Renal Colic & Pulmonary Embolism CT | Reducing Imaging: ACEP E-QUAL Network Podcast

Computed tomography (CT) is increasingly available across U.S. Emergency Departments and has changed the practice of medicine. However, it is coupled with potential side-effects from radiation and contrast media. Emergency Medicine is beginning to make a concerted effort to identify clinical scenarios in which CT may be unnecessary, producing outcomes research and validated clinical decision rules. Renal colic and pulmonary embolism, in particular, seem amenable to this area of investigation. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with experts Dr. Chris Moore (Emory University) and Dr. Jeffrey Kline (Indiana University). We present highlights from their discussion with Dr. Jason Woods.

First Time Flank Pain

It is common for EPs to evaluate a patient’s first occurrence of acute flank pain with a CT. The seminal paper on this topic, from 1996, showed CT to have a sensitivity of 97% and specificity of 96% for diagnosing ureteral stones in patients in whom the diagnosis is uncertain.1 Soon after, CT replaced IV pyelography. However, CT is often obtained for patients in whom a diagnosis of nephrolithiasis is highly likely. Should this be our standard of care? In the podcast, Dr. Chris Moore gives a well-referenced answer, and concludes that there is a paucity of evidence for obtaining a CT for highly suspected nephrolithiasis in first time flank pain.

The Relevance of Radiation

It is possible to identify a kidney stone with either a non-contrast CT or one with a minimal dose of contrast media. These limit the potential risks associated with radiation and contrast, and likelihood of a identifying an incidental finding. The American Urological Society, American College of Radiation, and American College of Emergency Physicians all recommend that a CT performed for acute flank pain be completed with a reduced dose of contrast. However, there is significant variation across the U.S. with regard to the dose of contrast included in a CT “stone protocol.” Ultimately, it is the responsibility of the EP to discuss protocols with colleagues from radiology. For help, the Dose Optimization for Stone Evaluation (DOSE) project, funded by AHRQ, is available to provide CT best practice techniques to EDs nationwide.

An ED Patient’s PE Risk Profile

The risk factors for PE are different in ED patients versus the general population. For example, obesity, tobacco use, and atrial fibrillation increase the risk of PE in the general population, but not in ED patients.

What are some points from the history and physical that should raise the suspicion for PE in an ED patient, and contribute to any decision to obtain a CT-PE?:

  • recent surgery or limb immobility
  • prior VTE
  • active cancer
  • estrogen use (and the post-partum period, in particular, is a powerful predictor)
  • pleuritic pain or dyspnea
  • HR > 100 bpm or an oxygen saturation < 95% on room air
Clinical Decision Rules:
It is helpful to be familiar with the components of a clinical decision rule; however, when applying a rule to a patient encounter, reference these variables on either a computer or smart phone. Memory is prone to human error, and even a seasoned EP can make a mistake.

Learn more about the E-QUAL Network!

Smith R, Verga M, McCarthy S, Rosenfield A. Diagnosis of acute flank pain: value of unenhanced helical CT. AJR Am J Roentgenol. 1996;166(1):97-101. [PubMed]

Author information

Derek Monette, MD

Derek Monette, MD

ALiEM Deputy Editor-in-Chief
PGY4 Resident
Department of Emergency Medicine
Harvard Affiliated Emergency Medicine Residency
Massachusetts General Hospital
Brigham and Women's Hospital

The post Renal Colic & Pulmonary Embolism CT | Reducing Imaging: ACEP E-QUAL Network Podcast appeared first on ALiEM.

ALiEM AIR Series: Environmental Module

air series traumaWelcome to the Environmental Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to environmental emergencies. 3 blog posts within the past 12 months (as of December 2017) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 0 AIR and 3 Honorable Mentions. We recommend programs give 1 hour (about 20 minutes per article) of III credit for this module.

AIR Series Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is only given to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the quiz at ALiEMU:  ALiEMU AIR Environmental Module Quiz

Interested in taking the quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts on Environmental Emergencies

Article Title Author Date Label
ALiEM: Venom John Riester, MD and Christina Shenvi, MD, PhD 6/23/2017 HM
EMDocs: Electricity Rachel Bridwell, MS4 and Erica Simon, DO, MHA 9/10/2017 HM
CoreEM: Mammal Bites Anand Swaminathan, MD, MPH 4/24/2017 HM

HM = Honorable Mention

If you have any questions or comments, please contact us!

