Case: A 19 year old male with no past medical history presented with 4 days of painful oral lesions, swollen gums that bled easily, and fever. His temperature was 38.5C. What is the following is true regarding this patient’s diagnosis?
It is treated with chlorhexidine and metronidazole
Acute necrotizing ulcerative gingivitis (ANUG), also known as trench mouth, is an acute infectious intraoral disease characterized by red, ulcerated gingiva, halitosis, friable mucosa and punched out interdental papillae. Fever, malaise, and lymphadenopathy are often present .
The term “trench mouth” was coined during World War I when the disorder was seen in trench-bound young soldiers . It is most common in young males, and is associated with malnutrition, smoking, stress, immunosuppression, and poor personal hygiene. The infection is generally polymicrobial [3-4].
Treatment includes local mouth care with hydrogen peroxide or chlorhexidine oral rinses. If systemic symptoms are present, oral antibiotics (metronidazole or penicillin) are indicated. Follow up with a dental clinic needs to be arranged to help reduce the likelihood of recurrence .
Master Clinician Bedside Pearls [5-7]
Stacey L. Poznanski, DO
AWAEM President 2015-2016
Associate Program Director & EM Clerkship Director
Wright State University Boonshoft School of Medicine
Department of Emergency Medicine
Prabu Selvam, MD contributed significantly to the content of the podcast.
Sangani I, Watt E, Cross D. Necrotizing ulcerative gingivitis and the orthodontic patient: a case series. J Orthod. 2013 Mar;40(1):77-80. PMID: 23524550.
Laughlen GF, Warner WP, Holmes HA. So-Called Trench Mouth and other Manifestations of Vincent’s Disease as a spreading Infection in Canada. Can Med Assoc J. 1919 Apr;9(4):345-50. PMID: 20311252.
Hodgdon A. Dental and related infections. Emerg Med Clin North Am. 2013 May;31(2):465-80. PMID: 23601483.
Atout RN, Todescan S. Managing patients with necrotizing ulcerative gingivitis. J Can Dent Assoc. 2013;79:d46. PMID: 23763733.
Beaudreau RW. Chapter 240. Oral and Dental Emergencies. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
Srour ML, Wong V, Wyllie S. Chapter 29: Noma, Actinomycosis and Nocardia. In: Manson’s Tropical Diseases Edition: 23rd Edition. 2014:379-384.e1
Are you getting a CT or bedside ultrasound as your first-line diagnostic approach to patients with undifferentiated abdominal or flank pain in whom you suspect kidney stones? In a landmark 15-center, multidisciplinary study published in the New England Journal of Medicine in September 2014, Dr. Rebecca Smith-Bindman (UCSF Department of Radiology) and her research team looked at exactly this question for emergency department patients. In the paper, “Ultrasonography versus CT for suspected nephrolithiasis,” Dr. Smith-Bindman and Dr. Ralph Wang (UCSF Department of Emergency Medicine) kindly joined us on a quick discussion about her paper.
Start with the bedside ultrasound to evaluate patients with suspected kidney stones. According to this large multicenter trial, about 2 out of every 3 patients will NOT need a CT scan.
Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, Camargo CA Jr, Corbo J, Dean AJ, Goldstein RB, Griffey RT, Jay GD, Kang TL, Kriesel DR, Ma OJ, Mallin M, Manson W, Melnikow J, Miglioretti DL, Miller SK, Mills LD, Miner JR, Moghadassi M, Noble VE, Press GM, Stoller ML, Valencia VE, Wang J, Wang RC, Cummings SR. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014 Sep 18;371(12):1100-10. DOI. PMID: 25229916.
00:00 Introduction to article
01:40 Q1: About 1/3 of patients in the ultrasound study arms eventually went on to get CT’s in the same ED stay. What would you recommend to clinicians about when that should be? The STONE score was mentioned.
08:30 Q2: Can you address generalizability issues in this 15-center study whereby the cohort has 40% with a history of previous kidney stones and only 60% demonstrating microscopic hematuria. Also what are your recommendations for obese patients (men >280 lb, women >250 lb) who were excluded from your study? CT them all?
16:45 Q3: What has been the feedback from urologists since the paper was published? What are the drivers of CT ordering? See the #UroJC journal club summary by nephologist Dr. Joel Topf.
23:10 Q4: What’s next? What’s NOT in your paper?
Background: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography.
Methods: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy.
Results: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups.
Conclusions: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.)
