60 Second Soapbox: Messman (Vertigo), Dolcourt (Charcoal), Stiell (C-spine Rules)

60 second soapboxAfter a bit of a hiatus we are back with another round of 60-Second Soapbox! Each episode, one lucky individual gets exactly 1 minute to present their rant-of-choice to the world. Any topic is on the table – clinical, academic, economic, or whatever else may interest an EM-centric audience. We carefully remix your audio to add an extra splash of drama and excitement. Even more exciting, participants get to challenge 3 of their peers to stand on a soapbox of their own! 

Dr. Anne Messman
@AnneMessman
Associate Program Director
Wayne State University/Sinai-Grace Hospital, Detroit, MI

#FutureSoapboxChallenge

References

  1. Cohn B. Can bedside oculomotor (HINTS) testing differentiate central from peripheral causes of vertigo? Ann Emerg Med. 2014 Sep;64(3) PMID: 24530107
  2. Ozono Y, Kitahara T, Fukushima M, Michiba T, Imai R, Tomiyama Y, Nishiike S, Inohara H, Morita H. Differential diagnosis of vertigo and dizziness in the emergency department. Acta Otolaryngol. 2014 Feb;134(2) PMID: 24308666

Dr. Bram Dolcourt
@dolcourt
Associate Program Director
Wayne State University/Sinai-Grace Hospital, Detroit, MI

#FutureSoapboxChallenge

  • Michael Cole
  • Ryan Kirby (@kirbyERDR)
  • Mohammed Moussa

Dr. Ian Stiell
@EMO_Daddy
Distinguished Professor and University Health Research Chair
University of Ottawa

#FutureSoapboxChallenge

References

  1. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17 PMID: 11597285
  2. Stiell IG, Clement CM, Grimshaw J, et al. Implementation of the Canadian C-Spine Rule: A prospective 12 centre cluster randomised trial. BMJ. 2009 PMID: 19875425

Author information

Sam Shaikh, DO

Sam Shaikh, DO

Editor, 60-Second Soapbox series
Assistant Clinical Professor, Rocky Vista University
Clinical Instructor, University of Colorado School of Medicine
2014-15 ALiEM-CORD Social Media and Digital Scholarship Fellow

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Wellness and Resiliency During Residency: Life happens despite your best plans

When I got back home from taking [my board exams], having all these [negative] feelings swirling through my head, I remember driving up and seeing my wife and baby sitting on the porch and suddenly being like, “Isn’t this what life is all about? Is it really about studying for an exam? Is it really about pushing yourself to get triple-boarded or do this or that within medicine? I mean, isn’t THIS what it’s about? Having a wife and a child, a family to call your own, aren’t these the things that are most important that we should value?” After that point, after seeing them on the porch and over the next couple weeks, things really started to change for me.

— Haney Mallemat, MD

resident wellness consensus summit

Life Happens

Sometimes life just happens, despite our best-laid plans. Training to become an emergency physician follows a very defined timeline that begins intern year and relentlessly progresses all the way through board certification. Sometimes we even fool ourselves into believing that we can schedule our personal lives to follow the same timeline. Get married after medical school, have kid in fellowship, buy a house with that first attending job. But as Woody Allen famously said, “If you want to make God laugh, tell him about your plans.” Dr. Haney Mallemat, who is an Associate Professor of EM and Medicine at Cooper Medical School of Rowan University, certainly learned this the hard way, as he recounts in this month’s podcast.

There is nothing like an upheaval in your personal life to make you question your priorities. Life isn’t like football where we can stop the clock by running out of bounds or calling a timeout when things aren’t going according to plan. We can’t tell that baby to stay unborn so that we can finish our ICU rotations or a parent not to have cancer so that we can study for the boards. When our personal life starts shoving its way into our professional life, it can feel like we suddenly have too many balls in the air to juggle at once and leave us wondering which ones we absolutely have to catch and which ones we can let go.

Featured Podcast with Dr. Haney Mallemat

Listen to Dr. Haney Mallemat (@CriticalCareNow), famed lecturer and podcaster, talk about juggling family, work, and personal goals. Dr. Mallemat is board certified in not just Emergency Medicine, but also in Internal Medicine, Critical Care, and Echocardiography. He lectures nationally and internationally, runs the Keynotable presentation course, and has won multiple teaching awards. But despite his busy schedule, he still tries to find time for the things that are most important in life.

Defining Wellness

In our recent JGME-ALiEM Hot Topics in Medical Education Journal Club, Dr. Kristin Raj defined wellness as a sense of life satisfaction, feeling that you’re living in accordance with your deeply held values, and feeling fully engaged with life. So one of the keys to being well is figuring out what those deeply held values are in the first place. At the end of the day, what’s really important to you?

