A few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the great, creative ideas that came up during our discussion. An always popular topic is the drainage of peritonsillar abscesses. Sometimes it can be difficult to aspirate from a syringe using only one hand, especially with the awkward angle that you might encounter.
Risk stratification of the undifferentiated chest pain patients in the Emergency Department continues to plague emergency physicians. It’s partly the reason why I created a TIMI risk score card for unstable angina and non-ST elevation MI in 2010.
Have you heard of the 9-variable GRACE risk stratification score? Thanks to Jeff Bray (physician assistant in a rural critical access ED), I have now. He graciously shared his personal reference card on this with me, which I only minimally reformatted to fit my Paucis Verbis card dimensions.
GRACE stands for Global Registry for Acute Coronary Events. It supposedly outperforms the TIMI scoring slightly in accurately predicting complications in the short and long term. Instead of calculating this manually, which can be a pain, now there are calculators out there:
Anyone use this scoring system?
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
A reader, Mark, posted a question yesterday in the chat box about screencapture softwares out there. I personally use iShowU to capture such videos as my instructional video on linking your Evernote account (above) to automatically read and download my weekly public Paucis Verbis notebook. Mark also specifically asked about what Dr. Rob Rogers (Univ of Maryland) uses.
A 25 year old woman presents to the Emergency Department having syncopized in the waiting room, where she was triaged with the chief complaint of abdominal pain. Ectopic pregnancy immediately bubbles to the top of your differential diagnosis. The patient is too dizzy to walk to the bathroom to give you a urine specimen to check a urine pregnancy test. Plus, she admits that she just urinated in the waiting room bathroom a few minutes ago – so no urine now.
Apply several drops of whole blood (instead of urine) into the pregnancy test cassette. In the photo below, the patient was pregnant with a serum beta-HCG level of 250 mIU/mL whose urine and whole blood qualitative tests were both positive.
Did you know that most urine pregnancy test kits are approved for both urine and serum samples? On a quick Google search, I found that Accutest, Cardinal Health, ICON, OSOM, and Rapid Response all are approved for both. The question is whether this will work for whole blood.
One study 1 in the Journal of Emergency Medicine by Dr. Fromm from Maimonides Medical Center looked at exactly this issue. Whole blood pregnancy test performed extremely well, especially if positive:
In their study, very low beta-HCG values (<159 mIU/mL) occasionally yielded a false negative for whole blood pregnancy tests. The whole blood testing approach missed a total 9 of 425 pregnancies. Interestingly, the urine pregnancy test was also negative in 5 of those 9 and not performed in the other 4.
Believe a positive test. Confirm all tests with a urine qualitative test or quantitative serum beta-HCG.
Another example courtesy of Dr. Joe Habboushe (New York Hospital–Queens of Cornell University) and Dr. Graham Walker (Stanford) 2 :
S = Sample well; T = Test specific (will show bar if +HCG); C = Control (will always have a bar)
This is a guest post by Dr. Ian Brown (Stanford):
The Roberts textbook describes the procedure of corneal fluorescein staining as touching a moistened fluorescein strip to the cornea. Maybe it is an irrational fear of a paper cut to the sclera, or a fear of touching an already abraded cornea with the paper, but I try to find an alternative. I have seen physicians hold the eye open with one hand, hold the fluorescein with a second hand and then drip tetracaine on the paper and let it drip into the eye with a third hand. I, unfortunately, only have two hands.
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Last month, I announced Dr. Timothy Peck (Beth Israel Deaconess EM resident) as one of the winners of the Blog Incubator Contest. Starting today and for the next 2 Mondays, he’ll be posting a 3-part series, which will eventually end up on his blog “Modern EM” at ModernEM.blogspot.com. His blog will feature examples of how Web 2.0 influenced the management of specific patient encounters. Also guests will be allowed to contribute mini-case presentations where they will report how a Web 2.0 activity changed how they managed a patient.
The blog is still in development phase. In the meantime, you are in for a treat. His upcoming blog entries are great examples demonstrating the impact of online and app-based clinical decision support tools in the ED.
Let’s welcome Tim to the blogging community!