Modern Resident - The newsletter of AAEM/RSA
February/March 2013
Volume 4: Issue 5  |  FacebookTwitterLinkedIn


Your 2012-2013 Leaders:

President
Leana S. Wen, MD MSc

Vice President
Stephanie Gardner, MD

Secretary-Treasurer
Taylor McCormick, MD

Immediate Past President
Teresa M. Ross, MD

At-Large Board Members
Rachael Engle, DO
Ali Farzad, MD
Megan Healy, MD
Sarah Terez Malka, MD
Meaghan Mercer, DO

Medical Student Council President
Mary Calderone

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

Modern Resident Contributors

Copy Editor: Rachael Engle, DO
Managing Editor: Lauren Johnson, AAEM/RSA Staff

Special thanks to this issue's contributors:
Mary Boyle, MD; Mary Calderone, MSIII; Thomas Damiano, MD; Kaitlin Fries, OMSII; Michael Gottlieb, MD; Ashley Grigsby, MSIII; Casey Grover, MD; Alex Hunter, MD; Michael Moore, MSIV; Alexandra Murray, OMSII; Jennifer Stancati, MSII; Pollianne Ward, MD; and Julie Widdison, MD

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by March 25th for the April/May edition.

Medical Student Council President's Update
Mary Caledrone, MSIII
Loyola Stritch School of Medicine

Spring is in the air. Fourth year students eagerly await the Match. Third year students make major career decisions. Second year students dream of putting Step 1 behind them, and first years finally feel like they're getting the hang of things. Regardless of where you are in your medical school career, I hope that you've been able to find the resources that AAEM/RSA provides its student members valuable. This year, your Medical Student Council has been hard at work to ensure just that.

Over the past year, we've had two successful medical student symposia, the Midwest Medical Student Symposium in Chicago at the Loyola Stritch School of Medicine and the Midatlantic Medical Student Symposium in Washington, D.C., at the Georgetown School of Medicine. Thanks to the program directors and faculty speakers, the Student Track at the Scientific Assembly in Las Vegas was also a great success.

We have also created a section of "Helpful Documents" for students that is now posted on the AAEM/RSA website. Check out the piece on how to ace your interview by past Medical Student Council President, Meaghan Mercer, as well as a great guide to emergency medicine resources by current Medical Student Council Vice President, Rick Herold.

The Medical Student Council has also been involved in creating international EMIG partnerships. Please contact us if your EMIG is interested in pairing up with the EMIG at an international school.

In addition, the first winners of the newly created AAEM/RSA Medical Student Scholarship were announced. Congratulations to Kari Gorder and Bill Burns!

We're always looking for new ideas and projects that will help us to best meet your needs as a student interested in emergency medicine. What would you like to see the Medical Student Council work on in the future? Please contact me or other members of the Council. We want to hear from you!


Deadly Rashes Not to Miss in the ED
Alexandra Murray, OMSII
Ohio University Heritage College of Osteopathic Medicine

There are a variety of dermatological complaints that present to the emergency department resulting in approximately 5-8% of all ED visits.1 While some of these cutaneous presentations are relatively benign, such as in cases of atopic dermatitis, urticaria, eczema and psoriasis, there are multiple dermatological emergencies that can be fatal without rapid identification and treatment. Highlighted below are the characteristic skin manifestations of seven of the most common, acutely deadly diseases. Each of the listed diseases has a high risk of mortality within 48 hours if left untreated.2-4

Rocky Mountain Spotted Fever: The rash begins on day three to four of the infection, typically on the wrists and ankles, before spreading to the palms and soles. The rash subsequently spreads centrally to involve the proximal extremities and trunk. Gangrenous areas may eventually develop on fingers, toes, nose, ears, scrotum and vulva.1-3


Photo Courtesy of Wikimedia Commons: Rocky Mountain Spotted Fever

Neisseria Meningitis: The rash first appears as an asymptomatic petechial eruption that begins over the ankles and wrists and may progress to involve almost any part of the body. Over a few hours the rash evolves into a pathognomonic palpable purpura with gunmetal gray necrotic centers.2-4


© Copyright 2007 – 2011 Auckland Regional Public Health Service, ADHB. All rights reserved. Disclaimer

