Buprenorphine prescribing: The Get Waivered Initiative makes it easier to get your DEA-X Waiver

A major development in curbing the opioid epidemic is the introduction of the medication buprenorphine to address opioid addiction. Being able to prescribe this medication, however, requires a special DEA-X Waiver in the United States. Dr. Alister Martin, the Founder of the Get Waivered initiative, is working to reduce the barriers for clinicians to obtain the training and paperwork necessary to obtain this waiver. Dr. Michelle Lin talks with Dr. Martin on this podcast about the backstory of the Get Waivered program, the lowered barriers to obtaining training, and some sneak peaks on what is new on the launching pad for his program.

Interesting fact: Medical students can participate in the free DEA-X waiver training now. The certificate of completion has no expiration date and can be submitted, when eligible for this waiver license.

Podcast with Dr. Alister Martin on the Get Waivered program

ALiEM · Get Waivered Initiative and the DEA-X Waiver with Founder Dr. Alister Martin

Visit the Get Waivered site to learn of their upcoming online training events and hot off the press news.

Additional Reading

A Tale of Two Epidemics: COVID-19 and the Opioid Crisis

ACEP E-QUAL podcasts on the opioid epidemic

Disclosure: ALiEM is proud to be a collaborator with the Get Waivered Initiative. This work was funded by the Foundation for Opioid Response Efforts (FORE). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE. FORE is authorized to reproduce and distribute reprints for Foundation purposes notwithstanding any copyright notation hereon.

By Michelle Lin, MD|2020-11-30T14:11:47-08:00Dec 2, 2020|Podcasts, Tox & Medications|

SAEM Clinical Image Series: Eye Pain After Assault

A 33-year-old male presents with intermittent blurry vision and left eye pain for 3 months, and a left-sided orbital headache for 1 day. He reports getting punched in the left side of the head during an altercation a few months ago. The eye pain is worse with ocular movements and is associated with bilateral conjunctival injection and white/green discharge from the left eye.

The patient was seen at another emergency department 3 months prior for the same symptoms. He was then found to have left-sided proptosis, visual acuity 20/60 in the left eye, no fluorescein uptake, and a normal fundoscopic exam. The patient was instructed to follow up with ophthalmology but did not. The patient denies fevers, chills, dizziness, nausea, vomiting, and abdominal pain.

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By Lauren J. Kraut, MD|2020-11-29T21:57:02-08:00Nov 30, 2020|Academic, Emergency Medicine, Ophthalmology, SAEM Clinical Images, Trauma|

SAEM Clinical Image Series: Surfing Sting

A 38-year-old male presents 8 days after being stung in the left foot while surfing. He reports the sudden onset of sharp pain while walking in the ocean. He was seen initially in the emergency department. The puncture wound on his left foot was anesthetized, explored, and irrigated. No X-ray was obtained, no foreign body was discovered, and he was discharged home.

Two days ago, he noticed worsening heat, itchiness, swelling, and skin changes (red bumps and patches extending from the foot up to the lower calf) in his left foot. His current pain is rated 3/10 and localized to the left foot. The patient is able to walk and bear weight. He has been taking ibuprofen for pain control and is not taking antibiotics. He denies fevers, but reports fatigue and feels more cold than usual.

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By Sunny R. Patel, MD, MBA|2020-11-29T21:29:33-08:00Nov 30, 2020|Academic, Emergency Medicine, SAEM Clinical Images, Tox & Medications|

Tricks of the Trade in Emergency Medicine book holiday sale

Well wishes to all of you for this COVID-19 holiday season. As a thank you for your public health efforts and sacrifices during this pandemic, we are discounting our autographed Tricks of the Trade in Emergency Medicine book from $69 to $59 to clear out our remaining few copies [order site]. This sale will end December 31, 2020 or whenever we run out of books in my garage. Get it for yourself, or gift it as coffee-table book for your emergency medicine colleague or trainee. Proceeds go entirely to the ALiEM endeavor to allow us to continue delivering you educational content and innovations.

You can also read many of these these for free on the ALiEM site in our Tricks of the Trade series.

By Michelle Lin, MD|2020-11-25T18:41:09-08:00Nov 27, 2020|Tricks of the Trade|

13-year-old M presents to the ED with acute left knee pain that occurred about 2 hours prior to arrival while playing football. No direct trauma. Reports two audible “pops” followed by knee instability. Radiograph as pictured (Image 1. Plain film of the left knee. Image courtesy of John Kiel, DO).

What is your suspected diagnosis?

Patellar subluxation. This patient likely had a spontaneous dislocation and relocation (the two “pops”). There is a very small avulsion fracture noted along the lateral femoral condyle.

PEARL: Patellar subluxations and dislocations are most commonly seen in the pediatric population [1].
PEARL: Patellar subluxation most frequently occurs in the lateral direction. Most commonly secondary to trauma, however, can also be seen in people with hypermobile joints.

What are important aspects of your physical exam?

