Modern Resident - The newsletter of AAEM/RSA
October/November 2014
Volume 6: Issue 3 | Facebook  Twitter  LinkedIn

Inside This Issue

Smartphone Ultrasound
Alexandra Murray, OMSIV
Ohio University Heritage College of Osteopathic Medicine

The rapid advancement of technology has changed the face of medicine by aiding in the diagnosis of numerous disease processes. In particular, the imaging quality and screen capabilities of smartphones and tablets offer new opportunities for diagnostic imaging.1,2 In 2011, the FDA approved MobiUS by Mobisante, the first FDA-approved smartphone-based portable medical ultrasound unit. This device consists of a small ultrasound wand attached to a smartphone by a USB cord. This device can easily fit in a lab coat pocket and the entire system, including the software and phone, costs between $7,000 and $8,000.3,4 With this type of relatively inexpensive device commercially available, there is a whole new spectrum of possible applications for ultrasound technology.

Over the past few years, smartphone ultrasound has proven to be useful for evaluating cardiac abnormalities, placing venous catheters, aiding in difficult intubations by acquiring images of the suprahyoid airway and in resuscitation.5-8 These ultrasound devices are relatively easy to use and studies have shown that medical students, residents and surgical interventionists are all able to identify organ structures with reasonable accuracy despite having little to no training in ultrasound.9-11 Furthermore, the images can be recorded and transmitted wirelessly using the smartphone device so that remote experts can confirm the ultrasound interpretation.12 The wireless application of these smartphone ultrasound units also creates the opportunity for EMS personnel to take these devices into the field. In one study, emergency medicine technicians, ski patrollers and nurses were remotely guided to perform FAST exams in the field and transmit the exam images using a smartphone or laptop. The results of this study concluded that most emergency medicine physicians were able to accurately interpret the transmitted images and they found the images clinically useful.8

The current smartphone ultrasound devices are not meant to replace a formal ultrasound evaluation; however, they can provide valuable real-time information at the bedside.13 Some of the limitations of these devices are that the screens on most smartphone devices are small and may interfere with image interpretation.2 In addition, these ultrasound units are still relatively new and need further evaluation to determine their accuracy.14 Despite these limitations, with the rapid improvements that are occurring in technology and the relative ease of use, it is possible that we will see smartphone ultrasound devices in the pocket of every future physician.

References:

  1. Székely A, Talanow R, Bágyi P. Smartphones, tablets and mobile applications for radiology. Eur J Radiol. 2013 May;82(5):829-36.
  2. Rodrigues MA, Visvanathan A, Murchison JT, Brady RR. Radiology smartphone applications; current provision and cautions. Insights Imaging. 2013 Oct;4(5):555-62.
  3. Rollins, S. FDA Approves a Smartphone-Based Ultrasound System. Time. February 10, 2011. Available at: http://healthland.time.com/2011/02/10/fda-approves-a-smartphone-based-ultrasound-system/. Accessed September 3, 2014.
  4. U.S. Food and Drug Administration, Center for Devices and Radiological Health. K102153. 21 CFR 892.1560 approval letter, January 20, 2011. Retrieved September 3, 2014, from http://janeganter.com/crastudentwriters/cite_fda_approval_ltr.pdf.
  5. Biais M et al. Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting. Crit Care. 2012 May 14;16(3):R82.
  6. Thomale UW et al. Smartphone-assisted guide for the placement of ventricular catheters. Childs Nerv Syst. 2013 Jan;29(1):131-9.
  7. Wojtczak J, Bonadonna P. Pocket mobile smartphone system for the point-of-care submandibular ultrasonography. Am J Emerg Med. 2013 Mar;31(3):573-7.
  8. McBeth P et al. Help is in your pocket: the potential accuracy of smartphone- and laptop-based remotely guided resuscitative telesonography. Telemed J E Health. 2013 Dec;19(12):924-30.
  9. Andersen GN et al. Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students. BMC Med Educ. 2014 Jul 28;14:156.
  10. Mjølstad OC et al. Feasibility and reliability of point-of-care pocket-size echocardiography performed by medical residents. Eur Heart J Cardiovasc Imaging. 2013 Dec;14(12):1195-202.
  11. Manasia AR et al. Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients. J Cardiothorac Vasc Anesth. 2005 Apr;19(2):155-9.
  12. Choi BG et al. Interpretation of remotely downloaded pocket-size cardiac ultrasound images on a web-enabled smartphone: validation against workstation evaluation. J Am Soc Echocardiogr. 2011 Dec;24(12):1325-30.
  13. Sicari R et al. The use of pocket-size imaging devices: a position statement of the European Association of Echocardiography. Eur J Echocardiogr. 2011 Feb;12(2):85-7.
  14. Charron C et al. Difficulties encountered by physicians in interpreting focused echocardiography using a pocket ultrasound machine in prehospital emergencies. Eur J Emerg Med. 2014 Apr 4.


Board Review: Traumatic Globe Rupture
Sophia Johnson, DO
Shane Sergent, DO
Conemaugh Memorial Medical Center

A 32-year-old male presents to the ED after being struck in the right eye with a ball during a friendly tennis match. He complains of discomfort in the right eye, decreased visual acuity and nausea secondary to pain. Physical exam reveals periorbital ecchymosis, an irregularly shaped pupil and a shallow anterior chamber.

