#EMexams | Crowd-sourcing questions for test-enhanced learning

CALLING ALL STAFF EMERGENCY PHYSICIANS
We need your help! Remember not so long ago when you wrote that little quiz known as the Emergency Medicine Board Exam? No? Have you gone through CBT to forget it? Think back to those days when your life revolved around that little quiz because BoringEM needs your help.

What we’re up to: Introducing #EMexams

We’re compiling a database of practice exam questions to help residents prepare for their tests. Questions will be tweeted from the @BoringEM account using the #EMexam hashtag once a week and followed by a post containing the question and answer on the BoringEM blog. Hopefully we will create an amazing repository of practice questions from staff physicians from across the country and around the world.

There is great education theory that suggests that frequent retrieval practice (e.g. through testing) can enhance memory.  In fact, in medical education it has been suggested that more effortful retrieval (e.g. short-answer questions) may promote better retention than recognition-based testing (e.g. multiple choice questions). [1-3]

We will be focusing on written, short-answer questions because we believe that, in addition to being difficult, they are covered poorly by existing preparation materials and are better for discussion on social media. Remember that these questions do not represent actual exam questions and that any similarity with decades worth of historical board exam questions is purely coincidental. The answers that we publish will be the best that we can determine using this crowd-sourced method and there is no guarantee that it would be considered the most correct answer if you were asked a similar question on an exam. Our goal is simply to assist in exam preparation by providing reasonable potential exam questions and answers.

What we need from you!

We need you to submit your 2nd favorite practice exam question! (Your favorite can be saved to stump your residents.) Submit them, along with your best answer, using the Google form below and we will get them into the realm of social media.

Here’s how it will work:

1. Fill out the form below.
2. Your questions questions/answers will be uploaded onto our database. The BoringEM editorial team will then review the questions and answers in a pre-publication peer review fashion.
3. Once a week a question will be tweeted from @BoringEM using the hashtag #EMexam – please help us create the best answer possible by responding!
4. A few days later a reminder tweet with a link to the answer will be posted on BoringEM.
5. Comments from staff & residents from across the country and around the globe will be welcome as we try to refine the answers to those particularly controversial questions!

Submit your practice question here:

References

1. Larsen, D. P., Butler, A. C., & Roediger III, H. L. (2008). Test‐enhanced learning in medical education. Medical education, 42(10), 959-966.
2. Kromann, C. B., Jensen, M. L., & Ringsted, C. (2009). The effect of testing on skills learning. Medical education, 43(1), 21-27.
3. Larsen, D. P., Butler, A. C., & Roediger III, H. L. (2009). Repeated testing improves long‐term retention relative to repeated study: a randomised controlled trial. Medical education, 43(12), 1174-1181.

Author information

Andrew Petrosoniak
Andrew Petrosoniak
Emergency Physician & Trauma Team Leader. St Michael's Hospital, Toronto, Canada. Interested in both simulation & social media. #FOAMed supporter.

The post #EMexams | Crowd-sourcing questions for test-enhanced learning appeared first on BoringEM and was written by Andrew Petrosoniak.

Boring Question: What is required for ‘medical clearance’ before referral to the psychiatry service?

The Case

A 29 year-old man is brought to the ED by police. He was found wandering on the street, predictably at 3 a.m. He is well-dressed and appropriately-groomed, slightly agitated, paranoid, apparently responding to internal stimuli, and uncooperative. He has no known history on file.

The Question

What is required for ‘medical clearance’ before referral to the psychiatry service?

The Background

Patients presenting to the ED with psychiatric complaints represent a sizeable portion of total ED visits, with some sources citing rates of 6% or greater.[2] Though psychiatric complaints are common, there is little standardisation with respect to workup prior to referral to the psychiatric consult service. As conscientious physicians, we want to avoid missing organic illness in these patients, but also ensure appropriate use of resources, good departmental flow, and timely referral to the appropriate clinical service.

 

What does the literature say?

A variety of screening tools [3,4] have been tested in limited settings. None have been validated beyond the single studies that produced them. The literature is consistent, however, on a few points:

1. Of utmost importance in the evaluation of the psychiatric patient is a complete set of vital signs, including capillary glucose level. Any vitals outside normal parameters should prompt investigation,

2. An adequate history must be obtained, as much as possible. Particular attention must be paid to behavioural changes, appearance, medication use, and drug use. Collateral history can be helpful,

3. As complete a mental status exam as possible should be performed,

4. A screening neurological exam, and any other physical exams that may be necessary based on history, should be completed, including particular attention to the presence of a toxidrome.

What about lab work?

Multiple studies [1,5,6]have confirmed that screening bloodwork, including CBC, lytes, LFT’s, TSH, T4, serum drug levels, urine drug screens and urine pregnancy tests are NOT routinely indicated. If there is a specific indication in the patient history, then appropriate labwork could and should be ordered. If the patient requires chemical restraint, it is important to obtain an ECG, as many antipsychotics, including Haldol produce QT prolongation.

