05.24.13
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CaRMS Application Preparation

It seems like match season only just finished. And yet, as the last of the Saskatchewan snow drifts left us, a new crop of medical student clerks (or, as we call them on the prairies, JURSIs) began preparing to sweat through the annual ritual they had been hearing stories about since their earliest premed days: CaRMS. Of course, with CaRMS season comes more mentorship posts. In January/February of this year I wrote a lot about CaRMS interviews for the class of 2013 with posts on pre, intra and post interview periods as well as reference letters.

My blog wasn’t around during the application portion of the 2013′s CaRMS cycle, so I missed writing about this part of the process. When Chris Byrne (the medical student guest author of this great knowledge translation piece on point-of-care ultrasound) requested a mentorship post on CaRMS applications I decided to get right back into it. This post on CaRMS application preparation will focus explicitly on letting you know what information you will need to enter into the portal when it opens on September 4th. It will be followed by a post on CaRMS application optimization later this year.

I think this will be useful because many of you will find yourselves on busy rotations or away on electives when the CaRMS portal opens. I remember being on a busy General Surgery rotation at the time and finding it time-consuming to look up and/or write up all of the information that the CaRMS application requested. I kept thinking that if I had only known beforehand what I would need I could have recorded it as I went through clerkship. Hopefully this will save some of you from that situation and give you more time to procrastinate on your personal statements ;)

What is a CaRMS Application?

A CaRMS application consists of the information that is submitted by every student applying no matter what specialty they are applying to. Basically, it looks like a long CV in a standardized format. Every program that you apply to sees it so it cannot really be customized to a particular program. In general, if you have a detailed CV you will have most of the information that you need to fill it out. However, there were a few things that I had not included on my CV that I had to look up or write. In particular, getting the descriptions of my activities just right took a lot of time.

Based only on my anecdotal recollections, the information that CaRMS requests for their application has been fairly stable over the years that I have applied and reviewed (2010-2013). With the additional disclaimer that I have no idea if they have/will change anything for this year, I hope you can use this information to get yourself just a bit more prepared than I was.

What does the CaRMS Application ask for?

The parts of the application that you may not have on-hand involve elaboration about what you have done over the last number of years. While the personal information and educational history sections are straight forward, other sections ask for things that I had to go look up. The information that I think it would be helpful to start gathering now so you’ll be ready to hit the ground running is below. You could also consider writing out brief descriptions of each item so you do not have to do that later. The majority of my descriptions were around 50 words. I’m not sure if there is a cap, but I wouldn’t recommend writing a whole lot more than that.

Electives - dates you did them, location, names of your supervisors, descriptions of your experiences (ie – Emergency Medicine, Best University, Dr. Awesome, During this I elective I learned this and got experience with that and blah blah blah)

Other Professional Training / Certifications – dates you got them, descriptions of unfamiliar certifications (ie – CPR, ACLS, Lifeguard, Accounting, whatever you think fits)

Work experience – month/year you worked there, company you worked for, address of the company, description of your job

Publications/Presentations – date published, conference or journal/volume/pages, author list, publication type (this is specifically for your publications and presentations)

Research experience – month/year you did the research, title of research project, names of your supervisors, description of your research (when/what you did as a research job to get your publications and presentations)

Volunteer experience - month/year you did it, organizations you volunteered with, location of the volunteering, position with the organization, description of your volunteering

Activities & Interests / Awards – this section allows substantially more room to write about Professional Associations, Memberships and Committees  (ie – CAEP, student societies)/ Accomplishments and Interests (ie – cooking, scuba diving, climbing Everest, whatever it is that med students do these days) / Honours and Awards (ie – scholarships, research prizes, extracurricular awars)

Conclusion

This is not groundbreaking stuff. However, it is basic information that I think will help the type A med students that read my blog to start preparing for CaRMS a bit earlier and make the application component of the process a bit less stressful. This would be an easy thing to start from day one of medical school. Building as you go would just leave some simple editing for fourth year when you will be busy with clerkship.

Of course, this is not the only think you will put together for CaRMS. Personal letters (will link to a blog on this when I write it!), reference letters and interviews are also very important parts of the application package and process.

If you think your classmates would benefit from this post please share it! If you want to make sure you catch the next chapter on this subject (CaRMS Application Optimization) later this year you can follow my rss feed, follow me on twitter, like BoringEM on facebook or sign up for e-mail delivery of BoringEM posts in the column on the right.

Thanks for reading!

Peer reviewed by: Danica Kindrachuk, Eve Purdy & Chris Byrne

Author information

Brent Thoma
Emergency Medicine Resident at University of Saskatchewan
A Canadian that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.
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The post CaRMS Application Preparation appeared first on BoringEM and was written by .

05.24.13
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Dolore addominale, TAC e appendicite

E’ mattino, per fortuna i pazienti da rivedere dopo la notte non sono molti: “C’è poi Josè , un uomo peruviano sui 45 anni, che è venuto stanotte per un dolore epigastrico, sembra un reflusso gastroesofageo, abbiamo fatto un po’ di terapia sintomatica inizialmente con beneficio. Ha riposato tutta la notte  ma quando gli chiedi se [...]

The post Dolore addominale, TAC e appendicite appeared first on EM Pills.

05.24.13
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The politics of EHR implementation

I've pretty much kept my distance from the right-wing noise machine. They don't often talk about my professional interests, and when they do, it's not usually cited by a colleague or fellow academic.

But this morning, someone I respect shared this screed from Michelle Malkin on the great EDBA listserv - which I'd always equated with intelligent discussion of applied emergency medicine informatics.

So, let's dive into Malkin's piece on "Obama's crony," the CEO of Epic Systems:
The stimulus law provided a whopping $19 billion in “incentives” (read: subsidies) to force hospitals and medical professionals into converting from paper to electronic record-keeping systems.
I take issue with the past tense "provided" because these $19 billion will be allocated over many years, and only a small fraction has been given out already. And while $19 billion seems "whopping", healthcare spending was $2.7 trillion in 2011, and Medicare spending alone was $557 billion that year.
Obamacare bureaucrats claimed the government’s EMR mandate would save money and modernize health care.
This had nothing to do with "Obamacare" and in fact I don't think that term had been coined when the stimulus bill passed in February 2009. Lots of people thought, and still think, that EMR will save money in the long run (and moving from paper to electronic pretty much modernizes care, by definition). And of course, there's the reasonable expectation that patient care will be improved, too.
After hyping the alleged benefits for nearly a decade, the RAND Corporation finally admitted in January that its cost-savings predictions of $81 billion a year — used repeatedly to support the Obama EMR mandate — were, um, grossly overstated.
Among many factors, the researchers blamed “lack of interoperability” of records systems for the failure to bring down costs. And that is a funny thing, because it brings us right back to Faulkner and her well-connected company. You see, Epic Systems — the dominant EMR giant in America — is notorious for its lack of interoperability.
OK! Malkin has made a point that can't be dismissed out of hand: Epic systems do tend to be closed. There's lots to criticism about that system and the state of EHR in general. And yes, the 2005 Rand report (which, by the way, was funded by EHR vendors) estimated big savings and the "Obamacare bureaucrats" paid attention to it (though one has to wonder what Malkin would write if they had ignored the report.) Since that time, experts agree interoperability has limited the expected savings - but those many-billions a year are still anticipated soon .