Patients may present with globe rupture after blunt or penetrating injury.1 They may complain of pain in the eye or decreased visual acuity.1 Maintain a high index of suspicion in patients who have any injury that may have penetrated the cornea.1 This includes projectile objects launched while mowing the lawn, weed whacking or working with metal.1 Blunt trauma to the eyeball or trauma with objects that impact the ocular rim and create a seal around the orbit can cause a rapid peak in intraocular pressure that ultimately leads to globe rupture.1

Thorough ocular examination is important in patients with an eye injury and includes slit lamp exam and fundoscopic exam.1 An irregularly shaped or tear-drop shaped pupil suggests rupture.1,2 Some patients may have an irregularly shaped pupil from past eye trauma, so it is important to inquire about previous history.1 A flat or deep anterior chamber on slit lamp exam may also indicate rupture.1 Other suspicious findings include full thickness lid laceration, periorbital ecchymosis, limited extraocular movement after eye trauma, blindness in the affected eye, afferent pupillary defect, large subconjunctival hemorrhage, hyphema, hemorrhagic chemosis, obvious site of penetration, or intraocular foreign body.1,2

Once globe rupture is suspected, shield the eye and obtain emergent ophthalmology consultation.1,2 Make the patient NPO and give tetanus prophlaxis.1,2,3 Prevent and treat nausea and vomiting as increased ocular pressure from valsalva can cause extrusion of ocular contents.1 Administer broad-spectrum antibiotics, keep the head of the bed elevated, do not check intraocular pressure, and refrain from touching the eye any further or administering any topical drops.1,2,3 Some suggest that succinylcholine can cause an increase in intraocular pressure, so if the patient requires rapid sequence intubation, a nondepolarizing agent may be better.1

References:

  1. Walker RA, Adhikari S. Eye Emergencies. In: Tintinalli JE, Stapczynski J, Ma O et al. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=693&Sectionid=45915587. Accessed September 13, 2014.
  2. Go S. Chapter 149. Ocular Emergencies. In: Cline DM, Ma O, Cydulka RK, Meckler GD, Handel DA, Thomas SH. eds. Tintinalli's Emergency Medicine Manual, 7e. New York, NY: McGraw-Hill; 2012. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=521&Sectionid=41069084. Accessed September 13, 2014.
  3. Greenberg RD, Daniel KJ. Chapter 31. Eye Emergencies. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment Emergency Medicine, 7e. New York, NY: McGraw-Hill; 2011. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=385&Sectionid=40357247. Accessed September 13, 2014.


HINTS to Diagnosing Posterior Stroke: A Three-Step Exam to Distinguish Central and Peripheral Vertigo
Ashley Grigsby, DO
Indiana University

Acute vestibular syndrome (AVS) is a constellation of symptoms including sudden onset of vertigo, nystagmus, nausea, vomiting and unsteady gait.1 AVS is often due to peripheral lesions, such as vestibular neuritis; however, it can also be caused by vertebrobasilar strokes.1 Typical cerebellar physical exam findings may be falsely normal in patients with stroke, and performing MRI on all patients with AVS would not be feasible. It is important to identify patients with cerebellar stroke on the first presentation to the emergency department (ED); missing this diagnosis on the first visit leads to an eight-fold increase in mortality.2 The HINTS exam is a three-part neurologic exam used to assess for stroke in patients with AVS.

The HINTS acronym stands for “Head Impulse, Nystagmus and Test of Skew.” When these three components are used together, the exam is 100% sensitive and 96% specific for stroke in patients with AVS. If on head-impulse testing the patient has a corrective eye saccade, this is considered abnormal and is a sign of peripheral lesion. Therefore, a normal head-impulse exam in the setting of AVS is more predictive of stroke.2 Direction changing horizontal nystagmus, i.e., right nystagmus on right gaze and left nystagmus on left gaze, is also predictive of a central lesion.1 Abnormal test of skew on alternating eye cover test is also more suggestive of central lesion.1

If any of the three components of the HINTS exam are consistent with central lesion, further investigation into posterior stroke should be done. The HINTS exam was found to be more sensitive than MRI in the first 48 hours of stroke and, therefore, a normal MRI in the setting of an abnormal HINTS exam does not rule out stroke.1 It is important to understand how to perform this exam and interpret the findings in order to decrease mortality of posterior stroke patients presenting to the ED.

References:

  1. Kattah, JC et al. HINTS to diagnose stroke in the acute vestibularsyndrome: three-step bedside oculomotor examination more sensitive than early MRI diffused-weighted imaging. Stroke. 2009;40:3504-3510.
  2. Newman-Toker, DE et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20(10):986-96.