Staphylococcal Toxic Shock Syndrome: Patients present with an explosive onset of diffuse, red, sandpaper-like, macular erythroderma followed by desquamation (especially of the hands and feet within 5-14 days). Appears as an exaggerated sunburn.1-3


Photo Courtesy of Wikispaces : vdsstream VDS

Streptococcal Toxic Shock Syndrome: Patients present with rash in less than 10% of cases. The rash is commonly seen in the setting of an invasive soft tissue infection. There may be violacious, hemorrhagic bullae with surrounding erythema, and edema sometimes compounded by subtle evidence of soft tissue necrosis.2-4


Photo Courtesy of Journal of Medical Case Reports

Toxic Epidermal Necrolysis (TEN)/ Lyell Syndrome: Rash begins with non-pruritic, 1-2cm, urticarial plaques, which rapidly progress to coalescing bullae that rupture to leave red, denuded integument that is extremely painful to light touch. Mucosal erosions are also seen involving the oral, genital, conjunctiva and nasal mucosa accompanied by widespread epidermal sloughing.2,3


Photo Courtesy of Wikimedia Commons: Toxic-Epidermal-Necrolysis

Necrotizing Fasciitis: Patients initially present with areas of erythematous skin and a few blisters that are extremely painful to light touch. Within 24 hours the skin appears dusky blue in color with numerous bullae, the roofs of which slough with mild pressure.2,3


Photo Courtesy of Wikimedia Commons: Necrotizing Fasciitis Left Leg

Erythema Multiforme Major (EM)/ Stevens Johnson Syndrome (SJS): EM minor (mild form) presents with a highly regular, circular, wheal-like erythematous papule or plaque. EM major (severe form) presents with Stevens Johnson Syndrome (SJS) in the presence of multi organ system illness. SJS rash is characterized by widespread, non-pruritic, painful vesiculobullous lesions and erosions of the mucous membranes. 2,3


Photo Courtesy of Wikimedia Commons: Stevens-Johnson-Syndrome

References

  1. Jack, AR., et al. Cutaneous Conditions Leading to Dermatology Consultations in the Emergency Department. West J Emerg Med. 2011 November; 12(4): 551–555.
  2. Brady, WJ. Dermatological Emergencies. Am J Emerg Med. 1994 Mar; 12(2):217-237.
  3. Levine, N. Emergency Room Dermatology. Dermatol Nurs. 1999 Oct; 11(5):331-346.
  4. Drage, LA. Life-Threatening Rashes: Dermatologic Signs of Four Infectious Diseases. Mayo Clin Proc. 1999 Jan; 74(1):68-72.

Energy Drinks in the ED
Kaitlin Fries, OMSII
Ohio University Heritage College of Osteopathic Medicine

In order to put up with the demands of the fast-paced society we live in today, many Americans have turned to using energy drinks on a regular basis. Due to increasing popularity (sales have increased 240% in the past five years) these drinks are now readily available in stores, bars and even vending machines across the nation.3 In addition to containing high amounts of caffeine, these flavored beverages have other additives such as vitamins, taurine, herbal supplements, creatine, sugars and guarana (a plant product containing concentrated caffeine).3 These beverages have been found to have up to 500mg of caffeine in them compared to 100mg in a 5-ounce cup of coffee or 50mg in a 12-ounce soft drink.3 This fad has gained the attention of many public health professionals because of the dangers of caffeine intoxication, the drink's ability to mask symptoms of alcohol intoxication, and the high calorie content due to sugar in these beverages.

According to the Drug Abuse Warning Network (DAWN) report, the number of emergency department visits recorded due to energy drink use doubled from 10,068 visits in 2007 to 20,783 visits in 2011.3 A little over half of these 20,000 visits were due to energy drink use alone, whereas the other 42% involved combinations with other drugs (Figure).3


From The DAWN Report: Update on Emergency Department Visits Involving Energy Drinks: A Continuing Public Health Concern

Potential concerns in children and adolescents are the effects these drinks have on cardiovascular health, bone mineralization, and caloric intake, especially in diabetics.2 Among college age adults, recent studies have shown an association between energy drinks and alcohol dependence.2 In the older population there is a larger safety concern due to increased medication use and medical conditions.2 Further research needs to be done to identify the mechanisms that occur when such high doses of caffeine are mixed with various factors.