And hey, allocating $19 billion over many years to generate annual savings greater than that - on a $550 billion dollar program - just doesn't seem so crazy to me. If additional savings are delayed a few years, well, it's still a reasonable investment, to say nothing of the other benefits from adopting EHR. Who knows? Medicare spending is already slowing, maybe EHR is involved? At least you can't argue: this part of the stimulus accomplished the goal of, well, stimulating economic activity (I've seen the construction activity at Epic HQ first hand).

But here's something to think about: If Epic runs the table and becomes a monopoly, as Malkin (and others) allege will happen, doesn't that render the issue of interoperability moot? Wouldn't that accelerate the cost savings? Seen in this light, Epic political influence doesn't just benefit their company, but the taxpayer as well. It seems like this is something Malkin would be rooting for, instead of decrying.

Of course, I don't think Malkin has thought through her argument - she's just stringing together half-truths to score points with her audience. Because on the topic of political influence, she notes:
Epic employees donated nearly $1 million to political parties and candidates between 1995 and 2012 — 82 percent of it to Democrats. 
Again, I think some perspective may help - averaged over 17 years, Epic employees gave less than $50,000 a year - in total - to the Democratic party. I wonder if this is the reason Republicans candidates lost so many presidential elections over this period. If $50k per year is all it takes to be an "Obama crony" then what does the $18 million Google spent in 2012 alone mean? What do you call the Koch brothers?
The shadow of tyranny and the stench of corruption are unmistakable.
Goodness. Well, we can agree something stinks. EHRs, and Epic in particular, are a subject worthy of debate, but Malkin's piece does nothing to advance understanding of policy or this industry.

(The last time I waded into a right-wing leaning discussion of electronic health records, over at the WSJ blog, commenters compared folks like me, who help implement and study EHR, to the Tuskegee researchers. Let's hope things have improved since then).
05.24.13
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WWWTP#7 Answer

Apparently the patient had been admitted to another hospital with sepsis recently.  On the Chest Xray you can see a thin metallic wire extending from the superior vena cava to the left hemidiaphragm area.  This was initially missed on the Xray and found on further imaging.  The patient had an abdominal CT (she had right lower quadrant pain) and with mediastinal windows the metallic object can be seen:

Guidwire chest CT 1Guidewire chest CT 2

The patient had a retained guidewire from a previously placed right IJ catheter.  This was a very weird incidental finding!  She was eventually sent to interventional radiology where it was removed.  Unfortunately it had nothing to do with her abdominal pain.

Author:  Russell Jones, MD

Image Contributor:  Aaron Hougham, MD


Filed under: WWWTP
05.24.13
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Facebook use in the Emergency Department

New study shows that emergency department workers are on Facebook quite a bit. They spend an average of 4.3 minutes per hour on Facebook during day hours, which is just under an hour out of every 12 hour shift. However, during night shifts when the study hospital was busier, the staff spent an average of almost 20 minutes per hour — just on Facebook.

So are the results good news based on other studies showing that engaging in brief mindless tasks decrease worker fatigue and stress while increasing worker productivity and happiness? Or are the results bad news suggesting that patients aren’t getting full attention?

I also wonder about how the study determined active use of Facebook. Researchers set limits of 3 minutes for each interaction with Facebook, so someone checking their status for a few seconds would have been deemed to have spent 3 minutes on Facebook, as would someone who surfed Facebook for the entire shift. My guess based on my observation of computer use in my emergency departments is that the methods caused the times of use to be overestimated.

And the study also reminds us of another important point … when you’re on a work computer, what you’re doing is being watched.

05.24.13
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A New Home for The EM Res Podcast and Blog!

I started the EM Res Podcast and Blog about one year ago, and things have taken off in that time.  To accommodate the growth of the podcast and the blog, I am excited to announce that I have a new website: www.emrespodcast.org.  ​

The new site offers a number of exciting advantages.  First, it offers a better aesthetic and navigation across all platforms, including smartphones and tablets.  It is overall much cleaner and easier to use.  It is also everything EM Res in one location.  You get the blog, the podcast, and the show notes all in one place.  The podcast is still on iTunes, but is also hosted here for streaming from any device.  The new format allows for easier commenting and interactivity between myself and readers/listeners.  The search functionality is much easier, allowing you to search blog posts and podcast episodes all at the same time.  I can also make more dynamic, involved posts with more capabilities than I had before.  Finally, you get one click connectivity to all my social media outlets, including Facebook, Twitter, Google, Vimeo, and Tumblr.   

For those of you who are die hard Tumblr fans and following that, the Tumblr site is not going away.  You can still follow along there, as all future blog posts and podcasts will be pushed to Tumblr as well.  ​

Thank you all for reading, listening, and making this such a fun and rewarding experience for me.  Hopefully you get as much out of it as I do.  I’m looking forward to what the next year has to bring, and please bookmark/head on over to emrespodcast.org!​

05.24.13
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Heat-Related Illness

Hot in Herre

With the subtly that only Mother Nature has, the days in the Northern Hemisphere have started to get longer and become consistently warmer.  This, along with the fast approaching end of the school year, heralds the beginning of summer time.  Summer time certainly brings wonderful times… and a new assortment of potential hazards!  While we rightly focus on bike safety and swimming safety, let us not forget the dangers of heat-related illness.

Heat-Related Illness

  • Spectrum of disease from mild, self-limited illness to major, life-threatening conditions.
  • The vast majority of patients presenting to the ED with heat-related illness will be able to be discharged from the ED (~93%).
  • There majority of the morbidity and mortality associated with heat-related illness is preventable.

  • Heat Cramps

    • Painful muscle spasms.
    • Body temperature is normal. There is associated sweating. No CNS derangement.
    • Treat with fluid re-hydration and pain control. 

  • Heat Exhaustion

    • Systemic symptoms exist – dizziness, postural hypotension, nausea, vomiting, headache, weakness, and syncope.
    • Body temperature can be normal or moderately elevated. There is profuse sweating.
    • Often seen in unacclimatized individuals.
    • Low morbidity when treated appropriately.
    • Cause is salt or water depletion.
    • Treat with cooling measures and re-hydration.