Prioritizing Life

In his book First Things First, Dr. Stephen Covey shares the following story. One day a professor stood in front of his class with a large mason jar and a stack of fist-sized rocks. He carefully placed all of the rocks into the jar until they reached the top and then the professor asked the class, “Is this jar full?” The class said, “Yes.” The professor then reached under the table and produced a bucket of gravel. He poured the gravel into the jar and shook the jar so that the gravel fell into all the spaces between the rocks. He asked the class, “Now is the jar full?” The class had caught on by now and one student piped up and said, “Probably not.” Next, the professor pulled out a bucket of sand from under the table and poured the sand into the jar, filling all the spaces between the gravel. He asked, “Now is the jar full?” The class responded in unison, “No!” Finally the professor pulled out a pitcher of water and poured the water into the mason jar. The professor then looked at the class and asked, “What was the point of this illustration?” One eager student raised his hand and said, “The point is, no matter how full your schedule is, if you try really hard you can always squeeze more stuff in.” “No,” the professor responded, “That’s not the point. The point is that if you don’t put the big rocks in first, you’ll never get them in at all.

What are the big rocks in YOUR life?

Teaching your kid to spell her name? Exploring a new country with friends? Searching for a life partner or bonding with the one you have? Learning to resuscitate a critically ill patient? Championing a cause? Take some time to think about the things that are truly important in your life and make the time for them. Write them down and put the list on your refrigerator. Schedule them in your calendar next to your shifts. If you remember to put the big rocks in first, you’ll be well on your way toward a more fulfilled future.

Take the next step

If you’re an EM resident, join us on May 15th, 2017 at the 16th annual Essentials of Emergency Medicine course. Unite with residents from all throughout North America who are coming together for the first-ever Resident Wellness Consensus Summit (RWCS), and be a part of innovating real-world solutions to physician wellness issues just like this one. The RWCS is a joint partnership between Essentials of EM, Emergency Medicine Residents’ Association (EMRA), and ALiEM. EMRA members register at EMRA’s Hippo Education page for a greatly discounted rate of $249 (from $899), which includes the entire Essentials of EM 2017 Live Experience.

 

Author information

Arlene Chung, MD

Arlene Chung, MD

Chief Strategy Officer,

2016-17 ALiEM Wellness Think Tank
Assistant Professor of Emergency Medicine
Assistant Program Director
Mount Sinai Emergency Medicine Residency
Editor, AKOSMED (EM wellness blog)

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I am Dr. Heather Farley, Director of Provider Wellbeing: How I Stay Healthy in EM

Dr. Heather Farley is an emergency physician from Newark, DE. She has the unique position of being the Director of Provider Wellbeing at the Institute for Learning Leadership and Development (iLEAD). Dr. Farley is definitely a champion of wellness. From staying active, to eating healthy, and ensuring she makes time for herself, she definitely makes wellness a priority. Her attitude of trying new things and always challenging herself, is something we should all try! Here’s how she stays healthy in EM!


  • Name: Heather Farley, MD, FACEPheather farley
  • Location: Christiana Care Health System, Newark, DE
  • Current job(s): Director of Provider Wellbeing, Institute for Learning, Leadership, and Development (iLEAD). Emergency Physician, Christiana Care Health System. Associate Professor of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University.
  • One word that describes how you stay healthy: Self-care
  • Primary behavior/activity for destressing: Playing with my 2 dogs

What are the top 3 ways you keep healthy?

  1. Exercise. I am pretty religious about getting in at least 45 min of cardio (running, swimming, or biking) 5 days/week. I am trying to work in more weight training, but I find that less enjoyable, so I’m still struggling with finding the right balance.
  2. Eating healthy. That means lots of veggies and healthy fats. I try to limit my carbs, and go heavier on protein, good fats (I love coconut milk in my coffee), and vegetables. I have found that I have more sustained energy, and less irritability than when I eat a diet heavier on carbs. I say “try”, because my achilles heel is chocolate. And graham crackers. And Goldfish. It’s a work in progress….
  3. Vacation. My husband and I use all of our allotted vacation time every year. Yes, we use 1 week to attend a conference, but other than that we prioritize using the rest of the time to get away. We find “stay-cations” less effective, since it’s so easy to get sucked into work obligations or doing household chores. We try to find places to go that don’t have wifi so that we can truly unplug. Otherwise my husband has to lock my iPhone in the hotel safe— I can’t be trusted not to check my email! This dedicated time together helps us reconnect, and remember what’s really important in life.

What’s your ideal workout?