In the meantime, as medical professionals, we should begin questioning patients on the specifics of their caffeine intake. It is important to educate patients on the potentially harmful effects of these beverages alone and in combination with various other agents. The DAWN report urges health professionals to "discourage use of energy drinks by explaining that perceived health benefits are largely due to marketing techniques rather than scientific evidence."3

References

  1. Arria AM, Caldeira KM, Kasperski SJ, Vincent KB, Griffiths RR, O’Grady KE. Energy drink consumption and increased risk for alcohol dependence. Alcohol Clin Exp Res. 2011;35:365–375.
  2. Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics. 2011;127(3):511–528. doi: 10.1542/peds.2009-3592.
  3. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (January 10, 2013). The DAWN Report: Update on Emergency Department Visits Involving Energy Drinks: A Continuing Public Health Concern. Rockville, MD.

Image of the Month
Alex Hunter, MD
Christiana Care Health Systems

Clinical Vignette
Four-year-old male brought to the ED by his mother with chief complaint of fever and vomiting. The mother reports that the child had multiple episodes of vomiting last night, and has had a fever as high as 102.1°. Since the vomiting began, he has been complaining of sore throat and neck pain. Vital signs are Temp 37.9 C, HR 120, BP 106/68, RR 20, SpO2 99% on RA. The patient appears uncomfortable and sits upright with his head and neck forward, and is occasionally drooling. Upon examination his neck is tender and stiff, pharynx is normal, and no lymphadenopathy is appreciated. There is no stridor, and breath sounds are clear and equal bilaterally. No accessory muscle usage or retractions with inspiration. Heart rate and rhythm are normal with no murmur. The rest of the exam is unremarkable. The following images were obtained.

Question:
What diagnosis do the x-rays depict?

  1. Epiglottitis
  2. Pneumothorax
  3. Pneumomediastinum
  4. Retropharyngeal abscess

Answer:

C is correct. Spontaneous pneumomediastinum is uncommon in pediatric patients. Precipitating factors include vigorous vomiting, cough, valsalva maneuver, illicit drug ingestion and activities leading to barotrauma such as scuba diving.1 Presentation is varied but subcutaneous emphysema in the neck, or the presence of a crunching sound (Hamman sign) over the heart during systole, is present in up to 76% of patients.2 Other symptoms include chest pain, fever, dyspnea, dysphonia and sore throat. Diagnosis is made most often by chest radiography that shows free air tracking along the margins of the heart, within the retrosternal space and retropharyngeal space, or surrounding the trachea. Common radiographic findings include the thymic sail sign and the continuous diaphragm sign. Treatment is most often symptomatic, with few requiring intubation and mechanical ventilation due to escalating respiratory distress.

References

  1. Carolan, P. (2012). Pneumomediastinum. Retrieved from: emedicine.medscape.com/article/1003409
  2. Brunett PH, Yarris LM, Cevik AA. Chapter 258. Pulmonary Trauma. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, 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=6389704. Accessed January 27, 2013.

AAEM Residnet & Student Association: Toxicology Handbook


Toxicology Board Review Questions
Michael Gottlieb, MD
Cook County Emergency Medicine Residency

1. Which of the following is NOT a side effect of Digoxin toxicity?

  1. Bradycardia
  2. Yellow vision changes
  3. Scooping of the T segment on ECG
  4. Hypokalemia
  5. Gynecomastia

Answer:

D is correct. Despite the number of patients who come in taking Digoxin, it is important to remember that this medication comes with a large range of side effects. Bradycardia (along with any of the other SLUDGE Toxidrome symptoms) is a common effect due to the parasympathetic activity of Digoxin. (Note: This is also the reason it works as a second-line agent for rate control of atrial fibrillation.) Yellow, halo-like vision changes (think Van Gogh's 'Starry Night') are a more rare, but classic finding. The "scooped" ST segment is also a classic finding, commonly seen on ECGs — I recommend looking this up if you are not familiar with the appearance of this finding. Gynecomastia is an idiopathic and rare side effect of Digoxin. Finally, hyperkalemia (not hypokalemia) occurs due to Digoxin's primary effect on the Na-K ATPase Pump, blocking Na from leaving and K from entering the cell. It is also important to know that hypokalemia can increase Digoxin's toxicity by enhancing its binding to the Na-K ATPase Pump.

