In this episode of the EM Res Podcast, we welcome back Dan Kaminstein, MD. Dr. Kaminstein is our director of the section of International Medicine in the Emergency Department at Wellspan York Hospital, and a guru of ultrasound. Dan got in touch with an old residency pal, Dr. Emory Patterson from Athens, GA to talk about all things Emergency Ophthalmology. Lots of great leaning points and practical tips to be had. Some of the highlights from the discussion:
You must know three things when you call the ophthalmologist: visual acuity, pupils, and pressure.
If you can’t get a visual acuity, have them count fingers, then identify hand movement, and if all else fails, ask about light perception.
- If the patient has a detached retina - whether mac on or off - call the ophthalmologist.
- If you are going to dilate, use a shorter acting agent, such as 2.5% phenylephrine and 1% tropicamide,
- There are few, if any, conditions you will diagnose in the ED that require acute topical steroids when it comes to eye complaints. You don’t need to prescribe them in the ED for the most part, and if you need to, you should at least talk with an ophthalmologist
- When it comes to retrobulbar hematoma - know the pressure. Just because they have one does not mean it is causing elevated pressure, which is why you do the lateral canthotomy.
- Dilute proparicaine is probably not ready for primetime. Make sure you are talking to your local ophthalmologist about stuff like this before jumping on a small amount of data.
- When it comes to ocular exposure to alkali or acid, anything you can flush with is better than acid or alkali. Normal saline is fine. So is tap water.
There is a bunch out there in social media and FOAMed lately about “dogmalysis,” or the idea that some of the things we do have no evidence base, and should not be done. I love it. Being quite cynical and skeptical myself, I love to see us start to question our practice’s evidence base to try to come up with the best care for our patients. But new EM residents and new EM attendings may want to take some of this content with a grain of salt.
Here’s my take:
- New EM Residents: Before you go quoting advanced topics and dogmalytic principles (the “I heard it on a podcast” phenomenon), make sure you are well read and understand the basic concepts first. I think it is great people are questioning things like Kayexalate for hyperkalemia, but make sure you know how to diagnose and treat the condition otherwise. Lay the foundation before you spend too much time on advanced topics.
- New EM attendings: Get the lay of the land for the first 6-8 months. You are not going to change an entire hospital system in one day, and you may in fact hurt your chances of effecting change in the future by being known from day one as the guy who pitched a hissy fit about protonix for an upper GI bleed on your first shift out when that is the standard of care across all practices at your place. Remember change takes time, and educating your colleagues, both within your specialty and without, takes time and trust.
We have all answered that call from radiology or a radiology tech. In this episode, we talk about the myths and truths behind the use of oral contrast in the ED, ED imaging in pregnancy, and contrast induced nephropathy.
1. Oral Contrast in the ED: With new generation scanners, most patient with non traumatic abdominal pain do not need oral contrast. Multiple studies have shown that with new generation scanners, CT for appendicitis does not suffer when oral contrast is not administered. In high grade bowel obstruction, the American College of Radiology (ACR) actually says we should NOT be giving oral contrast as it is bad for the patient (potential aspiration), and may obscure radiologic evidence of bowel wall ischemia. With motion artifact reduction in new generation scanners, it really isn’t adding much to diverticulitis, either.
2. Imaging in pregnancy: Remember this is all about how we communicate risk. We always want to follow the ALARA (as low as reasonably achievable) principle, but we must not punish the patient for being pregnant by not doing the appropriate study. CT versus VQ is controversial, but I feel this guideline from the American Thoracic Society/Society of Thoracic Radiology is a reasonable approach:
Abdominal imaging can be tricky, but the answer should generally be US first in the pregnant patient, followed by MRI if possible. Again, if they need the CT, discuss the risk/benefit ratio and educate your patients.
3. Contrast Induced Nephropathy (CIN): The incidence of CIN is likely lower than we thought previously. In general patients with a GFR < 30 are at highest risk, and those with a GFR between 30-45 may be at higher risk. The majority of are patients, however, are at a minimal risk of CIN. To prevent it in high risk patients, the best we can try is hydration with isotonic fluids and educate the patients. But again, if you need the scan, you need the scan.