It is very important to complete a full neurovascular exam. As well as performing a thorough musculoskeletal exam, assessing the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), lateral cruciate ligament (LCL), medial cruciate ligament (MCL), and patella. View the ALiEM 2 minute knee examination.

What further investigations should be considered?

If there is an abnormal neurovascular exam or unstable knee examination, pursue further workup such as a CT scan. As an outpatient, further imaging that can be considered is an MRI knee. See below for images from this case.

Potential complications of patellar subluxations

Image 2. Knee MRI – Sagittal cut showing large knee effusion. Image courtesy of John Kiel, DO.

Image 3. Knee MRI – Axial cut showing the osteochondral defect of the patella. Image courtesy of John Kiel, DO.

PEARL: In this case, the patient has a large effusion and loose body on the outpatient MRI. The medial constraint of the patella that prevents lateral subluxation, the medial patellofemoral ligament (MFPL), is torn.

What is your management in the ED?

This is one of the few times a knee immobilizer is appropriate. However, close follow-up with sports medicine or orthopedics should be stressed as atrophy and contractions can occur if the patient remains in the knee immobilizer for an extended duration. Provide crutches and ask the patient to be non-weight bearing. Anti-inflammatories as needed are appropriate and encourage icing and movement.

PEARL: Most common complaints include pain, joint effusion/swelling, lockage, decreased range of motion, joint instability, and/or crepitation [2].

What is your disposition?

An urgent follow-up is needed with sports medicine or orthopedics for further evaluation [3]. In the case of this patient who already had an MRI, he will typically require chondroplasty of the patella and MFPL reconstruction as an outpatient. Post-operatively, he will undergo standard physical therapy with an emphasis on range of motion and quadriceps strengthening.

PEARL: In about 60% of the pediatric population, the zone of the MFPL injury is the predominant site of patellar insertion, which is an indication for surgical reconstruction [4].

References

Chotel, F., Knorr, G., Simian, E., Dubrana, F., & Versier, G. Knee osteochondral fractures in skeletally immature patients: French multicenter study. Orthop Traumatol Surg Res. 2011;97(8). PMID: 22041573
Kramer, D. E., & Pace, J. L. (2012). Acute Traumatic and Sports-Related Osteochondral Injury of the Pediatric Knee. Orthop Clin North Am. 2012;43(2), 227-236. PMID: 22480471
Griffin, J. W., Gilmore, C. J., & Miller, M. D. (2013). Treatment of a Patellar Chondral Defect Using Juvenile Articular Cartilage Allograft Implantation. Arthrosc Tech. 2013;2(4). PMID: 24400181
Dixit, S., & Deu, R. S. Nonoperative Treatment of Patellar Instability. Sports Med Arthrosc Rev. 2017;25(2), 72-77. PMID: 28459749

By Parwaiz Rashidzada, MD|2020-11-25T18:20:09-08:00Nov 25, 2020|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|

SAEM Clinical Images: Man vs Snow Blower

A 28-year-old man presents to the emergency department after a snow blower accident while at work. The patient was performing maintenance and he placed his hand into a clogged snow blower while the machine was still on. His hand subsequently got jammed in the snow blower, catching his second and third digits. The patient has an obvious amputation of the right third digit with the stump still connected to the hand via the flexor tendon, which is attached to the distal phalanx. He has pain in the right hand and lack of sensation to the distal phalanx.

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By Ivana Marji, MD|2020-11-23T08:34:03-08:00Nov 23, 2020|Academic, Emergency Medicine, Orthopedic, SAEM Clinical Images, Trauma|

Welcome to the AIR Immunology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to immunology in the Emergency Department. 5 blog posts within the past 12 months (as of September 2020) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 2 AIR and 3 Honorable Mentions. We recommend programs give 3 hours (about 30 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Immunology Quiz at ALiEMU

Interested in taking the Immunology quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Immunological Emergencies

Site	Article	Author	Date	Label
EMCrit: IBCC	Angioedema	Josh Farkas, MD	1 Aug 2019	AIR
EMDocs	Prolonged Pediatric Fever and Evaluating Patients for Kawasaki Disease, Toxic Shock Syndrome, and Multi-inflammatory Syndrome of Children	Chance Sullivan, MD, Skyler Lentz, MD, and Joe Ravera, MD	3 Aug 2020	AIR
EMCrit/PulmCrit	How to Use IV Epinephrine for Anaphylaxis	Josh Farkas, MD	26 Aug 2019	HM
CanadiEM	Convalescent Plasma for COVID-19	Kevin Shopsowitz, MD	7 Jul 2020	HM
Taming the SRU	Angioedema in the ED	Marlena Wosiski-Kuhn, MD	10 Aug 2020	HM

AIR = Approved Instructional Resource; HM = Honorable Mention

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

By Chris Belcher, MD|2020-11-15T16:32:16-08:00Nov 18, 2020|Approved Instructional Resources (AIR series), Infectious Disease|

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