Today we are back with Dr. Resa Lewiss (@ultrasoundREL), ultrasound guru and pioneer. She has championed ultrasound via each of the three pillars of academics. She is a clinical master of ultrasound, has taught its use worldwide, and has published extensively on the topic. To top is all off, she has taken institutional leadership as the past President of the Academy of Emergency Ultrasound of the Society of Academic Emergency Medicine and the current chair for the Ultrasound Section of the American College of Emergency Physicians. Plus, she has a TEDMed talk. Nominated by Dr. John Bailitz, Dr. Lewiss offers some pointers how she transduces work to success.
Name: Resa E. Lewiss
Location: Denver, Colorado
Current job: Director of Point-of-Care Ultrasound, Department of Emergency Medicine, Department of Radiology, University of Colorado School of Medicine
One word that best describes how you work: Like a vector (velocity plus direction)
Current mobile device: iPhone 6
Current computer: 13” MacBook Pro, Solid state hard drive, Retina display
What’s your office workspace setup like?
What’s your best time-saving tip in the office or home?
Make a list, run the list, run the list again. Everything counts and checking off boxes gives a feeling of productivity.
What’s your best time-saving tip regarding email management?
Be mindful of response content and response time.
Err on the side of politeness. Tone and intention may be lost in email translation.
Less is more and people do not read long and/or dense messages.
What’s your best time-saving tip in the ED?
Ask friends and family to step out of the room (details otherwise would not be heard and the patient would not volunteer; I have been very wrong with the presumed relationship of the patient with the accompanying individuals).
Patients are undressed and in a gown (details otherwise not be seen or smelled and the patient would not volunteer).
Roll the ultrasound machine into the room real time (details otherwise would be missed and more tests ordered).
ED charting: Macros or no macros?
No macros. Scribes: A surprising opportunity to improve communication and educator skill sets. Most are pre-med and interested.
What’s the best advice you’ve ever received about work, life, or being efficient?
Love and giving can be boundless.
Balance this knowing that you must take care of yourself – because if you don’t, nobody else will.
Time is something that you must protect and curate.
Is there anything else you’d like to add that might be interesting to readers?
Never underestimate the power of nature, exercise, and the arts to inspire productivity, creativity and working smarter.
Who would you love for us to track down to answer these same questions?
Azita Hamedani, MD, MPH, MBA: Chair, Emergency Medicine Madison, WI
James Li, MD: one of the first people I knew to use ultrasound and amongst the first to use it on global health missions (former chief resident at Charity in New Orleans).
“Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things. I knew these truths abstractly, but I didn’t know them concretely – that they could be truths not just for everyone but also for this person right in front of me, for this person I was responsible for.” Atul Gawande, Being Mortal.
Both narrative and informative, Being Mortal: Medicine and What Matters in the End, is Atul Gawande’s (@Atul_Gawande) in-depth exploration of end-of-life care. This highly acclaimed book brings readers to a heightened understanding of the complexities of aging and dying and the equal struggle physicians and patients undergo when making end of life decisions. Through historical references, personal observations, and citations from academic literature, Gawande encourages us to critically examine common notions about modern aging and terminal illness.
At the center of Being Mortal, is a reminder of the natural course of life and death, and the role of medicine during this process. Gawande begins the book by introducing the reader to Tolstoy’s, The Death of Ivan Ilyich, a book he was assigned to read in medical school, which is his only memory of discussing mortality during those early training years. Ivan was a man in his mid-forties, a social elite of his time who became suddenly ill. Gawande explains that what tormented Ivan most, was that no one spoke of dying – not his doctors, friends, or family. He wished to be cared and pitied above all else, yet those who surrounded him failed to acknowledge his suffering. The lack of compassion and honesty of death was the ultimate tragedy.
Through various narratives, Gawande paints a picture of what aging looks like in modern times. He compares the story of his wife’s grandmother, Alice Hobson, an elderly woman reluctant to give up living alone for the safety of assisted-living, to the story of his own grandfather, Sitaram Gawande, a man who aged alongside his multi-generational family in rural India. Gawande reflects that medical advances have allowed people to live longer lives than ever before in history, yet this progress is also responsible for a shift in the culture of dying – where death is most likely to occur between hospital walls, a mere medical experience. This is a change, Gawande argues, that we have not prepared well for.
Sharing his interviews with the elderly as well as experts in elderly care, Gawande highlights the importance of maintaining independence as one ages. In many of the stories, what individuals fear most as they age is not dying, but losing the things that matter most in their lives – their independence, their home, the ability to drive, and to be able to make their own choices for as long as possible.
Gawande refers to geriatrician, Dr Bladue, who describes that her obligation to her patients is no different than that of any other doctor.
