Modern Resident - The newsletter of AAEM/RSA
March 2011
Volume 2: Issue 5


Your Leadership

We welcome your comments and suggestions. Feel free to get in touch with your elected leaders:

President
Ryan Shanahan, MD

Vice President
Heather Jiménez, MD

Immediate Past President
Michael Ybarra, MD

Secretary-Treasurer
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
Brett Rosen

Modern Resident Contributors

Copy Editor: Teresa M. Ross, MD
Managing Editor: Jody Bath, AAEM/RSA Staff

Special thanks to this month's contributors: Robert Katzer, MD; Sandra Thomasian, MD; Michael Holman, MSIII; Douglas Kuxhausen, DO; Meaghan Mercer, MSIII; Stephanie Nicole Lewis, MSIV; and Cameron McLaughlin, OMSIV.

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by April 1st for the April/May edition.

Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA.


In the News: Specialty Updates – EMS Becomes the Sixth Approved EM Subspecialty for Board Certification
Robert Katzer, MD
Georgetown/Washington Hospital Center

The upcoming years will surely prove exciting for the subspecialty of emergency medical services (EMS). This September, the American Board of Medical Specialties (ABMS) approved EMS as the latest subspecialty certification of emergency medicine. It becomes the sixth subspecialty that members of the American Board of Emergency Medicine (ABEM) are eligible to train for. The EMS subspecialty involves the treatment and transportation of patients either from the field or between facilities using medically-trained personnel and specialized vehicles.

Although the evolution of military EMS systems dates back hundreds of years, the history of civilian EMS in the United States began only in the last 50 years. The initial development of cardiopulmonary resuscitation (CPR) helped create a need for in-field providers, but it was not until the Highway Safety Act of 1966 and the federal EMS Act of 1973 that a federal push, along with funding, helped drive the establishment of EMS systems throughout the country. What followed was curriculum development for the different levels of pre-hospital providers. Over the years, the EMS system has suffered from variable quality of care, lack of evidence for interventions, underfunding and a highly-fragmented organizational structure. In the 2006 publication of the Institute of Medicine, EMS at the Crossroads, the committee recommended ABEM establish a subspecialty certification in EMS. This additional training and standardization should now lead to improvements in several identified deficient areas.

The ACGME accreditation of EMS fellowship programs will begin in the next few years. The subspecialty is anticipated to administer the first board exam in the fall of 2013. There are three ways that ABEM diplomates will be able to meet criteria per the ABEM EMS Eligibility Criteria for Certification document, as quoted below:

  1. "EMS Practice Pathway: Physicians who apply through the EMS practice pathway must demonstrate that within the six years immediately preceding the date on which they submit their EMS certification application they have completed a minimum of 60 months of EMS practice (of at least 400 hours per year) as Assistant, Associate, or Medical Director of an EMS agency with patient care responsibility or as a direct provider of prehospital emergency care.
  2. EMS Practice-Plus-Training Pathway : Physicians who apply through the EMS practice-plus-training pathway must have:
    1. Successfully completed an acceptable, unaccredited fellowship in EMS, and
    2. Within the 6 years immediately preceding the application, completed a minimum of 24 months of EMS practice (at least 400 hours per year) as Assistant, Associate, or Medical Director of an EMS agency with patient care responsibility, or as a direct provider of pre-hospital emergency care.
  3. EMS Training Pathway: The EMS training pathway requires that applicants successfully complete an ACGME-accredited fellowship in Emergency Medical Services."

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Image of the Month: Evaluating Neonatal Seizure
Meaghan Mercer, MSIII
Western University of Health Sciences
AAEM/RSA Medical Student Council VP

Patient Vignette:
A 3-week old female born to a 23-year old mother with no prenatal care is brought to the emergency department (ED) with a history of poor feeding, multiple episodes of vomiting, seizure-like activity and failure to thrive. On exam, the patient is resting comfortably and has stable vitals but only weighs 5lb 3oz (birth weight 6lb 5oz). She shows no suckling reflex and is hypotonic. After appropriate labs are ordered, your attending decides to obtain a bedside ultrasound (US) of the abdominal cavity and brain to evaluate for abnormalities. The abdominal US appears normal. The brain US (obtained through the open fontanel) is shown below.

