May 2013
1 post
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WatchPeritonsillar Abscess
About a month ago, I posted a video with the following history and questions. Let’s take a look at the answers:
A 23 year old male presents to the ED with 4 days of sore throat, getting much worse over the last 24 hours. You note that he has a muffled sounding voice. On exam, he has trismus, uvular deviation, L sided tonsillar asymmetry, and could seriously use a...
April 2013
4 posts
1 tag
The latest episode of the EM Res Podcast talks...
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WatchA Case of a Sore Throat
A 23 year old male presents to the ED with 4 days of sore throat, getting much worse over the last 24 hours. You note that he has a muffled sounding voice. On exam, he has trismus, uvular deviation, L sided tonsillar asymmetry, and could seriously use a breath mint. Your attending decides to perform an intraoral ultrasound to evaluate the patient, and you see the above...
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The Answer to Dr. Shafer's Neuro Dilemma
From the last post:
A 57 y/o male presents to the ED with a chief complaint of sudden loss of memory. His wife reports that when he awoke this morning he was his normal self, had coffee and ate breakfast but while his wife was showering he suddenly told her that he felt “weird”. His wife realized that he had forgotten everything that had happened not only this morning but also the night prior...
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A Neuro Dilemma from Dr. Shafer
Welcome back Dr. Krystle Shafer, who has the following conundrum for us:
A 57 y/o male presents to the ED with a chief complaint of sudden loss of memory. His wife reports that when he awoke this morning he was his normal self, had coffee and ate breakfast but while his wife was showering he suddenly told her that he felt “weird”. His wife realized that he had forgotten everything...
March 2013
4 posts
4 tags
The Importance of A Good History in Tox Patients
From our last post: “EMS brings in a 22 year old male who has presented multiple times previously with suicidal gestures. Tonight, they state he took an unknown quantity of acetaminophen about 4 hours prior to arrival. You draw a 4 hour acetaminophen level, and it is 105 micrograms/mL. Feeling good that he is below the treatment threshold of 150 micrograms/mL, you are just about to call the...
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Want to learn about Point of Care Ultrasound?
Do you want to learn about Point of Care Ultrasound (POCUS)? Have you ever wanted to learn about point of care echocardiography from Haney Mallemat (@CriticalCareNow)? Have you ever wondered what I am like in non-blog, podcast or Twitter form?
You can accomplish all of these things by attending the Wellspan York Hospital Point of Care Ultrasound Conference, June 13-14, 2013. This is a two day...
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What kind of Tylenol was it?
EMS brings in a 22 year old male who has presented multiple times previously with suicidal gestures. Tonight, they state he took an unknown quantity of acetaminophen about 4 hours prior to arrival. You draw a 4 hour acetaminophen level, and it is 105. Feeling good that he is below the treatment threshold, you are just about to call the psychiatrist when the patient tells you he actually...
6 tags
Altered Mental Status: The Forgotten Four
Altered mental status is an all too familiar complaint to emergency physicians. The differential is broad, and includes multiple life threatening diagnoses. We of course think the worst: does the patient have a head bleed or a stroke? Are they septic? Have they ingested some life threatening drug or toxin?
All too often, we get caught up in the rush to get the patient to CT without thinking...
February 2013
2 posts
2 tags
Good Luck!
To any American EM residents who follow the blog and/or podcast, good luck on the inservice exam tomorrow. Remember to take the exam seriously. While your results do not directly help or hurt your cause to become board certified EP’s, the results will give you great insight into your knowledge base, and will help you identify areas where you need to improve.
Do whatever you normally do...
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The last doctor gave me that "D" medicine...
There has been a fair amount of discussion recently about the national epidemic of prescription drug abuse in the United States. I recently read an interesting article in EM News on the topic. I have some personal opinions on the subject, and I feel that this is an important topic for Emergency Medicine Residents and Registrars to consider.
First, I notice frequently that we refer to the...
January 2013
3 posts
6 tags
Turn the Oxygen DOWN!
One of the most common knee jerk reactions in medicine is to give oxygen. Short of breath? Oxygen. Chest pain? O2. Abdominal pain….you get the idea. And why not, oxygen is harmless, right? While we do require oxygen to live, and it is 21% of our atmospheric pressure at sea level, oxygen in the medical setting should be considered a drug. It is a substance that you are administering to...
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Please, don't cut it!
We had some good responses, and everybody was right on.
This is an image of Herpetic Whitlow. Herpetic whitlow is an infection of the digits caused by herpes simplex virus (HSV). It can be caused by HSV 1 or two. The common pathophysiology is inoculation of the affected area through a break in the skin and subsequent exposure to bodily fluids.
Patients present with a complaint of...
2 tags
December 2012
4 posts
1 tag
Emergency Board Review
Hey faithful readers, and belated Happy Holidays! Sorry for the lag in posts, but I’ve been spending time with the family, and working on this…
You may remember back a few months I started doing some board review stuff, but noted it was going to be a huge project to tackle on my own. Fortunately, Jon Schonert from EM Chatter (@EMChatter, www.emchatter.com), came to the rescue with...
