The Fast Track Winter 2014 - Issue 9
Winter 2014
The Fast Track Tired of the cold yet? Start looking at AZ for Spring Conference! An Emergency Medicine Publication
AN EMERGENCY MEDICINE PUBLICATION
BUUURRRRRRRRR! Be prepared for the cold-weather emergencies coming to your ED
You’ll shoot your eye out...
Check out this visual diagnosis inspired by Ralphie
Numb?
Balancing empathy with sympothy in the ED
Rosh Review
The board review experts are back with more
March 2011 - Issue 2
Pediatric Corner Comnia doluptio estiatus nonsendam venditius eatem ex et voluptatem non
Pediatric emergency physician explains febrile seizures
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Fast Track TheTheFast Track An Emergency Medicine Publication
Winter 2014
Editors & Publishers Tanner Gronowski Drew Kalnow Joe Sorber Andrew Little Jeremy Lacocque Giles Gifford Danielle Turrin Kaitlin Fries
Issue Contributors Kaitlin Fries M. Steve Brandon Drew Kalnow Richard Limperos Danielle Turrin Bruce St Armour Angela Kuehn James Hensel Brian Lehnhof Tanner Gronowski David Teng Jay Anderson Chase Ungs John Casey Ashley Guthrie
Presidential Message - SC With the New Year off to a running start and the holidays coming to a close, now is the perfect time to set some goals for the remainder of the school year. Some would say the demands and stresses of medical school are enough on their own. However, I would challenge you to push yourself a little bit further this year! What is holding you back from becoming more involved? Now is the time to immerse yourself in the field of emergency medicine; find out more about the specialty, learn about the most cutting edge technology in the field, expand your networking base, all while adding more activities to your CV. Your student chapter is working hard to continue to provide you with tons of possibilities. Consider writing an article for the Fast Track, enter the spring poster competition, link up with a mentor, participate in the Leadership Academy or if you are new to the ACOEP simply join us in Scottsdale this spring to find out what we are all about! We, on the student chapter board, have made our own New Year’s resolutions for this upcoming year! A new mentorship program will debut this spring, providing local clubs with a specific ACOEP mentor as well as a list of additional mentors available to their geographical area. We hope this will help aid in the yearly leadership transitions that local clubs experience. Our new research chair is working hard to develop resources and tip sheets to make it easier for students to become more involved in the research process. We have also pledged to streamline our conference lectures by moving to a new twentyminute rapid-fire format. These are just some of the many things we are working on to provide students with the best experiences and insight into their future career field. So join us in our New Year’s resolutions and give yourself that little extra push this year. We guarantee you won’t regret it! If there is anything else we can do to help please contact us so we can work together to make this year the greatest success.
Sincerely, Kaitlin Fries, OMS-III ACOEP Student Chapter President
Interested in contributing? Let us know: acoepfasttrack@gmail.com
CONTENTS Letter from the Editor...................................... 05 By Andrew Kalnow
Rosh Review......................................................... 06 Emergency Medicine Board Style Questions
Ultrasound Corner............................................ 08-09 On the Cover: Photo courtesy of page 2 Tanner Gronowski
By Richard Limperos
The Fast Track
Winter 2014
An Emergency Medicine Publication
20
11
VISUAL DIAGNOSIS
36
RESIDENCY SPOTLIGHT Good Sam, NY
38
INFLUENZA
40
THANKSGIVING
COLD WEATHER EMERGENCIES By Tanner Gronowski and Drew Kalnow
Pimpology............................................................. 10 By Danielle Turrin
Visual Diagnosis................................................. 11-12 By Bruce St. Amour
Difficult Road Ahead........................................ 13 By Angela Kuehn
All for One............................................................. 14-16 By James Hensel
View from the Bottom.................................... 18-19 By Brian Lehnhof
Pediatric Corner................................................. 32 By David Teng
Influenza Battle................................................... 38-39 By Jay Anderson
Tricks of the Trade............................................ 41 By Chase Ungs
Numb....................................................................... 44-45 By Ashley Guthrie
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The Fast Track
An Emergency Medicine Publication
PRESIDENTIAL MESSAGE - RESIDENT CHAPTER Winter 2014
In the last two weeks I had two cases that caused me to pause. The first was a young woman with epigastric pain and vomiting. Her work up was normal, her abdominal exam was completely benign and she was feeling better with conservative management. Only after I sat down to write up her gastroenteritis discharge papers did I find my attending had ordered a CT of her abdomen. This girl, who was about to go home, ended up having appendicitis and went straight to the operating room from the emergency department. The second patient was a woman in her fifties who was complaining of chest pain. After just one dose of morphine her pain was well controlled. Her vital signs, EKG, chest X-ray, and blood work were all well within normal limits. She, however, did have some cardiac risk factors so I was going to admit her for observational chest pain rule out. As I sat down to do this I noticed my attending leaving her room and was surprised when she asked me to add on a D-dimer. That test came back elevated so a CT of her chest was ordered. This woman, who I was about to admit for a one night stay with a stress test in the morning, ended up having a dissection from the start of her ascending aorta that continued all the way into her abdomen. While I recognize I still have much to learn, these two cases were particularly humbling. Aortic dissection and appendicitis are two diagnoses that I should be an expert in, “bread and butter� emergency medicine cases. Emergent diagnoses that are time sensitive and not something a third year emergency medicine resident should miss. So what did I take from this? Why tell you this? Well, it’s not to persuade you to order a CT on every abdominal pain and a dimer on every chest pain. We must avoid the pitfall of getting our mind set on a diagnosis and attempting to fit all of the signs and symptoms into it. Rather, we should use every fragment of information to expand our possible differential. It turns out the chest pain patient mentioned indirectly that her back also hurt, and that the abdominal pain patient had cited a twinge in her right lower quadrant. Both of these factors required me to expand my differential, but they were also easily explained by my initial diagnoses and much of my work up really went against dissection and appendicitis. The lesson learned is that there is no such thing as a routine patient. Throughout our careers we must strive to learn from every patient encounter and embrace a growth mindset from these experiences. As students and residents this is our primary task. We must learn from everyone we can, including attending physicians, other residents, nurses, techs, and clerks. Many of whom have been in the field longer. We need to glean all that we can from their experience. Then, and only then, will we succeed in our training and our careers. Sincerely, M. Steve Brandon, DO President, ACOEP-RC
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The Fast Track
Letter From The Editor
A
s students and residents, we spend the vast majority of our time looking ahead. Whether it is the next test, the next rotation or the next step such as starting residency and even life as an attending, we are forward focused. In fact, the very nature of the practice of emergency medicine keeps us focused on the next patient. If we spend too much time thinking about the last patient or procedure, we will not be focused on treating the next patient seeking our care.
Winter 2014
An Emergency Medicine Publication
At the Fast Track, we also spend much of our time looking to what’s next. Even as the finishing touches were being placed on this edition, we were looking forward to the Spring edition. All of this looking forward comes at a price. As students, residents and attendings, we often fail to appreciate how far we have come. For the Fast Track, the past two years have seen dramatic changes. Over this time, we have completely revamped the look, feel and focus of the Fast Track. What used to be not much more than a newsletter, is now pushing forward to become something much more impactful. This issue is the first with our new editing team and while we are certainly looking to drive the Fast Track forward, we are also proud of this edition and what the publication has become. Just as we take time to look back, we invite you to pause for just a moment to reflect on all you have accomplished.
Will we see you in Denver?!
The Fast Track
December 22, 2011 Volume 1, Issue 1
Fall 2012 - Issue 04
Winter 2014 - Issue 9
Welcome to the Fast Track
AN EMERGENCY MEDICINE PUBLICATION
BUUURRRRRRRRR!
Are you ready for fall conference?
Message from the Student Chapter President
Sincerely, Joe Sorber ACOEP-SC President OMS IV, WVSOM
The Fast Track
ANNUAL RESIDENCY FAIR 2012
The Fast Track Every January the new year brings with it things like football, a new semester in school, and newly elected ACOEP-SC officers. Having just had elections in October, your new ACOEP-SC officers would like to welcome you to the chapter and share with you all of the projects we are working on for the coming school year in this copy of the Fast Track. As medical students, the new year is generally a time when all of us are just starting to hit our strides regardless of how far along we are. First years have made the transition to graduate school, while second years are becoming student leaders and planning for rotations. Third years have gotten their first required rotations under their belts, and fourth years are interviewing for residency slots and waiting for the match. It’s an exciting time of year for all of us as we each start to adjust and get comfortable with where we are in our training. Once you have found your stride stick with it and let it carry you through winter. As your new officers we have hit the ground running and look forward to serving our members throughout the year. As always, please contact us because we are happy to help and love hearing from you.
An Emergency Medicine Publication
Tired of the cold yet? Start looking at AZ for Spring Conference!
Be prepared for the cold weather emergencies that are coming to and ED near you!
You’ll shoot your eye out!
Shot in the face with a BB gun! Ralphie!
Carotid U/S in the ED?
You bet! We aren’t scared to throw a probe on a neck to help our medical decision making!
Denver 2012
Get set for the annual residency fair, incredible lectures and labs, and amazing evening events!
Rosh Review
The board review experts are back at it again.
Love/hate the night shift?
Read up on the effect your poor sleeping habits have on you!
Ultrasound Corner!
INSIDE THIS ISSUE Letter from the Editor ................3 The Other Side ..........................4 Death in the ED .........................6 StorytellERdoc ..........................8
Dr. Limperos kicks off the newest column in the Fast Track with a look at critically ill patients
WestJEM
Like research?? Check out some of the latest articles from this peer reviewed journal
36 Weeks of Denial…………….11 Global Health and EM…………13 PA’s in the ED………………….16
SPECIAL POINTS OF INTEREST • Case Presentation ………….3 • Visual Diagnosis …………..13 • “Rad” Diagnosis………..15-16 • Residency Spotlight……….18 • Research Articles………20-38 • Student Chapter Highlight...39 • Pimpology…………………...40
March 2011 - Issue 2
Pediatric Corner Comnia doluptio estiatus nonsendam venditius eatem ex et voluptatem non
Seizures are scary for parents, dont let them be scary for you!
“Take time to gather up the past so that you will be able to draw from your experiences and invest them in the future.” - Jim Rohn We wish you success in the new year!