For me, it’s a good week if I have been able to get in a good combo of running, swimming, and biking. It’s a great week if I have also improved upon prior times or distance.

Do you track your fitness? How?

I don’t formally track my fitness.

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

I am fortunate that in my new job I have not had to do night shifts since June. They are definitely harder at 40+  than they were at 30! I’m not sure I ever found the ideal prep or recovery strategy, but I did make sure that I didn’t schedule anything that required any significant mental or physical energy for the next day.

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

I don’t rely on being able to find food or time to eat at work, so I pack healthy snacks that I can eat periodically throughout my shift (bananas, trail mix, protein bars). However, whenever possible, I do try to take a 10-15 min break to leave the clinical area, decompress, and actually eat my food instead of inhaling it. This just takes a little planning and coordination. Unless you are actively managing a critically ill patient, you really can (and should) step away for 10 minutes. The lab/radiology studies to be checked, phone calls to be made, and charting to be completed will still be there when you get back, and you will be more focused and efficient if you have given yourself a much needed brief break.

How do you ensure you are mentally in check?

I think it’s important to know what brings you joy. I really like learning new things. Every few years I take up a new hobby, try out a new sport, or take a class in something I’ve always wanted to learn more about. Changing it up every once in a while challenges me, gives me something to look forward to, and gives me perspective.

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

I think we are so used to putting our heads down and powering through (since as far back as we can remember), that we forget that we are in this for the long haul. We think we just need to push through this next semester, this next rotation, this next week of tough shifts. But eventually we need to realize that there is no end game. It’s important to make whatever changes you need to make in your professional and/or personal life so that you are happy and healthy NOW, rather than assuming it will get better later. Medicine is hard, and EM is particularly difficult. We work in a chaotic environment, are continually asked to do more with less, endure physically grueling rotating schedules, and are exposed to an unending stream of human suffering. Practicing EM can be very rewarding, but working in this high risk environment day after day can also take its toll. Having a hard time handling it long term is the norm, not the exception, and it’s not a sign of weakness to realize you need to make some changes in order to continue to enjoy a satisfying EM career and personal life.

Best advice you have received for maintaining health?

Put yourself on your calendar. We put our shifts, our meetings, our multiple other deadlines and responsibilities on our calendars. If you allow your calendar to fill up with the things you “have” to do, you won’t have any time left for the things you want to do. So take 5 min each week or month to block out time for you. Whether that’s for exercise, date night with your significant other, a concert with friends, make YOU a priority on your own schedule. Then guard that time with your life!

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

Anne Zink

 

Author information

Zafrina Poonja, MD

Zafrina Poonja, MD

ALiEM Assistant Editor,
How I Stay Health in EM series
Emergency Medicine Resident
University of Saskatchewan

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MEdIC Series: The Case of the Resident at Risk – Expert Review and Curated Commentary

The Case of the Resident at Risk outlined a scenario of junior resident who is unsure of how to proceed when her senior discloses thoughts of suicide while on shift. This month, the MEdIC team (Tamara McColl, Teresa Chan, Sarah Luckett-Gatopoulos, Eve Purdy, John Eicken, Alkarim Velji and Brent Thoma), hosted a discussion around this case with insights from the ALiEM community. We are proud to present to you the Curated Community Commentary and our 3 expert opinions. Thank-you to all participants for contributing to the very rich and very important discussions surrounding this case!