“The job of any doctor… is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world.”
It is in this balance, Gawande believes, that we as a medical community have failed. No better than the doctors who surrounded Ivan Ilyich during his terminal illness, we are using medical advances to prolong life at the expense of letting the sick die with dignity. There always seems to be another treatment, another solution, until the body inevitably fails. In many examples, Gawande shows us that people at the extremes of old age can live happy, satisfying lives, if only granted a few basic liberties. He makes the case that older people actually can do well on their own, and can do even better when geriatricians are caring for them, and the focus is on retaining function rather than heroic actions to stave off disease.
A similar investigation of terminal cancer patients is also presented in Being Mortal. Cancer, unlike aging, can hit people at any time, as they are fully enjoying life, beginning a family, and in the midst of their careers. Perhaps nothing is more devastating than being diagnosed with a terminal illness at this time in one’s life. Gawande speaks of his own experience having end-of-life discussions with such patients. He and other physicians note that it is difficult to discourage a patient’s optimism, and so they often find themselves offering a possible solution rather than talking about the grave reality, even when the evidence says otherwise. In such situations, there is a pressure to pursue advanced care, despite the likelihood of complications and severe discomfort that will result from this decision. Here, Gawande introduces us to the better outcomes of palliative care. An approach with compassion at its center – patients with palliative support are more likely to avoid hospital visits; report more consistent days without pain or side-effects in which they can better plan how they are spending their time, and are even more likely to live longer than expected.
Relevance to Emergency Medicine
Gwande notes that he learned a lot in medical school, “but mortality wasn’t one of them.” His own uncertainty with how to handle end of life decisions both in his professional and personal life was the driving force behind Being Mortal. Gawande exposes his own doubts, in order to ask critical questions about how we are training physicians to care for the elderly and ill, and the culture that surrounds this most important and inevitable time in one’s life.
Being Mortal makes a strong case for the importance of compassion in medicine. When discussing the story of The Death of Ivan Ilyich, Gwande’s medical class all agreed they would act with more honesty and empathy if they were in a similar situation – this would come naturally to them. What they were concerned with was obtaining the medical knowledge to properly diagnose and treat. But what Gawande sadly notices many years later into his practice, was that we physicians often fall short of our promises from our training days to care compassionately for patients when we no longer believe we can medically cure them.
Perhaps, in emergency medicine, more than in any other field of medicine, there exists a strong and almost unbreakable mindset to do everything in our power to save a life. After all, we are the resuscitationists! Gawande notes that some of his most difficult cases are not the complex operations, but rather, deciding when not to operate. As emergency physicians, we can argue that deciding when to not be proactive and to not resuscitate is similarly as difficult. To recognize when comfort measures and compassion are what will be best for our patients is just as important as knowing when to intervene and act aggressively.
In Being Mortal: Medicine and What Matters in the End, Gawande opens our eyes to the opportunities to do better for our patients in their last stage of life. We can consider other treatment options and dispositions that are more in line with the care our patients need at this vulnerable time. We can better prepare ourselves and the next generation of physicians to have these difficult conversations so that our patients are listened to properly and are thereby able to make the right decisions for themselves. Although primarily focused on dying, Being Mortal is a story full of hope for a better way to live as we age and a more compassionate way to care for the most sick and vulnerable.
Google Hangout Discussion
The author mentions that in some situations a more paternalistic approach to medical care is appropriate, although in general he supports a shared decision making model. When is a paternalistic approach more appropriate?
Being Mortal presents many alternative living arrangements for older adults, though the nursing home is still a dominant model. What role should physicians play, if at all, in changing the status quo?
In Being Mortal, many examples are given on how to conduct a critical conversation about end of life wishes. Do you think the book provided useful tools for both patients and doctors? Which conversations did you find most effective
Gawande discusses the challenges Oncologists face with approaching end of life decisions? Is there, perhaps, an inherent conflict of interest between being “aggressive” and discussing death?
What are the challenges to conducting an adequate goals of care discussion with family members in the ED when the patient is in extremis?
Prior ALiEM Bookclub selections featuring similar discussions:
Welcome to the seventh ALiEM Approved Instructional Resources (AIR) Module! In an effort to reward our residents for the reading and learning they are already doing online we have created an Individual Interactive Instruction (III) opportunity utilizing FOAM resources for U.S. Emergency Medicine residents. For each module, the AIR board curates and scores a list of blogs and podcasts. A quiz is available to complete after each module to obtain residency conference credit. Once completed, your name and institution will be logged into our private Google Drive database, which participating residency program directors can access to provide proof of completion.