Drew Kalnow, DO EM Resident, Doctors Hospital ACOEP-RC Publication Co-Chair
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The Fast Track
An Emergency Medicine Publication
Winter 2014
Emergency Medicine Review with 1. A 43-year-old woman with a history of HIV (last CD4 count 231, viral load undetectable) presents with a sore throat that has progressively worsened over 1 week. She has been unable to tolerate solids for the last 3 days and has pain with swallowing liquids as well. Her vitals are normal. On exam, you note the findings seen in the image below. What management is indicated at this time?
Find more questions like these by visiting roshreview.com
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A. Acyclovir B. Clotrimazole troches C. Fluconazole D. Penicillin V potassium
2. An 18-year-old man presents after a syncopal episode. The patient states he was running when he suddenly felt lightheaded and nauseated leading to him passing out. On presentation, he is asymptomatic with normal vital signs. Examination reveals a healthy man with a crescendo-decrescendo murmur heard at the left sternal boarder. ECG shows left ventricular hypertrophy with deep, narrow Q waves particularly in the precordial leads. What diagnosis should be suspected in this patient?
A. Hypertrophic cardiomyopathy B. Hypovolemic state C. Vasovagal syncope D. Wolff-Parkinson-White syndrome
3. A 75-year-old woman with a history of sick sinus syndrome status post pacemaker implantation two weeks ago presents with pain over the pacemaker site and fever. Examination reveals erythema, warmth, fluctuance and tenderness over the pacemaker site. What management should be pursued?
A. Incision and drainage of the site B. Intravenous antibiotics, cardiology consultation and admission C. Oral antibiotics and follow up with cardiology D. Needle aspiration of the site
4. A 17-year-old woman presents after an isolated head trauma. On primary evaluation, she opens her eyes to painful stimuli, has incomprehensible speech and withdraws to pain. What is her Glasgow Coma Scale (GCS) score?
Find your Rosh Review Answers on page 42
The Fast Track
2014
ACOEP SPRING
STUDENT CHAPTER CONFERENCE
HIGHLIGHTS •LEADERSHIP ACADEMY •ATTENDING LECTURES •SKILLS LABS •RESIDENT AND PD PANELS •EVENING EVENTS WITH RESIDENTS
SCOTTSDALE, ARIZONA APRIL 23 - 25
Winter 2014
An Emergency Medicine Publication
FOR MORE INFORMATION www.facebook.com/acoepsc TO REGISTER www.acoep.org
page 7
The Fast Track
An Emergency Medicine Publication
Winter 2014
ULTRASOUND
in the critically ill patient Richard Limperos, MD, RDMS Clinical Assistant Professor of Emergency Medicine, OU-HCOM
Ultrasound Director, Doctors Hospital Emergency Medicine Residency, Columbus, Oh Critically ill patients can benefit from US Emergency point-of-care ultrasound (POCUS) was born in the trauma bay and has grown to more than 10 indications and counting. As the potential to do more with this modality grows, I would like to focus this article series on a comprehensive approach to the critically ill patient. Many protocols have been published and the references are provided at the end of this article. These have resulted in many different ways to approach the patient in shock. For this first article, we will focus on the ultrasound evaluation of intravascular volume status as the starting point for determining the initial therapeutic interventions and further POCUS and other diagnostics. Shock is an important concept to understand. A good definition is the state of inadequate tissue oxygenation and perfusion. Shock is not the diagnosis, but rather it is an unstable clinical condition that requires a prompt search for the underlying cause. Finding the reason for shock is the key to the patient’s survival, and this is where POCUS becomes an indispensable tool. By first looking at the volume status or preload, we can make quick interventions and focus further diagnostic ultrasound studies.
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Volume status can be estimated by measuring the diameter and respiratory variation in the inferior vena cava (IVC) diameter 2 to 3 cm distal to where it enters the right atrium. The preferred probe position is in the subxiphoid space in the longitudinal axis of the IVC. If this window is blocked by bowel gas, a lateral view through the liver can be used. As the patient takes a breath, the normal IVC will collapse as negative intra-thoracic pressure is generated and blood is sucked into the heart. The patient must be supine and not intubated for this to occur. Motion mode (M-Mode) ultrasound can be used to capture the variation in the diameter.
This ultrasound images shows the IVC with 2 calipers measuring the IVC at its maximum and minimum diameters. The maximum diameter and the percentage of respiratory variation can be used to estimate the central venous pressure.
IVC with > 50% collapse
IVC with < 50% collapse IVC size in cm Collapse during respiration CVP in cm of water < 1.5 1.5 - 2.5 1.5 - 2.5 2.5 2.5
> 50% > 50% < 50% < 50% none
0-5 6 - 10 11 - 15 16 - 20 > 20
The Fast Track
Works Cited
Winter 2014
An Emergency Medicine Publication
Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J. Cardiol. 1990;66: http://emcrit.org/rush-exam/ Bahner, DP Trinity: A Hypotensive Ultrasound Protocol. Journal of Diagnostic Medical Sonography July 2002 18: 193-198 http://www.acepnews.com/specialtyfocus/imaging/single-article-page/ inferior-vena-cava-ultrasound/0164c52 9bf3549ebb6bd64fbcb451c62.html
hio
There is a natural cutoff line based on greater than or less than 50 percent respiratory variability. If the patient is in shock, the optimized or ideal CVP is around 12 for complete volume resuscitation. Therefore, if the respiratory collapse is greater than 50 percent, fluid and/or volume resuscitation should be initiated and a search for the source of hypovolemia should be initiated. The next POCUS studies should be the FAST exam to evaluate for hemorrhage into the peritoneal or pleural spaces and the aorta to exclude aneurysm. Underlying conditions not able to diagnosed by ultrasound should be suspected with history and physical examination, such as sepsis, spinal cord injury, gastrointestinal hemorrhage, and numerous others. After the initial resuscitation, the IVC should be reassessed. If the respiratory variation is now greater than 50 percent, vasopressor support should be initiated. A central line may be necessary for adequate and timely fluid resuscitation and to use powerful vasopressors. Of course, ultrasound can make this procedure safer and easier. Finally, if there is little to no respiratory variation, there should be an immediate search for cardiac obstruction or dysfunction. The next ultrasounds should be of the heart looking for tamponade or poor right and/or left cardiac motion. The lungs should be scanned for tension pneumothorax. Also, the femoral arteries should be compressed to evaluate for deep vein thrombosis that would lead to the inference that a massive pulmonary embolism is causing the hypotension. Non-ultrasound based diagnostics would include an EKG, a chest x-ray, and a search for evidence of cardiotoxic overdoses or metabolic disturbances via blood work. With point of care ultrasound, a patient with undifferentiated hypotension can be quickly and efficiently evaluated at the bedside. By estimating the volume status first, initial therapeutics and further diagnostic testing can be better tailored to the clinical situation. This can make the difference between survival and further deterioration. While POCUS is rewarding in many clinical situations in emergency department, the potential to make a real difference in sick patients is the main motivation to continue to promote this modality. I hope this motivates you to seek opportunities to learn POCUS. It is never too early to learn, and just like most of your training, the more time you invest, the better you will become. to a better prognosis for patients. ď&#x192;&#x152;
Interested in learning how to do a carotid ultrasound? Check out our Facebook page for a step-by-step guide.
www.facebook.com/acoeprc
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Pimpology 101 The Fast Track
An Emergency Medicine Publication
Winter 2014
Top Things to Know on your EM Rotations Danielle Turrin, DO, MS PGY-2
Salter Harris is a classification system for pediatric fractures that involve the physis or growth plate. These fractures are classified according to their degree of involvement of the epiphysis, metaphysis and physis. This classification helps to dictate treatment and potential for future complications. There are five clinically important types of Salter Harris fractures.
Type I - Accounts for ~5% of growth plate injuries - Transverse fracture through the physis - Width of physis is increased - Growing zone is usually uninjured - Growth disturbance is uncommon - Usually treated with cast immobilization Type II - Accounts for ~75% of growth plate injuries - Occurs through the physis and metaphysis - Epiphysis is uninvolved - Minimal shortening, no functional limitations - Most treated with cast immobilization
Type III - Accounts for ~10% of growth plate injuries - Occurs through physis through epiphysis - Prone to chronic disability due to involvement of articular surface of bone - However, rare to have significant deformity - Treatment is often surgical with internal fixation to ensure proper alignment of growth plate and joint surface Type IV - Accounts for ~10% of growth plate injuries - Involves metaphysis, physis, and epiphysis - Prone to chronic instability due to involvement of articular surface of bone - Can lead to premature focal fusion of bone and resultant joint deformity
SALTER Mnemonic is at the base bone with epiphysis Which assumes long th plate) el as the physis (grow Type I = S = Same lev Type V e physis Type II = A = Above th is ys ph - Relatively uncommon, ~1% incidence e th an Type III = L = Lower th is, epiphysis - Compression or crush injury of physis without ys ph , sis hy tap me e h th Type IV = T = Throug the physis d injury or fracture to epiphysis or metaphysis he us cR = R = Type V
Reference: http://orthoinfo.aaos.org/topic. page 10
- Growth disturbances at physis leading to premature closure - Clinical history may aid in diagnosis as diagnosis may be difficult
For more quick, easy, factual pimp question information dont forget to check our Pimpology 101 in our next issue of the Fast Track......
The Fast Track
Visual Diagnosis
By Bruce St. Armour, DO
Winter 2014
An Emergency Medicine Publication
A 46-year-old, homeless male who was in a fight with his girlfriend and using multiple mood enhancing substances shot himself with a CO2-powered BB gun approximately one hour prior in the ED. Upon presentation, the patient was fully awake and alert without any focal deficits with the exception of slurred speech. After 3 hours, patient responsiveness has decreased, he exhibits confusion and bradycardia. Initial CT head
Initial Bone Window
CT and patient presentation discussed with trauma and neurosurgery and the patient was medically cleared. The patient was to be evaluated by the psych service for concerns of substance abuse and possible suicidal ideations. Continuing ED Course: After 1 hour, patient medically cleared and awaiting psych consult After 2 hours, patient beginning to become diaphoretic and increasingly agitated, substance withdrawal is suspected. After 3 hours, patient responsiveness has decreased, he exhibits confusion and bradycardia. Decision was made to repeat CT 4 hours after arrival, despite radiology objections... {Case Continued on Next Page}
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T
The Fast Track
An Emergency Medicine Publication
Winter 2014
Visual Diagnosis Initial CT
Follow-up CT Head
4 hours later
1. Interval development of 6.5 cm right temporal lobe intraparenchymal hematoma with partial effacement of the right lateral ventricle and 10 mm right to left midline shift. Associated uncal herniation. Appropriate surgical consult is recommended. 2. Subdural hematoma tracking posteriorly along the right tentorium cerebelli, with subdural hematoma along the superior falx cerebri. Trauma and neurosurgery alerted and an emergent hemicraniotomy. The patient was admitted to the the ICU for continued care. POD#3 â&#x20AC;&#x201C;Patient was extubated but without purposeful movement and leftsided paralysis.