2. Which of the following chelating agents is recommended for acute lead poisoning with signs of encephalopathy?

  1. Succimer
  2. Penicillamine
  3. Dimercaprol
  4. Calcium EDTA
  5. Dimercaprol + Calcium EDTA

Answer:

E is correct. Succimer is the agent of choice for asymptomatic, mild lead poisoning (45-70mcg/dL in children, 70-100mcg/dL in adults) because it is available PO and has a low side effect profile. Penicillamine is used predominately for the treatment of Wilson's Disease (Copper chelation) and is no longer used in lead toxicity due to its significant side effect profile. For severe toxicity with signs of encephalopathy, Dimercaprol (previously known as BAL, British Anti-Lewisite) is given IM followed by Calcium EDTA via continuous infusion to combine to chelate lead from the brain and body, respectively.

Dosages are as follows:

  • Succimer: 10mg/kg PO Q 8H x 5 days, followed by 10mg/kg Q 12H for 14 days
  • Dimercaprol: 4mg/kg IM Q 4H x 5 days
  • Calcium EDTA: 1500mg/m2 IV Q 24H via continuous infusion x 5 days (started four hours after Dimercaprol)

References

  1. Kanji S, MacLean RD. Cardiac glycoside toxicity: more than 200 years and counting. Crit Care Clin. 2012 Oct; 28(4):527-35.
  2. Smith TW. Digitalis. Mechanisms of action and clinical use. N Engl J Med. 1988 Feb 11; 318(6):358-65.
  3. Gracia RC, Snodgrass WR. Lead toxicity and chelation therapy. Am J Health Syst Pharm. 2007 Jan 1; 64(1):45-53.
  4. Mann KV, Travers JD. Succimer, an oral lead chelator. Clin Pharm. 1991 Dec; 10(12):914-22.
  5. Patrick L. Lead toxicity, a review of the literature. Part 1: Exposure, evaluation, and treatment. Altern Med Rev. 2006 Mar; 11(1):2-22.

Submersion Injuries in the Pediatric Population
Ashley Grigsby, MSIII
Arizona College of Osteopathic Medicine

For most of the country, people are still putting on their winter jackets and mittens. But in Arizona, swimming pool season is fast approaching and unfortunately, an increase in submersion injuries (near drowning) comes with it.

The number of swimming pool deaths is highest in Arizona, Nevada, Mississippi, and Florida. Drowning is the second most common cause of death for children ages one-four, after congenital anomalies. It is also the third leading cause of accidental death in the United States. Children age 14 and under account for one in five deaths from drowning and for every child who dies, another five will need emergency care for nonfatal injuries.1 For these reasons, it is critical that emergency physicians be familiar with the management of submersion injuries.

Signs and symptoms of near drowning include respiratory distress, tachypnea, rales, wheezing and possible hypothermia. Obviously, initial management includes the ABCs — Airway, Breathing and Circulation. The indications for intubation include: signs of neurologic deterioration, PaO2 less than 60mmHg or SpO2 less than 90% on high flow supplemental oxygen, or a PaCO2 above 50mmHg.2 If the patient requires intubation an orogastric tube should be placed. This will help to reduce the amount of gastric distension caused by water intake in near drowning.3 If intubation is not required supplemental oxygen should be given to maintain oxygen saturation at 94% or higher.3

A trauma evaluation should be done with imaging as needed. The cervical spine should not be immobilized in submersion injuries unless there is a mechanism of possible trauma. Cervical spinal cord injury is uncommon in near drowning patients; therefore, spine immobilization should not be done due to the possible interference with establishing an airway.3

Cardiac monitoring should also be conducted in all of these patients due to the high incidence of arrhythmias due to hypothermia, often encountered in submersion injuries. Arrhythmias should be treated according to ACLS guidelines. All wet clothes should be removed and rewarming initiated. Due to the neuroprotective effects of hypothermia, CPR should continue until the temperature reaches 32-35 ºC, even if CPR lasts for several hours.3