Snake Bite Envenomation
Kaitlin Fries, OMSIV
Ohio University Heritage College of Osteopathic Medicine

Each year throughout the summer, venomous snakes bite over 8,000 Americans, with copperheads and rattlesnakes being responsible for a vast majority of these bites.1 These crotaline snakes release a complex enzyme mixture known as venom that can cause numerous local and systemic effects including hypovolemia, coagulopathy and neuromuscular dysfunction. The patient will present with several significant indicators such as presence of fang marks, localized pain, and edema extending out from the bite site.2

Diagnosis of snake envenomation requires a history of snakebite plus some form of tissue damage. Tissue damage can be local swelling, pain and ecchymosis, or it can manifest as hematological abnormalities.2 Thus, the clinician should include CBC, PT, PTT and fibrinogen levels in the patient’s initial laboratory analysis and repeat these tests within a 12-hour period.2 In more serious cases, tissue damage can lead to systemic signs and symptoms including hypotension, tachycardia, oral swelling and paresthesias.2

Any patient with progression of local injury, abnormal lab results, unstable vital signs or altered mental status should receive anti-venom.2 Anti-venom, also known as CroFab or FabAV, consists of antibodies that bind to and neutralize crotaline venom, allowing it to be eliminated safely in the urine.1 Treatment begins with a control dose of four to six vials of FabAV.1 The control dose is repeated until symptoms become controlled, then maintenance dosing of two vials every six hours for a total of three doses is started.1,2 If at any time local tissue injury reoccurs, another control dose is given and the physician returns to the beginning of the algorithm.1 Following maintenance dosing, if there is no evidence of coagulopathy or bleeding, the patient’s treatment is complete.1 If there is any evidence of coagulopathy or bleeding, then the patient is a candidate for additional anti-venom use.1

The package insert has specific instructions as to how to administer each dose. There is no change in dosage in the pediatric population, however a smaller volume mixture may be considered.2 Even in areas prone to snake bites, most hospitals do not keep enough anti-venom on hand beyond the initial dose. It is important to begin contacting other local hospitals early on to obtain enough vials for your patient’s full course of treatment.

Any patient receiving anti-venom needs to be in the intensive care unit for close observation. Patients that receive anti-venom initially in the ED without the requirement for additional doses can be safely monitored on the floor. It is recommended that patients who present with an asymptomatic snakebite be watched for a minimum of eight hours before considering discharge.

References:

  1. Goto CS, Feng SY. Crotalidae polyvalent immune fab for the treatment of pediatric crotaline envenomation. Pediatric Emergency Care. 2009;25:273-282.
  2. Tintinalli JE. Tintinalli’s Emergency Medicine: a comprehensive study guide. McGraw Hill; 2011:1354-6.

Board Review: Side Effects of Thrombolytic Agents in Ischemic Stroke
Nicholas Pettit, PhD OMSIII
Ohio University Heritage College of Osteopathic Medicine

Case:
A 53-year-old woman arrives to the ED by EMS with focal neurological deficits, nausea and a severe headache for approximately 45 minutes. Her deficits include right-sided hemiparesis and right-sided hemisensory loss. Her past medical history is only significant for hypertension that is controlled with medication. The initial CT scan (without contrast) does not demonstrate evidence of an intracranial hemorrhage, and after questioning the patient it is determined a candidate for thrombolytic therapy.

Question:
What is the desired treatment at this time?

A. rt-PA, 50mg intravenous (IV) bolus
B. rt-PA, 0.9mg, maximum 50mg, 10% total dose as IV bolus in first minute
C. rt-PA, 9.0mg, maximum 90mg, 10% total dose as IV bolus in first minute
D. rt-PA, 0.9mg, maximum 90mg, 10% total dose as IV bolus in first minute
E. rt-PA, 0.9mg, maximum 180mg, 10% total dose as IV bolus in first   minute
F. Heparin 12 units/kg/hr, max of 1200 units + rt-PA 0.9mg, maximum 90mg

Answer:
D is correct. According to the 2009 Cochrane review on thrombolytics, administering a dose of 0.9mg/kg of recombinant tissue plasminogen activator (rt-PA) given IV is considered best practice.1 Receiving heparin within the last 48 hours and having elevated activated prothrombin time (APTT) is one of several absolute contraindications to thrombolysis.

Question:
Several hours following administration of rt-PA, the patient begins vomiting and subsequently suffers a series of seizures. The patient is subsequently intubated and transferred to the ICU. Given her initial presentation, what is the most likely cause of her current state?

A. Electrolyte imbalance secondary to dehydration
B. Status epilepticus
C. Hypoxia
D. Intracranial hemorrhage
E. Eclampsia
F. Propofol administration

Answer:
D is correct. Previous research into thrombolytic agents for the treatment of ischemic stroke have demonstrated that the primary side effect resulting in mortality is intracranial hemorrhage.2 While the side effects are clearly evident, a recent study examined the difference between various thrombolytic agents and method of thrombolytic administration. The authors subsequently concluded that no thrombolytic (t-PA, UK, desmoteplase, tenecteplase), dose or route of administration (IV vs intra-arterial) has been shown to be statistically superior.3

Intracranial hemorrhage post rt-PA administration is an uncommon, yet very unfortunate complication. While the current landscape of the rt-PA is variable and ever evolving, some recent literature demonstrates potential risk factors that are associated with worse outcomes. These risk factors for intracerebral hemorrhage include diabetes mellitus, cardiac disease, increasing stroke severity, advancing age, use of anti-platelet agents (other than aspirin) and elevated blood pressure.4 Furthermore, there exist “simple-to-use” calculators that help predict clinical outcome, mortality and risk of hemorrhage with ischemic stroke. One example of such a tool is the THRIVE score (http://www.thrivescore.org), which strongly predicts clinical outcome.5 While such tools may not yet be used routinely outside of large academic centers, understanding the prediction process can help physicians (especially at smaller, non-academic institutions) develop protocols for rt-PA administration.