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The Difficult Road Ahead The Fast Track
The challenges of transitioning into clinical medicine by Angela Kuehn, OMS-III
Winter 2014
An Emergency Medicine Publication
M
edical school is an experience that starts to mold you into a physician. It is a continuous competition with our classmates and ourselves for the better grades, the better scores and the most experience. We spend the first two years learning, reading books, doing practice questions and treating standardized “patients”. School becomes almost predictable, we know what to expect from professors and exams. Coming from this structured environment, how does one transition to treating patients and dealing with the emotions of life, death and everything in between and maintaining a sense of empathy and altruism? Personally, this realization came about after my third month of rotations. I was feverishly walking down the hallway so I could tell the attending my diagnosis before the medical resident could. So focused on the glory, I had almost completely forgot the person associated with this diagnosis, a particularly bad diagnosis. The patient’s life was about to change and even we didn’t have all the answers to give her. But at that moment all I cared about was being not only right but the first right person! How had I transitioned into this person who was more concerned about the glory than the patient that was getting a devastating diagnosis? Third year is a continuous transition from one clerkship to the next, where once we get comfortable and feel like we may understand what our responsibilities are, we move on to the next rotation, starting over again and again. We are constantly reminded of what we don’t know and how much time it takes us to do even the smallest tasks. The adjustment period in the beginning of a new clerkship consumes our ability to interact with a patient on a deeper level. We don’t necessarily know what the future holds for a patient regarding management and even severity of disease, so empathy can be difficult. Attending physicians and residents are there to teach us, challenge us and help us learn the art of medicine, but they also teach us the cynical side of medicine, the frustrations and the shortcuts. In the article titled The Darkest Year of Medical School Danielle Ofri examined the effect of the third year of medical school on the loss of altruism and empathy. She describes her view of this tradition in the article stating that, “However, there is a darker side of this transition to clinical medicine. Many of the qualities that students entered medical school with—altruism, empathy, generosity of spirit, love of learning, high ethical standards—are eroded by the end of medical training. Newly minted doctors can begin their careers jaded, self-doubting, even embittered (not to mention six figures in debt).” She speaks of the changes in third year curriculum to help prevent this transition to cynicism. One powerful quote is “It’s no wonder that the third year of medical school figures prominently in studies that document the decline of empathy and moral reasoning in medical trainees. But the beginnings of clinical medicine should be a time of awe and enthrallment, not a time of hardening. It is, after all, the moment of stepping into the flesh and blood of medicine.” So as we move along in our medical training and throughout our medical careers. Take the time to reflect on our experiences and grieve any losses. This should be a time of exploration and learning, not one that hardens us into jaded physicians. Ofri, D. (2013, 04 13). The Darkest Year of Medical School. Retrieved from http://www.slate.com/ articles/health_and_science/medical_examiner/2013/06/medical_school_dark_side_the_third_ year_makes_students_less_empathetic.single.html”
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The Fast Track
An Emergency Medicine Publication
Winter 2014
All for One: An RN Interview by James Hensel, OMS-III
Doug Taron, RN, BSN
W
hile on an ER audition rotation, or any rotation for that matter, the goal of any medical student is to shine in front the residents and attendings. Pimp questions and procedural savvy may be seen as the keys
to success and finding favor. However, there is much more to being a respected future physician and candidate for residency. Proficiency in procedures and knowing the “right answer” are far from all that make a successful ER physician. Students who keep such a narrow focus on their rotation may find themselves not getting “the spot” they are after. The residents and attendings are not the only people who students work alongside, and they are not the only people evaluating students. Patient care in the ER is a team effort that requires coordination between all levels of care. Those on rotation who seek to be an exceptional part of the entire ER team, will be the ones who stand out as the better candidates. As a former ER tech, I have had the opportunity to work several shifts with Doug Taron, who is a RN and current manager of the ER at Oklahoma State University Medical Center. OSU-MC has an ER residency program and functions as a site where many students rotate and interview. For many students, their first shift while rotating in the ER is their first exposure to how much of a team effort emergency medicine is. I thought it would be important to pick Doug’s brain, and see how much the impression students leave on nursing staff affects his or her chances of becoming a future resident. I asked Doug a few questions to get his take on the good and bad interactions that occur between students, residents, physicians and nursing staff.
JH: What is your official title and years of ER experience? Can you give a brief description of your current position in the ER as well as the interaction you have with students? DT: Clinical Resource Manager of the Emergency Department, VAD Department (IV team), and Employee Health. I have been a Registered Nurse for ten-and-a-half years. Currently, as the manager of the ER, I oversee all aspects of the nursing and tech roles: hiring, discipline, payroll, budget, education, maintaining certifications and competencies. While not directly supervising the residents and physicians, I work very closely with them on a daily basis. This ER, and this hospital, are great environments for students. We see nursing students, page 14
nurse aid students, paramedic students, EMT students, medical students and residents in various years of their training. We make a sincere attempt to provide them with exceptional
The Fast Track
An Emergency Medicine Publication
see and learn as much as possible. With all of the varying levels of people in training, it provides for a great learning environment. For example, residents are very willing to teach med students, or nurses, etc.
Winter 2014
learning experiences. We pair them up with appropriate preceptors, and allow them to
JH: How often do the attending physicians speak with you and the nurses about how and what a medical student is doing on rotation? If so, what kinds of issues are discussed? DT: All of the medical students do at least one shift with the nurses, so that they can see things from that point of view. Then, the nurses obviously interact with the medical students on a daily basis. The attendings do ask the nurses about their interactions with the students sometimes because they realize that the nurses may see things that they do not. They ask for positive and negative interactions.
JH: What are some bad things that medical students do that get noticed by the emergency room nursing staff? DT: Some students act put out to be there. Don’t do that. For example, if they are on a shift with the nurses, they sit in a chair in the nurse’s station and read, or look at their phone, or do anything else other than interacting with patients. Don’t talk down to the nurses. Most of the time, the nurses have years of patient care experience over the medical students. That’s years of practical, hands on knowledge that can’t necessarily be found in a James Hensel, OMS-III
book.
JH: On the flip side, what are some good things students do to impress the nursing staff? DT: A nice thing about medical students constantly rotating through our ER is that medicine is constantly changing. Since the students are in school at that present time, they have a means to stay more up to date on new and innovating changes, over a nurse that would just have to be doing research on their time off. Also, there are some students that come in with a very positive attitude and a proactive mind set. They look for opportunities to learn things that they may not know. That is always well received. page 15
The Fast Track
An Emergency Medicine Publication
Winter 2014
JH: How would you describe the ideal medical student-nurse interaction? What kinds of things can a student do to set him/herself apart as an ER team player? DT: Be proactive. Look for opportunities to learn and help out. Ask the nurse to show you things. Ask for opportunities to start IV’s, or place an NG, etc. Realize that each patient gets interviewed by multiple people. Ask the nurse to describe how to take the teamwork approach so that everyone gets their assessment done, and their questions answered.
JH: How would you describe the ideal physician - nurse “team interaction” and what kinds of habits and mindsets should we as students start developing? DT: We have some physicians that have come through that have been great team players with the nurses. For example, when a patient comes in a room, the nurse has to interview them to complete their assessment, the resident does too, and possibly the attending. With some physicians, this is a seamless process. They ask a question, the nurse asks a question, they feed off of each other. If a nurse needs help getting a patient into a bed, they help. If something needs to be done and the nurse is not available, or if the nurses needs help, they help to facilitate that. That is the best example that I can think of. Realize that we are all there for the patient. We all want to do what is best for that patient. As aspiring physicians, it is important to understand that no one part of the patient care team can function successfully alone. Knowing the diagnoses and treatments to patient ailments is only part of being a successful and respected physician. Especially in the ER where the status of acuity is very volatile, there needs to be trust and collaboration on all fronts of patient care, and it is important to learn that early. I want to thank Doug for taking time out of his very busy schedule to shed some light on how we as medical students can become better resident candidates, and more importantly, better future physicians.
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The Fast Track
Itâ&#x20AC;&#x2122;s never to early to start thinking about Spring Conference in Scottsdale, AZ April 22nd-26th, 2014. Visit www.acoep.org/ meetings for more details about pricing and how to register.
Winter 2014
An Emergency Medicine Publication
SCHEDULE OF EVENTS
THURSDAY APRIL 25
WEDNESDAY APRIL 24
TUESDAY APRIL 23
APRIL 23 - 25, 2014 RESIDENT CHAPTER | KIERLAND RESORT, SCOTTSDALE, AZ
10:00 am - 5:00 pm 6:00 pm - 8:00 pm
Committee Meetings ACOEP Welcome Reception
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The Fast Track
An Emergency Medicine Publication
Winter 2014
The View From The Bottom: An Interns look at how things really were and are..... By Brian Lehnhof, DO PGY-1
A
fter just a few short months as a doctor I sustained my first needle stick injury. The culprit was the ever-threatening Keith needle. This experience turned out to be an educational experience in several ways. A brief moment of distraction while suturing placed me in the ED I had come to know and love; however, on this occasion I was on the other side of the curtain. I had become the patient. Spending time on a hospital gurney provides a perspective that cannot be obtained in any other way. Occupying the role of a patient has influenced a lot of how and why I do things I do as a physician. This wasnâ&#x20AC;&#x2122;t my first time as a patient; in a life prior to medical school I was involved in a significant skiing accident that dramatically changed my life. I had been minding my own business when a tree interfered with my journey down the hill. Shortly after my face was dug out of the snow and my consciousness regained, I quickly began to appreciate the distress that an acute medical condition can cause, and I now realize that this is the distress that is common amongst many of the patients in our EDs. As a result of this accident, I sustained a tension pneumothorax and my respiratory status rapidly deteriorated. This particular resort was known for its epic snowfall, which means the ski patrol spent most of their time managing avalanche dangers and not much time brushing up on their pneumothorax management skills. It quickly became apparent that the patrollers caring for me were not confident in themselves or their skills. Their insecurities only further increased my distress. I felt a sense of vulnerability and I wanted to take control of the chaotic scene. Despite the chaos, the EMT inside me knew what was going on inside my chest, and I yearned for something to decompress my chest. After what seemed like forever, I was transported down the hill and met my new best friend, a flight medic with a 14 gauge needle. The relief I gained with a simple violation of my chest wall was as intense as the distress I had been experiencing seconds earlier. I share this experience because it changes the way I see my role in practicing medicine. People show up at our doorstep on some of the worst days of their lives. In many instances, we cannot comprehend what they are going through and appreciating the concerns of our patients is sometimes a challenge. As an intern, I am still trying to just minimize the damage I cause each day that I show up to work. Mastering the basics of EM is a big enough task that at times trying to sympathize and empathize with my patients feels beyond my current abilities.