  • Heatstroke

    • State of complete thermoregulatory failure and multiorgan system dysfunction.
    • Mortality ranges from 17% to 80%.
    • Present with CNS derangement: disorientation, seizures, or coma.
    • Other organ system derangement: hemorrhagic complications, rhabdomyolysis, intestinal ischemia, etc.
    • Classic Heatstroke
      • Seen typically in extremes of ages (infants and elderly).
      • Develops over a period of days.
      • Skin is hot and dry.
    • Exertional Heatstroke
      • Most commonly seen in the <19 years of age population.
      • Skin may be dry or sweating.
      • Temperatures range 41.1 to 42.2 C.
      • Greatest risk seen in those performing high-intensity exercise for a relatively short time span.
    • Treatment requires medical stabilization (ABCs), cooling measures, and re-hydration.

  • Cooling Measures

    • Use all means to dissipate heat (convection, conduction, evaporation, and radiation).
    • Spray the skin with room-temperature water and direct fans to blow across the patients skin.
    • Ice pack to groin and axilla can be added, but do not apply ice-water widely over the patient’s body surface, as this may cause vasoconstriction and impair heat dissipation.
    • Continuous hemofiltration can be a useful strategy to lower the temperature and also deal with potential multi-system injury.

     

Prevention is Better than Therapy

I think that prevention education can be administered to anyone at any time… for instance when you are sewing the star softball player’s forehead.  Here are a few pointers that parents can use to keep their kids from having heat-related injuries… and, thus, stay out of your ED.

Stay cool!
  • Schedule events during cooler hours of the days.
  • Arrange to be back in cooler environments during the hottest times.
  • Taking frequent breaks.
Start drinking fluids before the activity!
  • Unfortunately, if they start the activity dehydrated, they are going to have a hard time becoming adequately hydrated.
Drink often during the activity!
  • It is important to drink even if “not thirsty.”
  • Drinking 8 – 16 ounces of fluid (water or appropriate sports drink) every 20 minutes has been recommended.  This may need to be adjusted for the age and size of the child.
  • AVOID caffeinated and alcoholic beverages (naturally).  Excessively sugary drinks (like sodas) are also not recommended.
Know the weight of the matter!
  • Knowing pre-activity weight and post-activity weight can give an indication of the actual amount of water that has been lost and, thus, needs to be replaced.

 

  1. Center for Disease Control and Prevention: Nonfatal sports and recreation heat illness treated in hospital Emergency Departments – United States, 2001-2009. Morbidity and Mortality Weekly Report. July 29, 2011; 60(29): 977-980.
  2. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Climatic heat stress and the exercising child and adolescent. Pediatrics. 2000; 106: 158–159.
    Falk B, Dotan R. Temperature regulation in elite young athletes. In The Elite Young Athlete. Chapter 8, edited by Armstrong N, McManus AM. Unionville, CT. S. Karger Publishers, Inc. 2011; 56: 126-149.

The post Heat-Related Illness appeared first on Pediatric EM Morsels.

05.24.13
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Sesiones PAC: Manejándonos en la incertidumbre

Es lo bueno que tiene ser un grupo variado: los temas de nuestras sesiones también lo son. Hoy nuestro compañero Marcos Ruiz (médico del CS de Lesaka) nos ha hablado sobre algo que nos rodea a todos en nuestra tarea habitual: la incertidumbre. Ha hecho una bonita reflexión sobre este ingrediente siempre, o casi, presente en nuestras consultas y nos ha dado algunas pistas para aprender a torearla, a asumirla y a tomar decisiones a pesar de su inquietante presencia. Escuchar al paciente, ser sinceros, valorar el enfermar como un proceso bio-psico-social y compartir las decisiones fomentando la autonomía del paciente son elementos a tener en cuenta.
Muchas gracias, Marcos, lo has hecho muy bien y creo que nos será muy útil reflexionar sobre lo comentado.
Y como de costumbre, os dejo con su presentación.

05.24.13
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Maximizing Conferences through Twitter


Conferences are necessary. It’s how we network, exchange research ideas, and share advances in emergency medicine. The reality is that we cannot attend every conference out there because of time, money, and schedule conflicts. But thanks to Twitter, it is no longer necessary to be physically present to reap benefits of a conference.

This post lists information on how to get involved and stay involved with the Twitter conversation and learn from our great conferences without breaking your bank or schedule.


Tweets
In general there are 5 different types of tweets that are sent out from conferences:
  1. Session related – discussions about sessions/workshops
  2. Social – arranging unofficial meetings/meeting new people
  3. Logistics – change in room locations/events, information about an individual’s presentation
  4. Advertising – Tweets from companies present at the meetings
Efficiently filtering through the various tweets will expose you to new material, gain exposure to expert opinion on evidenced based medicine, while also be sure to not miss out on a poster session due to a venue change.

#  Hashtags
Knowing which hashtag to follow is the next step. Generally conference hashtags are intuitive and therefore searchable. For example, this past SAEM meeting's hashtag was #SAEM13. Simply using your twitter account to follow the hashtag will keep you in the loop of the conversation. Websites such as Symplur and its Healthcare Hashtag Project can help you create hashtags for conferences and keep track of healthcare related conferences that are easy to find and follow.

Contributing and filtering conference tweets
It can be overwhelming deciding whose tweets to follow while at conferences. Admittedly, it can be distracting if you are in the middle of an interesting session but can’t put down your twitter feed that is buzzing about another session next door. Some people will tweet 1-2 pearls per workshop, while others are giving a second by second playbook to the action, akin to a CNN newsfeed. It is up to you to decide which type of tweeting is your style.



Introducing ALiEM Conference Twitter account (@ALiEMconf)
The writers at this blog have decided to create a joint twitter account that can represent the ALiEM blog at conferences. Our goal is to share pearls, evidence based medicine, and exciting events in the world of emergency medicine. 

Virtually follow us at conferences and join in on the conversation!


Note: David Marcus, EM IM resident from Long Island Jewish Hospital in NYC has also approached the problem of getting conferences onto the social media band wagon. Through his blog www.emimdoc.wordpress.com, he has assembled an up to date list of upcoming EM/IM/Critical Care conferences with affiliated hashtags.

Please share your comments!

Nikita Joshi, MD 
(@NJoshi8)
Medical Education Fellow
Stanford University, Division of Emergency Medicine

References:
Neill A et al. The Impact of Social Media on a Major International Emergency Medicine Conference. Emerg Med J 2013; 0: 1 – 4. PMID:23423992.

05.24.13
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More Endovascular Junk Science


So far, we've seen nothing but poor outcomes in endovascular cerebral reperfusion trials.  The MERCI devices were simply dysfunctional and lethal and, despite advances with newer devices, we're still waiting for a decisive trial demonstrating clear benefit.  But, the money is out there for the taking if the science will support it – and thus, more "science".