Question:
These images represent:

  1. Contrast MRI and ultrasound of normopressure hydrocephalus
  2. Noncontrast MRI and ultrasound of normopressure hydrocephalus
  3. Contrast MRI and ultrasound of lissencephaly
  4. Noncontrast MRI and ultrasound of lissencephaly

Click on image to enlarge photo.

Image of the MonthImage of the Month

Click here for the answer


EM Insights: I'm Becoming an Attending in 6 Months!
Sandra Thomasian, MD
University of Nevada Medical Center

AAEM/RSA Secretary-Treasurer

It's February of your last year of residency! For many emergency medicine seniors, this is the time to start getting serious on the job hunt. It is estimated that 60-70% of EM residency graduates change jobs in their first two years of practice. Fortunately, graduate residents in EM can choose many exciting career possibilities. Whether you want to practice in the private sector, academic emergency medicine, rural setting, or pursue a fellowship, the choice is up to you.

Preparation is key, and it begins with soul-searching and ranking your personal priorities such as geographic location, climate, proximity to family and salary. It is never too early in your residency to start thinking about these issues, particularly when attempting to enter tight geographic markets like San Diego or Denver. State licensure processes are widely variable and may take months up to a year, so begin your quest early. Now that you have chosen your career path, you should organize a rough timeline. First and foremost, your CV should be ready with revisions no later than the beginning of your final year. For help with CV preparation, the AAEM Young Physicians Section (YPS) offers graduating residents a CV and cover letter review service for $25, with the fee going towards YPS membership dues for the following year.

Second, start contacting prospective employers. This should be done as early as possible in your senior year of residency. AAEM offers all members access to the AAEM Job Bank, which contains numerous job advertisements for EM physician opportunities. Begin sending out your CV and cover letter to prospective employers you are interested in. If an employer is interested, an interview will be arranged.

During the interview, never hesitate to ask questions that are important to you. The AAEM/RSA Rules of the Road for Emergency Medicine Residents book has an excellent section on interview questions to ask to assist you in determining the attributes and shortfalls of a position.

The best advice I can give to residents is to start early. Depending on geographic location and type of career you are looking for, everyone will have their own timeline. Some seniors may already have their academic appointment contract signed one year prior to graduation, while another senior may sign on with a private group in a highly desired location a few months before graduation. Either way, with advanced planning, persistence and focus, you will be ready to pursue any career opportunity according to your own timeline.

References:

  1. Career Planning Guide for Emergency Medicine (2nd ed); Gus M. Garmel, MD FACEP FAAEM
  2. Rules of the Road for Emergency Medicine Residents and Graduates (4th ed); Tom Scaletta, MD FAAEM

AAEM/RSA Exclusive - A Must Have!

Emergency Medicine: A Focused Review of the Core Curriculum
Emergency Medicine:
A Focused Review of the Core Curriculum

22 chapters, 225 board-style questions, 79 images...one way to excel!

To purchase this incredible new resource, visit http://www.aaemrsa.org/bookstore for your member discount!

Clincal Pearl: A Review of Physical Exam Findings in the CHF Patient
Cameron McLaughlin, OMS IV
Arizona College of Osteopathic Medicine

The physical exam is regularly discussed in medical school but is often minimized in residency and beyond as physicians become hurried, rush to other diagnostic testing, or simply forget the details of a certain focused exam. In recognition of this fading "art," JAMA1 has published a series of articles discussing just this topic. Here, we will review their publication on the important physical exam findings in heart failure patients.

Above all other findings, the presence of a third heart sound increases the likelihood of heart failure the most, with a likelihood ratio (LR) of 11.1 (Sens 13%, Spec 99%). However, this means a high number of false negatives, so do not be thrown off the trail if this finding is absent.

Jugular venous pressure (JVP) has LR 5.1 (Sens 39%, Spec 92%).1 JVP is measured by lowering the patient's bed to 45 degrees and measuring the jugular vein from the sternal notch. Add 5cm to your measurement to accommodate for the additional distance to the right atrium. Remember, JVP is NOT an exam of fluid status, but of right atrial pressure, as heart failure will cause increased RA pressure.

Finally, rales have LR 2.8 (Sens 60%, Spec 78%). Wheezing, however, has a LR of 0.52 (Sens 22%, Spec 58%).1 So, wheezing actually decreases the likelihood that the patient is in heart failure.

