may exist. During a specific condition — refractory ventricular fibrillation — research shows that using a beta blocker can have a better chance of bringing that patient out of their dysrhythmia than when using epinephrine and antidysrhythmics alone.

Cardiac electrical storm (ES) is often defined as three or more episodes of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours. It is a dangerous arrhythmia that leads to refractory VF and will kill most of its victims despite treatment with the current ACLS recommendations of epinephrine, antidysrhythmics, CPR, and defibrillation.[1]

Digoxin Toxicity: Myths, Truths and Management

Bigstock

This post was peer reviewed.
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Author: Andrew V. Bokarius, MD
Emergency Medicine Resident
University of Chicago
AAEM/RSA Publication Committee Member

The Case:
A 68-year-old male with a history of heart failure presents with weakness, confusion, and visual disturbances including yellow/green halos and scotomas. Digoxin is on the list of current medications. Vitals are notable for bradycardia with a HR of 55. The patient is awake but confused.

The Clinical Decision-Making:
While your differential diagnosis may include calcium channel toxicity, beta blocker toxicity, sick sinus syndrome, clonidine toxicity, organophosphate poisoning, and other potential diagnoses, digoxin toxicity should be at the top of the list.

You quickly recall how digoxin works: it inhibits the Na/K ATPase, causing intracellular sodium levels to rise. Sodium is then exchanged for calcium via a Na/Ca transporter. The intracellular calcium concentration is thus increased, thereby increasing contractility. Furthermore, digoxin also may increase vagal tone and can lead to bradyarrhythmias.

When SCUBA diving goes wrong – Decompression Illness

Bigstock

Jonathan Morgan, MSIV

This post was peer reviewed.
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Medical Student

Lake Erie College of Osteopathic Medicine-Bradenton

A 54 year-old male presents to your emergency department complaining of dizziness that started shortly after completing a dive. He is a biologist who was studying the nearby river. He reports that about 10 minutes after surfacing he became profoundly dizzy. He also reports nausea that has since resolved. He thinks his hearing is normal. He can walk, but stumbles sideways.

His companions administered oxygen immediately and called 911. He is currently alert, oriented, complaining of only dizziness. His vitals are: BP 130/70, Pulse 76, RR 14, Temp. 37.0 C, SpO2 98% on room air.

What do you need to know about his dive?

Basic information includes maximum depth of the dive, time at maximal depth, decompression or safety stops used, previous dives within 12 hours, and type of gas and equipment used. [1]

Use of Mechanical CPR Devices has Increased 1,511% - What You Need to Know

Image - Bigstock

Author: Jake Toy, OMS II
Western University of Health Sciences
College of Osteopathic Medicine of the Pacific, Pomona, CA
AAEM/RSA Publications Committee Member

This post was peer reviewed.
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Introduction
There are an estimated 424,000 out of hospital cardiac arrests (OHCA) among Americans annually.[1] Survival rates for OHCA are low, ranging from 10.6% to 31.4%.[2] External defibrillation and CPR represent the first line treatments for OHCA. The American Heart Association (AHA) defines high-quality CPR as 100-120 compressions per minute (CPM) at a depth of 2 inches on the average adult. Allowance of full recoil, minimization of compression interruptions, and avoidance of excessive ventilation are also important (Figure 1).[3]

Figure 1. 2015 American Heart Association Adult CPR Guidelines (Source – American Heart Association[2])

Drowning in your own Blood: Managing Massive Hemoptysis

Bigstock

Author: Jonathan Morgan, MSIV Lake Erie College of Osteopathic Medicine-Bradenton

Case:
EMS calls; they are 5 minutes out
with a 50-year-old female patient in cardiac arrest with massive airway bleeding. She began coughing up blood and collapsed several minutes prior to EMS arrival. She is currently intubated with a 7.0 ETT, 3 doses of epinephrine have been administered, and CPR is ongoing; she has been alternating between

This post was peer reviewed.
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PEA and asystole. Family reported a recent diagnosis of lung cancer.