This is a study involving authors sponsored by Stryker who do a retrospective review of cases at two hospitals, comparing infarct volume and short-term outcomes of patients who underwent either endovascular intervention, conventional thrombolysis, or no treatment for their large-vessel acute ischemic stroke.  The accompanying editorial probably sums up their limitations best:
"Retrospective, nonrandomized nature of the study; the comparison between 2 hospitals in the same health care system in which endovascular interventions were performed in one and not the other, which may have resulted in some unintentional differences in overall care; the combining of data among patients who received intravenous thrombolysis with those who received no reperfusion therapy, which may have diluted treatment responses; ... and the lack of long-term clinical outcomes that could be correlated with the imaging findings."

So, they have a collection of patients for whom it is in no way appropriate to compare outcomes and generalize any sort of conclusions – and that's precisely what they do.  And, specifically, after reporting full-cohort baseline characteristics, their conclusions are based on subgroups of that cohort – and using an imaging surrogate outcome measure!

I'd tell you these authors conclude patients with an NIHSS of 14 or higher may be the best candidates for endovascular reperfusion therapy – but then I'd be further perpetuating this "science".  Again, what they claim may be true – but they're overestimating the ability of their data to claim it.

"Comparison of Final Infarct Volumes in Patients Who Received Endovascular Therapy or Intravenous Thrombolysis for Acute Intracranial Large-Vessel Occlusions"
http://archneur.jamanetwork.com/article.aspx?articleid=1686897
05.24.13
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Paediatric UTI – Dispelling the Myths

UTI is a problem that is frequently reported as a source of infection in children, but in a recent paper by Newman, Shreves and Runde some of the dogma surrounding this common problem was examined with some interesting conclusions;
  • Asymptomatic bacteriuria is as common in children as it is in adults, which suggests that a significant proportion of children labelled as having a UTI may just have asymptomatic bacteriuria rather than a pathologic infection.
  • True urosepsis in the paediatric population is rare and less often life threatening than other causes of sepsis and usually limited to high risk groups such as neonates and those with congential anomalies.
  • UTI frequently progresses to pyelonephritis in the paediatric population, and scarring of the renal cortex is a common sequelae of this process.
  • The current evidence does not support the fact that renal scarring results in longer term kidney problems such as hypertension and the need for dialysis.
  • The majority of the literature shows no change in incidence of renal scarring with early vs. late antibiotic administration
  • Prophylactic antibiotics appear to be non-beneficial (although a small benefit may possible)
  • Surgical correction of vesicoureteral reflux is non-beneficial.
  • Imaging of the renal tract after UTI leads to little yield.

Reference
  1. Newman D, Shreves A, Runde D Pediatric urinary tract infection: does the evidence support aggresively pursuing the diagnosis? Annlas of EM; 2013; 
05.24.13
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You are EMS

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In honor of this year’s EMS Week (May 19th to the 25th) I  asked others to share EMS-related events that had a profound impact on their life. Below is what my friends and colleagues chose to share. Mine is already posted here.

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David


YOUR STORIES

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 Russ

I remember responding to a call on rt 280 a car crossed over the center striking a camero killing a young lady driver instantly. A guy was notably upset found out later it was her husband who was following her home they had just bought the camaro. A call that went in slow motion.

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Dave

So many thoughts, so little time. I will say the majority of my memories are of my fellow EMS personal I worked side by side with. The look in their eyes, the touch of their hand, the knowledge we were all on the same wave length as we worked to aid the ill and injured…stamp out death, dying, and disease…and stop the grim reaper. As I can still see some of the patients I cared for, remember the smells of their homes, and even feel the heat/cold of the ambient temperatures of the area we cared for them in. My most vivid memories are of the people who have dedicated their lives and time to care for people they never met. Congratulations to all of you and thank you for all you did, do, and continue doing.

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Meghan

The car accident with Ronnie Sansone. A night with Jen I will never ever forget.

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Pam

First CPR save.

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Christine

My mutual aid infant code at Rutgers when I wasn’t even working, just visiting . I can still see the wispy hair on his head.

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Joan Marie

Sitting down to a holiday dinner and having all three sons have to leave to take a call (more than once). 

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Mike

The night of the South Orange Rescue Squad fire and feeling helpless watching it burn! But we were back in service the next day, Thanks to Maplewood Fist Aid Squad, And St. Barnabas loaning us ambulances to use and a local business giving us space to work out of. 

August 23, 1989 at 11:30 pm South Orange Police Officer John Monsees was shot in the line of duty while responding to a burglary in progress, If having a friend shot is not bad enough, his wife was on on dut with us that night. John recovered from his wounds.

Responding and transporting patients brought over by boats to Liberty State Park on 9/11.  

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Lesli

New to Brick City

At the age of 19, I got my first EMS job in the city of Newark at UMDNJ.  I had arrived.  I rode around that city day in and day out on that ambulance and learned some very valuable life lessons.  I was as green as they come but I learned quickly.

The most important lesson I learned early on was while riding with my partner through south Newark.  We came upon what appeared to be an abandoned building and I said to him that it was a shame that all the windows were broken out because if they weren’t, then people could live there.  He then replied, “Oh people live there.”   I was appalled and shocked and had a difficult time hiding it.  I then said to him, “It is terrible that people have to live that way.”  He then said, “Oh, they’re used to it.”  I was quiet for a moment and then I replied, “That doesn’t make it right.”

It was on that day that I really realized that we are all human beings.  No matter where we live, or how we grow up, how we dress, or behave.  Everyone comes from somewhere, and each one of us is someone’s something; mother, father, sister, brother, son, daughter, or friend. We all deserve to be treated well regardless of who we are or where we live.  I have carried that lesson with me throughout my life and it has served me well.

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Joslyn

The first time I did CPR was on a young, previously healthy woman in her 30s who aspirated while eating lunch and went unresponsive. I was 16, a brand new EMT.

The medics pronounced on scene, but even after we stopped I couldn’t take my eyes off her sneakers – white, laced up, brand new – I can still see them today. It made me think that when she left the house that morning, and put those sneakers on, she never planned for this to happen.

My late partner, Tony (who must have noticed me staring), read my mind, then said out loud, “No one ever sees this coming. That’s why we do what we do. Not so we can save everybody- because we won’t- but to be ready to act when bad things happen, and so that the loved ones of each of our patients know that everything possible has been done for them.”

I never forgot his words, or that day. Ironically, a few days after that, her sister wrote a letter to our squad thanking us for trying to save her sister’s life, and the efforts we made that day. EMS is not just about making a save- it’s about touching lives and providing comfort and compassion when it’s needed most. In the scuffle of day-to-day, too often, we lose track of this.