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Critical care questions: Hypotensive A Fib
I got a bunch of critical care questions for the Weingart-Mallemat interview for the last podcast. Of course, I did not have time to get them all answered, and I felt some of them were already well answered elsewhere. So I’m going to answer a few of them with my references for good resources already out there, starting with this question:
“I have a situation that’s come up a...
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Miss that procedure? Good!
I have had a few cases recently where, while supervising a procedure with a resident, the procedure does not go perfectly smoothly, and I have had to step in and lend a hand. This usually results in the resident beating themselves up. I’m here to talk you down off the ledge.
Remember, you are learning how to do procedures the attendings you are working with have done hundreds, or even...
November 2012
4 posts
3 tags
Episode 7: Airway Tips and Tricks
Well, Episode 7 is here, and I finally caved. That’s right, I’m doing an airway talk.
Obviously, airway is king. As it turns out, the A in ABC’s stands for airway and not Ativan. (I know, I was surprised when I first learned that too). There is a ton of stuff out there on airway, and I wanted to try to do the topic some justice. Part of my job is to synthesize what is out...
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Disaster Planning and the EM Physician
Today we have our first post from Bryan Wexler, MD. Bryan is currently a fellow in Disaster Medicine and Emergency Management. Check out his bio on our guest author page. He also incidentally holds the title as the real most interesting man in the world. Being a disaster medicine specialist, Dr. Wexler is going to tell us all about the world of disasters, how to prepare for them, and what we...
6 tags
Can we treat that PE as an outpatient?
A great conversation broke out the other day on Twitter, when it was asked by a US emergency physician if anyone sends home their low risk PE patients on LMWH. An international discussion ensued, with EP’s from Sweeden, the UK, and the US to name a few discussing how they manage PE.
Check out the initial conversation.
This discussion generated the links to a number of great references...
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Is it Really Guillain-Barre?
Another interesting case from Krystle Shafer, MD:
A 62 y/o Chinese American male presents to the ED with a chief complaint of nausea, generalized weakness, and vertigo. His physical exam is unremarkable with the exception of slight hand grasp weakness noted in the patient’s right hand compared to his left. He has no noted gait abnormalities or nystagymus. His potassium is noted to be...
October 2012
3 posts
4 tags
WatchA 32 y/o female presents with complaints of shortness of breath. She has a leg immobilizer on, and had noticed some swelling in that leg earlier this week. She is tachycardic, and had a pulse ox of 70% when EMS picked her up. She is 98% on 6 L nasal cannula, but when she tries to exert herself in any way, she desats to the upper 80’s. She is tachycardic, but her blood pressure is...
4 tags
You did what???
Hey everyone. First, just wanted to say sorry for the 2 week or so absence. My wife and I just recently had our second child, and between going back to work after paternity leave and not sleeping, I’ve been a bit preoccupied. I’m back on a better schedule now, so thanks for your patience and understanding. The next podcast, part 2 of the RUSH exam, should be out in the next few...
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So what did she have?
Alright Dr. Shafer, what is the answer to your 2 year old with a fever?
As was well pointed out in one of the comments, the differential diagnosis includes scarlet fever, rubella, and Kawasaki’s disease, as well as toxic shock syndrome. The patient clinically does not likely have rubella, as she is up to date on her immunizations, and kids should get their first MMR between 12 and 15...
September 2012
10 posts
3 tags
A 2 Year old with fever
The following case was submitted by Krystle Shafer, MD (pictured above). Dr. Shafer is an EM-1 at my institution. She went to University of Maryland (just like me, fear the Turtle!) for medical school. She has a special interest in pediatrics and critical care, and we will certainly be hearing more from her down the road.
A one and a half year old female presents to the emergency department...
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A Bad Haircut
I promise, this is related to Emergency Medicine. Stick with me…
Recently, I went to get my hair cut. I am by no means picky about my hair, and it seems a rather simple ‘do. I go to a chain, but I go to the same location and usually one of two people cuts my hair.
Last week, I went in during my week off (sorry for lack of posts). The two people who usually cut my hair were...
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WatchA 10 month old comes to the ED with his mother with concern for dehydration. Mom states he has 2 brothers at home with diarrhea and vomiting recently, and she thinks this child caught the same bug. The child is actually quite sleepy on exam, even bordering on lethargic. As you are talking to mom, he begins to scream and flex his hips. Mom says he has been doing this today, screaming for awhile...
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Answer: Question 2. Avoid the Foils
2. Which of the following drugs is not amenable to dialysis in acute overdose?
A. Amytriptyline
B. Lithium
C. Salicylates
D. Theophylline
Answer: A, Amytriptyline
This is an example of a type I question, as we discussed before. It asks a question, and you either know the answer or you don’t. In some ways these are the easiest ones, as they usually are right there for you....
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Board Review: Question 2
2. Which of the following drugs is not amenable to dialysis in acute overdose?
A. Amytriptyline
B. Lithium
C. Salicylates
D. Theophylline
The answer and explanation to come Wednesday morning.