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A 62 year old man presents after he tripped and fell on his R shoulder. His only complaint is of R shoulder pain, and on exam his pain is localized to the distal clavicle. The R shoulder X Ray shows the following. What is your interpretation? What are the different types of this injury? What is your treatment plan?
The above image shows an acromioclavicular (AC) joint separation. This should be considered in anyone who falls onto the the shoulder, particularly the apex, or an outstretched hand. If you watch (American) football, think about the running back you see who gets tackled with his arms holding onto the ball, and they land right on the shoulder pad while being driven down. Patients may complain of generalized shoulder pain and limitation of their range of motion, but will have point tenderness over the AC joint. As with any injury, make sure to do a full neurovascualr exam distal to the injury, palpate the entire clavicle, and evaluate the ribs for possible injury and consider pneumothorax if you suspect thoracic injury. And, as with any upper extremity injury, determine the handedness of the patient.
It is important to know that there are different grades for AC injury. The common classification is known as the Rockwood classification, and describes six types of AC injury. To understand them, we must understand the anatomy involved.
The Rockwood classification system requires interpretation of a few things:
- The acromioclavicular ligament
- The coracoclavicular ligament
- The AC joint capsule
- The deltoid
- The trapezius
- The relation of the clavicle to the acromion
There are six types of AC injury (Type I -VI). A great description of each of the above factors in each type can be found here. If pictures are more your thing, this will help:
It is important to know what type it is as it relates to treatment. Types I-II are generally treated conservatively with a sling and no surgical intervention, although severe type II injuries may require surgical intervention depending on occupation, severity, and clinical course. Management of Type III is controversial, but may require operative intervention as well. Types IV-VI require operative correction, and probably warrant more urgent orthopedic evaluation and consultation at the time of injury. If you suspect an AC injury, but your film does not show a clear unobstructed view of the AC joint that allows you to evaluate the relationship of the inferior border of the acromion and the clavicle, consider a Zanca view (the XR gets a bit of cephalic tilt to allow clear visualization of the AC joint).
So what about our patient? The image shows that the inferior border of the clavicle is elevated when compared to the inferior border of the acromion, but does not pass its superior border, so this is likely a type II AC Joint injury. The patient should be placed in a sling, given analgesia, and referred for urgent orthopedic evaluation.
- Macdonald PB, Lapointe P. Acromioclavicular and sternoclavicular joint injuries. Ortho Clin North Am. 2008 Oct; 39 (4): 535-545.
A 14 year old presents to your ED after a fall on an outstretched hand during a basketball game. He is complaining of left wrist pain. He is tender diffusely over the distal radius and ulna with associated soft tissue swelling, but is neurovascularly intact throughout the left upper extremity with no pain above or below the wrist. He denies snuffbox tenderness, or wrist pain with axial loading of the thumb. You obtain the following radiographs. Click each question below for the answer.
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- What is their hand dominance? Consider this with all upper extremity injuries. Much like you start an OB presentation with the G’s and P’s, let your orthopedist know if the patient is Right or Left hand dominant.
- What kind of fracture is it (i.e. transverse, oblique, buckle, etc.). Is the fracture comminuted or not?
- What is the location of the fracture - midshaft, distal, metaphyseal, etc.
- Is the fracture displaced, and if so in what direction? Remember, this refers to the relation of the distal segment with the proximal segment. So in the case above, the distal segment is displaced dorsally. You describe this with a percentage of the distal segment that is displaced.
- Is the fracture angulated? Again, this is described by the direction and angle of the distal segment, and the angle of the distal segment compared to the axis of the proximal segment.
- Is the fracture rotated or impacted?
- Is the fracture open? It is crucial to take any dressings down to identify any signs of an open fracture.