What defines massive hemoptysis?
There is no consensus on the definition of “massive.” Many sources use a definition of 600cc of expectorated blood per hour, but proposed cutoffs run between 200 and 1000 mL/hr. [1] However, estimating blood volumes can be difficult and it may only take 100-400mL of blood in the airway to cause impaired gas exchange.[1,2] Because of this, some proposals call for inclusion of other clinical data including evidence of impaired gas exchange or hemodynamic derangements to define “massive.”[3]

What is the likely etiology of this patient’s cardiovascular collapse?
Asphyxiation rather than exsanguination is the most likely cause of cardiovascular collapse in massive hemoptysis.[4] 90% of cases of massive hemoptysis are caused by bleeding in the bronchial circulation, which is exposed to systemic pressures; bleeding in the low pressure pulmonary circulation accounts for only 5% of cases.[2]

Synthetic Cannabinoids, a NEW Problem

Image Credit: Image from
Lance Cpl. Damany S. Coleman

This post was peer reviewed.
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   Author: Nishma Sachedina, MD
   Emergency Medicine Resident
   University of Chicago
   AAEM/RSA Publications Committee Member

In the 1980s, scientists developed synthetic cannabinoids as a means to study the endocannabinoid system.[1,2] While some earnest chemists characterized cannabinoid receptors, more entrepreneurial chemists created a novel market of NEW drugs—nontraditional emerging web-based drugs.[3] Synthetic cannabinoids (SCs) are one varietal of these NEW drugs, and their use has been growing exponentially since they were first recognized as drugs of abuse in Europe in 2000.[4]

When SCs came to the USA in 2008, they flourished because of a lack of legislation against them and because they evaded standard medical toxicology screening tests.[1] Sold over the internet, in head shops, and in even in gas stations and convenient stores, SCs are often marketed as “legal highs.”[1] They can be consumed in a number of ways, from adding the compound to plant materials to dissolving the compounds in liquid for use in e-cigarettes or beverages.

Ocular Emergency: Chemical Burns, A Non-Ophthalmologist Approach to Initial Treatment and Referral

Image from Maxxl2 - Wikimedia Commons

This post was peer reviewed.
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Author:
Fernando Pellerano, MS-V Universidad Iberoamericana (UNIBE) School of Medicine

Chemical burns represent potentially blinding ocular injuries and constitute a true ocular emergency requiring immediate assessment and initiation of treatment. The sequelae of an ocular burn can be severe and particularly challenging to manage. An appropriate initial emergency management may be the most important factor in determining visual outcome.[1]

Chemical eye injuries can occur from any exogenous material contacting the eye. This includes alkalis (e.g., lye, cements, plasters, airbag powder, bleach, and ammonia), acids (e.g., battery acid, pool cleaner, and vinegar), solvents, detergents, and irritants (e.g., mace).[2] Severity of the eye injury depends on the pH, concentration, and the nature of the chemical.

Diphenhydramine Overdose in the ED

Image Credit: Flickr Andrew Ranta

Author: Kaylinn Dokken, OMSIV
Western University of Health Sciences

You are just at the beginning of your shift when paramedics call in and notify you that they are bringing in a 35 year old female who reports that she took 3,000 mg of diphenhydramine in a suicide attempt. Her BP is 145/80, her pulse is 160 beats per minute (bpm) with sinus tachycardia on the monitor, and her respiratory rate is 24 breaths per minute. Upon presentation, the patient is disoriented, continuously writhing, and having intermittent myoclonic jerks. An initial EKG is obtained and is shown below.

Clonidine Toxicity: A Brief Review

Image Credit: Flickr Pranjal Mahna

Author: Matt Rosen, MSIV
Georgetown School of Medicine

This post was peer reviewed.
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Background:
Clonidine was once a popular antihypertensive agent, and while its use as a primary blood pressure agent has declined, it continues to have a role in hypertension management for some patients. Clonidine is also being used in other applications such as treatment of migraines, treatment of vasomotor symptoms associated with menopause or withdrawal, and in a number of pediatric applications such as pre-anesthesia, postoperative pain management, and panic/anxiety disorders.[1, 5]

Sunday, December 13, 2015

Retinal Detachment: What You Need to Know

Image Credit: Subhadra Jalal - Flickr

Author: Stephanie Cihlar, MSIII
Medical Student
Loyola University Chicago Stritch School of Medicine
AAEM/RSA Publications Committee Member

This post was peer reviewed.
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Introduction
Retinal detachment is one of the most common ophthalmic emergencies, affecting approximately 1 in 10,000 people per year.[1] Because of the risk of permanent vision loss, it is important that emergency physicians are able to identify a retinal detachment and consult a retinal specialist as soon as possible.

