Trauma in a Hemophiliac

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

While Emergency physicians certainly see their fair share of trauma, managing a patient with hemophilia is quite infrequent. This case highlights some key management points, including:

  • The importance of administering early Factor VIII replacement
  • The need to monitor for delayed intra-cranial hemorrhage
  • The importance of determining capacity when a head-injured patient becomes agitated

Clinical Vignette

You are working in a level three trauma centre and are told that EMS just arrived from an MVC involving a 16-year-old female passenger who has known hemophilia. Vitals are stable. She has a laceration to her arm, and a bruise on her head, but has GCS 15 and only complains of arm pain.

Case Summary

A 16-year-old female presents following an MVC. Past medical history is significant for hemophilia A. She has a laceration on her arm and a bruise on her forehead, but denies HA/N/V. The learner should recognize high potential for bleeding, and implement immediate treatment with rVIII replacement, along with pan-CT imaging. The CT head will show a small ICH. The patient wants to leave AMA following normal CT results, and the learner must preform a capacity assessment and outline a plan of action for the incompetent patient. The patient should be sedated and/or intubated anticipating decline using neuroprotective measures. Consults should be made to the ICU and hematology.

Download the case here: Hemophilia Case

CXR for the case found here:

normal female CXR radiopedia

(CXR source:

PXR for the case found here:


(PXR source:

Forearm x-ray for the case found here:

R forearm cropped

(X-ray source:

ECG for the case found here:


(ECG source:

FAST image for the case found here:

no FF

Cardiac U/S showing no pericardial effusion found here:

(U/S images courtesy of the McMaster PoCUS Subspecialty Training Program)

no PCE

Advice for the First Year Attending

As a female first-year attending, I am 100% about women’s equality in the workplace, but that’s just not everyone’s reality right now. Over the last year while working at a community hospital in rural CT, I’ve heard many unabashed, gender-biased comments from my colleagues. Though none of them targeted, it still often makes the environment seem a bit unfair. Through learning from various scenarios that have come up with me, I have the following five tips for future female physicians to achieve respect and a gain a cordial workplace environment.

  1. Err on the side of being affirmative to all suggestions without compromising on patient care. In general, as a new attending, you should already be more receptive to suggestions. However, there are times where you may feel it is more appropriate to take a different path than that suggested. Still, you should try to make the other person feel like their suggestion is well received. This sometimes takes tact…  E.g. “Let’s call this code.” “Yes, we should. Let me just check one more thing first.”
  2. Learn to recognize when people signal that they are either not convinced or uncertain of your plan and invest extra time with those colleagues, either with asking them to voice their concerns or in education. People will feel that you care about their professional judgement and that you are open to criticism, which will garner you more respect. Though it often feels exhaustive and maybe unnecessary, this extra effort will go a long way, especially for first years. Every conversation is a small step away from their feelings of uncertainty about you and your medical judgment, towards feelings confidence that you know what you’re doing.
  3. Practice having difficult interactions without 1. raising your voice, 2. becoming emotional, and 3. becoming irrational. In other words, though it may feel or may even be personal, try not to show that you’ve taken it personally. Furthermore, you should only really engage if you feel like it is extremely important to a patient’s care. How you engage in conflict will often shape the way people judge your character, so maximize every instance as a way to show your professionalism and leadership skills.
  4. Try to reach out to friends and family in healthcare and/or female colleagues at your workplace for advice when you feel stuck or support to get you through tough times. They might have insights about you or your workplace that could be helpful with moving forward in developing a trusting and respectful relationship with your colleagues. If you do not feel like you can talk to anyone you know, there are many folks in the FemInEM community that you can be connected with if you ask.
  5. If you feel like there are certain people who are central to your negative experiences, reach out to them for a conversation to 1. clear up any misconceptions about you, and/or 2. try to find common ground on which you can work together (a good one is something relevant to patient care). If nothing else, you can use this conversation to communicate that you want to better your relationship for the betterment of patient care. Letting them know you value them as a colleague is also a good thing to try to communicate. Without portraying weakness, make yourself vulnerable to them to be more relatable and perhaps help gain their empathy. E.g. “You are an extremely talented colleague, and I care what you think about my professionalism and patient care, so please let me know if you see areas for improvement.”