AIR Stamp of Approval and Honorable Mentions
In an effort to truly emphasize the highest quality posts, we have two subsets of recommended resources. The AIR stamp of approval will only be given to posts scoring above a new, 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 <30. All posts will still be part of the quiz needed to obtain III credit.
AIR Series: Ob/Gyn
Below we have listed our selection of the 10 highest quality blog posts within the past 12 months (current as of January 2015) related to obstetrics and gynecology, curated and approved for residency training by the AIR Series Board. In this module we have 4 AIRs and 6 Honorable Mentions. We strive for comprehensiveness by selecting from a broad spectrum of blogs from the top 50 listing per the Social Media Index.
After reading, please take the quiz. Feel free to ask questions in the blog comment section below. The AIR Board faculty will answer them within 48 hours of posting. Be sure to include your email or contact information where requested in the Disqus blog comment area, so that you will be notified when we reply. We recommend programs give 3 hours (just under 20 minutes per article) of III for this module.
SGEM#104: Let’s Talk about Sex Baby, Let’s Talk about STDs
The ‘look-alike, sound-alike’ nature of many drug appearances and names is problematic. In high-stress environments such as the Emergency Department (ED), potential disasters can arise if “drug swap” or other medication errors occur. Drug swap is the accidental injection of the wrong drug . The anesthesiology literature contains several published reports presenting various ideas on how to properly label syringes used in the operating room to reduce medication errors. Techniques include color-coding the labels , labeling of the plunger , double-labeling [4, 5], and specific placement of the labels on the syringe .
Because labeling is such an important medication safety topic, Dr. Nicholas Chrimes (@NicholasChrimes) and others have started petitions in Australia, New Zealand, and the United Kingdom aimed to improve mandatory national standards for manufacturer-applied drug packaging. A Twitter account (@EZDrugID) and hashtag (#EZDrugID) have been created to raise awareness of the topic.
With regard to user-applied anesthetic labels, international standards do exist for color-coding these syringe labels. The standards have been adopted in the UK, the USA, Canada, Germany, Australia, and New Zealand (though they are not universally practiced) . An abbreviated example is shown here from .
Syringe Labeling in the ED
Many EDs (like mine) don’t have the luxury of stocking color-coded labels for preparing drugs in emergent situations. When preparing syringes at the bedside, the literature supports two commonalities about what information is absolutely needed on the label: drug name and concentration. 
Drug Name: This one is obvious, though generic names should be used preferentially rather than brand names.
Concentration: It’s easy to simply write a dose on the label. Using ketamine as an example, let’s imagine that the label says Ketamine 100 mg. If 50 mg of the drug were administered and the syringe is placed back down, the next person to grab that syringe might still assume there is 100 mg left. However, if the concentration is written on the label, there will never be a question as to how much drug remains in the syringe.
Here’s how I prepare meds at the bedside using some generic yellow labels I have in my ED.
Other tips to potentially reduce errors (not all-inclusive):
Don’t place the syringe down (as in my example above).
Use the repeat back method when handing the syringe off to someone else.
Discard the syringe when done (but save the bottle – see next tip).
Save the manufacturer bottle – in case there is an adverse event, having the bottle available makes it easier to track back the error to the user/drug or lot number for further investigation
If more than one medication is being drawn up, label each immediately after preparation (and not at the end of drawing up multiple medications).
Make sure the graduations on the syringe remain visible after the label is applied.
If able, specify route of administration on the label as some medications can be given via multiple routes (IV, IO, IM, or SQ). Syringes are also often used to give intranasal or oral medications, especially in pediatrics.
It should go without saying, but… make sure the writing on the label is legible. In fact, preprinted labels are an even better option. Dr. Scott Weingart (@emcrit) has graciously shared his label sheet template which can be printed in large quantities. Tall Man lettering is recommended.
Depending on institutional policies, there may be other information needed on the label such as preparation time and date. However, drug name and concentration are crucial. Keep in mind that color-coded labels have not been proven to eliminate errors completely. This is in part because the colors generally represent a drug category and not an individual agent [8, 9]. There may be a false sense of security that the bedside clinician has chosen the correct medication simply based on color. In a recent study using pediatric resuscitation simulation models, innovative color-coded syringes decreased the critical error rate to zero .
The Joint Commission National Patient Safety Goals include a specific goal (NPSG 03.04.01) stating “Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.” This goal is meant to improve the safety of using medications.
For further discussion, I had the privilege of talking about syringe labeling and other ED medication errors with Dr. Weingart on his EMCrit podcast 103.