 


05.24.13
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ECG of the Week – 27th May 2013

This rhythm strip is from a mid forties male who presented following an episode of syncope.
He complains of nausea and dizziness on arrival to the ED.
Whilst being assessed he has an episode of unresponsiveness, the rhythm strip below was taken during this period.




Click to enlarge
Paper speed 25mm/s
VAQ Corner


This rhythm strip is from a mid forties male who presented following an episode of syncope.
He complains of nausea and dizziness on arrival to the ED.
Whilst being assessed he has an episode of unresponsiveness, the rhythm strip below was taken during this period.

a) Describe & interpret his ECG (50%)
b) Outline your management (50%)
05.23.13
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#SAEM2013 on Twitter

The Society for Academic Emergency Medicine just held it’s 2013 Annual Meeting during mid May.  Before the conference the hashtag #SAEM13 was advertised online by SAEM and in distribution materials.

Here is a collection of some of the Symplur graphical interpretations of the hashtag usage at the conference.  All of the tweets that were pulled by a #SAEM13 search during the conference are listed, the last pull being on May 18th, after the conference was finished.

There are 1.767 tweets in the list (including retweets).  Enjoy the pearls chosen by our colleagues for sharing via twitter.

 

 

 

05.23.13
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Digoxin toxicity: check the magnesium level!

digoxin3 out of 5 stars

Digoxin Toxicity with Normal Digoxin and Serum Potassium Levels: Bewre of Magnesium, the Hidden Malefactor. Rao MPR et al. J Emerg Med 2013 May 16 [Epub ahead of print]

Abstract
This case report from Oman describes at 66-year-old woman (inexplicably described as “elderly”) who presented to hospital with one day of nausea, vomiting, abdominal distress, and palpitations. Her medications included furosemide, spironolactone, digoxin, carvedilol, lisinopril, metformin, and calcium. Initial EKGs showed evidence of junctional tachycardia and digoxin effect.

The treating physicians initially considered digoxin toxicity, but were nonplussed when testing showed that both the digoxin and the serum potassium levels were “normal”. [Digoxin = 2.4 nmol/L; potassium = 3.9 mmol/L]  However, further testing revealed significant hypomagnesemia. [Serum magnesium = 0.39 mmol/L, with normal = 0.65-1.25]  After magnesium repletion with 2 g given over 60 minutes, the increased automaticity resolved, and her EKG showed a sinus rhythm at a rate of 70 beats per minute. No digoxin immune Fab was administered.

In the discussion of this case, the authors touch on the following important points:

  • Enhanced automaticity and impaired conduction are hallmarks of digoxin toxicity.
  • Hypokalemia and hypomagesemia sensitize the myocardium to digoxin
  • Digoxin toxicity can be precipitated by conditions such as hypokalemia, hypomagnesemia or hypothyroidism, even if the digoxin level is “normal”.
  • Administration of magnesium is contraindicated in patients with bradycardia, AV block, or severe renal failure.

Note that although a serum digoxin level of 2.4 nmol/L is technically “therapeutic” [reference level 1.9-2.6 nmol/L], some recent commentators have recommended lowering the upper therapeutic level by about 50%.

The key take-home lessons:

  1. Do not depend solely on laboratory values to diagnose digoxin toxicity.
  2. If digoxin toxicity is suspected, check the magnesium level.
05.23.13
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Welcome to ED

Welcome

Hello and welcome to ED

Here are some useful resources for doctor’s starting off in ED. They are short videos about how we approach common ED presentations. They are also available in audio format so you can listen and learn on your bike, at the gym or in your car.

The approach to an ED patient

Chest pain

Headache

Sepsis

Syncope

Toxicology

Shortness of Breath

Abdominal pain

This page will be expanded and updated regularly.

Enjoy

The post Welcome to ED appeared first on EM Tutorials.

05.23.13
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Senkop hastası ve EKG’si – Tanınız Nedir?

Brugada Tip 2

Bu EKG, hastaya tanıyı koyan MÜTF Acil Tıp AD asistanlarından Dr. Ömer Faruk Çelik tarafından çekilmiş ve paylaşılmıştır.

 

21 Mayıs 2013 tarihinde Senkop ile acil servise başvuran hastada yukarıdaki EKG çekilmiştir. Tanınız nedir?

Yorumlara yazabilirsiniz.

Aşağıdaki video usta Amal Mattu’dan. Yukarıdaki vakanın tanısına yönelik ayrıntılı bir anlatım yapıyor. Bu video 4 Mart 2012′ye ait.

Diğer Yazılar

The post Senkop hastası ve EKG’si – Tanınız Nedir? appeared first on acilci.net.

05.23.13
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24 yo woman with chest pain: Is this STEMI? Pericarditis?

A 24 yo with no past medical history and no risk factors except for tobacco smoking presented with chest pain.  The pain started in her left chest at 6:20 AM and radiated up through her arms and into her back. She admitted to drinking heavily the previous night and returned home about 1:30 or 2 AM.  She had multiple episodes of vomiting overnight. She's never had chest pain like this before.  BP was 140/100 and pulse of 93.  There was no rub on exam.

Here is her prehospital ECG at 0720:

Sinus rhythm.  Inferior and lateral ST elevation with reciprocal ST depression in aVL.  There is no significant PR segment depression

She was given 2 sublingual NTG and her pain improved from 10/10 to 7/10, and continued to improve.  Here is her first ED ECG at 0748:
Not much change except for less STE in lateral leads.


Chest X-ray confirmed absence of Boerhaave's syndrome.

Some might suspect pericarditis in a young person with diffuse ST elevation.  However, you diagnose pericarditis at your peril!  I believe pericarditis is over diagnosed, even in the literature, and that many cases assumed to be pericarditis in the past would not be proved to be Acute MI.  This is conjecture based on many cases that I have seen, not based on peer-reviewed evidence.

Furthermore, in our study of benign inferior ST elevation vs. inferior STEMI, ST depression in aVL was nearly perfect in diagnosing MI.

I activated the cath lab immediately. A bedside echo performed by a world expert, Dr. Asinger, showed no effusion, and he could not discern a wall motion abnormality.  The patients pain was almost gone by this time. 

While waiting for the team, we recorded another ECG at 0826:

Again, not much change.

And a right sided ECG at 0827:
This appears to show right sided ST elevation, though perhaps not a full mm.  This strongly suggests an RV infarct. 

At cath, the culprit was a proximal LAD lesion (open, with TIMI-3 fllow)!  It had embolized to the distal LAD, which was a "type III" or "wraparound" LAD supplying the inferor wall.  So this was an antero-infero-lateral MI.  The proximal lesion was stented and the distal was treated with antiplatelet and antithrombotic therapy.