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My short career in EM has shown me we encounter situations and people that vary wildly and we engage with people we would otherwise never have the opportunity to meet. All of these unique experiences plus those from our personal lives come together to make us who
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I was on the other side of the curtain. I had become THE PATIENT.
“
“
Winter 2014
An Emergency Medicine Publication
we are. These dramatic and dynamic interactions, accustom us to seeing the world through a vantage point significantly different from that of most of society. In fact, we tend to have a distorted sense of reality in many aspects of life. The challenge we have is to not expect our patients to share this same perspective. They come into our lives with completely different experiences and values. Each patient reacts to his or her circumstance differently and each patient has different expectations and perceptions. Our opportunity is to identify these perceptions and work with them. Making a difference in someone’s life is much easier if you know what that difference feels like. I believe in order to become an effective healer, you must first know what it is like to be healed. As an intern I have felt vulnerable many times. I am trying to come away from those situations with a bit more empathy for the patients that come to me during their time of vulnerability. Understanding this can make the long days and nights seem a little more worthwhile, and a little more real. I am not endorsing that you sustain some trauma that gets you admitted in your hospital. Rather, I simply encourage each of you to look deeper into the person behind the chart in front of you. Challenge yourself to find out what the patient is really experiencing. Try to find where they are coming from, what their values are and what their expectations are. Spending a few moments to know them better will make your job much easier. Recently while on Internal Medicine rounds, my attending made a joke about how I seemed to care about my patients, and how this was strange for an EM resident. I have become accustomed to the IM attendings trashing everything about the ED, but this caught me off guard. I think most Emergency Physicians go into medicine because they do genuinely care about people. Sure we might also be some of the most cynical people out there, but at the end of the day we show up for our shifts because we enjoy making a difference. Caring for patients in the vulnerable times of their life is what we specialize in. Doing this provides unmatched fulfillment. We all have a fire, burning within us, making us want to show up for our shifts. That flame may burn at varying intensities from time to time, but it’s there. This flame is what helps us cope with the struggles we face. Find whatever fuels this fire inside you and harvest the power from it.
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The Fast Track
An Emergency Medicine Publication
Winter 2014
For most of us across the country, cold weather is fast approaching or already upon us. In order to be ready for the patients we may be treating due to the cold, here is a primer for some of the cold weather related complaints that will be visiting an Emergency Department near you.
It had been so cold for so long, trudging down the snowshoe trail. The day had started out beautifully with those light snowflakes transitioning to the large, catchon-the-tongue size and before I knew it the snow packed trail I was following had disappeared under the new blanket of white. The pit of my stomach let me know quickly
COLD
WEAT
that I was lost. But I had been on this trail once before and I was pretty sure of what direction I needed to go. That was four hours ago. Or was it 6 hours ago? 8? I can’t remember… At
eme
first I had been keeping warm by moving, but after I started sweating like crazy I strapped
my jacket to the back of my backpack to cool off. Somewhere along the line the strap didn’t hold and now my expensive winter jacket was probably buried under some snow bank somewhere. But my teeth had stopped chattering not too long ago, and my body no longer shivered uncontrollably. That was a good thing right? Meant I was getting warmer? I couldn’t help but smile, it felt good to be warm again in the snow. I almost felt like I was on a white sandy beach all by myself. Maybe I should just lay down for a bit and relax, enjoy the scenery. Heck, a nap sounded good right now, I felt tired and could use a little rest before continuing on. This pile of fluffy snow right here looks perfect…
“my body no longer shivered...” page 20
The Fast Track
Winter 2014
An Emergency Medicine Publication
Are you ready for the cold? Burrrrrrrrr.....
D
THER
ergencies Clinical Information by Drew Kalnow, DO PGY-1 Stories By Tanner Gronowski, DO PGY-1
Hypothermia Of course hypothermia is a winter related problem, but it can actually be a problem anytime of the year. There are several potential causes of hypothermia including metabolic disorders of the thyroid or adrenal glands, infectious issue such as sepsis, neurological dysfunction and environmental exposures. Environment exposures occur due to the mechanisms of conduction, convection, radiation or heat loss through respirations or evaporation. Hypothermia is commonly defined as a core body temperature below 35oC (95oF) and the level of hypothermia the body is experiencing will manifest with both protective mechanisms to attempt to reduce heat loss and produce heat, as well as clinical signs of the hypothermia itself.
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At just over a degree Celsius below Winter 2014
normal, the body will induce shivering to produce heat and simultaneously form “goose bumps” and start peripheral vasoconstriction as heat retention mechanism. As the body temperature dips below 34oC the central nervous system is affected and the patient will show signs of confusion and decreased coordination. Below 32oC the body loses its protective mechanisms, shivering stops, heart rate and respirations slow and level of consciousness decreases. Also around the 32oC mark, the heart will show signs of strain with bradycardia, widening QRS, absent p-waves, inverted t-waves and the pathanuemonic j-wave (Osborne wave) may appear. Around 28oC cardiac arrest will occur. Diagnosis: Diagnosis Diagnosis of hypothermia is as simple as measuring the patient’s core body temperature below 35oC… Yes, that means a RECTAL temperature! While the criteria are simple, it is likely that hypothermia is under diagnosed and certainly under treated. Not only do we need to consider hypothermia in the patient exposed to extreme cold temperature or cold water, but also in the elderly who my fall, not be able to get themselves up and become hypothermic due to exposure to room temperature. Treatment: Treatment The first step in treatment of hypothermia is extracting the patient from the cold environment including removing any clothing, particularly wet clothing, that will inhibit rewarming. Other steps in the ED include: -IV, O2 (warmed is possible), cardiac monitor and basic labs -Warm blankets and/or warming blanket -IV saline or dextrose with warmed fluid -Heating lights or simply raising the room temperature More aggressive warming, which may begin in the ED but are more commonly performed in the ICU are central warming with gastric lavage, bladder lavage,
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peritoneal dialysis/lavage or hemodialysis all with the goal of raising the core temperature at least .5 – 1oC per hour.
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patch of ice and while I had remained unharmed thanks to my seatbelt and airbag, I was 25 miles from the nearest city and had
Winter 2014
My car had slid off the side of a remote freeway after hitting a
nothing but my cloth tennis shoes to walk in. By the time I had found someone to pick me up, the hours of trudging through the snow and slush had taken their toll on my feet. It hadn’t been so bad when they went numb, kind of made the walking easier. But the little ER where I was now at was about to start to rewarm my feet, which looked almost fake with their yellowish-white appearance and obvious lack of life to them. They told me the water was really hot, but that it was necessary to try to unfreeze my tissue. Sliding my feet into the
“obvious lack of life to them...”
pot of warm water, I held my breath, waiting for the feel of the warmth…. But there was nothing. My eyes could see my feet in the water but I felt nothing. What if I never felt anything again in my feet? Would they still work again? I wonder if… “AHHHHHHHHHHHHHHHHHHHHHH! IT HURTS!” My feet were on fire, like they had been dipped into a pool of lava somewhere on the surface of the sun! Only a few hours ago they had been frozen blocks of ice, numb to the touch and immobile. Now it felt like shards of glass were ripping my flesh apart while they soaked in a bath of warm water. “OH. MY. MAKE. IT. STOP!” They had told me it was going to hurt but they didn’t tell me it would KILL me! Where is that pain medication they had offered me earlier?!
Frostbite Similar to hypothermia, frostbite occurs in the setting of prolonged exposure to the cold and is similarly affected by the physiological mechanisms of heat loss. Environmental factors such as wind and wet (trench foot) will exacerbate the body’s heat loss and sensitivity to be affected by the cold. Frostbite typically occurs at below freezing temperatures and the severity of injury is directly related to the extent tissue freezing. Frostbite, and its milder form, frostnip, typically occur on the extremities such as fingers, toes and the nose. This is due to both the increased surface area contact with the environment, and as discussed in the hypothermia section, the body’s natural defense to cold exposure is
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peripheral vasoconstriction. The number one way to combat Winter 2014
frost bite, other than warming of the area, is through movement, forcing both increased blood flow to the area and the production heat through muscle contraction.
Diagnosis Diagnosis: The first symptoms the patient will display are pain, followed by numbness to the affected area and gradual loss of function. Frostbite is staged similar to that of burns. First-degree frostbite is superficial and presents with pain, erythema and swelling of the affected area. Second-degree frostbite includes all of those symptoms, plus the addition of skin blisters and numbness. Third-degree injuries are full-thickness skin injures with extension of damage to the subcutaneous tissues. These injuries are characterized by loss of sensation, blistering and a dusky blue/gray skin discoloration. Fourth-degree frostbite includes the extension of cold injury into the muscles, tendons and even bone. Treatment: Treatment As with all environmental exposures, the top priority is removal from the cold. Active rewarming should not begin until it is certain that the patient will not be re-exposed to the cold. All frostbite treatments begin with rewarming of the tissue in warm water baths that are maintained at 40-42oc in 15-30 cycles until the area has undergone complete thawing. Return of circulation can be confirmed by the skin returning to its normal coloration. The process of thawing can be quite painful so proper analgesic treatment is indicated. Further treatment involves determination and debridement of viable tissue, particularly in the case of third and fourth-degree burns. The affected area may need warm water baths over the period of several days. Blistered skin is very prone to infection as it heals, so proper antibiotic use and tetanus prophylaxis is also indicated.