References:

  1. Wardlaw JM, Murray V, Berge E, et al. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst. Rev. 2009;7 doi:10.1002/14651858.CD000213.pub2.
  2. IST-3 Collaborative group et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischemic stroke (the Third International Stroke Trial [IST-3]): a randomized controlled trial. Lancet. 2012; 379: 2352-2363 doi:10.1016/s0140-6736(12)60768-5.
  3. Landry A, Koyfman A. In patients with acute ischemic stroke, do different thrombolytic doses, agents, or routes of administration lead to different outcomes. Annal of Emerg Med. 2014;63:435436 doi:10.1016/j.annemergmed.2013.10.010.
  4. Tanna D, Kasner SE, Demchuk AM et al. Markers of increased risk of intracerebral hemorrhage after intravenous recombinant tissue plasminogen activator therapy for acute ischemic stroke in clinical practice: the Multicenter rt-PA Stroke Survery. Circulation. 2002; 105: 1679-1685. doi:10.1161/01.CIR.0000012747.53592.6A.
  5. Flint AC, Faigeles BS, Cullen SP et al. THRIVE score predicts ischemic stroke outcomes and thrombolytic hemorrhage risk in VISTA. Stroke. 2013;44:3365-3369. doi:10.1161.STROKEAHA.113.002794.



 


Management of Atrial Fibrilation with Rapid Ventricular Response — Choosing Rate Control Wisely
Nathan Haas, MD
University of Michigan Department of Emergency

Atrial fibrillation (AF) with rapid ventricular response (RVR) is relatively commonplace in the ED, and practice patterns vary in how rate control is achieved. Presented below are different approaches to accomplishing rate control, broken down by medication class and clinical situation.

Big Picture: Calcium Channel Blocker Versus Beta Blocker
The mainstays for rate control agents include calcium channel blockers (CCBs), such as verapamil or diltiazem, or beta blockers (BBs), such as esmolol or metoprolol. Recent literature has trended towards favoring CCB from an overall standpoint, although the difference between the two classes is far from clear-cut.1

A recent prospective, randomized, double blind study suggests diltiazem may achieve rate control more rapidly and more effectively than metoprolol.2 Another earlier study also favors this trend, suggesting diltiazem decreases heart rate by a greater magnitude and more quickly than metoprolol.3 However, another study suggests esmolol and verapamil both offer adequate rate control, with esmolol more likely to result in cardioversion to normal sinus rhythm.4

It is clear that no large-scale, global difference between CCBs and BBs has been identified thus far. Most studies, as referenced above, tend to focus on time to rate control or how well rate is controlled, as opposed to more clinically relevant patient outcomes, such as mortality. In fact, one recent study found no significant difference in admission rate, ED length of stay, adverse events, or ED re-visits between CCBs and BBs used in AF with RVR.5 From a global standpoint, it appears that both CCBs and BBs are effective for rate control, and specific patient characteristics should guide decisions, as discussed below.

Specific Clinical Conditions
CHF: Both BBs and CCBs should be avoided in decompensated heart failure, as both have negative inotropic effects and can worsen progression of heart failure acutely. Alternatives in this setting include amiodarone and digitalis. However, BBs have long-term mortality benefits in patients with CHF, and thus should be considered prior to CCBs for this patient population.

Pulmonary Disease: BBs should be avoided to prevent worsening bronchospasm, and thus CCBs may be preferred in this setting.

Hypertension: CCBs may be preferred over BBs, as they are considered first line anti-hypertensives.

Hypotension: Electrical cardioversion is preferred. If this proves unsuccessful, phenylepherine can be considered as a temporizing measure. Alternatives include magnesium, amiodarone, and repeating electrical cardioversion.6

References:

  1. Hayes BD. Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers? ALiEM. N.p., 4 June 2014. Web. 15 Sept. 2014.
  2. Abstracts of the SAEM (Society for Academic Emergency Medicine) Annual Meeting. June 1-5, 2011. Boston, Massachusetts, USA. Acad Emerg Med. 2011;18 Suppl 1:S1-268. PubMed PMID:21598455.
  3. Demircan C, Cikriklar HI, Engindeniz Z et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J. 2005;22(6):411-4. Erratum in: Emerg Med J. 2005;22(10):758. PubMed PMID: 15911947.
  4. Platia EV, Michelson EL, Porterfield JK, Das G. Esmolol versus verapamil in the acute treatment of atrial fibrillation or atrial flutter. Am J Cardiol. 1989;63 (13):925-9. PubMed PMID: 2564725.
  5. Scheuermeyer FX, Grafstein E, Stenstrom R et al. Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness. Acad Emerg Med. 2013;20(3):222-30. PubMed PMID: 23517253.
  6. Weingart S. The Crashing Atrial Fibrillation Patient. EMCrit Blog Emergency Department Critical Care. N.p., 2009. Web. 15 Sept. 2014.

