We welcome your comments and suggestions. Feel free to get in touch with your elected leaders:
Ryan Shanahan, MD
Heather Jiménez, MD
Michael Ybarra, MD
Sandra Thomasian, MD
At-large Board Members
Melissa Halliday, DO
Ketan Patel, MD
Zachary Repanshek, MD
Teresa Ross, MD
Leana Wen, MD
Medical Student Council President
Copy Editor: Teresa M. Ross, MD
Managing Editor: Jody Bath, AAEM/RSA Staff
Special thanks to this month's contributors: Robert Katzer, MD; Karen Serrano, MD; and Austin Payor, DO.
Opinions expressed in Modern Resident are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA.
AAEM/RSA Board Updates
New Resident Duty Hours: ACGME to Initiate Change in July 2011
Whether you've heard or not, the Accreditation Council for Graduate Medical Education (ACGME) has submitted a proposal to update the standards for resident duty hours. You recall their 2003 guidelines that initiated the 80-hour work week, 30-hour call, q3 overnight (averaged) and one-day-off-in-7 (averaged). Now, ACGME is proposing further limitations: 16-hour call for interns, 28-hour call for residents and q3 overnight (not averaged). The document was submitted for public review on June 23, 2010, and closed for review on Friday, August 6. The final guidelines will take effect July 2011. Supporting considerations include a concern for ongoing resident fatigue and a desire to promote quality over quantity of hours. Concerns include insufficient training time, lack of continuity, increased handoffs and potentially longer residencies. How do you feel? Read the AAEM/RSA ACGME position statement now.
AAEM Continues Effort to Protect
Residency-Trained EM Board Certification
The American Board of Physician Specialties (ABPS; http://www.abpsus.org/index.html) is an organization that grants "EM board certification" to any physician who completes a primary care residency or an ABPS approved one year fellowship in emergency medicine.
AAEM/RSA continues to support AAEM's position that "board eligibility" through any means other than completion of an approved Accreditation Council for Graduate Medical Education (ACGME) Emergency Medicine residency compromises the safety of our patients and undermines the standards of the specialty as a whole. We are working through the AAEM/RSA Vice President's Council to identify hearings in every state where ABPS is seeking to legalize their alternative route for appointing "EM board certification." AAEM is actively involved in defending the academic integrity of emergency medicine by opposing alternative boards that do not recognize the necessity of emergency medicine residency training to determine board eligibility.
Capitol Area Symposium/ Georgetown University, Washington DC
Saturday, October 9th
Hey med students! Come explore a career in emergency medicine and learn about all the opportunities available in this amazing field. Speakers to include program directors, residents and emergency physicians in the Federal Government. STAY TUNED! DETAILS COMING SOON!
AAEM Scientific Assembly, Orlando, Florida
February 28-March 2, 2011
Mark your calendars! All AAEM/RSA members get a HUGE DISCOUNT at the annual AAEM meeting. The Student track is currently scheduled for Sunday, February 27 and the Resident track for Tuesday, March 1. More information coming soon!
Tox Talks: Jellyfish Envenomations
Robert Katzer, MD
Georgetown-Washington Hospital Center, Dept of Emergency Medicine
Of the 10,000 jellyfish species, 100 sting humans. Jellyfish contain microscopic nematocysts with hollow barbs of venom on both their tentacles and around their oral openings. Typically these are released into the surrounding environment after a change in pressure or osmolarity.
For the most part, stings result in a similar localized presentation: parasthesias, burning and pain. This is followed by change in skin color to red, brown or purple. Edema or blistering may also be involved.
More severe exposures may develop necrosis, ulceration or secondary infection. Most will resolve completely in one to two weeks. Severity of exposure is influenced by number of nematocysts involved, species of jellyfish involved, age and size of the victim. Physalia Physalis (Atlantic Portuguese man-of-war) and Chironex fleckeri (Indo-Pacific box jellyfish) are the species most likely to result in systemic presentation and cardiovascular collapse.
Verify which species is involved, but nematocyst inactivation is usually achieved with 5% acetic acid applied topically. After inactivation, nematocysts can be mechanically removed, taking care not to self envenomate. Do not expose to fresh water. Warm, salinated water has also been shown to successfully deactivate nematocysts of several species. Systemic symptoms are treated with standard resuscitation maneuvers, and be observed for at least eight hours.
