Six Clinical Pearls from Intern Year

Image Credit: Flickr

Author: Casey Grover, MD
Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident October/November 2011

Looking back after finishing a year as an emergency medicine intern, the lessons that I remember the most come from the mistakes that I have made. I had one particularly rough month late in my internship that was filled with bounce backs and mismanaged cases. I learned six important lessons that will hopefully help to avoid another such month in the future.

1. Review every study that you order. While you may have ordered a chemistry panel just to check the creatinine, it's embarrassing to miss a sodium of 121.
   
2. Document your discharge decision process. If a patient has a problem or bounces back, it is extremely helpful to have documented everything (i.e., normal vitals, well appearance, consultant recommendations) that you considered when sending that patient home.
   
3. Review discharge vital signs. Vital signs are actually important – they reflect the patient's underlying physiology. Document normal vital signs when sending patients home; and when discharging someone with abnormal vitals, document your rationale and plan.
   
4. Document your discussions with consultants. Record at what time and to whom you spoke, as well as what they recommended. This allows others to see the basis of your decisions, which is essential if an adverse outcome occurs.
   
5. Be suspicious of patients signed out to you. Review the labs and vital signs of the patient you will be taking care of, and address all of their medical issues. Approach the case with fresh eyes and be willing to consider other diagnoses than those billed to you in sign out.
   
6. Approach procedures carefully. While it's fun to do procedures, be aware that complications may arise – particularly in a patient who is high risk for bleeding. Review labs and history, particularly for things like coagulopathy, that may make procedures difficult.

Tox Talks: Bath Salts

Author: Meaghan Mercer, MSIV
Western University of Health Sciences
AAEM/RSA Medical Student Council President '11-'12


Originally Published: Modern Resident October/November 2011




Walking onto my shift a few days ago, I heard shrieking coming from my pod, and I knew this would be an interesting night. I rushed over to find a female restrained by four police officers screaming that demons were out to get her. Witnesses reported that after snorting an unknown substance, the patient began running down the street, topless, yelling that something was after her. It required all four officers to control her and get her to the ED. She was agitated and combative, unwilling to answer questions, with a HR: 130, RR: 20, BP: 190/115, temp: 103, and an O2 saturation of 95% on room air. This was it, what I have been hearing so much about ... a bath salt ingestion.

There has been a recent insurgency of patients presenting to emergency departments across the country in an agitated delirium caused by a new designer drug called bath salts. On October 21st, the DEA issued a temporary one-year ban on methylenedioxypyrovalerone (MDPV), the main component of bath salts, classifying it as a schedule 1 substance. Manufacturers evade the restriction with minor alterations in the chemical structure, and bath salts are still available in gas stations, head shops and online.[1]

Board Review: Toxic Alcohols

Image Credit: Dr. Wanner

This post was peer reviewed.
Click to learn more.

 















Authors: Gregory Wanner, DO
Emergency Physician/Clinical Faculty
Christiana Care Health System
@gregwanner

Paul Kolecki, MD
Associate Professor, Emergency Medicine
Medical Toxicologist
Thomas Jefferson University

An 18-year-old male presents to the emergency department (ED) stating, “Doc, I’m really drunk.” He and a friend were drinking in the friend’s garage. The patient drank one “very strong” sweet-smelling drink, which was prepared by his friend. He began to feel sick and nauseated and rode his bike home (with difficulty due to this intoxication, but without any falls or trauma). He vomited twice and his mother referred him to the ED. Attempts to contact the friend were unsuccessful.

How would you evaluate this patient? 

Several intoxicants can cause similar symptoms. While ethanol is the most likely cause, in patients with unclear ingestions other alcohols should be considered as well. The following is a brief summary of the alcohols often tested on in-service and board exams; a summary table is included at the end:

Board Review: Heat-Related Illnesses

Image Credit: Flickr

Author: Kaitlin Fries, DO PGY-1
Doctors Hospital
Originally Published: Modern Resident June/July 2015

Heat-related illnesses are responsible for approximately 400 U.S. deaths each year.[4] Drastic spikes in mortality can be seen during severe droughts and heat waves, the latter of which is defined as temperatures greater than 90°F for three or more consecutive days.[3,4] Those at greatest risk for heat-related emergencies are children, the elderly, people with certain predisposing medical conditions and those taking medications that interfere with the body’s thermoregulatory center.[3,4] The spectrum of heat-related illnesses ranges from cramps, syncope and heat exhaustion to more serious conditions such as heat stroke. All of these conditions are easily preventable with public education and adequate access to hydration and cool shelters.

The main two cooling mechanisms used by the human body are radiation and evaporation.[2,3,4] Radiation can account for up to 65% of total heat loss.4 However, radiation can only occur in a cool environment. Patients who do not have access to air-conditioning must rely on evaporation to dissipate heat by producing sweat, which then evaporates from the skin’s surface due to body heat.[2] However, as atmospheric humidity increases, the effectiveness of evaporation decreases.[2] Below is a brief review of the minor presentations of heat-related complaints.

Sex-Specific Differences of Myocardial Infarction Presentation in the ED

Image Credit: Pixabay

Author: Jake Toy, MS3
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA
AAEM/RSA Publications Committee '16-'17

This post was peer reviewed.
Click to learn more.

Heart disease is the leading cause of morbidity and mortality among women in the United States and accounts for approximately 1 in 4 deaths among women­.[1] Unfortunately, society fails to recognize this burden, often labeling heart disease as a “male problem”. In the past decade, only 54% of women recognized heart disease as a number 1 cause of mortality.[2] Exacerbating this issue further, the “classic” symptoms of myocardial infarction (MI) were historically based off studies analyzing MI in men.[3] Additionally, women often experience greater delays in care during an MI and have higher associated mortality rates when compared to men.[4, 5]

A significant body of literature exists describing sex-specific differences in MI presentation and outcomes. In the emergency department (ED), awareness of these variances in MI presentation is crucial toward providing timely and effective care to women presenting with an acute MI.

Typical vs. Atypical Chest Pain

The textbook symptoms of “typical” chest pain are well-defined – (1) precordial chest discomfort, pain, heaviness, or fullness, possibly radiating to the arm, shoulder, back, neck, jaw, or epigastrium; (2) symptoms worsened by stress or activity; (3) symptoms relieved by rest or medications, such as nitroglycerin; (4) associated symptoms that include shortness of breath, diaphoresis, weakness, nausea, vomiting, or lightheadedness.[3]

In comparison, “atypical” chest pain does not present in the aforementioned classic pattern. Signs may include: burning, sharp, pleuritic, or positional chest pain or discomfort; chest pain that is localized by one finger and reproducible; pain only in the arm, shoulder, back, neck, jaw, or epigastrium, or pain concentrated in regions of the body other than the chest, arm, shoulder, back, neck, jaw, or epigastrium.[3]