About 75% of drowning patients survive; however, there are several factors that indicate poor prognosis: submersion more than 10 minutes, time to BLS more than 10 minutes, resuscitation longer than 25 minutes, age less than three years, Glasgow coma scale less than five, arterial blood pH <7.1 on presentation, and water temperature greater than 50 ºF. The colder the water in which the injury occurs, the better the neurologic outcome seen. This is due to the protective effects of hypothermia.3

Symptomatic patients should be admitted until symptoms resolve. However, review of asymptomatic patients showed that pediatric patients developed symptoms within seven hours of submersion. Therefore, asymptomatic patients should be observed for eight hours and admitted if their clinical appearance worsens. If there is no change or decline in the patient's vitals, oxygen saturation or a chest radiograph obtained at the end of eight hours, then the patient may be discharged. However, adequate follow-up and a responsible adult are absolutely necessary for discharge.3

References

  1. Unintentional Drowning: Get the Facts. Centers for Disease Control and Prevention [Internet]. Atlanta (GA). 2012 [cited 2013 Jan 6]. Avaliable from:  http://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html
  2. Brown III, C. The decision to intubate. Up to Date [Internet]. 2012 [cited 2013 6 January]. http://0-www.uptodate.com.millennium.midwestern.edu/contents/the-decision-to-intubate?source=see_link
  3. Chandy, D., and Weinhouse, G. Drowning (submersion injuries). Up to Date [Internet]. 2012 [cited 2013 6 January]. http://0-www.uptodate.com.millennium.midwestern.edu/contents/drowning-submersion-injuries?source=search_result&search=submersion+injuries+pediatrics&selectedTitle=7~28.

Clinical Pearl: Cardiac Stress Testing
Julie Widdison, MD
Casey Grover, MD
Stanford/Kaiser Emergency Medicine Residency

Chest pain is an extremely common presentation in the emergency department (ED), a complaint that is frequently evaluated with a number of different types of cardiac stress tests to rule out coronary artery disease (CAD). While the type of cardiac stress testing available is largely institution dependent, emergency physicians should be aware of the operating characteristics of each type of cardiac stress test.

Treadmill stress tests are used for patients who are able to walk on a treadmill and have a baseline ECG that is normal. While connected to a 12-lead ECG, the patient exercises on a standard treadmill protocol. This is to evaluate for the development of symptoms like chest pain or ECG changes. The estimated sensitivity and specificity for detecting CAD are 66% and 77% respectively.

Often, some type of imaging is used to provide additional information or to evaluate patients who cannot receive a treadmill stress test. The most common types are echocardiography, SPECT and PET. Each of these imaging modalities utilizes both rest and exercise imaging.

Stress Echocardiography uses rest and stress echocardiogram images to evaluate for wall motion abnormalities that would suggest an occluded or narrowed artery in a particular territory. If the patient is unable to exercise for the stress portion, medications can be used to increase cardiac output, usually dobutamine. The estimated sensitivity and specificity for detecting CAD are 76% and 88% respectively.

Myocardial Perfusion Imaging (MPI) uses a radioactive tracer which is injected into the patient prior to obtaining resting images, then again before obtaining stress images with SPECT or PET cameras to evaluate for perfusion defects which suggest an occluded or narrowed artery in a particular territory. If the patient is unable to exercise for this type of study, medications can again be used as well, most commonly persantine or adenosine. The estimated sensitivity and specificity for detecting CAD are 97% and 87% respectively.

References

  1. Dedic, A., et al. Imaging Strategies for Acute Chest Pain in the Emergency Department.  American Journal of Roentgenol. 2013 Jan;200(1): W26-38.
  2. Weiner, Donald. Advantages and limitations of different stress testing modalities. UpToDate. Accessed via the web at uptodate.com, Nov 2012.

Postpartum Fever
Michael Moore, MSIV
Pacific Northwest University of Health Sciences

Fever in the postpartum period is a relatively common occurrence, with a frequency of approximately 5-7% of births and the majority of the occurrences happening more than two days after birth.1 Frequently, these are managed by a patient's attending woman's health specialist, but a brief review is helpful for the emergency medicine physician as they may present in the emergency department for care. Postpartum fever is defined as a temperature of 38.7 degrees C (101.6 degrees F) or greater for the first 24 hours or greater than 38.0 degrees C (100.4 degrees F) on any two of the first 10 days postpartum.2