From the ALiEM AIR Executive Board and ALiEMU Team

  • Jeremy Branzetti
  • Hari Bhatt
  • Sean Fox
  • Chris Gaafary
  • Andrew Grock
  • Jacob Hennings
  • Nikita Joshi
  • Jay Khadpe
  • Michelle Lin
  • Kasey Mekonnen
  • Allie Min
  • Eric Morley
  • Salim Rezaie
  • Lynn Roppolo
  • Matthew Rosen
  • Kaushal Shaw
  • Derek Sifford
  • Anand Swaminathan

Author information

Andrew Grock, MD

Andrew Grock, MD

Lead Editor/Co-Founder of ALiEM Approved Instructional Resources (AIR)
Assistant Professor of Emergency Medicine
UCLA Emergency Medicine Department

The post ALiEM AIR Series: Environmental Module appeared first on ALiEM.

Dr. David Wald, Assistant Dean of Clinical Simulation: How I Stay Healthy in EM

Dr. David Wald is an EP and Professor of Emergency Medicine at Temple University. When he’s not in the Department, you can find him out on the water, getting in another paddle. His gold medal wins highlight his commitment, skill, and passion for Dragon Boat racing! Not only does he keep physically fit, but he has figured out how to maintain a sense of balance while juggling several roles in and outside the hospital. Here’s how he stays healthy in EM!

  • Name: David A. Wald, DO, FACOEP
  • Location: Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University
  • Current job(s): Clerkship Director, Assistant Dean of Clinical Simulation
  • 1 word that describes how you stay healthy: PADDLE
  • Primary behavior/activity to help de-stress: I have participated for many years (almost 30!) in an off the beaten path sport: Dragon Boat Racing. This has been a family affair. My wife was the drummer for the USA team (analogous to the coxswain in rowing) for many years and now my daughter is involved.

What are the top 3 ways you keep healthy?

Not sure I have a top 3 list, but consistency is certainly a key to staying in shape and being healthy.

What is your ideal workout?

Slightly cool summer morning on the Schuylkill River in Philadelphia with the sun just coming up over the horizon. One advantage of training at 5:45 AM is that you finish your workout before most people get out of bed.

Do you track your fitness? How?

I have never been one to track my fitness with a heart rate monitor, but the simpler the better. The easiest is with the scale and watching your weight.

How do you prepare for a night shift? How do you recover from one?

I am very lucky to work in a department with a number of “Night Only” faculty. This makes the work-life balance of night shifts so much easier. We group our nights so that each faculty works 2 consecutive nights about every 5 weeks, not bad. As long as I can get a nap (perhaps 2 hours or so) before heading into a night shift, I am fine. I try to get home relatively early after a night shift, eat a small breakfast, and get to sleep. Typically, I will get up by noon and then get another nap later in the day if I have to work a second overnight. However, if I am not working the next night, I try to get up before noon and stay awake all day to get back onto a normal sleep schedule.

How do you avoid getting “hangry” (angry due to hunger) on shift?

For some reason, I was never the kind of person that needed to eat much during a shift. There are certainly times that I need to eating something, but more often I end up eating a meal before my shift and then after the shift is over.

How do you ensure you are mentally in check?

My kids do a pretty good job keeping me in check. My daughter is 14 and my son is 10. If I am grouchy, they will let me know.

What are the biggest challenges you face in maintaining a longstanding career in EM? How do you address these challenges?

Balance is the key. I am sure many people would say this. Balance at work with academic productivity, balance at home with quality time, which is different whether it is your wife or kids.  With my son, part of that balance is making sure I am available to coach his little league team, and for my daughter, it is making sure that I try to get to see her many soccer games. Part of the challenge is also setting your priorities. I actually find it easier in some ways as I have gained some measure of seniority at my institution. One key thing is to not fully overextend yourself and know when to say “no.” One way to help maintain some sense of balance is to set aside some alone time when needed. Perhaps to read a book or workout or whatever, just time to recharge.

Best advice you have received for maintaining health?

Staying healthy is a long term obsession. It is not like cramming for a final exam. Slow and steady wins the race.

Who would you love for us to track down to answer these questions?

David Manthey

Author information

Zafrina Poonja, MD

Zafrina Poonja, MD

Editor, How I Stay Healthy in EM series
Emergency Medicine Resident
University of Alberta

The post Dr. David Wald, Assistant Dean of Clinical Simulation: How I Stay Healthy in EM appeared first on ALiEM.