Twiddler's Syndrome: A Not-So-Rare-Entity
Jimmy Tam Huy Pham, MHS MA MSIV
Jonathan P. Zygowiec, MPH MA MSIV
Arizona College of Osteopathic Medicine

An 80-year-old female with a past medical history of hypertension, bifascicular block, and persistent atrial fibrillation status post pacemaker and automatic implantable-cardioverter defibrillator placement (PPM/AICD), presents to the ED due to a syncopal episode at home. No aura or prodromal symptoms were reported. The patient stated she had recent symptoms of hot flashes, dizziness, and intermittent episodes of shortness of breath. In the ED, vitals were BP 158/70, HR 92, RR 18, SpO2 100%, T 97.8°F. The chest X-ray (below) demonstrated twisting of the cables of her PPM/AICD. All other laboratory values were within normal limits. A diagnosis of Twiddler’s syndrome was made and the patient subsequently had the leads surgically replaced.

Twiddler’s syndrome (TS) is a potentially dangerous cause of lead dislodgment in patients with pacemakers and implantable cardioverter-defibrillators. It is due to the intentional or inadvertent manipulation of a pacemaker or implantable cardioverter-defibrillator with consequent malfunction of the device. First described in 1968, TS is no longer a rare entity due to the increasing numbers of patients receiving ICD and pacemakers.1,2

The diagnosis is confirmed by a chest radiograph, which often reveals a twisted, entangled and dislodged pacing lead. The syndrome can occur when the subcutaneous tissues are slack, if the pacemaker is untethered in its pocket, or if the size of the pacemaker pocket exceeds that of the device.

Twiddler’s syndrome occurs infrequently but its occurrence can lead to dysrhythmias. In most cases, it is a painless phenomenon. It occurs in both adults and children, though more common in the elderly, presumably due to the laxity of their subcutaneous tissues. Other risk factors include obesity, female gender, psychiatric illnesses and the small size of the implanted device relative to its pocket as previously mentioned. Manipulation may cause axial rotation of the pulse generator, twisting and eventual fracture or dislodgment of the lead. The majority of patients with Twiddler’s syndrome are often diagnosed within the first year of implant.

Though the prevalence of this syndrome was reported to be 0.07% in cases with a pacemaker, clinical suspicion is required as outcomes can be potentially poor.3 A pertinent history and physical exam, chest X-ray and the physician’s clinical suspicion will provide the basis for this diagnosis.4

References:

  1. Bayliss C, Beanlands D, Baird R. The pacemaker twiddler’s syndrome: a new complication of implantable transvenous pacemakers. Can Med Assoc J. 1968; 99: 371
  2. Fahraeus T, Hoijer CJ. Early pacemaker twiddler syndrome. Europace. 2003 Jul;5(3):279-281.
  3. Hill PE. Complications of permanent transvenous cardiac pacing: a 14-year review of all transvenous pacemakers inserted at one community hospital. Pacing Clin Electrophysiol. 1987;10:564–70.
  4. Nicholson WJ, Tuohy KA, Tilkemeier P. Twiddler’s Syndrome. N Engl J Med. 2003;348;17:1726-7.


Cows at the Gate: A Time to Reflect
Ian Symons, MD MBChB
University of Cape Town, South Africa
Temple University Hospital

It is the time of year when final-year emergency medicine residents find themselves consumed by the job search, a process that requires significant personal reflection. In every interview, you will be asked to reflect on where you have been and how you got there. Consider a would-be job posting in rural South Africa, an ED job I worked after internship in my home country:

Jack-of-all-trades required in Zululand, South Africa

Underserved community needs your help running ED with patient volume of 40,000. Wide range of pathology includes both blunt (i.e., horrific motor vehicle collisions) and penetrating trauma (i.e., injuries from tribal spears — assegai, and wooden clubs — knobkierrie). Human immunodeficiency virus and tuberculosis dominate a near overwhelming infectious-disease burden. Herbal intoxications, exotic poisonings and venomous snakebites are common.

There is single-attending coverage (i.e., you, alone). Forty hours per week are expected in-house. Duties include clinical work and getting house staff up-to-speed. The overnight team includes intern and physician (PGY-2 standing). You’ll be taking calls from home, so keep your phone on (every night). Procedures are plentiful, and you get to do them all.

Backup support varies, relying heavily on the annual influx of residents from the United Kingdom who will replenish acute care surgery/trauma, pediatrics, internal medicine, anesthesia and EM. A board certified internist two years back resigned after hospital administration was unable to meet his two simple requests:

1. A real office (functioned in a prefab structure in the parking lot)
2. Manometers for CSF-opening pressure (for cases of cryptococcal meningitis)

A tertiary referral center is a two-hour ambulance ride away. Beds are at a premium there, so call early and often. You will learn to expect disappointment. In the meantime, become proficient at watching over intracranial bleeds, treating ST-segment elevation myocardial infarctions (STEMIs) with thrombolysis and instituting aggressive palliative care. You will rely on your clinical skills. There is minimal advanced imaging and no endoscopy. The enduring 75-year-old radiologist, available from 8am to 4pm on weekdays, takes a stroll around the hospital perimeter after lunch to avoid post-prandial somnolence.

