Free Book Chapter on Infectious Diseases Available to ACEP Members

As relieved as we are that the Ebola outbreak appears to be limited and less of a daily concern in our emergency departments, we do still remain on alert for the outbreak of other infectious diseases. It’s been very gratifying to see several ACEP members who are subject matter experts in infectious disease step up and help us create the resources we’ve posted on ACEP.org for the entire emergency medicine community. Among those experts are Kristi Koenig and Carl Schultz from the University of California at Irvine. They’re working on a new edition of their book on disaster medicine and realized that the chapter on emerging infectious diseases would be very useful to us all right now. As they said,

“The emergency health care system must be prepared for an evolving public health event of international significance such as this. Emergency physicians are on the front lines and should be knowledgeable, up-to-date, and ready to effectively manage infectious disease threats. It doesn’t matter whether such threats arise from Ebola virus disease, Enterovirus D-68, MERS-CoV, SARS, the 2009 H1N1 pandemic, or the next big event, as yet unnamed. We should be leaders in our hospitals, EMS systems, and communities, advocating for protection of the public health, our patients, and colleagues.”

Kristi and Carl have donated a preliminary electronic draft of that chapter to the College – to all of you, really – as a resource to help you and your team prepare to screen for and treat the wide range of infectious diseases any of us could see any day of the week.

Just follow this link to download the chapter now.

Best wishes to you all, and be well. We hope to see you next week in Chicago for ACEP14.

Sincerely,

Alex M. Rosenau, DO, CEP, FACEP
ACEP President

Micahael J. Gerardi, MD, FAAP, FACEP
ACEP President-Elect

#TipsforEMexams: Heather Murray’s Exam Tips

Survivor of the 1997 exam (wow… does the exam really go that far back?)

There is not much to add to the excellent tips already posted. But here I go with my tips. Incidentally they are the same things that I frequently tell my children!

  1. Answer practice questions – over and over again. There is a whole pile of evidence which supports what you already know: highlighting an article or a textbook is a low level retention strategy. Writing out the content is better. But if you really want that information to stay in your head, practice retrieving it. Create practice questions for yourself and the others in your study group, find old practice exams, and ask your program to make questions during teaching sessions. Every time you retrieve the information, the neural pathway in your brain becomes clearer and better developed. This goes for oral examinations too.
  2. Get rid of distractions. Take yourself somewhere where no one can find you, turn off your phone and email, and focus on whatever you have decided to learn. You will be pleasantly surprised how rapidly you can get through what you need to do when you are not constantly interrupted buy the lure of a text, facebook post or an email. Or the sudden inexplicable need to reorganize your kitchen cutlery drawer.
  3. Study strategically. You can predict some of the exam content if you think about it carefully. Guess what? You might need to manage a difficult airway and a pediatric critically ill patient. There are certain emergencies that are core competencies, and guess what? They show up on the exam that is intended to test those competencies. These cases are coming and it is clearly an appropriate expectation for graduating emergency physicians to manage these well. So, have it down to a fine art – rehearse the cases you know you will see again and again, and take them to their worst possible conclusion. Your difficult airway will need a cricothyroidotomy and your pediatric case will arrest… eventually. Be ready to rock it like a champion.
  4. Reward yourself. You do not have unlimited stamina to crush information into your brain. Set yourself a time limit, study hard and then reward yourself with something – exercise, coffee with a fellow exam study sufferer, or a nice meal with your lonely partner. Repeat. Those little psychological boosts can get you through even the most tedious of study topics (workplace environmental toxicology, anyone?).

Good luck!

I tag …

1. Rachel Poley (St. Mike’s)

2. Conor McKaigney (Queen’s / KGH)

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #TipsforEMexams: Heather Murray’s Exam Tips appeared first on BoringEM and was written by Teresa Chan.