If all this seemed extremely obvious to you, then keep up the good work! Also, perhaps you can find other female colleagues to mentor.

Do you have any other tips? Share them in the comments section!

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Chemical Engineers Help Nanoparticles Better Target Brain Tumors

Nanoparticles (in red) being taken up in the brain of a live rat model with glioblastoma (in green).

Getting drugs into the brain by cloaking them within nanoparticles that can sneak through the blood-brain barrier has been the focus of a lot of nanotechnology research over the past few years. There’s quite a bit of progress toward that goal, including some notable successes. Because of this progress, scientists are coming to the realization that to achieve optimal results, the nanoparticles that reach the brain must also be discriminating enough to affect only the targeted types of cells. In reality, though, the same shell that cloaks drugs as they pass through the blood-brain barrier in many cases prevents the drugs from being absorbed by the cells in the brain.

Yale University scientists have been working on affecting the surface chemistry of poly(lactic acid) nanoparticles, a type that has been shown to be able to pass through the blood-brain barrier, in order to improve the uptake of the drugs within by brain cells. The investigators have discovered that attaching certain chemical bio-adhesive end-groups, specifically aldehydes, to the poly(lactic acid) nanoparticles makes the nanoparticles more prone to cellular uptake.

Aldehydes are attracted to amine, a compound found within many proteins, which in turn attracted the nanoparticles to reach the insides of cells. The Yale team also noted that tumor cells were particularly hungry for these new modified poly(lactic acid) nanoparticles, pointing toward an approach that will see more chemical tinkering to get the nanoparticles even more accurate in their targeting.

The team notes that increasing the uptake of the nanoparticles by cells should be evaluated in relation to the potential for increased overall toxicity by the nanoparticles.

Study in Nature Communications: Surface chemistry governs cellular tropism of nanoparticles in the brain…

Mindset in Medical Education: How does Mindset play a role in support after a medical mistake or adverse event?

Author: Bo Burns, DO, FACEP (George Kaiser Foundation Chair in Emergency Medicine, Associate Professor and Program Director, Department of Emergency Medicine, University of Oklahoma School of Community Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

“Remember that patient that you saw?  The patient with gastroenteritis?  Well they came back with a perforated appendicitis and overwhelming sepsis.  Wow, you really dropped the ball didn’t you?” Those words that we as educators may utter possess great power, most of the time don’t need to be said, and along with the related clinical experience might have a lasting negative impact that could influence that particular care team for quite some time.  That experience might shape both the immediate feelings/perceptions through what is known as the ‘second victim’ phenomenon but can help to form unhealthy negative coping mechanisms and emotions with less job satisfaction and increased feelings of burnout over time.  “Second victims” are health care providers who have been involved with patient adverse events and who subsequently develop difficulty coping with their emotions.  This has received well-deserved attention, but the interaction of mindset and how it impacts the second victims is yet to be determined.  (Suggested reading on Second Victims below).

As educators our learners will experience mistakes, setbacks, fatigue, burnout, bias, adverse events, a missed MI, failed airways, unexpected patient deaths, missed fractures, and applying incorrect diagnoses.  These experiences come by many names, but it is an inevitable part of our training (and professional life).  For many of us in medical education the first time that our residents experience this is in the post-graduate training phase.  Not only are they caring for patients (even though supervised) in a more independent fashion, this may be the first time that many of our very driven, goal oriented high achievers make a mistake or experience a significant life setback.

Over the past decade interacting with many EM residents at various levels of training, I have witnessed many mistakes and setbacks of varying severity and clinical relevance.  With time, I have come to embrace these moments as a time to build trust, provide support, listen, and help gain insight into the mindset of the resident.  I will admit, when I first became Program Director I dealt with these type of situations in more of a punitive fashion. (“Let’s talk about what you did wrong.”)  The understanding of the Mindset concept has helped me a great deal to open up a meaningful dialogue and gain understanding, then to provide support and instruction.