This follow-up post includes

  • Responses from our solicited experts:
    • Dr. Ramin Tabatabai (@tabair25) completed his training at LAC+USC and has worked in a variety of ED settings including both academic and community emergency department environments. He has previously been involved in international medicine as well as event medicine serving as an MD for large local events around Los Angeles. Now serving as an assistant residency program director at LAC+USC, his academic interests include residency wellness, clinical education, and procedural competency through his work with residents in the cadaver lab. Ramon is also Vice Chair of the CORD Resilience Committee.
    • Dr. Dimitri Papanagnou (@dmitripapa) is an Associate Professor of Emergency Medicine and Vice Chair of Education in the Department of EM at the Sidney Kimmel Medical College (SKMC) of Thomas Jefferson University (TJU). He also serves as Assistant Dean for Faculty Development at TJU; Director of the In Situ Simulation Program of TJU Hospitals; and Director of the Medical Education Fellowship Program in the Department of Emergency Medicine. His academic interests include medical education, interprofessional team training, patient safety, and professional development.
    • Dr. Gretchen Diemer (@gretchendiemer) is an Associate Professor and Vice Chair of Education for the Department of Medicine at SKMC/TJU.  She served previously as a program director for a 126 resident program but gave that up to serve in her current position of Associate Dean for GME and Affiliations at SKMC/TJU.  She graduated from University of Virginia Medical School and completed IM residency at Hospital of the University of Pennsylvania.  Her academic interests include medical education, particularly around communication skills and professionalism as well as teaching clinical reasoning.
    • Dr. Margaret Chisolm (@whole_patients) is Associate Professor and Vice Chair for Education in the Johns Hopkins Department of Psychiatry and Behavioral Sciences. She is co-author of a textbook on psychiatric evaluation and editor of a book on social media in medicine. She has written more than 70 scientific and clinical articles about substance use and other psychiatric disorders, humanistic practice, and medical education. Dr. Chisolm is a member of the Miller-Coulson Academy of Clinical Excellence and recipient of the 2014 Johns Hopkins University Alumni Association Excellence in Teaching Award, and has twice been recognized as an Arnold P. Gold Foundation Humanism Scholar.
  • A summary of insights from the ALiEM community derived from the Twitter and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
Expert Response 1: Suicide Prevention - Identification, Engagement and Referral (Dr. Ramin Tabatabai)
Expert Response 2: A Very Delicate Situation (Dimitrios Papanagnou and Gretchen Diemer)
Expert Response 3: More Common than You May Think: Let's Talk About Suicide (Margaret Chisolm)
Curated from the Community (Dr. Eve Purdy)

Case and Responses for Download

Click here (or on the picture below) to download the case and responses as a PDF (255 kb).

Author information

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba

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Epistaxis Management in the Emergency Department: A Helpful Mnemonic

epistaxisEpistaxis is a common presentation to the emergency department (ED)1 that can be challenging and time consuming. Knowledge of the pearls, pitfalls, and troubleshooting tips around managing nosebleeds often can be the difference between a frustrating versus straightforward ED stay for patients. Use the EPISTAXIS mnemonic to help you remember these points.

Epistaxis Mnemonic

E xamine

Attempt to distinguish between anterior and posterior bleeding

P ressure

Apply pressure over the nose with compression device or fingers

I rrigate

Irrigate with warm water

S ilver nitrate

Apply silver nitrate locally, if anterior vessel identified

T ampons

Insert anterior nasal or posterior balloon tampons

A frin

Oxymetazoline can be sprayed in the nose as part of conservative treatment or applied on tampon

X A

Apply TXA as gel or solution on tampon

I nterventional radiology

Contact interventional radiology for embolization in conjunction with ENT surgeon

S urgical consultation

Obtain an early ENT consult for severe or high risk bleeding

Anatomy

Anterior bleeding

  • Contributes to majority of cases
  • Occurs at the watershed area known as Kiesselbach’s plexus

Posterior bleeding

  • Contributes to severe cases
  • Arises from branches of the sphenopalatine artery (rare cases involve the carotid artery)

Etiology

  • Causes include direct trauma, nose picking, irritation, dryness
  • Associated with bleeding dyscrasia, congenital or traumatic arterio-venous malformations, anticoagulation, neoplasm
  • The majority of bleeding is self-limited and easily controlled.

Epistaxis Solutions in the ED

Recurrent or intractable bleeding has led to the development of management algorithms in the urgent care setting.2,3

Examine/Ensure secure airway

Attempt to visualize site of bleeding. Have patient gently blow nose to clear the clots. Obtain adequate lighting and use a nasal speculum, if available.

Pressure

As with any bleed, compression is key. Fatigue becomes an issue as patients tire of squeezing their nose. There are commercially available nasal compression clips, but in a pinch (get it?) you can create your own with tongue blades as demonstrated in this trick of the trade.

Irrigation

Irrigation of the nares can improve visibility. Warm-water irrigation has been demonstrated to facilitate hemostasis in posterior bleeds by causing mucosal edema that constricts vessels.4

Silver Nitrate/Cautery

If a bleeding anterior vessel is identified, an attempt at chemical or electrical cautery can be made. Silver nitrate sticks offer an easily accessible and efficacious option.5

Caution:

  • Avoid bilateral septal cautery to prevent septal perforation.
  • Carefully apply silver nitrate very focally on the mucosa being sure not to touch the skin, because it can accidentally burn and stain it (e.g. patient’s nasal ala) black.6

Tampons/Packing

Nasal tampons, often made of Merocel, are used for nasal packing. Patients may be pre-treated with topical lidocaine (2%) and/or oxymetazoline. Nasal tampons can be coated with bacitracin for lubrication before inserting along the nasal floor. Apply saline to expand the tampon. Tampons can also be inserted into the contralateral nostril for further compression.