Reference:

  1. Charlie S. Wang, J. Mark FitzGerald, Michael Schulzer, Edwin Mak, Najib T. Ayas. JAMA. 2005;294(15):1944-1956.

Board Review: The Use of CT in Children with Head Trauma
Michael Holman, MSIII
Georgetown University School of Medicine

Every year, more than 650,000 children are seen in emergency departments across North America for mild head injuries, about half of which will receive CT scans. In fact, in the last decade, the pediatric population saw the largest increase in use of diagnostic CT. It has been estimated that the attributable lifetime risk of death from cancer ranges from 0.065% per head CT in neonates to 0.005% per scan in teens.

Although several studies have developed methods and rules to reduce the use of pediatric CT scans, only the 2009 PECARN study has been validated. The PECARN prediction rules identify children that are at low-risk for a clinically important traumatic brain injury and do not need to be scanned. Rules apply if the patient presents within 24 hrs of the traumatic event and has a Glasgow Coma Scale score of >14. For patients meeting all clinical criteria, the negative predictive value for clinically-important TBI is minimal (below). For those who do not meet all six criteria, the decision to scan is recommended, but ultimately should be based on the clinical judgment.

Less than 2 years of age

  1. normal mental status
  2. no scalp hematoma, except frontal
  3. loss of consciousness < 5 sec.
  4. non-severe injury mechanism
  5. no palpable skull fracture
  6. acting normally according to guardian

* NPV = 100%, Sensitivity = 100%

Between 2 and 18 years of age

  1. normal mental status
  2. no loss of consciousness
  3. no vomiting
  4. non-severe mechanism
  5. no signs of basilar skull injury
  6. no severe headache

*NPV = 99.95%, Sensitivity = 96.8%

References:

  1. Brenner, David J., Hall, Eric J. Computed Tomography – An Increasing Source of Radiation Exposure. N Engl J Med. 2007;357: 2277-84.
  2. Kuppermann, Nathan, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. For the Pediatric Emergency Care Applied Research Network (PECARN). Lancet. 2009; 374: 1160-70.
  3. Osmond, Martin H, et al., CATCH: a clinical decision tool for the use of computed tomography in children with minor head injury. CMAJ. 2010; 182: 341-348.

Board Review: Managing Sickle Cell Pain Crisis
Stephanie Nicole Lewis, MS IV
Meharry Medical College

Painful vasoocclusive crises are the most common reason for sickle cell patients to visit the emergency department. Patients may present with joint pain, muscle pain, bone pain, priapism, swelling of the hands or feet due to dactylitis, flank pain and/or hematuria due to infarction of the renal medulla, and diffuse abdominal pain. Common precipitants include cold exposure, dehydration, high altitude and infections with encapsulated bacteria such as Haemophilus influenza or Pneumococcus.

Management - is primarily supportive, while evaluating for possible precipitants of acute crises.

  • Patients with acute pain should be rehydrated orally or with IV fluids (0.45 NS or NS at 1.5 x maintenance).
  • For severe pain, administer narcotics.
  • Oxygen and cardiac monitoring are only indicated for hypoxia and cardiopulmonary symptoms, respectively.
  • Cultures should be drawn for patients with a temperature over 38°C or symptoms of acute infection. Administer a broad spectrum antibiotic, such as cefuroxime or ceftriaxone.
  • Patients with bone pain suggestive of osteomyelitis should have cultures drawn and IV antibiotics that cover Staphylococcus aureus and Salmonella typhimurium.
  • Priapism requires hydration, analgesia and immediate urologic consultation.
  • Exchange transfusion is indicated for significant cardiopulmonary decompensation, an acute central nervous system event or priapism.

Admission criteria - Includes pulmonary, neurologic, aplastic or infectious crises; splenic sequestration; intractable pain; persistent nausea and vomiting; or an uncertain diagnosis.

Discharge - Give the patient oral pain medicine, close follow-up, and instructions to return immediately for temperature above 38°C or worsening symptoms.

Reference:

  1. Emergency Medicine Manual, 6th edition. O.John Ma, David M. Cline. Copyright The McGraw-Hill Companies 2004.

EKG of the Month: 56yo Female with Palpitations
Douglas Kuxhausen, DO
Tufts Medical Center

Patient Vignette:
A 56 yo female with a history of asthma presents with palpatations. She just got done using her albuterol and felt her heart racing. Her husband drove her in. Her admission EKG is below.

Question:
This EKG represents:

  1. Ventricular tachycardia
  2. Ventricular fibrillation
  3. Supraventricular tachycardia with aberrancy
  4. Sinus tachycardia with a right bundle branch block

Click on image to enlarge photo.