Aren’t there some cases where I should be more suspicious of organic etiology?

Absolutely – there are some indications that put an organic cause much higher up on our differential:
1. Abnormal vital signs,
2. Patient older than 30-40 presenting with no psychiatric history,
3. Visual or tactile hallucinations. [1,2,5,6]

Back to the Case

Vital signs obtained once the patient has calmed enough to cooperate:

T- 37.2
HR – 87
BP: 134/87
RR: 18
O2 Sats: 98%
CBS: 7.1

The patient denies drug use, denies medical history of any kind, and is not currently on any medications, confirmed with collateral history. His screening exam is normal, and there are no signs of toxidrome. He is remains disorganized, delusional, paranoid, and is having auditory hallucinations, but is cooperative with physical examination.

This man would be suitable to refer to psychiatry following the thorough history obtained, normal vital signs, and normal physical exam.

The Bottom Line

Vitals, a thorough history, and a good neurological exam are adequate for most patients presenting with presumed or likely isolated psychiatric complaints.

References

1. Janiak, B., & Atteberry, S. (2012). Medical Clearance of the Psychiatric Patient in the Emergency Department. The Journal Of Emergency Medicine, 43(5), 866-870.

2. Larkin G, Beautrais A.L. (2011). Chapter 283. Behavioral Disorders: Emergency Assessment. In Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e.

3. Lukens, T., Wolf, S., Edlow, J., Shahabuddin, S., Allen, M., Currier, G., & Jagoda, A. (2006). Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine, 47(1), 79-99.

4. Shah, S., Fiorito, M., & Mcnamara, R. (2012). A Screening Tool to Medically Clear Psychiatric Patients in the Emergency Department. The Journal Of Emergency Medicine, 43(5), 871-875.

5. Szpakowicz, M., & Herd, A. (2008). “Medically Cleared”: How Well are Patients with Psychiatric Presentations Examined by Emergency Physicians? The Journal Of Emergency Medicine, 35(4), 369-372.

6. Zun, L. (2005). Evidence-based evaluation of psychiatric patients. The Journal Of Emergency Medicine, 28(1), 35-39.

Reviewing with the Staff, Dr. James Huffman (@jameslhuffman)

This is a concise and accurate review of an area filled with nuance and is also one of those places where I find available literature and consulting services don’t always agree.

Part of our job is to be a “guardian of the resources” and not work things up unnecessarily. That may mean limiting work-ups before discharge or before consulting another service for admission. It can also mean having a frank discussion with said services about your interpretation of the available literature, so you can express why you don’t feel like a more exhaustive search for an organic cause for the symptoms is warranted while discerning why they are concerned (perhaps they caught something on their exam we have missed, maybe the vitals changed over time, maybe getting other investigations at a later time is systemically challenging). You’ll find that having these kinds of conversations, rather than just saying “there is no need for testing in this patient…all-stop” will not only help you reach a mutually acceptable consensus, but also build trusting and productive relationships with the non-EM physicians while building your credibility as a specialist.

The last thing that I’ll add is something I think we all start to learn through experience and that’s although it’s foolish to let anecdotes and one-off stories guide practice as a whole, sometimes that “Spidey sense” is telling you to do more of a work-up for a reason (and it seems like the medical workup of patients presenting with new possibly psychiatric issues is an area where this comes up every now and again). Do your due diligence, read and learn as much as you can, see as many patients as you can to build your “portfolio of presentations” and document your decision making processes when it comes to areas where you may be on the fence. You’ll be doing yourself and your patients a great service.

Author information

Danica DeJong
Danica DeJong

The post Boring Question: What is required for ‘medical clearance’ before referral to the psychiatry service? appeared first on BoringEM and was written by Danica DeJong.

US against the world: ultrasound in differentiating COPD from CHF

The Case:

A 75-year-old male with a history of COPD and CHF presents with worsening shortness of breath over the past 24 hours. EMS states that they heard wheezing on exam and began standard COPD exacerbation treatment, including nebulized albuterol and atrovent and intravenous steroids. When he arrives in your ED after a 45-minute transport, the patient looks sick. His BP is 90/60, HR 118 , he is afebrile and he has an oxygen saturation in the low 80’s. Why did this patient with wheezing not respond to the treatment for obstructive airways disease?

Introduction:

Bedside diagnostic modalities of a crashing patient with suspected COPD vs CHF typically include a physical exam (with emphasis on auscultation) and a chest x-ray (CXR). While these tests may help with the management of our patients with dyspnea, they may not be as accurate as we think.

Many of us (myself included) were taught that diffuse wheezing equals COPD and diffuse crackles equal CHF. While this is often the case, when reviewing the literature it is evident that this examination can be unreliable. Multiple publications report that crackles can occur in COPD [1, 2, 3, 4] and wheezing in CHF [3, 5, 6].

