Best Case Ever 33: Over-correction of Hyponatremia

Rapid over-correction of Hyponatremia can have devastating consequences: for one, osmotic demyelination syndrome (ODS) can result in destruction of the pons and a locked-in state. We don't see ODS very much as it's onset is delayed and usually sets in after the patient is admitted to hospital (or worse, sent home). Nonetheless, we need to know how to manage Hyponatremia in the ED so that we prevent ODS from ever happening. In this Best Case Ever, Dr. Melanie Baimel describes the case of a young woman who came in to the ED after drinking alcohol and taking Ecstasy, wanted to leave AMA after her Hyponatremia had inadvertently been corrected too rapidly, and the conundrum that ensues.

In the upcoming episode, Dr. Baimel and the first ever Internal Medicine specialist on EM Cases, Dr. Ed Etchels, discuss a rational step-wise approach to managing Hyponatremia, tailored for the EM practitioner; when you might consider giving DDAVP in the ED, the best way to correct Hyponatremia, how to manage the patient who's Hyponatremia has been corrected too quickly, and an easy approach to the differential diagnosis. Get a sneak peak at the algorithm that will be explained and reviewed in the upcoming episode......

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Getting testy: Parents who demand tests in the ED and doctors who may or may not order them

There are many demands in the emergency department. Perhaps the most important ones come from patients and their families. This post originally appeared on as a part of the Art of Medicine series and looks at those situations in which patients/parents are requesting – nay demanding specific tests. As I noted in a previous post in this series the ED is an emotionally charged environment. Often parents are seeking an answer as to why their child is ill. That answer may come in the form of a specific diagnosis or further elucidation as to the reason for particular symptoms. I’m sure that many of you have encountered a parents asking for a “test” to tell them what’s wrong with their child. Perhaps they’ve even asked for it by name. “I just want a CBC.” or “She needs an MRI.” Let’s explore this conundrum in a little more depth, shall we? Why are they demanding a test? Because they are scared. Sense a theme here? Coming to the ED is oftentimes a frustrating, terrifying experience. Uncertainty drives many a visit, and in order to mitigate concerns parents are seeking answers. In many ways we have been taught to seek out objective evidence. In an era where any test is possible parents may be conditioned to think that the only path to a diagnosis is through a confirmatory test. Empiricism this is not. So before getting that test explore why the parent is “demanding” it in the first place. I’ve found that it is frequently possible to convince the parent that your diagnosis is justifiable based on H&P and clinical reasoning alone. All that this takes is time. Before ordering any test you should answer the following questions: Is it justifiable based on the clinical scenario? Is it justifiable from a billing standpoint? Will it make a difference in the patient’s clinical care? Is the risk worth the potential benefit? Don’t they trust me? Unless they explicitly say so the answer to this one is no. Many patients have been to multiple providers/had multiple visits before coming to the ED. Keep that in mind, and you will better empathize with a certain degree of skepticism that surrounds select encounters. Also, know your limitations. It’s cliche for sure, but trust is earned. You should always be honest with the family about what you think is going on and why you need/don’t need to pursue testing. What if the referring physician said they should get a test, but you disagree or feel that a different test would be better? Let’s consider the example of a belly CT for abdominal pain. Sure, it’s a great imaging modality, but the risk of exposure to ionizing radiation is great. Remember that to work in the ED is to work in a place where the worst case scenario should be considered and ruled out. This begins with an appropriately thorough H&P and selection of the best tests to aid in situations where the diagnosis or next course of action is still uncertain. Lot’s of things hurt inside of the belly. You don’t need imaging in a child to diagnose pancreatitis – so if the amylase/lipase are abnormally high skip that CT. Also, you should always call the referring physician in any instance where a child has been sent to the ED. Perhapsthe referring provider has only spoken to the family on the phone. It’s quite possible that they said to the mother of a child with a barky cough – “Sounds like croup. The ED might have to give a breathing treatment or get an XRay.” Consider […]

Work as an emergency fellow in Ireland

I posted on this last year but the department I work in as a few upcoming vacancies in July so I thought I would update things for those who might want to come work.