Most people hate Christmas shopping. The crowds! The lines! The page 24
constant jingle of bells and Christmas music playing over and over and overâ&#x20AC;Ś But I love it! Proudly voted by my sorority as â&#x20AC;&#x153;Queen of
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An Emergency Medicine Publication
shop anyone and in high-heels non-the-less. Like right now, even though I am carrying 3 bags in my
Winter 2014
the Credit Card”, I took pride in being able to out
left arm from Kohl’s and 4 bags on my right arm from Macy’s I’m still powering on! Where is my next stop? Oh yes, I need to go to Anthropology for Becki to get her that top. I’ll just drop these bags off outside at my car and double back to that end of the mall. Now, where did I park again? … The ice came out of nowhere, probably hidden beneath the dusting of snow outside. The tiny surface area of the right high heel didn’t have a chance on the near frictionless surface. The right leg went shooting
“She knew her shopping day was over...”
forward in front of her, and a high pitched yelp escaped her lips as she began to fall backwards. Her arm full of Kohl’s gifts reached back desperately to try and catch the brunt of the force. The cold concrete met her outstretched arm with a solidifying crunch, the weight of her body and gifts slamming their mass directly to the bone… With a quick snap and a blaze of pain, she knew her shopping day was over.
Slip and Fall Injuries Anybody who has spent even a day in the ED know that musculoskeletal injuries are a frequent complaint, but when snow and ice come out, people tend to slip and fall in even greater numbers. While we always need to be cautious to fully examine these patients and rule-out life threatening injuries such as head trauma and spinal injuries, most of what walks, limps or is rolled into the ED ranges from a sprain/strain to fracture. When discussing injures from a slip and fall the main place to focus is the wrist.
Diagnosis When we fall, particularly slip, we almost always fall backwards onto an outstretched hand. The brunt of the impact is channeled through the palm of the hand and wrist up the arm. The weak link in the system is often at the metaphysis of the distal radius fracture in the form of a Colles or Smith fracture. The Colles fracture is more common and involves dorsal displacement of the distal
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radius, often described as a “dinner fork” deformity. Winter 2014
The Smith fracture is the opposite with volar displacement and is described as a “garden spade” deformity. Both fractures, once identified with an H&P and X-rays, require closed reduction to properly realign the displaced segment. The injuries themselves are painful, but often tolerable when properly supported, it is the reduction that causes severe discomfort. The reduction can be performed using regional anesthesia, a hematoma block or procedural sedation (preferred in pediatric patients). Of utmost importance during evaluation and treatment of these injuries is assessing and documenting motor, vascular and neurologic function of the affected limb. While many ED’s have the ability to consult Orthopedics for any such injury, if there is concern for neurovascular compromise, an immediate consult is indicated. Once reduced, the injury requires 4-6 weeks of immobilization.
Treatment Anytime there is concern for a wrist or hand injury, it is important to consider and assess for a scaphoid fracture. Scaphoid fractures are the most common carpal fracture, often occur due to falls and are easily missed (or not present) on initial X-ray. Any tenderness at the anatomical snuff box needs to be treated initially as a scaphoid fracture, placed in a thumb Spica splint and given follow-up with repeat X-rays. The reason for this aggressive treatment is that a fracture of the scaphoid can lead to avascular necrosis due to the bone’s retrograde and fragile blood supply.
It was my 8 year old son Jared’s birthday party today and just prior to the party starting with his friends coming over we had decided to cave and turn on the furnace. The winter weather was coming and with everyone going to be spending the night we figured we should start up the furnace for the first time to make sure no one got cold at night. page 26
At about 7pm one of the kids came up to me and told
The Fast Track
An Emergency Medicine Publication
Winter 2014
me he wasnâ&#x20AC;&#x2122;t feeling well, so we gave him a popsicle and had him lay down in the living room to rest for a bit and see if he got any better. Then another one started to complain. And another. And another. I was worried we had a flu-bug going around until I too began to feel sick, almost lightheaded and dizzy. That was the final straw. My husband and I loaded up the kids into the minivan and drove to the ER. After some initial testing and some probing the ED doc got a funny look on his face when we mentioned we had just turned on our heater due to the cold outside. And here we are now, sitting around the room, all eight of us, with plastic tubes extending from the center of the room where a metal gas container looked almost like a sad excuse for a hookah setup. The tubing connected to the plastic masks all strapped to our faces like examples of when an airplane cabin depressurizes, and we sat around the staring at each other. I still had that queasy feeling in my stomach and a slight throbbing headache, but it was good to see the kids starting to perk up a bit and smiling. What a way to celebrate a birthday.
Carbon Monoxide Poisoning What would a cold weather or winter medical emergency discussion be without carbon monoxide (CO) poisoning? When the weather turns cold and the heat turns on, carbon monoxide has to move up the differential for your patients that present to the ED without a clear explanation for their complaints. Numbers vary, but CO poisoning/exposure is estimated to account for 40,000-80,000 ED visits annually with approximately 10% of all exposures resulting in death. The problem with CO is that we cannot detect it when we are exposed to it. CO is tasteless and odorless, causes a myriad of non-specific complaints and at increasing levels leads to confusion and unconsciousness. Exposure to CO can come from several sources. In the winter, the most common source of exposure is malfunctioning heaters and furnaces. Any gas burning furnace, whether using natural gas, propane or another similar source, emit CO as a product of combustion and if not properly vented the furnace can off gas into living and working spaces. The rise of carbon monoxide detectors in residential and commercial building
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has mitigated exposure to an extent. Of course, itâ&#x20AC;&#x2122;s Winter 2014
not just furnaces that can lead to CO exposure; any combustion engine will give off CO. Other common causes of exposure are due to car emissions (intentional and unintentional), propane powered fork-lifts and the like in improperly ventilated areas, structure fires, etc. Diagnosis: Diagnosis Diagnosis of CO poisoning can be challenging in the ED, particularly if the presenting history does not explicitly point the physician in the right direction. Initial symptoms are typically vague, flu-like complaints such as headache, dizziness, fatigue, abdominal cramping, nausea and vomiting. The classic textbook, pathaneumonic sign, of CO poisoning is cherry-red lips and nail beds but this is often not present on exam. As the exposure worsens and there are increasing levels of CO in the blood, neurological symptoms predominate. The patient may present with acute altered mental status, seizure or coma. As in all medical emergencies, a complete set of vitals including pulse, pulse-ox, respiratory rate, blood pressure and EKG is critical, but can be misleading. In the patient experiencing CO poisoning, the SpO2 will be falsely elevated. A simple pulse-oximeter looks at the percent of hemoglobin saturation and delivers a readout. In the case of CO poisoning, the hemoglobin will be fully saturated, but with CO instead of O2, due to the high affinity of hemoglobin for CO. The ultimate diagnosis lies with obtaining a HbCO level via either ABG or VBG and correlating it to the patientâ&#x20AC;&#x2122;s history, symptoms and examination. Keep in mind, that chronic smokers will have a higher level of HbCO than non-smokers.
Treatment Treatment: Treatment of CO poisoning lies in displacing the CO from the blood and hemoglobin and replacing it with O2. Like any exposure, the first step must be removal from the hazardous environment. Once the patient and providers are in a safe location, high flow oxygen, cardiac monitoring and IV access are the initial treatments. Many patients that have not had prolonged or extreme exposure, will improve with O2 alone page 28
and not need further intervention. If the exposure is severe with significant neurologic
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improving, hyperbaric oxygen is indicated and is ideally administered within the first 6 hours post-exposure.
Winter 2014
and cardio-respiratory symptoms or the patient is not
“Damn snow. Stop making me shovel this damn driveway. Three times today!” The snow had been falling all day. It was Sunday. I was tired of wasting my weekend working on this in the cold when I should be relaxing and watching football. Huffing and puffing, another shovelful of snow was thrown off the concrete drive. “Seriously, next year, I am paying someone to do this. I’m too old for this stuff. Too old for these holidays in the cold”! I felt the cool air on my brow as the sweat started to roll down the bridge of my nose. This had to get done or else tomorrow when I tried to leave for work I would just pack it down and start creating ice. Push. Lift. Throw. Repeat. As I lifted the next heaping pile I felt a sharp pain over my left pec muscle. “Now what?!” I yelled out at the snow, not needing another thing added to my list. Then the pain became so intense I dropped the shovel, grabbing at the pain with my other arm. After a moments rest, grumbling to myself I bent down to pick up the shovel and the pain grabbed me again. “GRRRRRRRRRRRRRRRRRR! Damn snow”! The pain shot down my arm and my jaw clenched in pain. It was crushing me. The pain created a tightness that locked down on my chest, stealing my breath from me and making me gasp shallowly. I could feel my heart pounding in my chest, like it wanted to revolt and jump through my rib cage. I collapsed onto the driveway, clutching my chest and praying for the first time in decades. Please make this stop. What was happening to me?
Acute Coronary Syndrome The dreaded MI while shoveling is an annual winter-time rite of passage, or at least something EM physicians like to discuss and a good excuse for a quick review of acute coronary syndrome (ACS). The actual incidence of myocardial infarctions directly related to shoveling is difficult to measure, but studies have indicated a significant correlation between low temperatures and increased incidence of MI’s. Risk factors play a huge role in the incidence of ACS, combined with the significant increase in oxygen consumption while shoveling and the likely occurrence of at least
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some reactive airway constriction due to cold air, it’s easy to see Winter 2014
how something as simple as shoveling can cause an event. Diagnosis Diagnosis Diagnosis of a STEMI is in many ways straightforward. A patient that presents with chest pain or an angina equivalents and has ST-segment elevations is as close to a slam-dunk diagnosis as we get in the ED. It is the patients that present in a slightly more subtle way that force us to think of ACS in our differential. Certainly any patient with cardiac risk factors who presents with chest pain, exertional dyspnea, unusual fatigue or other related symptoms, with an HPI of shoveling snow deserve at least the consideration of a cardiac workup. Any patient with concern for ACS should receive a chest x-ray, serial EKGs and trending of cardiac enzymes (troponin and CKMB), as well as any additional imaging and laboratory that may be indicated. Treatment: Treatment Initial treatment of cardiac related chest pain in the ED consists of IV, O2, and cardiac monitor (the ED anthem); followed by Aspirin and Nitroglycerin (sublingual spray or tab). Additional treatments that may be considered in the ED depend on analysis of the EKG and the cardiology resources available. Patients with diagnosed STEMI’s or concerning NSTEMI’s may go directly to the cardiac cath lab for definitive diagnosis and treatment or may be started on anticoagulation or fibrinolysis. Less concerning patients will most likely be admitted to the hospital or placed in observation for further cardiac trending and work-up.