The EKG machine employs the time-honored sucker-and-gel method, and the paper-tray is frustratingly empty. Be prepared to draw your own labs (requiring your handwritten patient details). You may find yourself begging for blood products, or offering up your first-born child to the porter in order to get a sick patient to the CAT scan. Low-cost essentials include cling film to cover any burn wounds, and a single, sometime tenuous, carbon dioxide detector.

Medical records are contained in paper charts, stored in a hoarder’s paradise of clutter. Order is maintained by one individual, who just finished lunch and is now "on break." Basically every patient encounter is a chance to start fresh, given the lack of bias (or help) from past ED visit charts and discharge summaries. Waiting times are long, but your clientele is patient. Their complaints are valid, their diseases are real and their treatment is often neglected. They warrant your attention. You will not see gastroparesis or cyclical vomiting, and you’re unlikely to encounter drug-seeking patients when you only have acetaminophen and ibuprofen to offer.

Sound like the nightmare first job? Yes.
Is it frustrating? For sure.
Infuriating? At times.
Exhilarating, empowering and fulfilling? Most definitely.

Having temporarily placed yourself in the shoes of an emergency physician functioning in this setting, take some time and reflect on your own reality. Appreciate what your residency in this country has offered you. Undoubtedly, this will include a functioning hospital and ED structure, a caring residency program and experienced attending supervision, not only guiding your bedside learning but mentoring your emotional progress too. Don't disregard your fellow residents, who are motivated in their own training exerting their own agenda but reliably doing their job and sharing the workload. We enjoy a relative ease and efficiency in the U.S., which we oftentimes take for granted.

Back to Zululand, where you have accepted the job and conclude your first shift, nothing short of a marathon. As you attempt to leave, you find your path blocked by the herd of cows at the hospital gate. It’s the perfect time to reflect!


Advocacy Committee Feature: An Interview with Dr. L.E. Gomez, MD FAAEM
Heather Boynton, MSIV
Georgetown University School of Medicine

AAEM/RSA recently announced an exciting new opportunity: the Policy and Advocacy Congressional Fellowship in collaboration with Congressman Raul Ruiz, MD. This is a one-month fellowship for AAEM and AAEM/RSA members interested in medical policy and advocacy. The goal is to provide a solid understanding of the legislative and policy process, which will serve to equip the fellow with lobbying, legislative and policy work and help to empower the emergency medicine profession. Heather Boynton, a member of the AAEM/RSA Advocacy Committee interviewed one of the first individuals selected for the fellowship, Dr. L.E. Gomez, MD FAAEM.

How did you first become interested in advocacy?

We all advocate for our interests from the time we’re born to one degree or another. I saw my fair share of injustice growing up in the sixties and my passion for medical ethics and advocacy for professional integrity is just another extension of those values. AAEM’s mission and vision statements fairly well summarize the principals I’ve struggled to uphold during my fifteen-year career as an emergency medicine specialist. Although some of my colleagues have always considered this concern somewhat naïve, I've always felt it’s only logical we should defend the integrity of our profession, and our specialty. As a result, it was natural for me to apply for the AAEM/RSA Policy and Advocacy Congressional Fellowship, though it’s been quite a few years since my residency. I strongly urge every resident or physician that has an interest in health care policy or advocacy to apply to this program or others like it.

What interested you in the AAEM/RSA Policy and Advocacy Congressional Fellowship in Washington, D.C.?

My first goal was to develop a true understanding of legislative processes and the complex agendas I suspected, and now fully appreciate, are behind them. Policy is actually the result of an amalgam of competing interests. My hope was to develop tools to apply to advocacy for the professional values I mentioned above and perhaps benefit our specialty and our profession in the future.

Did you have any prior experience with lobbying, legislative or policy work?

During the time I served as director at-large and then vice president of our Florida Chapter of AAEM, I attended legislative sessions in Tallahassee to promote specific areas of concern for us, such as  prescription drug monitoring and alternate boards of emergency medicine, in an effort to protect the integrity of our specialty. These issues are repeatedly threatened, perhaps now more than ever. I’ve continuously tried to add my voice through support for letters directed to the governor or state boards of medicine. Most recently (since relocating to the mid-atlantic region), as a member of a Public Policy Committee working in collaboration with Med-Chi (The Maryland State Medical Society), I provided feedback on a resolution regarding Hospital Support for Scribe Services that was put forth by Maryland ACEP. I hope to call attention to the issue of clinicians being increasingly forced into electronic medical record (EMR) documentation for the benefit of third parties over concern for patient outcomes, and raise awareness of the shortcomings of increasing scribe and EMR applications. However, I had never considered full-time commitment to such efforts until this fellowship enlightened me to a wider range of possibilities for work in this arena.

What has been most surprising, rewarding and challenging about your experience so far?