Wheezing

Wheezing in patients with CHF occurs can occur. There are several theories for why wheezing occurs in heart failure, including reflex bronchoconstriction from elevated pulmonary vascular pressure, intraluminal fluid causing obstruction and bronchial mucosal swelling [6]. McCollough evaluated 87 patients with known obstructive airways disease who presented with new onset heart failure, and nearly half (42.5%) had wheezing on their initial exam [5], while Jorge and colleagues [6] found that in a cohort of patients aged >65 years old, 35% of those that were discharged with a diagnosis of CHF had wheezing on their initial exam.

Rales

If wheezing can sometimes occur in CHF and it often occurs in COPD, maybe rales can be a more helpful differentiator? Kataoka and colleagues [7] found that in patients >75 with no known lung disease or heart failure 34% had bilateral . A meta-analysis by Wang and colleagues [8] found that rales only had a positive likelihood ratio (+LR) of 2.8 and a negative likelihood ratio (-LR) of 0.51 for the diagnosis of cardiogenic pulmonary edema. Those likelihood ratios can add to the clinical picture but not necessarily rule in/out disease. To further muddy the waters, many publications also report that crackles can be seen in COPD exacerbations [1, 2, 3, 4].

CXR

The CXR has been a mainstay of the initial evaluation of a patient with dyspnea. This test would definitely be beneficial if a spontaneous pneumothorax is observed [11] or if obvious evidence of pulmonary congestion is seen [8], but if those are absent, CXR is of limited utility. A relatively recent meta-analysis in JAMA reported a +LR of 12 for CXR in the evaluation of interstitial edema or pulmonary venous congestion, but the negative likelihood ratio was 0.48, and its sensitivity was a dismal 54% [8]. Collins [12] found that up to 1/5 of patients discharged from the hospital with the primary diagnosis of heart failure had a negative CXR on admission.

A summary of the related likelihood ratios of these physical exam manoeuvres is below.

likelihood Ratios

Ultrasound

Ultrasound has become a useful adjunct to traditional bedside diagnostic tests, and appears to have consistently higher accuracies than physical exam and CXR [14 – 21].

This exam looks for B-lines, which are vertical hyperechoic reverberation artifacts that extend from the pleura to the bottom of the screen. They do not fade as they extend down the screen, and they move across the screen with respiration [22] (Figure 1; Clip 1).

Figure 1 - B-lines labeled

Figure 1 – B-lines

A phased array or curvilinear probe should be used, and each of the eight zones of the lungs should be evaluated including four anterior and four postero-lateral zones (Figure 2,3).

Figure 2 - Volpicelli lung fields (from the international guidelines article)

Figure 2 – Volpicelli lung fields

 

Identifying B-lines is not a difficult examination. One study found that agreement of the presence of b-lines between experienced and novice ultrasonographers had a kappa value of 0.92 (for reference, a kappa value above 0.81 is considered “very good”) [23]. A “positive” scan for pulmonary edema consists of two or more regions of the lung bilaterally with three or more B-lines [22]. The best way to accurately measure the amount of lines present in an area is to freeze the image and cine back to the frame with the most B-lines [24].

Figure 3 - Probe position for B-lines

Figure 3 – Probe position for B-lines

Lichtenstein compared auscultation, CXR and lung ultrasound (LUS), and found their accuracies to be 55%, 72% and 95% for interstitial edema. Xirouchaki and colleagues [19] compared US to CXR and found CXR and LUS to have an accuracy for diagnosis of pulmonary edema of 58% and 94%, respectively. These two previous studies used a CT scan as their gold standard, while the next two studies actually used clinical course in the hospital and discharge diagnosis of CHF or not CHF as their gold standard. Liteplo and colleagues [18] found a +LR of infinity and a –LR of 0.78 when all eight lung fields were positive. Prosen and colleagues [17] performed ultrasound on 218 patients that had diagnostic uncertainty between CHF or COPD and found B-lines on LUS to have a +LR of 20. Their lower +LR and better –LR was likely due to the fact that they only required 2 positive lung fields bilaterally before they called it CHF. A recent meta-analysis evaluating the utility of ultrasound for the diagnosis of cardiogenic pulmonary edema found the presence of b-lines to have an impressive sensitivity of 94.1%, a specificity of 92.4%, a +LR of 12 and a –LR of 0.06 [25].

The presence or absence of b-lines bilaterally is great at ruling in or ruling out CHF, but their absence does not necessarily mean the patient has COPD as the cause of their dyspnea. For instance, a patient can have a pneumothorax, pneumonia, anemia, or another diagnosis. If the main diagnostic dilemma is the differentiation of CHF versus COPD, however, the absence of b-lines can push you towards a diagnosis of COPD.

Conclusion:

Differentiating COPD and CHF in an acutely dyspneic patient is an important task that must be done quickly and often with minimal time and minimal resources. Unfortunately, we often make the wrong initial choice. A study by Collins and colleagues [26] found that in a sample of 173 patients that were subsequently diagnosed with heart failure, 33% were misdiagnosed in the ED. The most common factors associated with missed acute decompensated heart failure are a previous history of COPD, no previous history of CHF, and a BNP below 500 [24]. Making the wrong initial diagnosis can be detrimental to these patients, as giving beta agonists to patients with CHF exacerbations has been shown to lead to adverse outcomes, including death [3].