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References Clardy P, et al. Carbon Monoxide. UptoDate. 24 September 2013. Available at http://www.uptodate.com, accessed 24 November 2013. Goldman L, Ausiello D. Cecil Textbook of Medicine 22ed. Philadelphia, Pa: Saunders; 2004. Janardhanan R, et al. The snow-shoveler’s ST elevation myocardial infarction. American Journal of Cardiology. 2010 Aug 15;106(4):596-600. Ma O, Cline D. Emergency Medicine Manual. New York, NY: McGraw Hill; 2004 Petron D. Distal radius fractures in adults. UptoDate. 14 November 2013. Available at http://www.uptodate. com/, accessed 10 November 2013. Thakur C, et al. Cold weather and myocardial infarction. International Journal Cardiology. 1987 Jul;16(1):19-25.
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Winter 2014
Pediatric Corner: Febrile S N
ine month-old female presents to your emergency room after having a witnessed 4-minute generalized seizure. Presently, the child is crying but lethargic. The parents report that she has been febrile for a day, but she was otherwise playful and interactive prior to the convulsion. She is presently 103 degrees F in the emergency department. The parents are visibly upset, and terrified by the possibility of losing their child.
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Introduction: As a parent witnessing their child having a seizure, it can be extremely stressful. It has been reported that a high percentage of families think their child is dying or near death.(1) Although, as horrific an event this would be, even to our own children, thankfully it does carry a less than ominous prognosis. As a clinician, our responsibility is to convey accurate information and to extend an understanding about this disease process. The following is a review on current AAP recommendations and an overview on current evidence for initiating various management pathways.
What are your thoughts to this scenario? What are your diagnostic dilemmas? If the parents give you a different historical background that includes lethargy and vomiting for a day prior to her seizure, does that change your mind set and concerns Definition: towards the etiology of her condition? These are questions we will attempt From a clinical aspect, febrile seito answer in the following article. zures have an incidence of approximately 2-5% in the pediatric population and are characterized as an infant or child between the ages of 6 months to 5 years having a seizure in the setting of a fever. (2,3) Further stratification of febrile seizures is described as simple or complex. A simple febrile seizure is defined as generalized in nature, less than 15 minutes in duration and only a single event during a 24-hour period of time. A complex febrile seizure is described as focal in nature, lasting
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Seizures greater than 15 min in duration and recurs within 24-hour period of time. (2,3) Furthermore, the patient cannot be diagnosed with a febrile seizure if there is a pre-existing history of seizure disorder, a diagnosis of a central nervous system (CNS) infection or a previously acquired or congenital CNS illness (2,3). Historical Background: In 1976, Nelson and Ellenberg, followed 1706 children to record the frequency of afebrile seizures in children who experienced a convulsion during a febrile episode. (4) It was shown that having a febrile seizure does increase your risk of having epilepsy, although this number is still a small percentage 11 in 1000 verses 5 in 1000 in neurologically normal children who never experienced a febrile seizure. Additionally, it was also found that those children who went on to have epilepsy did had a higher frequency of complex features to their initial febrile seizures. (4) In 1996, the practice parameter for neurodiagnostic evaluation was published and addressed various diagnostic modalities and their clinical relevance for children who present with their first simple febrile seizure; focusing on lumbar puncture, neuroimaging, EEG and blood sampling for laboratory testing. (3) The conclusion was that EEG, blood studies and neuroimaging were not recommended. However, the committee did highlight strong consideration to perform a
By David Teng, MD
Winter 2014
An Emergency Medicine Publication
lumbar puncture in the younger age range. Furthermore, in 2011, the subcommittee on febrile seizures published a Clinical Practice guideline as an update to the 1996 Practice Parameter. Again, reiterating, “Clinicians…should direct their attention toward identifying the cause of the child’s fever.” (2) Now back to the patient. How will you treat this child? What are your concerns? What is this evidence to support your decisions? What will you do? Major decision points: To tap or not to tap: The 1996 Practice Parameter broadly states that performing and LP is strongly recommended in the patients less than 1 year of age. (3) The caveat was that the target audience for the practice parameter had a “wide range of pediatric experience”, and the com-
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Winter 2014
Pediatric Corner: Febrile S mittee chose a very “conservative approach” with its recommendations in diagnosing meningitis. (3) Most recently, the 2011 update produced several action statements that finalize this diagnostic question; “current data no longer support routine lumbar puncture in well-appearing, fully immunized children with a simple febrile seizure.” (2) However, importantly, it did re-iterate the support of the lumbar puncture in children who had clinical signs, historical symptoms, or physical findings consistent with acute bacterial meningitis. Two additional scenarios that a lumbar puncture can be considered a diagnostic option would include children that are unimmunized or partially immunized and those that have been “pre-treated” with antibiotics. Even though these recommendations are based on expert opinion, clinical reasoning and case reports it is considered an “option” to the clinical evaluator and consideration when exploring clinical risk factors. (2,5)
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As for complex febrile seizures, in the 1996 position statement, these patients were more likely to have abnormal cerebral spinal fluid. However in 2010, Kimia et al, identified 526 patients with CFS, and for 64% who received a lumbar puncture, 3 were found to have bacterial meningitis, and majority of these were ill appearing. In contrast, of those with CFS and did not receive a lumbar puncture, 87 % were followed up, and none re-presented with a diagnosis of bacterial
meningitis. Again, emphasizing the necessity to focus on the clinical presentation and overall appearance of the patient to guide medical decisionmaking. (6) To radiate or not to radiate: In 1996, the consensus was that neuroimaging for a patient with SFS was not recommended. And in the 2011 updated action statement, it continues to follow previous thoughts that “clinically important intracranial structural abnormalities in this patient population are uncommon”. (3) In 2006, a study was published that reviewed the utility of computed tomography for complex febrile seizures, by reviewing existing retrospective and observational studies (7). However, even with study-type limitations and small sample sizes, the data shows that no patient presenting with CFS had an abnormal neuroimaging requiring intervention. Electrolyte abnormalities and bacteremia: As stated in both current and past editions of the clinical parameters for febrile seizures, recommendations for evaluation of electrolyte imbalance as an etiology for seizures are not to be performed unless there is a historical or clinical finding suggestive for such abnormalities. It is further supported that decisions for performing blood testing for infectious causes should be “directed toward identifying the source of fever instead of a source for the seizure.” But reassuringly,
The Fast Track
An Emergency Medicine Publication
“the incidence of bacteremia in children younger than 24 months of age, with or without febrile seizures is the same.” (2,3,8) Pearls and Pitfalls: At our institution, it is often taught to the house-staff and students to not let the seizure itself direct your potential diagnostic work up. If you perform further testing, initiate it because of other factors such as age, sex of the child, height of fever, clinical symptoms and not just because the child had a seizure. This doesn’t suggest that the child cannot have bacteremia, UTI or other infections, it just needs to be clarified that the seizure is a result of the fever, and the risks of infection are not different or increased over those children who only present with a fever. Be cognizant of the pre-seizure condition, especially in regards to clinical signs and historical symptoms for serious bacterial infection including meningitis. “How were they were prior to the seizure”, is an important piece of evidence that will help guide your diagnostic testing or emergency room management. Prior to discharge, always make sure the patient returns to baseline mental status. Be sure to have the parents corroborate your clinical assessment with a vote of confidence that their child is indeed acting him or herself. Remember, this is a stressful scenario and the parents need to feel comfortable and reassured. But ultimately, as a responsible clini-
Winter 2014
Seizures cian, you have to be able to say upon discharge, “patient is well appearing and has no signs of neurological deficit or signs of meningitis.” Smart practices mean safe outcomes. References: 1) van Stuijvenberg M, de Vos S, Tjiang GC, Steyerberg EW, Derksen-Lubsen G, Moll HA. Parents’ fear regarding fever and febrile seizures. Acta Paediatr. 1999 Jun;88(6):618-22. 2) American Academy of Pediatrics, Subcommittee on Febrile Seizures. Clinical & Practice Guideline – Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure. Pediatrics 2011;127:389–394. 3) American Academy of Pediatrics, Provisional Committee on Quality Improvement and Subcommittee on Febrile Seizures. Practice parameter: the neurodiagnostic evaluation of a child with a first simple febrile seizure. Pediatrics. 1996;97(5): 769 –772; discussion 773–775 4) Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med. 1976;295(19): 1029 –1033 5) Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009; 123(1):6 –12 6) Kimia A, Ben-Joseph EP, Rudloe T, Capraro A, Sarco D, Hummel D, Johnston P, Harper MB. Yield of lumbar puncture among children who present with their first complex febrile seizure.Pediatrics. 2010 Jul;126(1):62 7) DiMario FJ Jr. Children presenting with complex febrile seizures do not routinely need computed tomography scanning in the emergency department. Pediatrics. 2006 Feb;117(2):528-30. 8) TrainorJL, HampersLC ,KrugSE, Listernick R. Children with first-time simple febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med. 2001;8(8):781–787 9) Kimia AA, Ben-Joseph E, Prabhu S, Rudloe T, Capraro A, Sarco D, Hummel D, Harper M. Yield of emergent neuroimaging among children presenting with a first complex febrile seizure. Pediatr Emerg Care. 2012
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The Fast Track
An Emergency Medicine Publication
Winter 2014
Residency Spotlight
Good Samaratan Hospital, West Islip , New York
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ood Samaritan Hospital Medical Center is a 437 bed, area trauma center on Long Islandâ&#x20AC;&#x2122;s south shore located in West Islip, NY. Good Samaritan is one of the largest providers of emergency medical care on Long Island, treating nearly 100,000 patients annually. In our unopposed emergency medicine residency program we currently have 22 phenomenal residents; accepting four new residents every year. Some of the Emergency Departmentâ&#x20AC;&#x2122;s many services include an Emergency cardiac care center, a Stroke center, a dedicated Pediatric Emergency Department, and a Fast Track treatment area. Good Samaritan is also affiliated with the New York College of Osteopathic Medicine (NYCOM), The Mount Sinai School of Medicine, NYC Poison control center, FDNY/EMS, urban and county hospitals, and the Baltimore Shock Trauma center to provide a dynamic and diverse educational experience.