Pathophysiology
Retinal photoreceptors (rod and cones) are metabolically highly active cells. In fact, the choroidal circulation responsible for nourishing these cells has the highest blood flow per cubic centimeter of tissue found in the human body.[2] In a retinal detachment, the neurosensory layer of the retina is peeled away from its underlying supporting tissues, the retinal pigment epithelium and choroid. The photoreceptors undergo ischemic damage, which can lead to vision loss and blindness in a matter of hours.[3]

Board Review: Hypothermia/Cold Water Submersion

Author: Kevin P. Beres, DO PGY-1
UTHealth Emergency Medicine Resident

Originally Published: Modern Resident, April/May 2015

Growing up in Wisconsin, one of the beloved New Year’s traditions was the polar bear plunge, which translates to a group of people jumping into the cold lakes on New Year’s Day. This event brings up two important concepts: cold water submersion and accidental hypothermia. Risk factors for accidental hypothermia include alcohol, AMS, behavior, extreme ages and certain comorbidities including peripheral vascular disease, trauma and diabetes mellitus.[1,2]

Cold Water Submersion:
When the body comes into contact with cold water, it leads to activation of the Mammalian diving reflex, resulting in bradycardia, shunting of blood to the CNS system and slow metabolism and may actually prolong survival.[1] This reflex affects children more efficiently than adults. Alcohol has been shown to reduce this reflex.[3]

Chilblains:
Chilblains are red and/or blue edematous plaques and papules that appear on the distal extremities that occur secondary to prolonged cold exposure. A variety of sensory symptoms such as itching or burning can accompany the skin changes.[1]

Maisonneuve Fracture - A can’t miss diagnosis!

Author: Benjamin Lindquist, MD

This post was peer reviewed.
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Chief Resident
Stanford/Kaiser Emergency Medicine Residency

A 50 year-old male pedestrian presented to the emergency department by ambulance after having his left foot struck by a bicyclist while the foot was firmly planted on the ground. He complained of severe pain to his medial ankle but denied knee or hip pain. He had no other injuries. On examination, he had slight eversion at the ankle with significant tenderness over the medial malleolus. He also had tenderness over his proximal fibula. He had normal strength, sensation and pulses.

X-ray showed widening of the medial tibiotalar joint space (Image A) and a comminuted fracture of the proximal fibula (Image B). These findings are suggestive of a Maisonneuve fracture with syndesmotic ligament disruption. He was placed in a splint and referred to orthopedic surgery. Ten days later, he underwent operative fixation of his syndesmotic ligament injury.

In evaluating patients with ankle injury, it is imperative to assess for concomitant proximal fibular fractures. As in this case, it is common for patients to complain only of ankle pain and not pain around the proximal fibula. However, Maisonneuve fractures are often unstable and require surgical fixation, whereas isolated fibular fractures or deltoid ligament sprains are managed nonsurgically.

Image A: Anteroposterior view L ankle

Image B: Anteroposterior view L tibia-fibula

References:

Taweel NR, Raikin SM, Karanjia HN, Ahmad J. The proximal fibula should be examined in all patients with ankle injury: a case series of missed maisonneuve fractures. J Emerg Med. 2013;44(2):e251-5. PMID: 23079149

Sunday, November 8, 2020

Saturday, June 1, 2019

AAEM/RSA Leadership:

AAEM/RSA Blog Leadership:

Publications Mentors:

Peer Reviewers:

Sunday, January 1, 2017

Thursday, December 29, 2016

Sunday, July 31, 2016

Thursday, July 28, 2016

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Sunday, February 21, 2016

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