MMUH resus

Are you an emigrated Irish doc in training in Oz or NZ and fancy coming home for 6 months as part of your training? Are you a kiwi or Aussie and fancy some time in Europe as part of your training?* Do you simply want to come and work in a different system and advance your practice. Then these might be the jobs for you. Are you an Irish trainee between basic and advanced training? If you’re working in Ireland and fancy a career development opportunity in one of the big Dublin hospitals then read on. 

[* the Mater is accredited for training in Ireland through the (recently Royal) college of emergency medicine which is the specialist college for emergency medicine in the UK and Ireland. From communication with the Australasian College in Emergency Medicine (ACEM) we have been told that any trainee wishing to undertake training overseas and have that time accredited toward their ACEM training can apply to ACEM prior to beginning the post and obtain prior approval to have the training added toward their ACEM training. So as far as we know we are eligible for training by ACEM too]

The Mater Misericordiae University Hospital (The Mater) in north Dublin is one of the main tertiary centres in the country. It has the national spinal injuries centre and all major specialities apart from neurosurgery and as far as I’m aware it’s the only place doing ECMO in the country. The hospital recently (2013) moved to brand new facilities including a new Emergency Dept, theatres and ICU.

The ED encompasses a large ‘acute floor’ model with acute medicine working out of the same department.  There is a 5 bed resus with CT scanning within the resus bay. There are 2 dedicated ED ultrasound machines.

The hospital serves one of the more deprived areas of Dublin with the obvious result that it sees a fascinating range of pathology from stab wounds, pedestrian trauma to complications of alcohol and  intravenous drug use and all the interesting infectious disease complications that come with it. One of the emergency medicine trainees is a lead for an international HIV screening project in the department.

The ED has created several posts at registrar level to attract new staff and facilitate career development. All posts have protected non clinical time to pursue the appropriate sub specialty. Clinical work will be on the registrar rota in the ED.

Link to official job advert [search for mater misericordiae]

Video ad from Dr Tomas Breslin, Consultant in EM, Mater Hospital

Feel free to contact myself [emergencymedicineireland [at]] or Tomas Breslin [tbreslin [at]] if interested.

Fellow in imaging

  • 20% protected non clinical time
  • 2 machines in ED
  • Weekly USS teaching (led by fellows)
  • Liaison with emergency radiology (fellowship trained)
  • Echo Module
    • 6 months
    • 2 hrs/wk in ICU with echo tech supervised scanning
    • 1hr/wk with ED/CCU patients with echo tech supervised scanning
    • Formal lectures
    • Examination
  • Early Pregnancy Module
    • based in local maternity hospital
    • this years fellows just starting
  • Suitable for (but not limited to)
    • post basic EM training, able to work clinically as registrar/advanced trainee in ED
    • prior to entry to formal higher training scheme, allows clinical development and level 1 USS skills with space to develop CV prior to application to higher training OR
    • post training as a fellowship to acquire higher level ultrasound skills
    • particularly well suited to UK/Australasian/South African trainees as registration recognised

Education fellow

  • University hospital with huge opportunities for educational development
  • Already happening in ED
    • weekly Registrar/consultant teaching (focused on FCEM exams)
    • weekly SHO teaching (focused on basic approaches to EM)
    • monthly radiology/EM/Acute medicine meeting
    • weekly ultrasound teaching
    • monthly joint EM/ICU meeting
    • Regular student placements as elective students throughout year or 4th year students for weekly placement jan-march
    • Online education induction package for SHOs and student placement
  • 30% protected time for non clinical activities to coordinate and develop education in emergency medicine
  • Suitable for (but not limited to)
    •  post basic training in EM,
    • able to work clinically as registrar/advanced trainee in ED

Conflict of interest statement

  • I work in the ED and really quite enjoy it there but no favours, cash or back rubs were exchanged for this post. I am happy to promote (on the same “no favours, cash or back rubs” terms) other interesting/innovative Irish emergency medicine jobs if people see the need.
  • My opinions are of course my own and do not necessarily represent that of the hospital.