The students and residents who we mentor and teach are very gifted and have much more experience with success and accolades than failure.  These difficult situations may represent uncharted waters and will require dedicated time and attention on our part to ensure that these events are approached, understood, and ultimately resolved in the healthiest way possible.

In her book Mindset: The New Psychology of Success, Dr. Carol Dweck explains how the Mindset of the individual can be a great determinant of their success.  She makes the distinction between what is referred to as the ‘Fixed’ vs a ‘Growth’ mindset. This book and the concepts discussed therein have helped me on numerous occasions to have more meaningful interactions with my students and residents (and Faculty) and has helped me to understand how to help our trainees navigate and work through a setback in a much more meaningful way.  Dr. Dweck discusses that praising learners for their talent instead of hard work does not build mental toughness or build confidence or help to develop resiliency and can actually be counterproductive.  This is albeit a much shorter review and description of the significance of the impact mindset can have during the evaluation and feedback process than is discussed in the book.

I suspect that many of us in medical education might recognize some examples of a Fixed mindset or that pivotal moment when the mindset of the learner is revealed.  The defensive pushback we encounter when we discuss a “miss” or the frustration/anger that is voiced from a learner after critical feedback received from an evaluation.  If you witness a learner push back, become defensive, and seem to give up with this type of feedback, this should be an indication to us of the mindset (at that time) of the learner.  This reflects the belief that their intelligence and talent are fixed, and no amount of effort or energy can change or improve these qualities.  As you can imagine, the quality and content of the conversation will improve as the distance increases from an emotional event.

Producing a growth mindset in your learners (and yourself) will take time and effort on our part.  We should view these tough conversations as wonderful opportunities to build trust with our learners and demonstrate to them that their intelligence and talent are not fixed qualities and do not determine their worth.  The Growth Mindset is one that welcomes challenges and opportunities as opposed to the Fixed, which places more value on praise and accolades.  This mindset believes that the most basic qualities of the learner, like talent and intelligence, can be improved upon by dedication and hard work.

After reading existing work on this concept, I have tried to incorporate these concepts into our resident and student curriculums.  I no longer try “to win” these crucial (non-behavioral) conversations that I have with my students and residents but simply listen to understand, to make sure that they are listened to and to gain insight into their mindset.  We must recognize these times of stress and setbacks as great opportunities to help our learners navigate successfully and lay the framework for their future.  Just as a novice learner requires our direct training initially, they recall it more over time as competence develops.  This same principle applies to the development of Mindset, and part of how we do that is to help identify characteristics of the type of mindset they possess at that particular time.  I have witnessed on many occasions that a learner who at a time displays characteristics of a Fixed Mindset will not internalize feedback as well as the Growth Mindset.  The defenses that are ‘up’ prevent the introspection necessary to make the steps to objectively consider the feedback, evaluate the situation, review the event in question, or to discuss that mistake.

We introduce these concepts to our students and residents, at regular intervals outside of crucial or difficult conversations.  The hope is that this training, coupled with resiliency development, and overall wellness will produce physicians much more comfortable with challenges and self-evaluation who are less likely to suffer from burnout.

Suggested Reading

  1. Mindset: The New Psychology of Success. Dweck, C.
  2. Mira JJ, Lorenzo S, Carrillo I, et al. Interventions in health organisations to reduce the impact of adverse events in second and third victims. BMC Health Services Research. 2015;15:341. doi:10.1186/s12913-015-0994-x.
  3. Burlison JD1, Quillivan RR, et al. The Effects of the Second Victim Phenomenon on Work-Related Outcomes: Connecting Self-Reported Caregiver Distress to Turnover Intentions and Absenteeism. J Patient Saf. 2016 Nov 2.  PMID: 27811593
  4. Grissinger M. Too Many Abandon the “Second Victims” Of Medical Errors. Pharmacy and Therapeutics. 2014;39(9):591-592.