Balloon catheter tampons provide an alternative option and can target posterior bleeding. They contain an internal balloon that is inflated for extra pressure. Such products have been shown to be easier to use and better tolerated; however, the efficacy is similar to Merocel tampons.7,8

If such balloon catheter tampons are not readily available for difficult cases of posterior bleeding, Foley catheters can be used.9 Insert a 10 or 12 French catheter so that the balloon lies in the nasopharynx. Inflate the balloon with 15 mL of saline, and then apply light forward traction on the catheter to tamponade the bleeding posterior vessels. If bleeding persists anteriorly or into the oropharynx, the balloon can be incrementally inflated up to 30 mL. Avoid inflation with air as the pressure can be lost over time.

Caution should be taken to avoid packing if there is concern for facial fractures.

Afrin/Medication

Oxymetazoline (Afrin), a selective alpha-1 adrenergic receptor agonist and partial alpha-2 receptor agonist, has been shown to be an effective vasoconstrictor even for posterior bleeding.10 Use cautiously in hypertensive patients because elevated blood pressure may contribute to further bleeding. One trick is to apply oxymetazoline directly onto the tampons after insertion. This allows cotton to expand while also providing vasoconstriction.

TXA

The use of tranexamic acid (TXA) in epistaxis and mucosal bleeding has been a topic of interest. While research is equivocal, studies are promising regarding TXA application for nasal packing.11–13 The TXA dosing in Zahed et al.’s paper was 500 mg in 5 mL, applied on the nasal tampon.11

Interventional Radiology or Surgery

ENT consultation should be obtained in a timely manner for severe, refractory bleeding that may require intravascular embolization or surgical ligation.

Disposition

Patients with posterior epistaxis and packing should be admitted to the hospital for observation and ENT consultation.14 These patients may be at higher risk for bradydysrhythmias and recurrent bleeding, requiring surgery. Patients with anterior epistaxis who are hemostatic can be discharged home, assuming stable laboratory testing and vital signs. If they have nasal tampons in place, arrange ENT follow-up at 24-48 hours for re-evaluation and removal of tampons. The routine use of antibiotics to prevent toxic shock syndrome and sinus infections remains debated.

1.
Pallin D, Chng Y, McKay M, Emond J, Pelletier A, Camargo C. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46(1):77-81. [PubMed]
2.
Traboulsi H, Alam E, Hadi U. Changing Trends in the Management of Epistaxis. Int J Otolaryngol. 2015;2015:263987. [PubMed]
3.
Newton E, Lasso A, Petrcich W, Kilty S. An outcomes analysis of anterior epistaxis management in the emergency department. J Otolaryngol Head Neck Surg. 2016;45:24. [PubMed]
4.
Novoa E, Schlegel-Wagner C. Hot water irrigation as treatment for intractable posterior epistaxis in an out-patient setting. J Laryngol Otol. 2012;126(1):58-60. [PubMed]
5.
Shargorodsky J, Bleier B, Holbrook E, et al. Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg. 2013;149(3):390-398. [PubMed]
6.
Maitra S, Gupta D. A simple technique to avoid staining of skin around nasal vestibule following cautery. Clin Otolaryngol. 2007;32(1):74. [PubMed]
7.
Badran K, Malik T, Belloso A, Timms M. Randomized controlled trial comparing Merocel and RapidRhino packing in the management of anterior epistaxis. Clin Otolaryngol. 2005;30(4):333-337. [PubMed]
8.
Singer A, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. 2005;45(2):134-139. [PubMed]
9.
Ho E, Mansell N. How we do it: a practical approach to Foley catheter posterior nasal packing. Clin Otolaryngol Allied Sci. 2004;29(6):754-757. [PubMed]
10.
Doo G, Johnson D. Oxymetazoline in the treatment of posterior epistaxis. Hawaii Med J. 1999;58(8):210-212. [PubMed]
11.
Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013;31(9):1389-1392. [PubMed]
12.
Kamhieh Y, Fox H. Tranexamic acid in epistaxis: a systematic review. Clin Otolaryngol. 2016;41(6):771-776. [PubMed]
13.
Tibbelin A, Aust R, Bende M, et al. Effect of local tranexamic acid gel in the treatment of epistaxis. ORL J Otorhinolaryngol Relat Spec. 1995;57(4):207-209. [PubMed]
14.
Supriya M, Shakeel M, Veitch D, Ah-See K. Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome. J Laryngol Otol. 2010;124(7):744-749. [PubMed]

Author information

Moises Gallegos, MD MPH

Moises Gallegos, MD MPH

Emergency Medicine Resident
Baylor College of Medicine
2017 Essentials of EM Education Fellow

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