Ultrasound is a fast bedside test which some studies show has immense diagnostic utility. Even with the great +LR of LUS, like any other test or physical exam maneuver we have in medicine, LUS should not be performed and interpreted in a vacuum. It should be used in conjunction with the rest of your history, physical exam and tests. B-lines also are present in a multitude of other pulmonary pathologies including pulmonary contusion, pulmonary infarction, pneumonia, pneumonitis, atelectasis, pulmonary fibrosis, and ARDS.

References:

  1. Epler GR, Carrington CB, Gaensler EA. Crackles (rales) in the interstitial pulmonary diseases. Chest. 1978;73(3):333-9.
  2. Piirilä P, Sovijärvi AR, Kaisla T, Rajala HM, Katila T. Crackles in patients with fibrosing alveolitis, bronchiectasis, COPD, and heart failure. Chest. 1991;99(5):1076
  3. Zeng Q, Jiang S. Update in diagnosis and therapy of coexistent chronic obstructive pulmonary disease and chronic heart failure. J Thorac Dis. 2012;4(3):310-5.
  4. Oshaug K, Halvorsen PA, Melbye H. Should chest examination be reinstated in the early diagnosis of chronic obstructive pulmonary disease?. Int J Chron Obstruct Pulmon Dis. 2013;8:369-77.
  5. Mccullough PA, Hollander JE, Nowak RM, et al. Uncovering heart failure in patients with a history of pulmonary disease: rationale for the early use of B-type natriuretic peptide in the emergency department. Acad Emerg Med. 2003;10(3):198-204.
  6. Jorge S, Becquemin MH, Delerme S, et al. Cardiac asthma in elderly patients: incidence, clinical presentation and outcome. BMC Cardiovasc Disord. 2007;7:16.
  7. Kataoka H, Matsuno O. Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients. Ann Fam Med. 2008;6(3):239-45.
  8. Wang CS, Fitzgerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. 2005;294(15):1944-56.
  9. Holleman DR, Simel DL. Does the clinical examination predict airflow limitation?. JAMA. 1995;273(4):313-9.
  10. Straus SE, Mcalister FA, Sackett DL, Deeks JJ. Accuracy of history, wheezing, and forced expiratory time in the diagnosis of chronic obstructive pulmonary disease. J Gen Intern Med. 2002;17(9):684-8.
  11. Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: Review of the literature and meta-analysis. Crit Care 2013;17:R208.
  12. Collins SP, Lindsell CJ, Storrow AB, Abraham WT. Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med. 2006;47(1):13-8.
  13. Müller NL, Coxson H. Chronic obstructive pulmonary disease. 4: imaging the lungs in patients with chronic obstructive pulmonary disease. Thorax. 2002;57(11):982-5
  14. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1):9-15.
  15. Agricola E, Bove T, Oppizzi M, et al. “Ultrasound comet-tail images”: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest. 2005;127(5):1690-5.
  16. Gargani L, Lionetti V, Di cristofano C, Bevilacqua G, Recchia FA, Picano E. Early detection of acute lung injury uncoupled to hypoxemia in pigs using ultrasound lung comets. Crit Care Med. 2007;35(12):2769-74.
  17. Prosen G, Klemen P, Štrnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011;15(2):R114.
  18. Liteplo AS, Marill KA, Villen T, et al. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med. 2009;16(3):201-10
  19. Xirouchaki N, Magkanas E, Vaporidi K, et al. Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med. 2011;37(9):1488-93.
  20. Lobo V, Weingrow D, Perera P, Williams SR, Gharahbaghian L. Thoracic ultrasonography. Crit Care Clin. 2014;30(1):93-117, v-vi.
  21. Silva S, Biendel C, Ruiz J, et al. Usefulness of cardiothoracic chest ultrasound in the management of acute respiratory failure in critical care practice. Chest. 2013;144(3):859-65.
  22. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-91.
  23. Cibinel GA, Casoli G, Elia F, et al. Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department. Intern Emerg Med. 2012;7(1):65-70
  24. Anderson KL, Fields JM, Panebianco NL, Jenq KY, Marin J, Dean AJ. Inter-rater reliability of quantifying pleural B-lines using multiple counting methods. J Ultrasound Med. 2013;32(1):115-20.
  25. Al deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D. Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis. Acad Emerg Med. 2014;21(8):843-852.
  26. Collins SP, Lindsell CJ, Peacock WF, Eckert DC, Askew J, Storrow AB. Clinical characteristics of emergency department heart failure patients initially diagnosed as non-heart failure. BMC Emerg Med. 2006;6:11.