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La jeringuilla que revierte las TPSV y…despedida a las/os resis de este año

La imagen es de aquí

En mi última guardia de PAC, compartida con una residente  que a punto está de terminar su andadura como tal, tuvimos la posibilidad de hacer un repaso por varias de las disciplinas que abarca esta nuestra especialidad, y así vimos una sospecha de cuerpo extraño  en faringe, una posible sordera súbita en un varón joven, una cefalea de reciente comienzo en una paciente de 77 años con inestabilidad y vómitos, una sospecha de  pielonefritis aguda que a pesar de tratamiento antibiótico seguía con fiebre, y el caso “estrella” motivo de esta aportación en el blog. Se trataba de un varón joven sin AP de interés, con un cuadro de palpitaciones de repetición ya valorado por cardiología con estudio Holter hecho y pendiente de nueva consulta en unos días, que acudía por un episodio de taquicardia de 15-20 minutos de evolución que había aparecido de repente y en reposo, como siempre, sin dolor torácico ni mareo ni disnea acompañantes.

Cuando llegó a nuestro servicio estaba tranquilo, eupnéico, estable hemodinámicamente con PA 120/84 mmHg, una FC de 145 lpm y una Sat O2 100%. La AC era rítmica sin soplos y en la AP no había ruidos sobreañadidos.

Realizamos un ECG que mostraba una taquicardia rítmica, de QRS estrecho y en la que no veíamos ondas P; lo interpretamos como una TPSV, que era lo que el paciente había tenido en otras ocasiones, y pensamos que debíamos intentar frenarla y/o conseguir que revirtiera a RS. El paciente nos decía que habitualmente con lorazepan sublingual  se le pasaba…

Yo, normalmente, las taquicardias/palpitaciones que suelo ver en el PAC son taquicardias sinusales generalmente por estrés, alguna por  hipertiroidismo  o extrasístoles aisladas que luego son seguidas por el MAP y que no precisan de mi actuación más allá que tranquilizarles y/o administrar un ansiolítico.

Pero ésta era diferente, pensamos en qué hacer y recordamos las maniobras vagales indicadas en estos casos previas a tratamiento farmacológico con Adenosina ® y recordé las entradas (1 y 2) de Marilis en el blog sobre el uso de una jeringuilla vacía… le hicimos soplar con fuerza para mover el émbolo de la jeringuilla ( os diré que le dimos una de 20ml y no de 10ml) y en unos segundos la taquicardia cesó y el ritmo pasó a ser un RS a 85-90 lpm. El paciente nos miraba extrañado y perplejo y no soltaba la jeringuilla de la mano y nos decía “yo me la llevo a casa por si me pasa otra vez”.

Tras un rato en observación se fue a su casa en ritmo sinusal y con “el arma salvadora” en la mano; es una pena que no os pueda mostrar el registro electrocardiográfico pero este fin de semana no pudimos registrar y transferir los ECG por la sospecha de ciberataque que nos dejó sin acceso a internet.

No quiero terminar esta breve redacción sin aprovechar para despedirme de los residentes que me acompañan en mi andadura de “guardiana de PAC”, de los que vienen a mi centro de trabajo y de todos los que pasan por otros PAC: son un estímulo, cada día aprendo algo nuevo con ellos/as, hacen mi trabajo más agradable…en fin, que son un disfrute y que  les deseo  mucha suerte en su nueva etapa y que seguro coincidiremos algún día.

Va por vosotros…

Autora: Cristina Ibeas, médica PAC OSI Bidasoa 

Aprovecho la ocasión de sumarme a la despedida de Cris de todos los compañeros/as que han compartido guardias a lo largo de estos meses y que terminan ahora su periodo formativo. Me voy a repetir: ha sido un verdadero placer conoceros, he disfrutado de cada una de las guardias compartidas, os doy las gracias y os deseo, cómo no, lo mejor de lo mejor. Ojalá que nos veamos...