It certainly took no effort to reflect my values as an emergency physician with every health care issue that was raised as an area of interest in Dr. Ruiz’s office, especially those I was specifically asked for formal consultation by his legislative team. His team is, incidentally, an exceptionally talented group of young lawyers and policy wonks. I fully enjoyed preparing vote and congressional letter cosponsorship recommendations, taking part in meetings with lobbyists, formulating legislative proposals and participating in briefings on a variety of health policy matters. What was most challenging was coming to grips with political practicality of supporting marginally acceptable ideological positions when there was more to gain in the long run than taking an alternate direct tact. Compromising on a particular issue is often required to attain a greater goal.

Congressman Raul Ruiz is a medical doctor and politician. What have you learned about dual roles from working with him?

I was initially most attracted to this fellowship by the fact that it provided an opportunity to work with a congressman who is also an emergency medicine specialist with a past in academic medicine, as well as medical mission work. Representative Raul Ruiz, MD, is an impressive young politician who has begun his career advocating for the medically underserved in his hometown community where he founded a health care initiative to improve public health and access to care. He also worked abroad on behalf of the underprivileged, including for the victims of the earthquake in Haiti. Like me, he is of Latin American decent and shares an appreciation for the challenge presented by uncovering common values within a politically diverse community. I better appreciate the complexities of taking political positions that address present goals without compromising a platform and yet allowing the legislator to continue to do his job is a challenge I do not envy.

Based on your experience in the fellowship, how do you think physicians and medical students who aren't directly involved in policymaking can be most helpful in shaping medical policy?

Try never to lose sight of the fact that your primary duty is to your patients. Let that be your guide in identifying threats to the professional integrity of your practice. Resist the tendency to make excuses on behalf of the corporatization of medical practice, particularly in emergency medicine. Continue to advocate for your patients. Specifically, be outspoken about defending medical ethics in your practice, author letters with colleagues in order to uphold your political positions, mail them to your congressmen, and don’t hesitate to appeal to the several physicians in the Senate and House as colleagues who also took the Hippocratic Oath. Most appreciate basic tenants of medical practice such as the value of the doctor-patient relationship.

What do you see yourself doing next? How has the fellowship affected your goals for the future?

In the near future, I hope to share these experiences with residents as a faculty member for Howard University College of Medicine. During the fellowship, I met colleagues involved in teaching health policy fellowships at other universities in the district, such as the emergency residency program at the George Washington University with whom I hope to collaborate in that effort. My hope is to connect with other emergency medicine and medical ethics faculty to expand the scope and influence of socially and ethically responsible physicians. Dr. Ruiz has graciously pledged to help us realize that goal.

I am also exploring other opportunities to apply what I have learned about the political process more formally to legislative advocacy work and will continue to be as engaged as I can in policy matters through my community and state medical societies.



Pediatric Emergencies Part 1: Fever
Jenna Erickson, MSIV
Chicago Medical School

Approximately 20% of all pediatric visits to emergency departments are due to fever. The approach to the child with a fever will vary depending on several factors including age, temperature, associated symptoms and past medical history. The first step is to verify that the patient has a fever (rectal temperature >38°) followed by history and physical. Febrile infants often have non-specific complaints such as lethargy, decreased feeding and irritability. Older children can show symptoms of a upper respiratory infection (URI), abdominal complaints, neck or back pain, and joint stiffness.

For the toxic appearing child, a serious bacterial infection (SBI) must be presumed until proven otherwise. Empiric antibiotics are often started before a full workup has been completed. Some ED physicians avoid excess antibiotics by administering rapid viral testing, a method investigated in a 2014 review article by Doan, et al. This article analyzed four trials of febrile pediatric emergency visits with and without rapid viral testing, discovering a trend toward decreased use of antibiotics, and significantly fewer chest X-rays in tested patients. Although this may be a future consideration when approaching the toxic-appearing child, a common approach to well-appearing febrile children follows a simple diagnostic algorithm.

The algorithm to explore febrile illness in the ED first breaks down patients by age. Anyone under one month will receive a full septic workup including CBC with differential, urinalysis and urine culture, lumbar puncture, and blood culture. If accompanying symptoms are present, this workup may also include liver function tests (jaundice), chest X-ray (lower respiratory symptoms), or stool WBC and culture (diarrhea). Infants one to three months old will have a similar workup, however the decision to perform lumbar puncture in this age group is debatable. Infants under one month and any deemed high risk for serious bacterial infection will be admitted to inpatient services.

In the age group of three months to three years the ED workup for fever typically starts with urinalysis and urine culture. Chest X-ray should be included if signs of lower respiratory infection are found on exam, and results of these initial diagnostic tests will guide the next steps in workup. If no identifiable cause is found in patients with fevers less than 39°C , discharge with supportive treatment and follow-up is preferred. Patients with a temperature above 39°C should have a CBC performed. WBC >15,000/mm3 indicates the need for blood cultures and empiric antibiotics, despite lacking a diagnosis. WBC <15,000/mm3 indicate a more likely minor cause of fever, and supportive treatment is recommended.

For all febrile children presenting to the ED, the physician must ultimately decide to admit or discharge home. General criteria for admission include all ill-appearing children, all infants under one month old, well appearing infants with high risk of severe bacterial infection (as determined through workup) or any child with documented immune deficiency. All febrile pediatric patients must be instructed to follow-up with a primary care physician after discharge, regardless of admission status.