Latson TW. Labeling of syringes to prevent “drug swaps”. Anesth Analg 1992;75(2):306-7. [PMID 1632552]
Kothari D, et al. Colour-coded syringe labels: a modification to enhance patient safety. Br J Anaesth 2013:110(6):1056-8. [PMID 23687318]
Bennett A. Labelling syringe plungers to reduce medication errors. Anaesthesia 2014;69(3):286-7. [PMID 24548366]
Phypers B. Double labelling syringes. Anaesthesia 2003;58(11):1125-7. [PMID 14616610]
Suriani RJ. Double labeling of syringes to prevent “drug swaps”. Anesth Analg 1993;76(3):665. [PMID 8507255]
Smith S, et al. Syringe labelling – bridging the gap. Anaesthesia 2014;69(6):652. [PMID 24813147]
Moreira ME, et al. Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations. Ann Emerg Med 2015. [Epub ahead of print] [PMID 25701295]
Expert Peer Review
This is an important safety topic for all EM providers. We all use IV medications at the bedside for procedures like endotracheal intubation and procedural sedation.
In addition to what is stated above:
Be sure the writing on the label is legible. One of the reasons we went to computer order entry was due to poor legibility of provider handwriting leading to medication errors.
If able, route of administration would be nice to include as some medications can be given via multiple routes (IV, IM, or SQ). Syringes are also often used to give intranasal or oral medications, especially in pediatrics. Side note but also for safety: Specific oral syringes are best for oral administration instead of using other syringes.
Brenna Farmer MD, FACMT
Assistant Professor of Medicine, Division of Emergency Medicine, Weill-Cornell Medical College; Director of Patient Safety, NY Presbyterian hospital/Weill-Cornell campus ED; Assistant Residency Director, NY Presbyterian hospital Emergency Medicine Residency; Twitter: @brennafarmer1
Thanks for your expert input. It is absolutely crucial that the writing be legible on the label. I have added this point as an additional tip. I have added the point about writing route on the label if possible. Using the specific oral syringes for oral administration is another great tip. For the sake of brevity in the post, I’d love to have this point added as a comment once the post goes live.
Bryan D. Hayes, PharmD, FAACT
ALiEM Associate Editor; Clinical Assistant Professor, University of Maryland (UM); Clinical Pharmacy Specialist, EM and Toxicology; Twitter: @PharmERToxGuy
Expert Peer Review
Thank you for addressing this important topic. EM providers will definitely benefit from this information, particularly the emphasis on ensuring that concentration is included on the label.
I agree with the information presented, but would recommend considering the following additions to the post.
Please consider expanding on the idea introduced in the 7th paragraph that colored labels have been associated with medication errors. ISMP has reported several instances where drug swap has occurred as a result of similarly labeled syringes, and it has been suggested that the coloration provides a false sense of security (assuming the purple syringe is push dose epinephrine, actually phenylephrine.) Reference 9 touches on this topic.
In addition, please consider adding a statement that the graduations on the syringe remain visible after the label is applied. This is a common error that makes it difficult to accurately measure partial doses.
Another common strategy that I have seen utilized is taping the vial to the syringe with clear transpore tape that is ubiquitous in the ED. While the resulting product is bulky and somewhat cumbersome; however, may be better than nothing in a bind.
Thank you for the opportunity to collaborate. I look forward to seeing this post go live!
Christopher J. Edwards, PharmD, BCPS
Clinical Pharmacy Specialist – Emergency Medicine; Clinical Assistant Professor – Department of Emergency Medicine; The University of Arizona Medical Center; Twitter: @emergencypharm
Thank you for the helpful comments. I have expanded the section about errors from color-coded labels to specifically point out that there may be a false sense of security that the bedside clinician has chosen the correct medication simply based on color. I have added an additional tip specifying that the graduation markings remain visible after labeling (definitely an important point). Regarding the taping of the bulk bottle to the syringe, that is definitely an interesting strategy. I would love for that to be added as a comment once the post goes live.
Bryan D. Hayes, PharmD, FAACT
ALiEM Associate Editor; Clinical Assistant Professor, University of Maryland (UM); Clinical Pharmacy Specialist, EM and Toxicology; Twitter: @PharmERToxGuy
Expert Peer Review
Glad you are bringing a post on this, Bri. Rather than handwriting, preprinted labels may be best. Using whatever sheets are used for the computerized labels already in the dept may be easiest way to go. Download the template online and create a sheet that can be printed in quantity. Here is the one we use.