Bounceback: An Unrelenting Headache

Author: Rachel Wightman, MD (Senior EM Resident, NYU) // Editors: Adaira Landry, MD, & Justin Bright, MD

CC: Headache

First visit

HPI: 29 year old female with a prior history of headaches, presented with two days of gradual onset, atraumatic, right sided headache that is throbbing in nature. The patient reported heaviness about the eye but no visual changes or disturbances. No neck pain, fevers, chills. She described feeling slightly light-headed but no balance loss. She had a mechanical trip and fall yesterday without head trauma, and her headache had been present for a day prior to the fall.
ROS: otherwise normal.
PMH/PSH: headaches, depression, anxiety, asthma
SH: no smoking, no etoh, no drugs
Allergies: Penicillin (rash)

Pertinent Exam
Vitals: 98.6F, BP: 156/85 P: 101, RR: 16, O2: 98%RA
Gen: A&Ox3, well-developed, well-nourished
HEENT: normocephalic, atraumatic, conjunctiva wnl, EOM wnl, PERRL, normal fundoscopic exam, crisp optic discs, normal ROM neck/supple
Chest: wnl
Abd: wnl
Musculoskeletal: wnl
Neuro: CN2-12 intact, normal reflexes, normal muscle tone, normal coordination

Labs: Serum HCG negative

Imaging: None ordered

ED Course: The patient was believed to be experiencing a migraine headache. She had no evidence of head trauma, no signs of infectious etiology, and had no clinical findings or hx for SAH. She was administered Toradol, IVF and Reglan, and discharged with instructions to follow up with neurology and possibly have an outpatient MRI.

Discharge Dx: Headache

Bounce Back Visit
The patient re-presented to the Emergency Department 14 hours later with worsening headache and nausea. Minimal additional history was obtained. The physical exam was documented as unchanged from the prior exam, and the patient was again diagnosed with a likely migraine. Her pain was uncontrolled with Toradol, Reglan, and IVF. The patient subsequently received dexamethasone and magnesium with improvement in pain. The new discharge plan was a steroid taper and outpatient neurology follow-up. At time of discharge patient reported worsening pain and requested a neurology consult. A head CT was also ordered at that time.

Neurology Consult Note:
29 year old obese female on OCPs with R frontal headache radiating to left, stabbing, unremitting. Headache associated with worsening on valsalva maneuvers, dizziness, pain on eye movement, but no vomiting. History tension-type headache in the past, but this headache is different, failing ibuprofen 400mg therapy which usually relieves her headache. FH: Maternal Grandmother with venous clots resulting in stroke, mother with PFO and stroke at age 40 unknown if hypercoagulability workup performed.

ED COURSE:
In addition to the medication given above, a head CT was performed. CT images demonstrated a right transverse and straight sinus thrombosis.

CVST1

CVST2

DIAGNOSIS: Cerebral Venous Sinus Thrombosis

Background:

Cerebral venous sinus thrombosis (CVST) is a rare but serious cause of neurologic symptoms. CVST results from venous outflow obstruction causing increased intracranial pressure, increased retrograde venous pressure, a decrease in cerebral blood flow, decreased cerebral perfusion pressure and eventually venous infarction. CVST is estimated to account for fewer than 1-2% of all strokes. It affects mostly younger adults and children with the mean age of presentation at 39 years. Women are affected more often than men with a 3:1 female predominance. This gender imbalance is thought to be due to the increased risk for CVST associated with pregnancy, puerperium, and with use of oral contraceptives. More than 85% of pts with CVST have at least one identifiable risk factor and multiple risk factors may be found in about half of patients with CVST. The most frequently cited risk factors include pro-thrombotic conditions including genetic and acquired conditions. Other less common risk factors include CNS/sinus infection, head injury, inflammatory bowel disease and cirrhosis.