References:

  1. Sherman SC, Weber JM. USMLE Road Map Emergency Medicine. New York: Lange, 2008. Print.
  2. Doan Q, Enarson P, Kissoon N, Klassen TP, Johnson DW. Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department. Cochrane Database Syst Rev. 2014 (Epub ahead of print).

Learning from International Medicine: A Prespective from Peru
Joe Gorz, DO
McLaren Oakland
Shane Sergent, DO
Conemaugh Memorial Hospital

I am on the third day going on the tenth straight hour in the clinic. A baby not more than 10 months old comes in with a serious burn on her foot. The mother is distraught and the baby is crying. As I assisted emergency physicians and dermatologists in addressing the wounds, I noticed the mother’s genuine gratitude for our care. At that moment I realized I was thousands of miles away from all of the red tape, able to simply help people and make a difference.

Opportunities like this make international medicine appealing and many programs are recognizing the growing interest amongst students and residents.1 Many hospitals and residency programs have implemented short- and long-term elective programs. International emergency medicine fellowships have also expanded.2 Recently, our residency program has partnered with the Michigan State University College of Osteopathic Medicine (MSUCOM) and DO Care International to offer our first international rotation along the Amazon River in Peru.

We spent our first two days in Lima, Peru, at a regional hospital where we encountered common ailments and infections rarely seen in the U.S., including parasites, malaria, dengue, tuberculosis and the plague. We spent time learning about the medical educational process at the University Cesar Vallejo, one of the premier medical schools in Peru. The next day, we toured a children’s hospital in Lima where we treated patients with poverty-related childhood illnesses, as well as advanced inborn diseases. In the U.S., most children with inborn diseases are identified and aggressively treated shortly following birth given the luxury of advanced and routine genetic testing.

The next day we traveled to Iquitos, the gateway to the Amazon. Travelers can only arrive by boat or plane, since no roads link the Amazon to the outside world. Once we arrived, we spent the remainder of the day arranging our makeshift clinic and pharmacy, which was the shell of a very basic military clinical outpost. The only medications available were the ones we brought with us. Our only diagnostic tools were a portable ultrasound we brought and an old X-ray machine.

Throughout the next week, we spent every day in the clinic. Hundreds of people waited to receive health care, forming a line several people wide that stretched all the way down the block and around the corner. We saw tropical diseases that we had only read about, including tuberculosis, malaria, parasites, and obscure dermatological presentations and infestations. In addition, we were exposed to advanced presentations of cancer, autoimmune disease and chronic disease. Residents also participated in and performed procedures, including excision of dermatological lesions, peritoneal lavage, fracture reductions, wound debridement and other various surgical procedures. The following week we created a floating clinic on an old ferry to provide care to remote villages located along the Amazon.

 

By the conclusion of the trip, we had provided care to over 2,000 patients in communities with little to no access to medical care, due to lack of trained health care providers, lack of medications, lack of transportation and overall lack of infrastructure. The students and residents who participated greatly improved their physical exam skills and, thus, felt more confident relying on physical exam for diagnosis. We gained a better understanding of tropical disease including clinical presentation and treatment. International medicine is more than just a mere mission trip or elective; it is an opportunity to travel outside of your comfort zone and look at medicine in a different way. Whether it is an organized trip or solo journey, international medicine is extremely rewarding.

References:

  1. Alagappan K, Holliman CJ. (2005). "History of the Development of International Emergency Medicine". Emergency Medicine Clinics of North America. (W. B. Saunders Company) 23(1):1–10. doi:10.1016/j.emc.2004.09.013. PMID 15663970.
  2. http://www.iemfellowships.com/

Your 2014-2015 Leaders:

President
Meaghan Mercer, DO

Vice President
Victoria Weston, MD

Secretary-Treasurer
Edward Siegel, MD

Immediate Past President
Leana Wen, MD MSc

At-Large Board Members
Nicole Battaglioli, MD
Mary Calderone, MD
Michael Gottlieb, MD
Sean Kivlehan, MD
Amrita Lalvani, MD
Andrew Phillips, MD

Medical Student Council President
Michael Wilk

Publications Advisor - Ex-Officio Board Member
Joel Schofer, MD MBA CPE FAAEM

Copy Editor: Mary Calderone, MD

Managing Editor: Lauren Johnson, AAEM/RSA Staff

Modern Resident Contributors

Special thanks to this issue's contributors:

Heather Boynton, MSIV; Jenna Erickson, MSIV; Kaitlin Fries, OMSIII; Joe Gorz, DO; Ashley Grigsby, MSIV; Nathan Haas, MD; Sophia Johnson, DO; Alexandra Murray, OMSIII; Nicholas Pettit, PhD OMSIII; Jimmy Tam Huy Pham, MHS MA MSIV; Shane Sergent, DO; Ian Symons, MD MBChB; Jonathan P. Zygowiec, MPH MA MSIV

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by November 15th for the December/January edition.

Articles appearing in Modern Resident are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM/RSA. Articles may not be duplicated or distributed without the explicit permission of AAEM/RSA. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to the AAEM/RSA, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel (800) 884-2236; Fax: (414) 276-3349, Email: info@aaemrsa.org.

 

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