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New Method for Creating Flexible Skin Worn Nanosensors (VIDEO)

flexible-nanosensorResearchers at the Technical University of Madrid have developed a cheap new method of manufacturing optical nanosensors that can cling to curved surfaces. The technique may allow for a widespread adoption of skin-worn health monitoring devices that will provide all-day tracking of parameters like body temperature, heart rate, and physical activity.

The technology relies on a combination of aluminum films, the polycarbonate coating used in compact disks, and standard Scotch tape. The aluminum film, only 100 nm thick, has a pattern of holes throughout its surface. The pattern defines how light moving through the film is modulated, revealing the underlying characteristics of the surface below.

Some details about the new sensor technology according to the Madrid team:

These flexible nanosensors enable us to measure refractive index variations of the surrounding medium and this can be used to detect chemical substances.  Besides, they display iridescent colors that can vary according to the viewing and illumination angle, this property facilitates the detection of position variations and surface topography to where they are stuck at a glance.

The creation method for flexible nanosensors consists, firstly, on manufacturing sensors over a compact disc (CDs) of traditional polycarbonate, and secondly, transferring these sensors to adhesive Scotch tapes by a simple stick-and-peel procedure. This way, the nanosensors go from the CD surface to the adhesive tape (flexible substrate).

Study in Nanoscale: Compact discs as versatile cost-effective substrates for releasable nanopatterned aluminium films…

Source: Universidad Politécnica de Madrid…

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Cherenkov Effect May Provide Dosimetry Data During Radiation Therapy (VIDEO)

output_drDcFhLight travels slower in water than through air, but when electrons are fired through water at a speed faster than that, a glow called Cherenkov radiation is emitted. Researchers at Dartmouth are investigating this phenomenon to see whether it can be used as a tool for measuring the radiation dose delivered to different tissues during radiotherapy.

Specifically, the team identified that the emitted Cherenkov radiation is indicative of the dose delivered by X-ray photons. Perhaps in the not too distant future, interventional radiologists will be able to see in real-time the exact amount of therapy delivered to treatment sites.

From Dartmouth:

Based on the findings of where dose correlates with Cherenkov emission, the Dartmouth team concluded that, for x-ray photons, the light emission would be optimally suited for: narrow beam stereotactic radiation therapy and surgery validation studies, verification of dynamic intensity-modulated and volumetric modulated arc therapy treatment plans in water tanks, near mono-energetic sources (e.g., Co-60 and brachy therapy sources), and also for entrance and exit surface imaging dosimetry of both narrow and broad beams. For electron use, Cherenkov emission was found to be only suitable for surface dosimetry applications. Finally, for proton dosimetry, there exists a fundamental lack of Cherenkov emission at the Bragg peak, making the technique of little use, although investigators say that post-irradiation detection of light emission from radioisotopes could prove to be useful.

Here’s Adam K. Glaser, a graduate student at Dartmouth, explaining the research his team is working on:


Study in Physics in Medicine and Biology: Optical dosimetry of radiotherapy beams using Cherenkov radiation: the relationship between light emission and dose…

Source: Norris Cotton Cancer Center…

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PEMBlog updates (New baby edition)

Sorry that there’s not been a new post this week – our third son was born and he requires some attention. Babies can be so selfish.

Anyway, more great content coming soon – including:

  • An in depth post on procalcitonin
  • A podcast interview with Todd Florin, one of the Pediatric Emergency Medicine faculty at Cincinnati Children’s Hospital Medical Center on therapies for bronchiolitis
  • An exploration of what it means when an ultrasound for appendicitis can’t find the appendix
  • More on ketamine for procedural sedation, including laryngospasm and its dissociative properties

Thanks for your continued support of the site, and stay tuned!

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