EKG of the month: 56yo Female with Palpitations

Click here for the answer


Image of the Month: Evaluating Neonatal Seizure

Answer:
D. Noncontrast MRI and ultrasound of lissencephaly

Lissencephaly (also known as agyria) is a rare anomaly where there is incomplete neuronal migration during the 10th to 22th week of gestation, resulting in a lack of development of gyri and sulci. Severe forms of lissencephaly are among the differential diagnoses for seizures in the neonatal period. Type 1 lissencephaly is associated with facial dysmorphism, sometimes with deletion of chromosome 17p (Miller-Dieker syndrome). Type 2 is associated with hydrocephaly and dysgenesis of the cerebellum.

Neonatal seizures are often associated with underlying neurologic abnormality. Along with standard evaluation for septic and electrolyte etiologies, seizure work-up should include cerebral imaging for hemorrhage and structural abnormalities, like lissencephaly. Ultrasound and MRI are both useful.1 Imaging provides significant prognostic value. Lissencephaly can be diagnosed by transvaginal sonograph as early as 24-26 weeks gestation, when gyri and sulci have become defined. The brain will have a smooth surface on coronal and oblique sections.

Ventricular dilatation is apparent in both coronal and oblique sections.3 Prognosis of lissencephaly depends on the degree of malformation. While the majority of patients die before age two or have severe developmental abnormality, others may develop relatively normally. These children retain high-risk of aspiration. 4

Follow-Up:
This patient was seen in the clinic one week later. She now has a G-tube for feeding and has gained 3oz. She is on seizure prophylaxis without any further episodes of seizure-like activity. She is pending evaluation with a geneticist to work-up possible chromosomal abnormalities.

References:

  1. Nigro, MA. "Chap 125. Seizures and status epilepticus in children." Emergency Medicine: A Comprehensive Study Guide. Ed. Judith Tintinalli. 6th edition: 2004.
  2. Dobyns, WB. Developmental aspects of lissencephaly and the lissencephaly syndromes. Birth Defects Orig Artic Ser 1987; 23:225.
  3. Ghosh T. Lissencephaly--not an uncommon cause of intractable seizure in children: report of 3 cases. J Indian Med Assoc. Feb 2010; 108(2): 114-5.
  4. "NINDS Lissencephaly Information Page." National Institute of Neurological Disorders and Stroke. Accessed 12 Jan 2011.

EKG of the Month: 56yo Female with Palpitations

Answer:
C. Supraventricular tachycardia with aberrancy

This is a regular rhythm at a tachycardic rate of 285, with wide complex. Although we typically associate wide complex rhythms with ventricular-originated rhythms, the key element is that it is so fast that it most likely is NOT ventricular in origin, as ventricular rates are usually 150-200. In consultation with cardiology, it was determined this was a supraventricular tachycardia (SVT): specifically, atrial flutter with 1:1 conduction. Atrial flutter is usually 2:1 conduction, with a ventricular rate of 150, but 1:1 conduction has rates closer to 300.

So, why does this SVT have a wide QRS? When SVT conducts as a wide QRS complex, it is due to a "rate-related bundle branch block (BBB)," also known as "aberrancy." Aberrancy occurs because the relative refractory period of each action potential changes with heart rate. When a supraventricular impulse reaches the His-Purkinje system while one of its branches is still in its relative or absolute refractory period, conduction is slowed through this bundle, delaying ventricular depolarization and creating a wide QRS in the absence of true bundle-branch pathology. An RBBB pattern is more common than an LBBB pattern, because the right bundle has a longer refractory period.

Follow-Up:
With this patient, treatment was initiated for stable, regular wide-complex SVT. Per the 2010 ACLS guidelines, adenosine is now an option for wide and narrow complex SVT.2 Unfortunately, the first dose of adenosine 6mg was unsuccessful. The patient's rhythm did not break, and she instead dropped her blood pressure to 50/20 and lost consciousness. She was then cardioverted with 100 J, in treatment for unstable wide complex SVT. The patient was then returned successfully to sinus rhythm.

References:

  1. Field JM, Hazinski MF, Sayre M, et al. Part 1: Executive Summary of 2010 AHA Guidelines for CPR and ECC. Circulation. In press.
  2. Shuster, CW. Callaway PJ. Kudenchuk, JP. et al. Part 8: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency. Circulation. In press.