For the Boards:
- If the offending creature is Jelly-like in nature (RASH) > 5% acetic acid, then remove nematocysts with salt water, tweezers or shaving.
- If the offending creature is "prickly" (PUNCTURE WOUND) > immerse the affected part in non-scalding hot water for 30-90 minutes.
- Emergency Medicine : A Comprehensive Study Guide, [edited by] Judith E. Tintinalli, Gabor D. Kelen, J. Stephan Stapczynski. - 6th Ed, 2004.
- Wilderness Medicine, [edited by] Paul S. Auerbach. - 5th Ed.
Journal Club: CPR Changes May Improve Mortality
Karen Serrano, MD
Chief Resident, Division of Emergency Medicine
University of Wisconsin School of Medicine & Public Health
Rea TD, Fahrenbruch C, Culley L, et al. CPR with Chest Compressions Alone or with Rescue Breathing. NEJM 2010;363:423-433.
Bottom Line: This recent study from the "New England Journal of Medicine" reported that survival from out-of-hospital cardiac arrest was similar when bystanders provided cardiopulmonary resuscitation (CPR) with compressions alone, compared to traditional CPR with compressions plus rescue breathing. In patients with cardiac cause of arrest and shockable rhythms, there was even a trend toward improved survival with chest compressions alone.
What is already known: Bystander cardiopulmonary resuscitation (CPR), followed by early defibrillation and expert advanced life support can be lifesaving and improve the chances of a favorable neurologic outcome following out-of-hospital cardiac arrest. However, the role of rescue breathing in CPR has recently been questioned. Research from animal models and observational studies suggests that using compressions alone may increase survival compared to compressions plus rescue breathing.
Premise of the study: In this study, the authors investigated whether survival was improved if bystanders initiating CPR on out-of-hospital cardiac arrest patients performed compressions alone compared to compressions plus rescue breathing.
Study design: The researchers performed a multicenter, randomized trial of dispatcher instructions to bystanders initiating CPR for out-of-hospital cardiac arrest. Laypersons calling 911 were given instructions either to provide compressions alone or compressions plus rescue breathing. The primary outcome was survival to hospital discharge.
Results: 980 patients were randomized to receive chest compressions alone and 960 to receive chest compressions plus rescue breathing. There was no significant difference in survival to hospital discharge between the two groups [12.5% for compressions versus 11% for compressions plus rescue breathing (p = 0.31)]. However, there was a trend toward improved survival with chest compressions alone in patients with a cardiac cause of arrest (15.5% versus 12.3%, p = 0.09) and those with shockable rhythms (31.9% versus 25.7%, p = 0.09).
Conclusions: Dispatcher instructions for CPR with compressions alone did not improve survival overall, although there was a trend toward improved outcomes in key patient subgroups. These results support policy changes minimizing the role of rescue breathing in bystander CPR, particularly for patients with cardiac cause of arrest.
Off Service Pearls: Chest Tube Tips in the Obese and Cachectic Patient
Austin Payor, DO
Largo Medical Center - Dept. of Surgery
The purpose of inserting a chest tube (CT) is to remove air, fluid or pus from the pleural cavity. Four common indications include pneumothorax, hemothorax, plural effusion or empyema. Two common challenges include: Finding anatomical landmarks in the obese patient and creating a good subcutaneous insertion point in cacectic patients to minimize air leak.
In the unlucky event your patient is obese, standard landmarks (between rib four/five at the mid anterior axillary line) can be elusive, with ribs difficult to palpate and the nipple being an unreliable landmark. In obese patients, first find the mid anterior axillary line. Then, in both males and females, a horizontal line from the inferior angle of the scapula or a horizontal line from the inframammary fold can be used.
You should also have a spinal needle available to anesthetize a very thick subcutaneous tissue and a larger set of instruments for CT insertion.
To prevent air leaks in cachectic patients, special technique is suggested beyond the standard technique. In standard technique, one must anesthetize with a wheal starting below the fifth rib and track the CT up to the superior edge of the fifth rib before crossing the intercostals muscles. If your patient is cachectic or very thin, simply start lower. Create a wheal at the skin between the fifth and sixth rib and then carefully track up to the superior edge of the fifth rib. This longer tract will decrease the chances of an air leak.