As I was perusing through a recent Academic Medicine journal, I came across this interesting perspective piece on Emergency Medicine, written by national leaders in our specialty.
This article essentially states that how the nation addresses ED crowding will define the future of EM. Currently, Emergency Departments are at a breaking point where overwhelming demands are commonly placed on under-resourced practices.
Recently, a patient presented with angioedema after starting taking an ACE-inhibitor. There was upper lip swelling, similar appearing to the case above. He also experience a hoarse voice. Before the advent of fiberoptic nasopharyngoscopy, it was assumed that there may be laryngeal edema. Fortunately, using technology, we were able to visualize a normal epiglottis and a grossly normal laryngeal anatomy.
The 1999 study on admission guidelines, of course, should be weighed with physician judgment and the patient’s social issues. The study was retrospective and the results should be weighed carefully. For me, generally I admit all cases involving intraoral structures and progressively worsening extraoral angioedema. I also perform fiberoptic nasopharyngoscopy on all patients with voice changes.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
A 6-year old boy has placed a hard bead in his ear and presents to the ED for care. How do you remove this foreign body as painlessly as possible? You can just barely see the edge of the bead by just looking at the external ear.
By experience, you know that mini-Alligator clips and forceps will not be able to sufficiently grab the edges of the bead. Additionally it may push the bead in even further.
I’m working on writing a CORD consensus article on the impact of ED crowding on education and innovations towards maintaining educational excellence. We posited 2 scenarios of ED crowding:
What approaches do you know of which improve the ED educational experience for learners? We have thus far categorized innovations into 3 areas:
“Medical Education in the United States and Canada in 1910” was a landmark article, published by Abraham Flexner (shown in photo) in 1910. It’s commonly referred to as the Flexner Report. It revolutionized medical education in its call for higher quality and standardization.
In summary the report advocated for the improvement of medical education and medical schools in 4 areas:
How accurate is the clinical knee exam?
JAMA published a meta-analysis trying to answer this question. Although they include patients with acute and chronic knee pain, it’s a good general review of the knee anatomy, historical clues, and exam elements.
In the ED, the knee exam is challenging because we see very acute injuries where knee pain and swelling often preclude an accurate exam. For patients with an equivocal exam, be sure to refer for orthopedic follow-up. A repeat exam should be performed once the pain and swelling subside.
This installment of the Paucis Verbis (In a Few Words) e-card series reviews the Knee Exam.
I used to be all confused and had a hard time memorizing all the different maneuvers (especially for the meniscus). It is much easier to remember after doing these knee exams routinely. Particularly, the lateral pivot test and McMurray test can be done with several rounds of simultaneous knee flexion-extension, internal-external rotation, and valgus stressing. Looking at diagrams almost makes things more confusing.
Go to ALiEM (PV) Cards for more resources.
You walk into a room where a patient is screaming and thrashing about in his/her gurney from some stimulant abuse. PCP, cocaine, methamphetamine… or all of the above.
When the number of people (police officers, security guards, nurses) is greater than the patient’s pupil size, you KNOW that you’ll need some chemical sedation.