Reviewing with the Staff |  Reviewed by Dr. Daniel Kim MD FRCPC

Dr. Kim is the Ultrasound Fellowship Director, University of British Columbia and an Emergency Physician, Vancouver General Hospital
He is a graduate of the University of Toronto’s Royal College emergency medicine residency program.  He completed an ultrasound fellowship at Denver Health Medical Center. Dan is currently an emergency physician at Vancouver General Hospital as well as the ultrasound fellowship director at the University of British Columbia. It goes without saying that his academic interest is… all things ultrasound!

Nice write up, and great case illustrating a conundrum that every emergency physician has experienced: does this dyspneic patient have COPD or CHF? In this scenario, it’s not unusual for a patient to receive antibiotics, steroids, albuterol, furosemide, and nitroglycerin – just to “cover all the bases.” But are we doing good for the patient?

As Jacob reminds us, the accuracy of our physical exam for diagnosing lung pathology is mediocre. CHF patients may have wheezing instead of crackles, and the opposite is true of some COPD patients. However, we should remember that our individual physical exam tests and findings do not occur in a vacuum. Instead, they are one piece of the puzzle that needs to be combined with a good history and appropriate testing for us to come to the right final diagnosis. In fact, Wang’s JAMA systematic review found that a high pretest probability for heart failure (based on clinician gestalt) had a positive LR of 9.9 for a final diagnosis of heart failure. We should feel reassured that our clinical judgment is valuable! But we aren’t perfect. An intermediate or low initial clinical suspicion decreased the likelihood of heart failure (LR 0.65) but did not exclude it. <1>

The chest x-ray is also an imperfect test, given that up to 1 in 5 patients admitted from the ED with acute decompensated heart failure have no signs of congestion on x-ray. <2> So where does this leave us?

Ultrasound provides us with a rapid, noninvasive, and radiation-free way of ruling in or ruling out pulmonary edema at the bedside. But is it accurate? Al Deeb’s recent systematic review indicates that it is. The pooled sensitivity and specificity of B-lines for pulmonary edema is 94% and 92% respectively. This translates to a positive LR of 12.4 and a negative LR of 0.06. <3> This can help to significantly change the pretest probability of disease to a posttest probability that gives us confidence in our diagnosis. While there are some issues with Al Deeb’s meta-analysis (like heterogeneity), there’s no doubt in my mind that ultrasound is accurate. Laursen showed that an ultrasound protocol for dyspnea provides the correct diagnosis earlier than usual diagnostic testing (88% in the ultrasound group vs 64% in the control group had the correct diagnosis at 4 hours after admission). There was no difference in mortality, but his study wasn’t powered for this endpoint. <4> Hopefully, future research is able to demonstrate improvements in patient oriented outcomes (like mortality). In the interim, we should use all the tools at our disposal to come up with the right diagnosis to provide the right treatment – and avoid unnecessary (and potentially harmful) treatment that “covers all the bases.”

 References

  1. Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 2005; 294:1944-56.
  2. Collins SP, Lindsell CJ, Storrow AB, et al. Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med 2006; 47:13-8.
  3. Al Deeb M, Barbic S, Featherstone R, et al. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med 2014; 21:843-852.
  4. Laursen CB, Sloth E, Lassen AT, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014; 2:638-46.

Author information

Jacob Avila
Jacob Avila
Jacob Avila, MD, RDMS. Trained at Loma Linda University in Southern California. Chief EM resident at University of Tn at Chattanooga. Has a passion for Emergency Medicine and Ultrasound in particular. #FOAMed fo' life!

The post US against the world: ultrasound in differentiating COPD from CHF appeared first on BoringEM and was written by Jacob Avila.

Life Beyond Medicine: Why I Run. And Run. And Run.

worlds 2010

My world before medical school included a lot of time spent in pools, and several blurry photos.

When I was applying to medical school, I got the sense that the more non-academic activities I participated in, the more well-rounded I was, the greater the chances of my success. It wasn’t a stretch for me. Among other activities, I was heavily involved in synchronised swimming and had been for many years; I was training for an international competition and varsity nationals the year I applied. If I wasn’t in the pool, I was stretching, cross-training, or half-heartedly chugging milkshakes to hold down enough calories to maintain my busy athletic schedule.

When I started medical school, much changed.

Medicine demanded most of my time, and my habit of drinking milkshakes was no longer adaptive. I was still swimming, but now only a handful of hours a week – less than a quarter of the time I had previously spent in the pool, and even less still of the total time I had spent training in the year prior. I gained forty pounds, was full of unfocussed energy no longer spent at the pool and in the gym, and was deeply unhappy. No longer spending all my time active, I now was able to acknowledge that I had a serious problem with my shoulders, and I had shoulder surgery at the end of my first year of medical school.

I spent the better part of six miserable months in a shoulder immobiliser – three months prior to surgery because I could not seem to keep my left shoulder from dislocating, and three months after surgery during which I was scarcely allowed to use my left arm for anything lest I disrupt the delicate repair my surgeon had wrought. Now with no physical outlet, I began to feel a little stir crazy.

When you run lots, you get to buy lots of shoes.

When you run lots, you get to buy lots of shoes.