The next day she has reperfusion T-waves in the anterior leads, as well as inferior and  lateral leads:

Looks like Wellens' syndrome in anterior leads, because it is analogous.

Formal Echo later showed moderate hypokinesis of the septum and dense hypokinesis of the apex and inferior wall.  Peak troponin I was 24 ng/ml.

Lessons:

1) Young women have myocardial infarction.  They need not have a lot of risk factors or do cocaine.  In these patients, MI is underdiagnosed, or diagnosis is delayed, probably because of the bias that leads us to say, as my chief of EM always expresses it: "Nah, couldn't be."  MI is much more common in young people, including women, than previously recognized.  Many MI in very young women, but not even most, are due to spontaneous coronary dissection.  If the ECG is diagnostic, as in this case, believe it!  Do not try to convince yourself that it "couldn't be."

There was a major article published in fall of 2012 showing that young women with STEMI have longer Door to Balloon times and higher mortality.  I cannot find it now and if anyone has the reference, please let me know.  There are a couple smaller studies with the same findings here and here.

2) You diagnose pericarditis at your peril

3) Absence of Wall motion abnormality may be misleading, especially if the pain and/or ECG abnormalities have resolved.  In this case, the difference between the informal and formal echo was the use of Definity contrast.


05.23.13
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On EKGs and Bicarb for Hyperkalemia

Just watched Amal Mattu (and Andy Neill’s) great EKG review, this time on (spoiler alert) — hyperkalemia! (If you’re not watching these videos, you’re missing out on free, amazing education from I think the best EKG teacher in the world.)

But I think there are two things worth mentioning:

You cannot — and should not — use an EKG to “rule out” hyperkalemia. I completely agree with Amal — if you see a bizarre looking EKG, you should think tox, potassium or calicum derangement (I like to throw LBBB in there too), but a normal EKG won’t rule out diddly squat in your patient. A few studies-in-point:

The Ability of Physicians to Predict Hyperkalemia From the ECG: Took patients with known hyperkalemia in the ED, had two physicians use the EKG to determine if the patient had hyperkalemia: sensitivity around 0.4; specificity around 0.85. Not great.

Electrocardiography is unreliable in detecting potentially lethal hyperkalaemia in haemodialysis patients: Took dialysis patients, got a pre-dialysis potassium level, and looked at T waves, R waves, ratios. Again, no correlation (but these patients had an average K of 4.9).

A few other cases:

And secondofly — I’d have to disagree on Amal’s recommendation of bicarb.

Sodium bicarbonate does not work — or at least, does not work well, or on its own — for treating hyperkalemia. And in patients with fluid/volume issues (heart failure, renal failure — you know, the typical people who get hyperkalemic), I always worry about giving a big intravenous hyperosmotic sodium bolus to these patients (as my nephrology professor used to remind us — “water follows sodium”). (NB: This was brought to my attention by one of my co-chiefs, Kim Medlej, who finished a critical care fellowship last year at Harvard, and now practices in Lebanon, so all the credit is his.)

Quick summary: We’re all taught bicarb works within 30 minutes, by intracellular shift/exchange of potassium ions for hydrogen ions, yada yada yada. That really doesn’t appear to be the case. I think in the ED we’re sometimes taught to just give them an amp or two of sodium bicarb, but that appears to have NEVER been studied. In the crashing/dying patient, yes, I give sodium bicarbonate, but I’m otherwise skeptical of the benefit and worried about the harm.

All the studies have really looked at bicarb infusions over hours, and if there’s any change to be found, it’s maaaybe at the 6 hour mark (after 6 hours of bicarb infusion, in patients who are already getting dialysis). Other studies with bicarb infusions show no statistically significant change, either. (One study that took patients and put them on a high or low dose bicarb infusion for an hour actually found a higher potassium levels after the infusion.) Probably the best study (Blumberg, 1992) found only a 0.5-0.7 drop, but they then attribute half the drop to the expansion of the ECF due to all the sodium the patients got.

Insulin definitely works. Albuterol works (but the studies are small and they usually give a good 10-20mg of it nebulized). There have been a few studies looking at combining bicarb + either of these other methods, and it looks like the bicarb probably DOES have some synergistic effect (it lowers the potassium more than just, say, albuterol alone). But by itself? Bicarb is probably pretty worthless.

Reviewing the literature, it seems like the insulin/D50, albuterol (? Lasix, not much literature on it) methods are the way to go. I know before I read this literature I felt better because I’d given the person kayexalate, or I’d given them bicarb, but really, the other methods are much more likely to keep the patient alive on the floor for 6 hours while they await their dialysis, without putting them into florid fluid overload.

To the stable, no dysrhythmias or severe symptoms patients I tend to give:

  • Regular Insulin 10 units IV with 1-2 amps D50
  • Albuterol 10mg nebulized
  • Calcium Gluconate 1-2g IV
  • Lasix if they make urine (pick your dose)

I’ve summarized the literature and we can send you the articles if you’re curious:

Burnell, 1956 http://www.ncbi.nlm.nih.gov/pubmed/13367188 Looks like this is where a lot of it started. Many articles from the 70s/80s cite this one. There’s very little on their methodology, but they have some pretty cool graphs that show an inverse relationship between pH and serum potassium concentration.

Schwarz, 1959 http://www.ncbi.nlm.nih.gov/pubmed/13629781 Case series of hyperK patients who had EKG changes who got better with bicarb. (Some of them got calcium as well, others required “5-10 grams of bicarb a day,” others got bicarb + blood transfusion.)

Fraley, 1977 http://www.ncbi.nlm.nih.gov/pubmed/24132 Methods: Took 14 hyperK patients, gave them bicarb infusions over 4-6 hours. Checked K every hour. Results: Divided groups retrospectively into “constant pH” and “changed pH” groups. Both groups showed decreases in their potassium, ~1.6-1.8mmol/L (never seen this significant of a drop reproduced).

Blumberg, 1998 http://www.ncbi.nlm.nih.gov/pubmed/3052050 Methods: Took 10 HD patients, checked their K (along with other labs), gave them a bunch of different agents for changing K (bicarb, insulin, epi drip, regular dialysate), and then checked their labs after an hour. For bicarb, it was 8.4% in water, 4mmol/min, for 1 hour only. They also tried a isotonic bicarb infusion of 1.4%. Results: The K actually went UP after both bicarb infusions.

They conclude that bicarb didn’t work, but in the past it’s worked over longer periods of time. So then they do …

Blumberg, 1992 http://www.ncbi.nlm.nih.gov/pubmed/1552710 Methods: Took 12 hyperK (>5.8) patients on dialysis, gave a bicarb (8.4% in free water) infusion 4mmol/min x1 hour, then 1.4% bicarb in water infusion 0.5mmol/min hours 2-6 and checked potassium levels throughout the time on dialysis. Also checked an EKG. Results: Average K was 6.0. K dropped at 4-6 hours, by 0.5-0.7, and they believe that half of the drop is probably due to the huge sodium load and increase in the extracellular fluid compartment.