I would advise that in order to best learn how to interpret plain radiographs, read them yourself, and do so before you read the radiology interpretation. At many EM training programs we have 24 hour radiology coverage, and the tendency is to wait for the radiologist’s interpretation. Try reading it, make a commitment to a read, and see how radiology interprets it. Many places you will eventually practice do not have real time reads for plain films, and your staff and patients will be counting on you to get it right.
Questions, comments, additional thoughts? Feel free to let me know below, or send an email to firstname.lastname@example.org
As we gear up for a new group of fourth year medical students rotating through our ED’s, hoping to eventually match in Emergency Medicine, we are all also starting to look forward to recruiting and interviews later this year. One of the common things I know gets asked of our medical students between June and December of each year is this: “Why do you want to go into Emergency Medicine (EM)?” We usually hear some standard stuff. I love the variety, I like to see all complaints, the undifferentiated patient, etc. Sometimes we hear less thoughtful answers. I’ve heard everything from “Well, its a good lifestyle,” to “I wanted to do procedures but surgery has too much call.” (On a side note, if you find yourself answering this question this way, strongly reconsider your decision to go into EM).
I worked a shift recently that I think warrants some discussion, and sheds light into what it really means to be an Emergency Physician (EP). No specific patient details will be provided, and this is not really about the medicine involved. The cases were interesting on their own, but this is about the bigger picture.
I was working an 8 hour shift, and the first 5 hours or so had been relatively smooth. We were double covered with attendings, and thus far everything had been relatively straightforward, with relatively bread and butter dispositions and treatment plans. Of course there was a diversity of patient population, chief complaints, and workups involved. And then, as often does, it hit the fan. A critically ill patient arrived, who required a significant resuscitation. This involved an entire team: nurses, assistants, our unit clerks, the patient representatives, multiple consultants, respiratory therapy, and of course a resident and me. As is usually the case, simple ACLS was not good enough. Tough decisions had to be made, things evolved and changed rapidly over the course of the next hour. The family was distraught, and multiple discussions had to take place from their standpoint as well. We have these discussions with people every day, and nothing that I was saying was something I had not said before. But for some reason, I really identified with this family, and it touched an emotional nerve. We also had to get consultants to come in from home (this was later on a weekend night), and convince them what we thought was going on was correct. An hour after I first met this patient and family, they were taken to get further care in another part of the hospital.
If you have listened to Scott Weingart and Cliff Reid’s great podcast discussing the book “Combat Physiology,” Then you will have a good idea of what may happen next. Having been running on chatecholamines for an hour, and having some heavy family discussions, I hit a wall, emotionally and physically - the true definition of a post adrenaline crash. I was fortunate to be able to step out of the department and compose myself for about 5 minutes. Upon returning, sure enough another sick patient that required immediate intervention had arrived. Over the next two hours until the end of my shift, another two patients would arrive that were also complex patients requiring resuscitation. All the while, the less critical patients were still showing up, and the ones we had seen previously still needed dispositions. My colleague had to stay almost an hour after their shift as they had helped run the department while we were in resuscitation number one, and I was there about an hour after my shift trying to get another patient stable for sign out and the ICU involved. I only live about 5 minutes from my job, so I do not have much decompression time before I get home. When I did, I was not the most fun person to talk to for awhile, as I’m sure my wife can attest, and then as soon as I went to bed I passed out, completely zonked.
I think for those training in Emergency Medicine, and those thinking about pursuing this career, there are some important considerations here. For those not in Emergency Medicine, I think it gives an important insight into what goes on in an ED on a daily basis.
For EM residents, and sudents thinking about EM as a career, think about what it took for each case. You of course are managing multiple patients at a time. Then someone incredibly sick shows up. You are meeting them and their families for the first time, working on limited, dynamic information, and making rapid critical decisions based on this limited information. You have to wear many hats in addition to being a “smart doctor.” You have to be an effective team leader, managing a team of people with multiple backgrounds, stress levels, comfort levels, and knowledge. You have to be an effective manager, making sure the different pieces of a resuscitation run smoothly, You need to be an effective communicator with consultants, recruiting them and mobilizing them to the common task of doing what is best for your patient. You also have to be able to talk to patients and their families. Sometimes, this means telling someone that you just met 10 minutes ago that their loved one is sick, or dying, and do so in a way that is caring, empathetic, and understanding, but also straightforward enough so that they understand the situation. This may involve taking care of someone or talking to people that strike a personal cord with you, but you must remain objective. We are giving people the worst news imaginable, and we only just met them.