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Links to resources from the "Case Conference 2"...
Here are the links I reference at the end of the Keynote:
UMEM Educational Pearl on BER
Amal Mattu’s EKG Video on Early STEMI Findings
Life in The Fast Lane: BER
In general, if you are not regularly looking at these three resources, you are missing out!
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Watch
And the Answer is…
The previous video showed a large pericardial effusion with evidence of tamponade. As it turns out, the patient, when more awake, gives you the history that she had sudden syncope while in her garden and was hypothermic because she passed out in the backyard during a light rain when it was 60 degrees outside and was down for a short time. Workup revealed a painless...
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WatchA patient presents from home after being found outside of her home on the ground complaining of weakness. She has a temp of 95.0F, HR of 110, and a BP of 80/40. You perform a RUSH exam and see the following on cardiac imaging.
What do you see? What else would you look for and image to confirm your suspicion?
7 tags
Think Before You Order
There has been a fair amount of conversation recently on Twitter and on several blogs about how we think in the ED, how we make complex medical decisions, and how we decide what to order. A recent interaction made me want to add my two cents, and my thoughts on the crucial questions you must ask yourself before you order a test.
A resident and I were seeing a patient who came with a complaint...
August 2012
6 posts
Organization!
In an effort to help you all out when visiting the blog, I have added a bunch of new links to the right that will send you to pages where my posts are linked by category. For example, click Cardiology and you’ll see all my Cardiology related posts in isolation. Also, please check out the links page, where I have linked to a few of my favorite blogs and educational websites.
Let me know...
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Answer: Question 1
Before we answer the question, let’s talk about how to approach these and break them down.
First, let’s look at the question type. This is a type 2 question. Type 1 questions are simple, straightforward questions. ”What is the recommended door to balloon time in a patient presenting to the ED for STEMI?” Simple question, simple answer. Type two questions require a...
1 tag
EM Board and Inservice Review
One of the things you will be seeing in the upcoming weeks and months is the addition of board/inservice exam review content. I will be making some board review podcasts, and will also be posting some questions here on the blog. My hope is for interaction, so feel free to answer questions, post questions, and interact.
One disclaimer: all questions that I post on the blog are ones that I made...
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The first rule of Fight Club...
So did he really cut that hand seen below at work?
The answer, of course, is no. On further questioning, he admits to being in a fight about 6 hours prior. He did not seek attention earlier, as he was concerned about legal ramifications.
This is a classic fight bite. A fight bite is a cut sustained during an altercation from the closed fist striking a sharp object, most often a tooth. It...
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Epley Maneuvers and YouTube?
As discussed in the podcast, the Epley Maneuvers can be used and have been shown to be helpful in the treatment of benign paroxysmal positional vertigo (BPPV).
Almost perfectly timed, this article in the July 24 Neurology crossed my desk:
“A prescription for the Epley Maneuver: www.youtube.com?”
They found 33 videos demonstrating the Epley maneuvers, but only 21 (64%) of the...
July 2012
5 posts
5 tags
Do you want to do something with that blood...
A 64 year old woman comes in with sudden onset left sided weakness about 7 hours minutes prior to arrival. You perform an exam and find her to have left sided weakness and sensory defecit. Blood pressure is 207/110. CT of the head shows no hemorrhage. You are going to be admitting the patient for ischemic CVA, when the nurse asks you the above question. What do you say? What if the patient...
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ED Echo →
An introduction to the basics of bedside echo for emergency physicians, presented at our intern US orientation day
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An introduction to biliary US →
Presented to our interns at their US orientation day, this lecture gives a basic intro to biliary US. By no means exhaustive, it is meant to get you started.
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WatchA patient presents with complaints of shortness of breath. They have a history of CHF, so you decide to perform a bedside echo. Where is the fluid?
June 2012
9 posts
5 tags
Diltiazem or metoprolol?
I remember this coming up frequently during my residency, and the answer widely varied based on which attending I was working with. It came up the other day as well during a shift.
One of the questions I get asked frequently is if you should avoid diltiazem if a patient is on beta blockers at home, and vice versa. From what I have seen, there is no evidence to support this case. Obviously,...
4 tags
PERC negative?
How appropriate with the recent podcast…
The June 2012 issue of Annals of Emergency Medicine is actually full of interesting articles. With the recent podcast giving you an introduction to clinical decision rules, my attention was drawn to an article entitled “Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.”
An...
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Cool update...
Hey everyone,
For even easier access to the podcast, it is now posted on iTunes. If you search for it, you can subscribe and then you’ll get episodes automatically. Obviously it is a free subscription.
Bob
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Episode 1 of the Podcast is up!
Hey all,
I’m happy to say I’m posting the first episode of the podcast. It’s a simple intro. I go through tips for the new interns to make yourselves look like stars and avoid common resident pitfalls. For the graduates, I have a quick blurb on some pearls for your first year as an attending. Finally, to get everyone on the same level to be able to have the discussion we...