Allon, 1996 http://www.ncbi.nlm.nih.gov/pubmed/8840939 Methods: Took 8 HD non-HyperK patients, put them through different combinations to lower their K (bicarb infusion, saline infusion, bicarb+insulin, saline+insulin, bicarb+albuterol, saline+albuterol). Results: Bicarb or saline infusions didn’t work. Anything with insulin or albuterol the combination worked, lowered them from 0.5-0.8, depending on the group. Of note, bicacrb + albuterol worked better than saline + albuterol (see Kim, 1997).

Kim, 1997 http://www.ncbi.nlm.nih.gov/pubmed/8852501 Methods: Took 9 HD hyperK patients, gave them separate or combined bicarb infusions (1/2 hour long) along with nebulized albuterol, checked K before and after. Thought maybe there would be combined/synergistic effects of the two meds. Results: Bicarb alone didn’t change the potassium. Salbutamol alone dropped the K by 0.6, and salbutamol + bicarb dropped the K by 0.9.

Kaplan, 1997 http://www.ncbi.nlm.nih.gov/pubmed/9043534 Methods: Took 8 dogs, gave potassium infusion until they got conduction disturbances, then backed down on the K, and gave either bicarb infusion (1.05% over 1 hour), bicarb bolus (8.4% over 5 minutes, then saline), or “saline” therapy (hypertonic saline 8.4% bolus + normal saline). Measured K before and after. Results: Saline worked just as well as bolus. Infusion worked better than both (but not statistically significant). Change was 1-2mmol/L.

Review Articles:

Kim, 2002: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3054237/ Don’t recommend bicarb, especially as a single agent, especially in dialysis patients. “Should not be used.”

Weisberg, 2008: http://www.ncbi.nlm.nih.gov/pubmed/18936701 Definitely doesn’t work short-term, but might still be useful for temporizing hyperK. “It has now been clearly demonstrated that short-term bicarbonate infusion does not reduce PK in patients with dialysis-dependent kidney failure, implying that it does not cause K shift into cells. Infusion of a hypertonic or an isotonic bicarbonate solution for 60 mins has been shown to have no effect on PK in dialysis patients, despite a substantial increase in serum bicarbonate concentration.”

Rachoin, 2010: http://www.ncbi.nlm.nih.gov/pubmed/21661096 “When treating hyperkalemic patients, hospitalists should use sodium bicarbonate to potentiate urinary elimination of potassium and should consider administering it either with acetazolamide or a loop diuretic, anticipating a lowering effect after a few hours.26 It should be avoided in patients with volume overload and anuria. Immediate translocation of potassium into cells is best achieved by insulin and b-2 agonists.”

Would love to hear others’ thoughts!

05.23.13
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Testes…testes…123.

My hand was shoved down, awkwardly positioned between the folds of trousers and half-pulled down underwear, in the man's groin crease, trying to palpate his testicles without pulling any of his pubic hair. Something didn't feel right, but it wasn't his testicles.

I was in my final surgical OSCE's and it was my first station, where the adrenalin was flowing and my mind was racing faster than my running commentary...

...and I would be checking to see if there were any hard lumps in the scrotum, or if I could not get above the swelling...

I had only just recovered from initially describing my landmarking for the deep inguinal ring as the "midpoint between the pubic trochanter and the anterior superior iliac spine" which caused my examiner to hover his pencil over the marking pad as I searched for the correct word that started with a "T".

TUBERCLE. Tubercle. Tubercle. Tubercle. Dammit. 

 Check.

Initially I hadn't been too flustered. It was a groin exam for a lump, which is pretty standard on a surgical final. But I didn't think that we'd be expected to actually tackle the tackle in the exam. I said the usual "Ideally I would like to expose the patient fully and perform a genital exam to complete my hernia assessment" and waited the beat for the examiner to butt in, rescuing the patient from a succession of 32 fumbling medical students.

Silence.

Maybe he hadn't heard me.

Ideally I would like to EXPOSE the patient fully and perform a genital exam...

Still nothing. So I went for it. Which is how I found myself rolling this 70 year old man's testicles around in my hand at 0905h on my last day of medical school, wondering WHAT it was that didn't seem right.

It wasn't until my rest station a few stops later that I saw, between a one inch crack in the curtain, a colleague pulling on a pair of gloves.

OH FUCK! 

That was what felt weird. I have been a nurse for 5 years and a medical student for 4. I put on gloves when I hear the ambulance bay doors open, even before I see the patient. So WHAT THE HELL WAS I THINKING DOING THE EXAM BARE HANDED?!?!? What felt weird was the fact that I didn't have a nice latex barrier between myself and that poor man's private parts.

I started wondering if maybe my mistake had been a red flag (i.e. cause for failure of my surgical OSCE's as a whole). When one of the emerg docs walked by and asked how I was doing during a later rest station I told her, "Well, pretty good for starting the day by ball handling without gloves, how's your day going? Do you think I red flagged???"

She said she couldn't be sure but told me not to worry as once during her emergency medicine exams she put in a chest tube without gloves (I'll point out that this involves sticking a FINGER INTO THE CHEST after you've made an incision in the rib cage). She did make me feel better.

Afterwards with some of my classmates during our postmortem on the exam I confessed to my ridiculous oversight. The color drained from one girl's face as she suddenly realized that she had done the same. Ohmygodohmygodohmygod. She seemed to be quite disturbed by this realization. It wasn't until much later in the evening when she had consumed a few celebratory pints that she approached me at the bar and confessed.

You know how freaked I got about not wearing gloves? Well...I couldn't tell you at the time because I was so mortified....but mostly the reason I was so upset was that when you said that I realised that right after that station I had EATEN A SCONE!!!!!








05.23.13
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The heart of a lion

This is a column of mine, published at Girls Just Wanna Have Guns.

Here’s the link:  http://girlsjustwannahaveguns.com/2013/04/heart-of-a-lion/

 

 

I was getting ready for work one morning, around 6 am, when I heard soft footsteps on the stairs. My youngest son, then 11, emerged into the entry way.  He was stepping carefully and in his right hand was his favorite Cold Steel brand machete.

I asked, ‘so, what’s up?’  (I was a little afraid he was sleep walking and would make quick work of dear old pop before I could get to the ER to take care of other injured folks.)

He replied, ‘I heard noises but wasn’t sure who was down here.’

Bottom line?  He was ensuring his family was safe.  And woe to any poor soul who felt the wrath of his blade.