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What makes Good Samaritan Emergency Medicine unique? As an unopposed program our residents do not have to compete with other specialties for clinical exposure. We ARE the trauma and critical care team for adult and pediatric cases. It is a procedure rich environment where seasoned attendings and skilled senior residents are focused on education and advancing clinical skills. The junior residents are brought up in an environment that is anything but status quo, where proficiency and excellence are the standard. At Good Sam great education meets unfettered opportunities for real time emergency medicine experience. Our residents mature through their four years of training to eventually run the critical care team and are prepared to be proficient emergency medicine physicians ready to excel in any situation and succeed in any environment. The program works with each resident allowing them opportunity to explore their interests whether it be International Medicine, Health Care Politics, or anything in between.
whatever the season, Long Island has it all. The Island has a rich culture and history, offering a diverse palette of attractions and points of interests. Families with children also benefit from some of the best school districts in New York.
Winter 2014
An Emergency Medicine Publication
3 Words To Describe Good Samaritan Emergency Medicine: • Dedication • Opportunity • Proficiency
“EDUCATION MEETS UNFETTERED OPPORTUNITIES FOR REAL TIME EMERGENCY MEDICINE EXPERIENCE”
What is there to do when you’re not at the hospital? Good Samaritan is located approximately 40 miles from the heart of New York City. From professional sports, white sandy beaches, water sports, museums, golfing, hunting and camping to ice skating, cross-country skiing and sledding,
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The Fast Track
An Emergency Medicine Publication
Winter 2014
Influenza Battle
Preparing for the coming storm
T
by Jay Anderson, OMS-III
he arrival of winter and the dropping temperatures are stimuli for a discussion of the influenza virus. It will not be long before emergency departments and clinics are packed with complications of the virus. Since the 1970’s, influenza virus outbreaks have caused 55,000 – 431,000 hospitalizations, about 226,000 office visits, and 3,000-49,000 deaths during each year’s flu season. The most effective and primary prevention tool is the influenza vaccine which receives an enormous amount of media coverage and advertising dollars each year. Despite this widespread attention however, there are countless individuals that fall into the high risk category for suffering complications who fail to receive the vaccine. The influenza virus is primarily spread through respiratory droplets, usually as a result of coughing or sneezing. The virus is typically associated with the sudden onset of symptoms including fever, myalgia, headache and weakness. The diagnosis can either be made clinically or through laboratory analysis. The CDC recommends only using laboratory tests when the results will lead to changes in management. The three commonly used tests are rapid antigen detection, immunofluorescence assay and polymerase chain reaction. Each test has significant differences in sensitivity, specificity and turnaround times. Another alternative is to obtain a viral culture, the only test that can determine the specific strains and characteristics of the virus. The rapid antigen test is the fastest and can be completed in less than 15 minutes but lacks the sensitivity that other tests offer. The outcome of the antigen test is also dependent on viral shed which can produce variable outcomes depending on when it is completed relative to initial symptom onset. During periods of peak outbreaks, clinical diagnosis is typically all that is necessary. Two main isolates of the influenza virus are known to cause human disease, type A and B. The type A virus is categorized based on the presence of two surface antigens, hemagglutinin and neuraminidase. The type B virus is separated into two lineages, Yamagata and Victoria. The annual influenza vaccine has traditionally been trivalent, consisting of a mixture of two subtypes from type A and the Yamagata lineage from the type B virus. Strains for the vaccine are selected in an attempt to anticipate the ones that will be circulating during the upcoming season. Coverage provided from the vaccine will typically not last more than one year, so an annual vaccine is recommended. The CDC has selected October as the ideal month for administration to offer protection during the peak infection months of late December through March. The Food and Drug Administration has approved a new set of vaccines for the 2013-2014 influenza season in an effort to expand vaccination coverage. The newly formulated vaccine is quadrivalent and has the additional coverage of the Victoria lineage from the type B virus. The quadrivalent vaccines are now available, but the trivalent vaccine will remain on the market. Model analysis data from the CDC website provides insight into the possible benefits of the quadrivalent vaccine, suggesting that up to 970,000 cases, 8,200 hospitalizations and 485 deaths could be prevented on an annual basis. There are a number of confounding factors like vaccination supply, coverage, effectiveness and the percent of type B cases that makes estimating precise numbers difficult.
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Influenza guidelines for receiving the vaccine have expanded over recent years in an attempt to decrease viral spread and limit the potential complications. Current recommendations for receiving the vaccine are anyone age six months and older and those that have no contraindications, which include any prior severe allergic reactions to the vaccine or any of its additive components. The vaccine is produced in chicken eggs, so any prior severe allergic reaction to eggs is a possible contraindication. The CDC maintains a stepwise approach to vaccination in people with a history of egg allergies. The Pharmacist’s Letter has produced a patient handout that includes explanations of the
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most common myths that prevent people from receiving the vaccine. The top misconceptions addressed are: the vaccine can cause the flu, the adverse effects of the vaccine are worse than the flu, only older people need the vaccine, the vaccine must be given prior to December, the vaccine does not need to be given each year, and patients with asthma should not get the vaccine.
Winter 2014
An Emergency Medicine Publication
History has shown there are several types of people who are more likely to experience complications as a result of the influenza virus. Vaccine recommendations were expanded largely to prevent illness in these types of individuals. The incidence of complications is highest in patients older than 65 years of age or who have a chronic medical disorder. 4 These include cardiac, pulmonary, immunosuppressive and endocrine disorders. Other high risk categories include pregnant women and children who are younger than 4 years of age. The 2009 H1N1 outbreak analysis revealed significantly higher fatal complications associated with pregnancy, clinical obesity and immunocompromised status. One of the concerning complications of the virus is viral pneumonia which can be followed by a secondary bacterial pneumonia. Patients suffering from asthma or COPD can experience severe exacerbations as a result of the virus. Children could potentially develop Reye’s syndrome after aspirin therapy during their infection. 4 Two neuraminidase inhibitors oseltamivir and zanamivir work by blocking the enzymes that would typically release the progeny viruses as they are budding from the cellular envelope. Clinical trials have demonstrated that when a neuraminidase inhibitor is administered within the first 48 hours after the onset of symptoms, the duration of the infection can be decreased by one day. The CDC is an excellent resource, and the page is updated frequently throughout the influenza season. The influenza virus can be associated with significant mortality, and has extensive financial and healthcare resource implications. Vaccination is the most important method of reducing deaths and preventing potential complications. Success will largely depend on the vaccination rate achieved. As the peak influenza months approach, vaccination education and advocacy will continue to be an essential component of the daily tasks for every health care professional. References Centers for Disease Control and Prevention. Information for Health Professionals. Cdc.gov/flu/professionals. November 26, 2013. Accessed November 15, 2013. Dolin R. Chapter 187. Influenza. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com/content. aspx?aID=9094339. Accessed November 15, 2013. Pharmacist’s Letter. Myths About Influenza and Influenza Vaccination. Pharmacistsletter.com. Published August 2010. Accessed November 18, 2013. Cydulka RK, Meckler GD. Chapter 157. Occupational Exposures, Infection Control, and Standard Precautions. In: Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6375423. Accessed November 16, 2013 Zolotusca L, Jorgensen P, Popovici O, et al. Risk factors associated with fatal influenza. Ministry of Health, Romania. November 20, 2013 [Epub ahead of print]
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The Fast Track
An Emergency Medicine Publication
Its never to early to start Winter 2014
thinking about Spring Conference in Scottsdale, AZ April 22nd-26th, 2014. Visit www.acoep.org/meetings for more details about pricing and how to register.
“Thanksgiving”
By John Casey, DO
It’s
pretty easy to get jaded around the holiday season, especially when your empathy tank is running a little low during a string of six shifts. I felt like I was doing pretty well
all things considered, but let’s face it… second year of residency is not conducive to an optimal work-life balance. One of the great ED nurses I work with, Mindy, had asked about my plans for the holiday and I let her know I was working straight through it. Fortunately, my Thanksgiving Day shift wasn’t super busy. There was the usual ED potluck dinner (meaning all day buffet), the patients that were there because they really need care (or a warm place to stay), and the camaraderie of the staff was even higher than normal. Having a good day overall, Mindy surprised me near the end of my shift showing up in “regular people” clothes to ask how my Thanksgiving was going. We talked for a few minutes and then she told me before I left to go home I must pick up my dinner plate from the staff lounge. Mindy had taken time away from her family to bring me a Thanksgiving plate that is the stuff dreams are made of. I thanked her profusely and when I asked why she brought it, she just smiled and said “because you needed it.” Mindy’s simple, yet incredible act reminded me how important it is to not only take care of patients but to take care of each other. I’ve thanked her many times but she still probably doesn’t know how much her kindness meant to me when I had to be away from my family. Thanksgiving dessert was especially sweet that year, because a wise ER nurse knew, far more page 40
than I did, what a young resident needed to have a special holiday!
Winter 2014
Tricks of the Trade
The Fast Track
An Emergency Medicine Publication
By Chase Ungs, DO PGY-2
Treating Frostbite:
1 2
. Early identification of frost bite is critical . Initial treatment includes rapid rewarming, ideally with warm water bath. Immerse extremity in warm water of 37째C-39째C. Water bath is ideal as it maintains a consistent temperature of heated water. Avoid warmer water or dry heat to reduce the risk of additional thermal injury. Do not rub/massage the area. . Elevate extremity and place clean gauze between toes/finger to limit maceration. . Debride white or clear blisters leaving hemorrhagic blisters in place as debridement may result in damage to the vascular supply and viable tissue. . Provide aloe vera (a thromboxane inhibitor) and antiprostaglandins (NSAIDs). Give tetanus prophylaxis if needed. . For large areas of frostbite including a pulseless limb presenting within 24 hours, consider tPA if no contraindications as well as further evaluation with angiography. . Consider prophylactic antibiotic use covering staphylococcus/streptococcus strains.