Clinical Presentation:

The clinical presentation for CVST is highly variable and non-specific. Signs and symptoms are divided into three categories: 1) isolated intracranial hypertension 2) a focal syndrome including focal deficits, seizures or both 3) encephalopathy causing multifocal signs, mental status changes, stupor, or coma. Patients can present acutely, sub-acutely, or with chronic symptoms. Other variables affecting presentation include site and number of occluded vessels, presence of parenchymal brain lesions, patient age and gender. CVST cannot be diagnosed on clinical grounds alone and neuroimaging is required for diagnosis.
Diagnostic Imaging:

Non-contrast head CT is typically the first study performed in patients with suspected CVST in the ED because it is readily available and the most useful test to evaluate for conditions that can mimic CVST clinically. Common findings of CVST on head CT are generalized swelling or localized areas of hyper-density indicating cerebral infarction (seen in up to 40% cases). Direct signs of CVST can sometimes be seen on CT scan and include the dense triangle sign, as seen on CT scan in our patient, which indicates fresh thrombus in the posterior aspect of the superior sagittal sinus. Non-contrast head CT can be normal in 25-30% of patients with CVST. In hospitals without MRI capability, CT venogram is the confirmatory test for CVST. However, MRI/MRV is the most sensitive and specific imagining modality for CVST and can best determine the location and age of a thrombus.

Management:

Anticoagulation with heparin is the standard therapy for CVST. At this time no clinical guideline exists to recommend un-fractionated heparin (UFH) versus enoxaparin (LMWH) for therapy and there are no prospective, randomized trials of systemic anticoagulation use in treatment CVST. Hemorrhagic infarction is associated with 40% of CVST, however, most experts recommend use of anticoagulation in patients with CVST even in the setting of known hemorrhagic infarction on imaging. Systemic TPA and direct endovascular thrombolysis are considered experimental therapy at this time and cannot be routinely recommended. Patients with CVST will require anticoagulation beyond hospital discharge. The duration of anticoagulation is dependent on the etiology of thrombosis.

Hospital Course:

The patient was admitted to the stroke unit for anticoagulation of right transverse and straight venous sinus thrombosis. She was started on a heparin drip, transitioned to enoxaparin, and then bridged to warfarin. Thrombophilia studies demonstrated a low anti-thrombin level and an elevated anti-2 beta glycoprotein antibody, suggesting a hypercoagguable genetic disorder. The patient was discharged home on hospital day seven with no residual deficits on warfarin with plans to repeat coagulation studies in six weeks.

Errors in Evaluation

Lack of full history: Patient risk factors for CVST were not elicited on first visit. Additionally, changes in headache symptoms from previous headaches were not adequately explored. Any alteration in patient headache symptoms should trigger further evaluation and consideration of possible secondary cause of headache.

Anchoring bias: Anchoring to the diagnosis of possible migraine headache from the initial visit likely led to delayed diagnosis and near-miss on second visit to the ED. It is important to ask all patients with reported history of migraines how the diagnosis was made because many patients with headache sometimes attribute any and all headaches to “migraine.” Making a new diagnosis of migraine headache in the Emergency Department should cause providers to pause and consider other possible etiologies of headache.

Failure to broaden differential: CVST is rare diagnosis with variable presentation and can often be missed on initial presentation. Physicians need to expand their differential and think about CVST in order to make the diagnosis. Not all headaches are migraines so we should be sure to document our thought process well when seeing these patients.

References

Ferro JM, Canhao P. Treatment and prognosis of cerebral venous sinus thrombosis. Uptodate.com. Accessed 8/14.
Ferro JM, Canhao P. Etiology, clinical features and diagnosis of cerebral venous sinus thrombosis. Uptodate.com. Accessed 8/14.
Fischer C, Goldstein J, Edlow J. Cerebral venous sinus thrombosis in the emergency department: retrospective analysis of 17 cases and review of the literature. J Emerg Med. 2010.38(2):140-7.
Matharu et al. Thunderclap headache: an approach to a neurologic emergency. Current Neurology and Neuroscience Reports. 2007. 7(2):101-9.
Singh A, Soares WE. Management Strategies for Acute Headache in the Emergency Department. Emergency Medicine Practice. June 2012. 14(6):1-42. EB Medicine.net.