Fever occurring over such a wide range of time during the postpartum course can obviously have a variety of causes. However, the most common cause of postpartum fever is endometritis, which is inflammation in the lining of the uterus, in this case from infection.3 Given that the source of the infections is both from the genitourinary tract as well as from the skin flora, the infection is usually polymicrobial,4 requiring the administration of antibiotics with specific activity against anaerobes. This infection usually appears two to three days after delivery, so it is the one most often encountered in the postpartum period accounting for over half of postpartum infections found after discharge post-delivery.2

Other significant causes of postpartum fever (in order of temporal occurrence after delivery) include atelectasis, urinary tract infection/pyelonephritis, surgical wound infection (the case of surgical delivery), septic thrombophlebitis and mastitis.5 Finally, unusual causes of acute abdominal pain should be considered if clinically appropriate, especially appendicitis and diverticulitis, which can be difficult to distinguish in the setting of normal postpartum or postoperative pain.

Diagnostic evaluation by laboratory studies customary in the evaluation of infection by source outlined above, along with appropriate diagnostic studies should be performed, and obstetric consultation should be obtained.6 Specifically in the treatment of endometritis, especially after surgical delivery, parental clindamycin and gentamycin are recommended along with appropriate fluid resuscitation and supportive care.7

References

  1. Yokoe DS, Christiansen CL, Johnson R., et al. Epidemiology of and Surveillance for Postpartum Infectious. Emerg Infect Dis. Sep-Oct 2001;7(5):837-41.
  2. Adair FL. The American Committee of Maternal Welfare, Inc: The Chairman's Address. Am J Obstet Gynecol. 1935;30:868.
  3. Cunningham G, Levano KJ, Gilstrap LC, et al. Williams Obstetrics. 22nd ed. McGraw-Hill; 2005.
  4. Tharpe, N. Postpregnancy Genital Tract and Wound Infections. J Midwifery Womens Health 2008;53(3):236-246.
  5. Hamadeh G, Dedmon C, Mozley PD. Postpartum fever. Am Fam Physician. 1995 Aug;52(2):531-8.
  6. Maharaj D. Puerperal pyrexia: A review. Part I. Obstet Gynecol Surv. 2007;62:393-399.
  7. French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. Oct 2004;18(4):CD001067.

Why is My Arm Swollen?
Pollianne Ward, MD
Temple University Hospital

A 16-year-old female presented to a children's hospital emergency department with two weeks of intermittent left shoulder pain. Over the last few days, her left arm had become diffusely swollen and painful with mottling of the skin, coolness of her left hand and paresthesias on the lateral forearm. Exam revealed strong radial and brachial pulses with her arm dependent, and decreased pulses when she raised her arm. She was a competitive swimmer and practiced up to four hours per day and symptoms were worse after exercise.

Thoracic outlet syndrome (TOS) is an uncommon condition with varying presentations and a constellation of signs and symptoms that make diagnosis very tricky. It is characterized by compression of the neurovascular bundle exiting the thoracic outlet, involving the subclavian artery, vein and Brachial plexus. Historically, it was categorized by the anatomic abnormality causing the compression, such as cervical or first rib, scalene muscle hypertrophy, costoclavicular and hyperabduction syndrome.

Symptoms can be a combination of neurologic, vascular or pain. The classic patient described in literature is a young athlete, more often female and about 95% neurologic. If blood supply is affected, patients can develop muscle atrophy, decreased pulses and other symptoms of arterial occlusion, including necrosis. Venous congestion can present with venous thrombosis and is more common in young men. Stretching of the brachial plexus can result in sensory and motor deficits in a single nerve distribution, usually ulnar.

There is no specific diagnostic test for thoracic outlet syndrome and patients usually end up having extensive workups, depending on their presentations. Although there are many specialized physical examination tests, only one can reliably pick up abnormalities in all three systems. The elevated arm stress test (EAST) is conducted by having the patient sit with both arms abducted to 90 degrees and elbows flexed at 90 degrees. The patient then opens and closes both fists for three minutes. Patients with neurovascular compression will not be able to complete the task and will reproduce their symptoms. Imaging and other diagnostic testing can be utilized to evaluate for arterial or venous occlusion and all patients should receive chest and cervical spine films.