3 4 5 6 7 8
. Surgical intervention is rarely needed other than debridement of blisters or fasciotomy due to compartment syndrome. Amputation is typically not urgently needed, it may take 1-3 months to determine if tissue is viable. Reference: http://emedicine.medscape.com/article/770296-overview#showall
Are you looking to get involved in the political process? Want to meet face to face with your Senator and US Representative in Washington D.C.? Then consider joining the ACOEP and the AOA at DO Day on the Hill 2014 on Thursday March 6th, 2014. www.osteopathic.org/inside-aoa/events/
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The Fast Track
Review Answers An Emergency Medicine Publication
Winter 2014
Question 1: Answer: C. This patient has esophagitis secondary to infection with Candida albicans. Infectious esophagitis is uncommon in immunocompetent individuals but is fairly common in immunocopromised patients (i.e. HIV/AIDS, transplant patients, chronic corticosteroid use, diabetes mellitus, chronic alcohol abuse etc.). Changes in the mucosal barrier in the esophagus in these patients leads to an increased susceptibility to infection. Candida species (specifically C. albicans) represent the most common infectious etiologies. Infections with Candida species produce characteristics white plaques. These plaques can be scraped off of mucosal surfaces revealing a raw, erythematous and sometimes bleeding base. In HIV, patients with CD4 counts <200 are more susceptible to Candida infection but this fungus can cause infections in all patients regardless of CD4 count. Although topical agents can be considered in immunocompetent patients with mild disease, patients with immunocompromise will usually require systemic medications (fluconazole, ketoconazole or itraconazole). Treatment usually runs for 3-4 weeks. Question 2: Answer: A. This 18-year-old man has exertional syncope raising the suspicion of hypertrophic cardiomyopathy (HCM). HCM is an autosomal dominant genetic abnormality in which the left ventricle (particularly the septum more than the free wall) is hypertrophied. The typical presentation is dyspnea on exertion in a young patient with no other cardiac disease. About 20-30% will present after a syncopal event and many present with sudden death. Physical examination may reveal a loud S4 gallop and a harsh mid-systolic crescendo-decrescendo murmur. The murmur can be increased by maneuvers that decrease left ventricular filling (standing or performing a Valsalva maneuver) and decreased by maneuvers that increase left ventricular filling (squatting, Trendelenberg). ECG is abnormal in 90% of patients and the classic ECG finding is left ventricular hypertrophy with deep, narrow Q waves particularly in the precordial leads. Diagnosis can be made by echocardiography but cardiac catheteriztion is the gold standard. Vasovagal syncope (C) is an autonomic response in which the patient experiences bradycardia and hypotension mediated by the vagus nerve in response to stress or pain. This is the most common form of syncope but is not associated with a pathologic murmur or exertion. The patient may be at risk of being hypovolemic (B) from dehydration as he was running but it is unlikely for a patient to have a syncopal episode due to hypovolemia and present with normal vital signs. Wollf-Parkinson-White (WPW) syndrome (D) is a disorder in which the patient has an accessory tract between the atrium and the ventricle predisposing them to develop reentrant tachycardias. The typical ECG findings in WPW are a shortened PR interval (< 0.12 seconds), a delta wave (upsloping deflection into the QRS complex) and a widened QRS duration (> 0.10 seconds).
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Find more questions like thes
The Fast Track
Winter 2014
An Emergency Medicine Publication
Question 3: Answer: B. The patient presents with a subcutaneous pacemaker â&#x20AC;&#x153;pocketâ&#x20AC;? infection, which requires intravenous antibiotics, specialist consultation and admission. As with all surgical procedures, pacemaker implantation carries a risk for infection. This risk is small; about 2% for local wound infection and 1% risk for bacteremia or sepsis. Unfortunately, bacteremia is unlikely to respond to conservative management with antibiotics alone and replacement is often necessary. When either local infection or bacteremia is suspected, blood cultures should be obtained and intravenous antibiotics should be initiated. Staphylococcus aureus and Staphylococcus epidermidis are the most commonly isolated bacteria (60-70%). Thus, empirical antibiotics should include vancomycin. It is difficult to distinguish local infection from systemic infection and 2025% of those with local infections will have positive blood cultures. Although it is tempting to attempt local incision and drainage (A) of a likely abscess, this approach is contraindicated as the scalpel may inadvertently sever the pacemaker leads. Oral antibiotics (C) may be adequate for the management of a mild cellulitis but it is difficult to distinguish cellulitis from a pocket infection. Additionally, the presence of fever and fluctuance suggests a more advanced infection. A hematoma at the pacemaker site can mimic a pocket infection and needle aspiration (D) can differentiate these two processes. However, needle aspiration should only be performed under fluoroscopy because the needle may cut insulation surrounding the pulse generator or pacemaker leads leading to malfunction of the device. Question 4: Answer: B. The patient presents after a trauma with head injury and altered level of consciousness compatible with a GCS of 8. The GCS is an objective method of measuring and following the neurologic status of a patient with head trauma. The scale was developed to clinically evaluate head trauma patients 6 hours after trauma. However, the GCS has widely been applied to the acute setting as well. This application is limited by a host of factors including concomitant injuries, vital sign abnormalities, intoxication and age. Despite this, the inter-rater reliability of the GCS makes it a simple tool to communicate mental status in trauma patients across providers. There are three components to the GCS exam: eye opening (maximum 4 points), verbal stimulus response (maximum of 5 points) and motor response (maximum of 6 points). This patient receives 2 points for eye opening (opens to pain), 2 points for verbal stimulus response (incomprehensible speech) and 4 points for motor page response (withdraws 43 from pain) giving her a total of 8 points.
se by visiting roshreview.com
The Fast Track
An Emergency Medicine Publication
Winter 2014
Numb 1…2…3…4
keep a rhythmic pace 15…16…17 don’t think, just keep going. When the numbers get too high to match my pace I start over 1…2…3…4. Stay numb, don’t think. As a fourth-year medical student working in the emergency department, I am regularly pushed to my boundaries in one way or another. Some days I may be probing the extent of my medical knowledge, other days test my ability to handle stress, or possibly even find the limits to my emotional capacity. I may even go beyond what I believe are my abilities only to discover I can in fact do what I didn’t think I could. But what happens when I don’t have the coping mechanism that matches my abilities? Trauma alert: 11 wk old in asystole is five minutes out. I was one of the first to hear the call and I headed straight into the resuscitation room; already I could feel the lump form in my throat. I know asystole in a baby prior to the arrival is not a good sign. As we are clearing the area to make ready to work the code, I am assigned to compressions. Immediately I began reminding myself how to do compressions in such a young patient. Hug the chest while using my thumbs go 1/3 to 1/2 the depth of the chest, making sure I allow for sufficient recoil. Don’t slow down. Pep talk…I can do this.
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The baby arrives, as does what seems like half the department to watch. Everyone wants to help but the people without assigned jobs don’t know what to do, so they hover in
hopes they can be useful. EMS comes sliding in front of the bed with the infant and I have to push my way to get in between the stretcher, and the large influx of people to take over compressions. I make the mistake of looking at the babies face as I start compressions. Count, just count 1...2...3...4. I realize looking back, as I advance in my career I will not have the luxury of just simply counting my way through a pediatric code to suppress my emotions, I have to be able to think. What could be the cause, what can I do to reverse the cause, what meds at what dose do I need to give? As a student, I have been part of little more than handful of adult codes but this was my first experience with a pediatric code. Counting is all I can do to function at the level required. I need to stay as numb as I can for as long as I can, even if that meant just focusing on the compression count. I can’t tell you how long we worked the code or how many rounds of compressions I did. What I can tell you and what I will always remember is the exact time we called the code. It had been my turn on compressions. My hands were the hands that let go of this little chest when the decision was made to stop. The mother who had been softly crying came over to hold her child for one last time. That was the point I couldn’t hold back the flood of emotions any longer. I quietly backed out of the now thinned crowd so I could go
Photos provide
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By Ashley Guthrie, OMS-IV
stand in some corner to try and pull myself back together. A pediatric code is the hardest thing I’ve been through emotionally as a student. Of course I have had the random lecture on death and dying, but usually it is how to break the news to family members. Never have I learned how to handle the overwhelming feeling of sadness for the lost life, let alone of one so young. I felt so helpless, despite knowing that the team and I did absolutely everything that could have been done for this baby. I am not even sure that any amount of knowledge or teaching could have adequately prepared me for that wave of emotions. As a future physician I did not go to school for death, even though there is 100% mortality to every patient, eventually. Ultimately, death is one thing I cannot fix. When death comes to someone so young, it is not something I can ever imagine getting used to. Looking back I realize the emotions I experienced were completely natural. Some important things I learned is that is okay to cry, yell, or even be angry, but of course, it needs to be done away from the scene, after the fact. For me, after I regained my composure, I found it best to keep working solely to avoid images of this baby in my head, but then as soon as my shift was over, I called family to talk about it when it wasn’t so fresh. Then, when I got home I read a favorite book. Above all, I learned not to bury what I am feeling; I can
ed by Andy Little
Winter 2014
An Emergency Medicine Publication
only imagine how the code would have eaten away at me and perhaps resurfaced later for me to deal with at an inconvenient time had I not dealt with what I was feeling then. Even having faced what I was feeling, I can still feel that tug of emotions thinking about it today, despite the fact that it has been months since this code. I, like many people, went to school to learn to save lives, but I have to be able to accept the fact that death is a real possibility I may have to handle everyday when I walk into the Emergency Department. I imagine that how we each handle this fact is different. For me, I think of it as staying “numb,” but perhaps that is not the right word. Merriam Webster’s definition of numb is, unable to think, feel, or react normally because of something that shocks or upsets you. Being shocked or upset is what I want to avoid feeling in the moment so that I can think and react to the medical situation at hand. Perhaps a better way to put it is to focus on my technical skills to try to avoid thinking about the emotional side of the situation. For me, delaying the emotional side allows me to do what is necessary for the patient, but it is of limited use for a limited time. When my technical skills are no longer needed, when I put down the paddles and call time, I have to be able to deal with and accept the flood of emotions so that I can be the compassionate and caring physician I want to be for all my patients and their families.
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Will you join us? The Fast Track
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Winter 2014
In Scottsdale, AZ, April 22nd-26th for Spring Conference 2014. For more information visit ACOEP.org/pages/meetings.
ACOEP Resident and Student Chapter 142 East Ontario Street Suite 1500 Chicago, Illinois 60611 page Phone: 312.587.3709 46 Fax: 312.587.9951 E-mail: acoepfasttrack@gmail.com
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