If you are not the one in resus, then you have to be able to change gears, picking up the slack your colleagues leave behind when their patient takes a turn. You have to work as a team. This may mean staying late. We all know about the nights, weekends, and holidays the job requires, time away from families, and the cumulative toll the job takes. Burnout is a real problem. The job can have physical effects. When you are in a high catecholamine situation like this, you crash afterwards. And when you are done, you may have to start doing it all over again, or even manage multiple teams with multiple patients at a time. As residents, this is sometimes difficult to appreciate as there are usually multiple residents at a time in the ED. When you are out on your own, however, it may just be you with multiple sick patients, or supervising multiple residents with multiple sick patients. Wellness outside of work is of tremendous importance, and will be discussed in further detail in future posts and podcasts.
You will note, the medicine is but a piece of the bigger picture. At CORD and other discussions amongst educators of EM residents, it is often said we as educators really need to point out when we are teaching. Remember that teaching and learning does not just happen when someone asks you a board style question, and is not just simply the nuts and bolts knowledge of EM. Managing a sick patient, running a resuscitation, talking to a consultant, giving bad news to a family - these are all incredible teaching and learning opportunities. Pay attention to them, get feedback, and learn as much as you can from these situations. The medicine is interesting, but each one of our patients and their families have so much more to teach us. If you have a chance, debrief after big resuscitations, and not just about the medicine. Talk about the good and bad of the non-medical aspects of that patient’s care.
So am I trying to depress you, or drive you away from EM? Not at all. After a good night’s sleep and some time with my wife and kids, I felt back to normal. I am learning a bunch thinking about the cases, mentally debriefing. And ultimately, I am extremely appreciative of the people I work with, and proud of the job that we do. There are few places in the hospital that could manage that number of crashing patients and the complicated social situations and non-medical work surrounding them on such limited information. Few in medicine are as lucky as we are. We have the chance to take care of many different types of patients, and help them through the worst day of their lives. It does not always have a happy ending, but we do an important job that makes a huge difference. We should never lose sight of this important responsibility. I firmly believe that nowhere in the hospital is there such a cohesive team that is so good at resuscitating sick patients, and coordinating all of these different aspects of their care. Ultimately, it takes a lot to do our job, but we have much to be proud of, and the sacrifice is worth it. I can not say it any better than Cliff Reid when he talked about what we do and how we can be heroes.
Residents, think of all the learning opportunities you get managing these cases day to day. Learning is so much more than the boards and learning how to do procedures. There is really an art to what we do. And for the medical students, if this sounds like your bag, than you might make a great EP. Just don’t tell me you are going into EM to make money without taking call - you can do better than that!
Sorry for the delay on this one everyone. Image of the Week 007 below answers some of my time away. Anyway, back to the case…
A 32 year old male with a history of HIV, noncompliant with his medications, presents to the ED with a fever, hypoxia, and a cough. CXR is shown below. Given his clinical/medical history, what does this most likely represent, and what lab value might help confirm your diagnosis? What other clinical entity might a CXR like this represent? What is the first line treatment, and what are the indications for steroid therapy in this patient?
This patient likely has Pneumocystis jirovecii pneumonia (formerly PCP pneumonia). This is usually noted by diffuse bilateral infiltrates extending from the hilum on CXR. Having a history of HIV makes this all the more likely. LDH may be helpful in the diagnosis, as levels are usually elevated (> 250) in patients with this disease process. LDH is relatively sensitive, but somewhat nonspecific. Highly elevated levels may indicate worse disease and prognosis. Another prime concern in an immunocompromised patient with a similar CXR would be miliary TB.