Patients with suspected thoracic outlet syndrome and no acute arterial occlusion or venous thrombosis should be referred to physical therapy, a general surgeon and other appropriate specialties depending on their site of compression. More serious presentations should be admitted for management of their complications.

Clinical Pearls:

  1. Suspect thoracic outlet syndrome in patients with shoulder or neck pain and neurovascular symptoms.
  2. Cervical rib is bilateral in 70% of patients and can be seen on chest X-ray.
  3. The EAST exam may be useful in identifying patients with possible TOS and intermittent symptoms.

References

  1. Thoracic Outlet Syndrome. Marx: Rosen's Emergency Medicine. Philadelphia, PA: Elsevier. 2006. Available at http://www.mdconsult.com

Lean Process
Thomas Damiano, MD
Christiana Care Health System

Lean, Mean, ED Resident Machine: Resident Application of Lean Tools

One of the first responses when asked what field of medicine I practice following "that must be interesting work," undoubtedly becomes "the waits are awfully long." The demand for emergency services has far outpaced supply over the last two decades. Administrators across the country are looking to the Lean philosophy to help deal with ED operational improvement. From a Lean perspective, resident involvement in advancing ED operations is essential.

If one were to search "Lean," results mentioning Toyota, various courses offering black belts and attempts at definitions may quickly confuse the inquirer. Lean has nothing to do with sticking accelerator pedals (too soon?). Courses are not taught by Chuck Norris (although I would be the first to sign up). Rather, Lean is a term for a production philosophy with the central concept that the expenditure of resources for any goal other than adding value for the customer is wasteful and should be minimized. Lean involves various tools for operational improvement and seeks to foster "a community of scientists" to employ these tools.

Many of the tools and principles of the Lean philosophy applicable to ED operations and health care in general were popularized in the manufacturing industry, particularly the Toyota Production System. As such, a variety of Japanese terms becomes the vernacular when discussing Lean tools. However, the concepts rather than the terms are useful.

The central concept of Lean health care is creation of value for the patient. The patient obtains value at the emergency department by seeing the doctor, having his or her problem diagnosed, treatment initiated and appropriately dispositioned on the path to wellness. Anything outside of these is considered muda, translated as waste or non-value-added.

Efforts should be focused to decrease the often described eight forms of muda. Movement of staff, and transportation of patients and equipment should be minimized. Stocks of supplies should be both properly managed and properly positioned. Obviously, waiting should be minimized but if it cannot, patients feel better if they are either waiting for results or informed of why they are waiting. Redundancy of questioning and ordering unnecessary tests contributes to waiting. Tasks should be completed correctly the first time. Wasting staff ideas to continuously improve the system must be avoided.

All staff should feel empowered to try to improve the system with the understanding that ideas will be respected and rewarded. Residents are often a link between attendings, nursing staff, ancillary staff and admitting teams. They are fresh in the system and often full of energy. As such, residents should ideally participate in the Lean tool of value stream mapping.

Value stream mapping involves members from departments involved with a process coming together to document all the steps and find waste or ways to improve the process. The multidisciplinary team assembles in the gemba, or meeting place, near or in the work area. The team walks through the process, taking note of the multiple steps involved and where the value from the patient perspective lies. Traditionally, the team places various colored sticky notes on a large paper with each step in the process, changing colors for value-added versus non-value-added steps. The teams should then walk through the process a second time, clocking duration of tasks and waiting as well as measuring distances traveled. Once the map accurately describes the process, brainstorming sessions commence looking for ways to increase the ratio of patient added value to non-value-added.

We have all walked into an ED storage room looking for a particular supply and spent inordinate time scanning across heaps of rarely used, or even expired inventory. Organization of the workplace environment is a vital component of efficiency. A fundamental tool of Lean processes is called 5-S. The 5-S's are Japanese terms that translate nicely to five English terms: sort, simplify, sweep, standardize and sustain. Items are rationally organized with standardized visual cues so that anyone should be able to find any item. The need for replacement can easily be signaled if organized in kanbans, or visual cues based on the industrial pull model that items need replenishment. For instance, shadow boarding can be used to easily denote an item is missing, or simply a card showing the usual time needed to obtain an item from the manufacturer, and minimum stock required so it never runs out. A kaizen, or improvement group meeting in the gemba, can chop minutes off your daily wasted time by applying the 5-S concepts to trays, supply carts and whole supply rooms.