When I was finally given the okay to re-start physical activity, it was with the understanding that I couldn’t swim for at least a few months. I needed a new outlet, and running was the safest activity I could take up. I had tried running several years previous and hated it, but now I couldn’t get enough. Before I had even run my first 5k, my best friend asked me if I’d like to run a half marathon with her. Within 13 months of my first 5k, I had completed my first full marathon. Eventually, I was able to get back in the water with my university synchro team, but I also kept running. In fact, between December 3rd of my third year of medical school and December 2nd of my fourth year, I was physically active for 365 consecutive days (you can read all about that journey at http://ksnsweat.blogspot.ca/).

Now, I’m often teased when I leave a shift because I usually leave in running tights or a running skirt, on my way to the gym or out to pound the pavement before I head home, even if my shift ends at 2 a.m. I usually work out about 5 times each week, sometimes more or less depending on my schedule. Running (and working out in general) has become an essential part of my well being as a resident. Here’s why:

1) It lets me sleep at night.

There’s nothing worse than not being able to sleep after a long shift or a night on call. I’m not much of a worrier, and I don’t spend much time ruminating, but I’m often so keyed up after work that it’s hard to relax and let myself drift off. If I don’t work out, I spend time pacing around my house, cleaning, cooking, and generally missing out on good sleep time. When I work out, I come home exhausted and really benefit from the good sleep I need.

2) It focuses my energy.

At the end of a particularly long shift where I had stayed late, a patient’s father asked me if I was always so energetic at the start of a shift. I couldn’t help laughing. In all honesty, I always feel a little tired, but I’m also always going hard, talking fast, and generally making myself a nuisance to all the calm people in my life. If I don’t spend some energy on working out almost every day, I start to feel unfocussed. I jump from task to task without finishing anything, and I start to use some of my energy on worrying about things that wouldn’t normally trouble me. Working out helps me dissipate some of that energy, and focus the rest on doing my best work for patients and colleagues.

3) It keeps me well.

I’ve now lost 30 of the 40 pounds I gained during medical school, and I feel so much better. I’m sick less often and happier. I have better cardiorespiratory capacity, and I am stronger. I like the thought that my inner machinery is working away as it should, with cholesterol and glucose levels well-regulated. Enough said.

4) It gives me a sense of control and mastery.

Sometimes I leave the hospital after a shift feeling absolutely useless. Maybe I failed to accurately diagnose a patient with an occult infection. Maybe I didn’t have the answers when my attending pimped me mercilessly. Maybe I just had patients I couldn’t do much for. It’s easy to feel stupid, useless, and just generally out of control, but I can go out for a run and sprint just a little bit father than before, or just a little bit faster, and be reminded that I can improve, work harder, do well. I think we each need something in life that we feel truly good at, and even though I am not a fast runner, running gives me that. I know I can run farther than most people I know, and under more challenging circumstances (Icy streets of Kingston in a blizzard? Sure thing! 42 k in hilly interior British Columbia in August? Bring it on!). At the end of the day that sense of mastery makes me feel good.

5) It reminds me that there is life beyond medicine.

When we are fully engaged in medicine, it can be easy to forget that there is life outside the hospital. Running reminds me that I am more than just a resident.

run run run

There’s nothing quite like the feeling of running it in at the end of a long race.

Reviewing with the staff: By @TChanMD (the ultimate non-runner)

I must admit, if there were an antithesis to a runner, it would be me. Maybe it’s because of my flat feet, or maybe my mild exercise-induced asthma, but I just plain don’t like it.

That said, physical activity is probably something that all of us need to find ways to incorporate into our lives. And something we should probably do a better job at as people…but also as physicians.

This series is intended to remind healthcare providers there is life outside medicine, so I would like to take this time to remind us all (even the emergency care providers) that it is possible to find time to take care of ourselves.

But also to consider reminding our patients about this too.

The following video by Dr. Mike Evans (@docmikeevans) out of the University of Toronto & St. Michael’s Hospital in Toronto, is a great video to watch from time to time to remind ourselves (and our patients) about the great benefits of just 30 minutes of WALKING per day.


Remember, you can’t take care of others people if you don’t find time to take care of yourself. (@sluckettg pipes in to say ‘In the wise words of your flight attendant, make sure your own mask is secured before you help the person next to you’!) You deserve as much attention as any of your patients do. Spend some time on yourself and on your own physical wellbeing.

Author information

Sarah Luckett-Gatopoulos
Sarah Luckett-Gatopoulos
Junior Resident Editor at BoringEM
Luckett is a resident at McMaster University. Newbie to the #FOAMed world. Interested in literacy, health advocacy, creative writing, and near-peer mentorship.

The post Life Beyond Medicine: Why I Run. And Run. And Run. appeared first on BoringEM and was written by Sarah Luckett-Gatopoulos.