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CASO 156: Disnea de 2 semanas de evolución. Rx TÓRAX.

Mujer de 72 años sin antecedentes relevantes acude por disnea progresivamente en aumento de 2 semanas de evolución. No refiere clínica de infección respiratoria ni de insuficiencia cardiaca.

Dice que desde hace unos 3 años tiene costumbre de fumar medio cigarro al mediodía con sus amigas y otro medio antes de acostarse. Desde hace un mes está a dieta por cifras de glucemia en el límite alto y sobrepeso.

Refiere hematuria intermitente desde hace 3 semanas sin clínica miccional. Hace 4 años, episodio autolimitado de hematuria, se le realizó ecografía renal que fué normal.

Se realiza Rx de Tórax:

export--8182268

Cuestiones:

- Interpretación de la Rx

- Diagnóstico de presunción.

- Otras pruebas?


The Reasons Why It Is Difficult to Match: A Closer Look at America’s Medical Training Status

Recently I came across an article in the New York Times describing the life of a foreign intern at Woodhull Hospital Center in Brooklyn, New York. The article highlighted many interesting aspects of interns’ daily life and revealed the expensive price that individuals pay to become doctors in the United States. Yet far more disturbing were the readers’ comments. Some went too far describing foreign doctors like Dr. Sanchez as the reason why some US medical graduates could not match into training. The taboo of US versus International Medical Graduates (IMGs) training in the US is an uncharted territory to explore, as it will upset many. At this time 10 years ago I was going through the application process to get a residency. From the start, I heard about IMG-friendly programs and was encouraged to apply for them. Sure enough I matched that same year. Today I hear of all these bright young graduates who are US or IMGs who cannot secure a spot. Even with nearly perfect board scores! Is it doomsday or what?! Residency and fellowship positions have steadily increased since then, but not at a rate that meets the demand of the increasing number of graduates. The more the market is flooded with graduates, the more competition there is to obtain a spot in training. Just in the past 10 years, MD schools increased enrollment by 30%. DO schools graduated 32% more physicians in 2014 compared to 2010. More than 60% of IMGs match with primary care specialties (top three: internal medicine, family medicine or pediatrics), while more than 60% of US seniors match into other specialties (<40% into primary care specialties). Over the last 5 years, approximately 3800 new PGY1 positions were added, 66% of which were in primary care (Internal Medicine: 1523, Family Medicine: 500, Pediatrics: 253, Psychiatry: 231). But the current pay for these specialties makes them less attractive for US seniors to pursue. Let’s not forget the debt they carry due to the costs of medical education, which is much less of a burden for IMGs. The story is not very different when you look at fellowship positions offered. The 5-year increase of 37% is widely spread between subspecialties, without addressing the market needs. While it puts pediatric emergency medicine as the most competitive pediatric fellowship to obtain, many of us are being drained clinically due to staff shortages and constant outbreaks. The difference between US and IMGs is obvious. But both constitute the threads of the American fabric of excellence. Each brings something to the table that is unique and outstanding. And without diversity in ideas, practices and backgrounds, our system would be diseased with a limited opportunity for innovation and advancement. Can we still blame IMGs for training position shortages? Or should we blame policymakers for poor planning? Please share your thoughts, personal experiences and comments.

Mechanical CPR: Three CHEERS or a boo?

Originally posted on AmboFOAM:

There has been a fair bit about mechanical CPR devices floating around the FOAMasphere lately, so I thought I should probably do a post.

These devices are not exactly new (check out the Thumper, in use in Victoria in the 70s) However, there seems to be a surge in interest in these devices, and I must say there seems to me to have been a largely positive buzz about them in spite of the evidence for their effectiveness being somewhat lacking to say the least.

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