The first line therapy is trimethoprim-sulfamethoxazole (TMP-SMX). Alternatively, clindamycin + primaquine can be given in patients who have a contraindication to TMP-SMX. Steroids may be considered as an adjunct therapy that might play a role in decreasing inflammation and respiratory failure. Indications for steroids include a PaO2 < 70 mmHg or an A-a gradient > 35. Don’t have an ABG handy? A pulse ox < 92% generally correlates with a PaO2< 70 mm Hg. This is a popular test topic in regards to diseases seen in HIV patients. #EMBoardReview
1. Emergency Medicine: A focused review of the Core Curriculum. pp 241-242.
As a graduate of 12 years of Catholic school, I learned about (and committed most of) the 7 deadly sins. I spend much of my time now teaching residents ultrasound, and reviewing their images. In the 7 major US categories (AAA, Biliary, Cardiac, FAST, OB, Renal, and Vascular Access), I have noticed there are common mistakes most novices make. So what are these 7 Deadly US Sins, and how can we avoid them?
- AAA: To find the aorta, do not look for the aorta. I know…mind blown. The aorta is anterior/anterolateral to the vertebral column, so setting your depth high initially and finding the hyper echoic vertebral body with posterior shadowing will guide you to the aorta so you do not mistake the SMA for the aorta.
- Biliary: Beware the ultimate SIN - stone in the neck. Pay special attention to the neck of the gallbladder. Sometimes, you will not even see the stone itself, so heavy anechoic shadowing behind the neck of the GB should clue you in. And remember, Hartman pouches can be tricky, so do not miss a stone in the neck of a Hartman’s pouch either.
- Cardiac: Always evaluate the posterior pericardium. In the subxiphoid view, this means having enough depth and far gain to get there. In the parasternal long axis, make sure you see the descending thoracic aorta just posterior to the LA/LV. Pericardial fluid will be anterior to this, and may split between the heart and aorta, while pleural fluid will be lateral/posterior to the aorta.
- FAST: free fluid should have sharp edges and take the shape of its container. Fluid that is encapsulated, walled off, or rounded in unlikely free fluid. In the RUQ, the GB sandwiched in between the liver and kidney may be mistaken for free fluid, while a beverage filled stomach may throw you off in the LUQ.
- OB: always find the midline stripe to make sure what you are seeing is truly in the uterus. A fair number of ectopic pregnancy may have a pseudo gestational sac in the uterus, so remember a yolk sac is the earliest definitive sign of pregnancy. And size does not matter, you can have a big ectopic.
- Renal: Not all hydronephrosis is ureterolithiasis with obstruction. A large AAA may compress the ureter, so remember to look for AAA in at risk patients. Renal colic is possible misdiagnosis of aortic disasters.
- Vascular access: Remember, the point of doing US guided procedures is to always know where your needle tip is. The US probe can only see what is directly beneath it. If you are advancing your needle but what you think is the needle is not moving on the screen, you may be looking at the needle shaft. Stop moving your needle, and move your probe to find it. TRV vascular access should be a two handed dynamic technique.
Thank you to everyone for reading and listening. 2013 was fun, and I have some great content planned for you coming up. As always, let me know if you have any questions/concerns/feedback. If you like what you hear, please go to iTunes to rate and review me. Know residents that aren’t listening? Let them know about the blog and podcast. If you are using a reader, I do have an RSS feed here.
Also, for US residents, the In Service exam is coming up in February. Be sure to check out www.emergencyboardreview.com, @EMBoardReview on Twitter. Hoping to get most of the content there finished in the next few months, and have a ton there already. Jon Schonert (@emchatter) has done a great job with this.
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Got an interesting question, and thought you might might be able to help me answer it. Interested to hear your opinions. Take a listen, then either leave a comment below or send me something at email@example.com.
You and your attending disagree. Your attending thinks less needs to be done, and it is a significant difference of opinion. How do you handle it? What would you want your residents to do? Leave a comment below, or let me know via email (firstname.lastname@example.org).