Five reasons to head to SMACC

I had the complete pleasure of attending smaccGOLD last year. I wrote about what made it such a rich experience here and I have been anticipating SMACC Chicago since my flight left Brisbane last March. I am helping coordinate the SMACC Junior (student) contingent this year. Let’s just say it is a VERY student friendly conference. So friendly, in fact, that there are bursaries available to support travel and competitions are running for free registration! Find out more info here. There are two upcoming competitions for free registration-  smaccUS: 24 (January 24) and #smaccthemusical (Feb 15).

SMACC24

Here are the top 5 reasons I can’t wait for #smaccUS and why you should register too!

  1. The people: If you think those you know online are cool, just wait until you meet them face-to-face. I was worried  that meeting offline might end up being the equivalent of a very disappointing failed online dating experiment  but it was entirely the opposite. Each and every person that I met at smaccGOLD was even more remarkable than they were online yet absurdly down to earth. For three days you will be surrounded by an intelligent, generous, enthusiastic and inclusive group. You will have no choice but to maintain that spirit long after you leave.
  2. The evidence-based debates: The people are nice, but it certainly doesn’t mean they always agree. It’s awesome. There are many formal debates planned- be prepared for experts to duke it out on stage- but my favourite were the off the record heated conversations on everything from about the best way to care for patients, to the best method to teach students, to the best beer on tap.
  3. The focus on education: As a learner it was completely inspiring to see how much the attendees of this conference care about their students. Experiences and individuals at smaccGOLD have fuelled my own passion for education and I am super keen to find out more about how to learn and teach.
  4. The resources: Going into smaccGOLD I thought I was up to snuff on my FOAM but at the conference I found a few more key resources that I now use on a regular basis. I can’t wait to find out what I’ll discover this year.
  5. FOAMaoke: Goes without saying. Seeing these people sing is simply the best. Picture Oli belting Les Mis. Enough said. It might be wise to start practicing now. On second thought, it is more fun without practice.

There are many Canucks headed south to make up the #SMACCanada contingent. Join this beautiful group (some of the many Canadian attendees are listed below) and register here.

  • Brent Thoma
  • Paul Jones
  • Matthew Hogan
  • David Juurlink
  • Ken Milne
  • Luckett
  • Anton Helman
  • Taryn Lloyd
  • Stephanie Dunn
  • Taylor Zhou
  • Kari
  • Teresa Chan
  • Dave Wakely
  • Cheryl Cameron
  • James Huffman
  • Zafrina Poonja
  • Tim Pyra
  • Eve Purdy

If you would like to keep in touch with the Canadian contingent, enter your information in the form at the bottom of the post (we will never share or sell your contact information and it will be used only to keep in touch at SMACC!) Hope to see you in Chicago!

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post Five reasons to head to SMACC appeared first on BoringEM and was written by Eve Purdy.

Approach to Geriatric Patients: Functional Assessment in the ED

The wave of baby boomers is coming to an ED near you and it’s time to get prepared [1]. ED overcrowding does not seem to be going away anytime soon, and anything we can do to get these patients back to the community is better for everyone.

While not all 80 year olds have multiple medical problems (we have a spectrum bias based on what we see at work) it does not take many geriatric patients to add significantly to our already busy ED workload. The ED is a focal point for access to the health care system for all patients, particularly the elderly, so we need to prepare ourselves better for their needs. With this in mind, there is a movement towards developing a ‘Geriatric ED’ based on population trends and studies that found implementing geriatric friendly strategies successfully reduced the admission rate of geriatric patients [2].

Currently, few ED’s are lucky enough to have a Geriatric ED or even physicians with geriatric expertise within their group. However, excellent training is available online (see Geri-EM.com) that covers the major issues facing geriatric patients in the ED. Additionally, there are usually an excellent array of services for these patients in your community; you just need to know how to access them! It does not take much for certain geriatric patients to fall below the threshold of dependence, and by using the strategies outlined in this post we might be able to get them back to their home.

The Approach to Geriatric Patients in the ED

The overall approach to the geriatric patient must include the functional, social, cognitive, and medical domains [3].

a) Functional assessment

A functional assessment evaluates the patients ability to complete activities of daily living (ADLs) and instrumental ADLs (iADLS). ADLs are the things you do in the first 20 mins of your day (transferring, toileting, bathing, dressing, feeding, and continence) while iADLs are the things you learned to do when you left to go off to university (meals, housecleaning, meds, finances, driving/transport, shopping, phone/technology).

b) Social assessment:

A social assessment focuses on their supports in the community. A good way to assess this is to ask ”If something bad happened, who would you call?”

c) Cognitive assessment

A cognitive assessment includes screens for Delirium (CAM) & Dementia (mini-Cog). The mini-Cog can be done quickly and should be a vital sign for a Geriatric patient. If it is abnormal, it should prompt further assessment with a mini-mental exam.

Confusion Assessment Method

 

 

Mini-Cog

d) Medical assessment

The physical assessment is something that we already do pretty well. It quantifies the reason for their presentation: Why did they faint? What was injured when they fell? etc. We could probably do a better job of checking their medications for appropriateness and interactions, but realistically we often don’t have the time for this in the confines of an ED visit. A topic most certainly worthy of another Boring EM post!