We had a chat.  I praised him for his bravery and then added a parental caveat:  ‘but, if you think we have an intruder, you must come and tell me or your mother.’

Like his siblings, he’s passionate and brave.  A student of history, he loves the idea of chivalry.  My children and I have had many long talks about courageous persons of the past, about battles and strategy and about the merits and disadvantages of ancient weapons.  My son’s walls, and the walls of his brothers, are festooned with assorted swords, axes, daggers and archery equipment.  Even little sister has a favorite blade, stored in her room in case of emergency.  (Don’t panic.  They’re unsocialized homeschoolers, so this is pretty normal in our world. Along with reading books that aren’t politically correct and going to school without bullies.)

Contrary to popular wisdom in the public school systems of the West and the lame-stream media, my kids are about as gentle and kind as any on earth.  Not that they aren’t capable of doing harm.  But you’d have to push pretty hard for them to launch a spear or tomahawk your direction.  And by that, I mean you would probably have to break into their home and threaten to harm them or the rest of the family.

I think there are some lessons here; and not just because I’m proud of my children.  The first lesson is this:  freedom can only be preserved when we teach our children valor.  This means explaining to them that there are times in life for bold, decisive, even dangerous action. There are times when it is appropriate to confront evil with force.  If we raise generations who believe that the most dangerous threat can be mitigated with hugs and negotiations, then freedom will die along with all of those who try to understand and dialog with tyrants and psychopaths.

Teaching valor involves telling stories of the past, talking about the news of the day, and providing our children with fitness and the sort of activities considered completely appropriate in centuries past; things like wrestling, boxing and marksmanship.

But here’s the second lesson.  Just as freedom must always be balanced by responsibility and accountability, so courage and valor must be kept in dynamic tension with morality and mercy, with kindness and gentility.  We cannot raise men, or women, capable of violence (and every human being is) if we deny the value of morals and ethics.  We may fight in the front yard with heavy plastic swords, shoot arrows at targets or shoot clay-pigeons with shotguns.  But we also discuss right and wrong through the lens of history and the teachings of our faith.

The world is dangerous.  And those of us who believe that self-defense is a right granted by the Creator, not sanctimoniously granted by politicians who think we’re peasants, also believe that we have to prepare our children for those dangers, moral and physical.

Much of the world disagrees with that assessment.  Oh, they know it’s dangerous.  But they don’t want anyone prepared to deal with it in any way other than calling 911 and waiting for the inevitable end.  Because of this, they want the masses disarmed.  But here’s what they don’t understand. Self-defense doesn’t reside in the weapon, but in the spirit.

This is what we have to teach our next generations.  Weapons are necessary to combat both tyrannical rulers and dangerous individuals.  Americans have developed a unique passion for the creation of weapons and the appropriate use of weapons.  But ultimately, the weapon is secondary.  The heart and mind are most important.

If we do that, if we teach right and wrong, if we teach freedom and justice, if we teach chivalry and courage, then the weapons themselves are not the issue. Trust the guy who saw the fire in the eyes of his son, who was prepared to clear the house of bad guys with nothing more than his machete…and the heart of a lion.

05.23.13
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Internal Medicine Senior Poster

At the end of every year, the Intennal Medicine residency at Hennepin County Medical Center holds a poster session for the graduating senior residents. Each resident is encouraged to display work from their time during residency. Most residents prepare a poster on research they worked on or quality improvement projects. Others have shown off education innovations they came up with, or simulation cases they developed.

I enjoy sketching/drawing and have prepared many figures for the presentations, papers, lectures, blog posts, and teaching that I have done during my residency. I thought it would be fun and unique to prepare a poster with a sample of my art. Nothing earth shattering, but I hope you enjoy.

Bruen_IM_Senior_Poster_Session

05.23.13
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Clinical Case 086: from Hell’s heart I stab at thee

Today’s case is a tough one.  This is not a happy story, but can you make it end well?

So lets lay it out and narrow it down to a few key decision points.

The patient is a 35 year old woman with a long history of schizophrenia – she has suffered with persecutory, paranoid delusions for many years.  She also has a tendency to use alcohol to “self-medicate”.  She is closely monitored by a community mental health team and has been managed under a community-treatment order for the last few years.

Recently she has been under a lot of stress and she has increased her alcohol use.  You have seen her in ED a few times with self-inflicted injuries resulting from delusional actions.

Tonight she has been brought in by ambulance after another delusional, self-inflicted injury….

Our patient has taken a long blade and hammered it into her sternum using a heavy torch.  This happened at least 2 hours ago.  On arrival tot the ED her obs are remarkably normal.

Apart from a bit of blood on her clothing there is little else to find other than a knife handle protruding from her anterior chest.

As you are assessing her she has a transient dip in her BP – down from 110/80 to 85/70.  This recovers without any intervention on your part.

So she gets some big IVCs, a cross match is sent, and the cardio-thoracic Reg is paged to attend ASAP.

ECGstab ECG

A quick FAST / ECHO show no fee fluid, no pneumothorax, and no pericardial effusion of any volume [no tamponade effect seen either] But…..  a spot troponin comes back at 0.18 – so must have some myocardial injury?

When the Surgical team arrives there is a case conference in the hallway….

They are keen to pull the blade in ED!  This seems like a bad idea…  after a bit of back and forth a CT is ordered

CT CHEST stab CT

Lets assume we are in a tertiary ED with all the usual resources – ICU, cardiac theatre, trauma surgeons etc….

There was a similar case presented on Life in the Fast Lane a few months ago which you should check out for reference. There is  a great “what would Weingart Do?” session around this case.

Here are a my questions for this scenario:

Q1:  The super keen CT Reg is reassured by your limited bedside ECHO, and the CT appears to show no cardiac injury.  He wants to give a bit of sedation and pull it out in ED – no point in bothering the nice Anaesthetic team….    what do you say to him?

Q2:  Imagine you are the Anaesthetic Reg called to do a pre-op assessment for this lady.  What is your basic plan to prepare for  this case?

Q3:  NOW, just as you are “discussing” the management paln with the CT Reg – the nurse rudely interrupts you to say: shes just gone unconscious and has no palpable pulse!   Ah, bugger.  What to do now?  This is one of those scenarios that Cliff Reid bangs on about - you need to have a premeditated plan.  What is yours?  What kit do you need?  Do you know where it is in your department?

Q4:  Whose famous last words are included in the title of this post?

OK gang.  First in best answer – you know the drill

Cover yourself in Broome Docs glory and get your answers in.  Love and respect are your rewards.

Oh, and keep you eyes open for the brilliant FOAMed goodness that you can now get as the SMACC 2013 lectures are released on iTunes and the various super blogs.  There will be a lecture from Dr Scott Weingart on “Just Crack the Chest” in the near future – I will link back to this post when it is available.

Casey