Beyond inventory organization, Lean flow and rapid turnover are other concepts important to improving metrics such as door-to-doc time, and ultimately, patient outcomes and satisfaction. Focus should be placed on value-added steps from the patient perspective. For instance, if residents and attendings are free they can eliminate waste by entering patient rooms during nursing assessments together to avoid repetitive questioning and to "get everyone on the same page." While it may be uncomfortable to break from "the way we have always done it," using rapid cycle testing to show measurable improvement makes such an example catch on and become the new culture.

Small improvements effect the big picture. While residents may only be peripherally aware of metrics in the ED, the government is attentive and already attaching reimbursements to meeting metrics. Concerns about lack of resident experience secondary to decreased duty hours can be obviated if residents can see more patients in a shorter amount of time in an efficient system. While residents focus on obtaining the knowledge base and procedural competency to care for patients, an understanding of ED operational improvement and contributing to such, helps care for our patients and eventually sustain our field.

References

  1. Crane, Jody. The Definitive Guide to Emergency Department Operational Improvement. 2011.
  2. Graban, Mark. Lean Hospitals: improving quality, patient safety, and employee satisfaction. 2009.

Choosing a Specialty: Is EM Right For Me?
Jennifer Stancati, MSII
Mary Boyle, MD
Loyola University Chicago Stritch School of Medicine

Less than 18 months from now, I will decide what I want to do for the next 35 years of my life. Many careers (e.g. law) require you to "specialize" in a way, but not like in a field as diverse as medicine, and not in a way that you are locked into one specialty for the rest of your working life. As a second year medical student, I feel as if I know very little about specialties, medicine or anything else for that matter. How am I supposed to know what I want to do for the rest of my life?

As I started to think about why emergency medicine (EM) is my first choice specialty right now, I decided to make a list of what I find appealing about it: complex problem-solving, fast pace, variety, teamwork. Sometimes I think I am crazy for wanting to take on such an intense job for the rest of my career. So I decided to get some input from other MS2s who are interested in EM, and this is what they said:

MS2s:

Pros: Cons:
  • unpredictability
  • fast pace
  • diverse patient population
  • variety
  • solving complex medical puzzles
  • being the one that people look to in a moment of crisis
  • death
  • lack of patient-physician relationships
  • burnout
  • patients with challenging social behaviors

The pros of EM are: unpredictability, pressure, and complex problem-solving — with the added cons of death and a lack of patient-doctor relationship? What crazy medical student would choose EM as his or her specialty? Granted, some of the cons we see in EM are not specific to EM, but instead belong to medicine in general. Regardless, this list of pros and cons does not necessarily appeal to everyone. Next, I asked the opinions of some MS4s who are going into EM (hoping they were a little bit more rational):

MS4s:

Pros: Cons:
  • unpredictability
  • fast pace
  • diverse patient population
  • variety
  • making the initial diagnosis instead of having to manage an already packaged patient
  • teamwork
  • multitasking
  • shift work
  • most of the information you need is right in front of you if you just talk to your patient
  • knowing how to remain cool, calm and collected when things get stressful
  • EM people are cool
  • death
  • being charged with the task of knowing a ton of information and being ready to treat whatever walks through the door
  • struggling to get beds in the hospital
  • unfortunately misinformed older physicians, who are outside the specialty of EM, who have negative opinions of EM as a specialty
  • drug seekers, intoxicated patients, malingerers, etc.

Comparing the responses of the MS4s to those of the MS2s, there are many similarities and I am once again asking the question, who would want to sign up for this career?

"For most students, specialty choice is based on a personal or medical school role model, or as much on emotions as rational thought, with no two people choosing their specialty for exactly the same reasons." - AAEM's Rules of the Road for Medical Students

I cannot speak for the rest of the students that I surveyed, but for me the best way I can describe my feelings about EM is that the thought of going into EM invokes a certain emotion in me. It is an emotion that can't be precisely described in words, yet it is something very exciting and something that I want to be a part of, hopefully for the next 35 years.

Special thanks to the MS2s and MS4s who took the time to provide their input.

References

  1. Kazzi, AA, Schofer, JM. (2003). AAEM's Rules of the Road for Medical Students.