Specific Scenarios

There are also some specific situations which we need to be aware of that require additional assessment in the geriatric patient:

a) Does your patient have impaired mobility?

Often geriatric patients can have impaired mobility after a minor injury or flare of arthritis. Consider performing a “Timed Up and Go” or TUG Test [4]. This test is performed as outlined below and gives you a sense of whether or not a patient requires a mobility aid. If they do, physical therapy (PT) can often see them in the ED and make the necessary arrangements. If they will be discharged and require help at home for a couple of days, an appointment with a community PT for follow-up and mobility aid teaching can often be set up for them at their residence. If larger concerns are identified the community PT can refer them for a Geriatric Assessment.

TUG test

 

b) Is your patient at risk for falls?

Effective decision tools have been developed by Carpenter and Tiedeman [5,6] to predict falls in the elderly. (Editor’s note: For some more #FOAMed on geriatric fall assessment, be sure to check out The SGEM Episode #89: Preventing Falling to Pieces where Dr. Milne reviews Dr. Carpenter’s latest meta-analysis on the topic with him as a guest!)

Carpenter [5]:

Carpenter fall assessment tool

Tiedeman [6]:

ED falls screening tool

If your patient screens positive for as a fall risk, community occupational therapy (OT) can go to their home and see what improvements can be made for reducing their risk (ie shower bars, bath seats, removal of throw rugs, etc.). If larger concerns are identified, community OT can refer them for a Geriatric Assessment.

c) Does your patient have complex geriatric issues?

Patients with multiple medications, dementia, fall risk, etc who do not require admission need referral for a geriatric assessment. Prior to consult, they can often send someone to their home to collect information and to collect their medical records. A full geriatric assessment might include assessment by OT, PT, social work, nursing, physician +/- geriatric psychiatry, pharmacy, recreational therapy, and a dietician.

d) Can future medical events be prevented?

Prevention is the future of the geriatric ED. Tools are being developed to identify seniors who are at risk (the ISAR questionnaire [7]) and determine appropriate interventions (SEISAR [8]):

ISAR questionnaire

A score of 2 or higher on the ISAR questionnaire suggests need for intervention and prompts further assessment with the SEISAR (Systemic Evaluation & Intervention for SRs at Risk) Tool [8] to see which interventions would be of benefit.

The SEISAR Tool

As these assessments are quite in depth, they would require more than just a home care coordinator. Dedicated individuals are needed for these types of geriatric assessment. I suspect that resources for these types of services will increasingly be made available as our population continues to age.

Conclusion

The ED’s geriatric population is going to continue to increase. This population has unique needs that historically, have not been well addressed in the ED. This post outlined a basic approach for the assessment of geriatric patients and some common scenarios that emergency physicians should be prepared to address with evidence-based resources. Emergency medicine trainees and attendings that familiarize themselves with these resources will be better prepared to address the unique needs of our geriatric patients.

Edited / Reviewed by Brent Thoma (@Brent_Thoma)

References

  1. Foot, D. K., & Stoffman, D. (1997). Boom bust and echo: how to profit from the coming demographic shift (1st Edition). Saint Anthony Messenger Press and Franciscan.
  2. Keyes, D. C., Singal, B., Kropf, C. W., & Fisk, A. (2014). Impact of a new senior emergency department on emergency department recidivism, rate of hospital admission, and hospital length of stay. Annals of emergency medicine, 63(5), 517-524.
  3. Retrieved from Geri-EM.com September 8th, 2014.
  4. Bohannon, R. W. (2006). Reference Values for the Timed Up and Go Test: A Descriptive Meta‐Analysis. Journal of geriatric physical therapy, 29(2), 64-68.
  5. Carpenter, C. R., Scheatzle, M. D., D’Antonio, J. A., Ricci, P. T., & Coben, J. H. (2009). Identification of fall risk factors in older adult emergency department patients. Academic emergency medicine, 16(3), 211-219.
  6. Tiedemann, A., Sherrington, C., Orr, T., Hallen, J., Lewis, D., Kelly, A., … & Close, J. C. (2012). Identifying older people at high risk of future falls: development and validation of a screening tool for use in emergency departments. Emergency medicine journal, emermed-2012.
  7. Dendukuri, N., McCusker, J., & Belzile, E. (2004). The identification of seniors at risk screening tool: further evidence of concurrent and predictive validity.Journal of the American Geriatrics Society, 52(2), 290-296.
  8. Retrieved from http://stmarysresearch.ca/en/publications_and_tools/clinical_tools/isar-seisar December 28, 2014

Author information

Rob Woods
Rob Woods
Program Director at University of Saskatchewan
Rob Woods is the Program Director of the University of Saskatchewan Emergency Medicine Residency Program.

The post Approach to Geriatric Patients: Functional Assessment in the ED appeared first on BoringEM and was written by Rob Woods.