Trick of the Trade: Sodium Bicarbonate for Acute Symptomatic Hyponatremia

A 25-year-old woman is brought into the emergency department by friends due to “acting weird.” She was at a rave and is reported to have consumed alcohol, marijuana, and ecstasy. On exam, she is afebrile, tachycardic, normotensive, and breathing comfortably on room air. She is lethargic, mumbling incomprehensibly, and does not follow commands. Her glucose is 115 mg/dL, her pregnancy test is negative, her EKG reveals sinus tachycardia, her ethanol level is 30 mg/dL, and a stat CT head is negative. Her chemistry panel reveals a sodium level of 114 mEq/L. You order a 100 mL 3% sodium chloride bolus, but it may take 30 minutes to arrive from the central pharmacy. At this point, the nurse informs you that the patient is seizing.

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By Jonathan Hootman, MD|2020-05-11T06:50:15-07:00Jun 3, 2020|Tox & Medications, Tricks of the Trade|

Social Distancing Simulation: Tips for Leading a Virtual Session With Student Learners

We’ve all had to get a bit creative over the past few weeks. COVID-19 has ushered in an era of not only pushing healthcare workers and hospitals into uncharted territory, but also challenging the structure and delivery of medical education. Simulation education is one of many teaching modalities that is affected by this change given its case-based, in-person structure with a team of learners. These characteristics unfortunately violate the 6-foot rule of social distancing. While traditional simulation is not typically conceptualized as a virtual modality, many of its principals can be successfully adapted for remote learning.

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By Ashley Rider, MD|2020-05-31T19:16:34-07:00Jun 1, 2020|COVID19, Education Articles, Simulation|

Figure 1: Photo by Tim Bish on Unsplash

Paramedics bring in a 5-month-old boy in respiratory distress. He’s crying furiously and has normal tone and color. Thick, copious secretions are coming from his nose. He is tachypneic with diffuse wheezes, crackles, retractions, and nasal flaring. His respiratory rate is 70 and his oxygen saturation is 88% on room air. Would you order a chest radiograph (CXR) for this child?

CXRs are routinely obtained in adults with respiratory symptoms. Children, however, are more sensitive to radiation and can have multiple respiratory infections every year. CXRs can increase cost, length of stay, and may not always be necessary.

This post presents some guidelines on when (and when not) to get a CXR in pediatric patients.

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By Katrina Stime MD|2020-05-02T11:46:09-07:00May 27, 2020|PEM Pearls, Pulmonary, Radiology|

The rapid code status conversation guide for seriously ill older adults in acute respiratory failure

You are working a shift in your emergency department (ED) when an 85 year old female presents with a complaint of altered mental status. She comes from an extended care facility, where paramedics are able to tell you “they called us to come get her,”you are handed a stack of paperwork, given some vital signs, and you notice the patient is altered and unable to provide any further history. You dig a little in the paperwork and note a history of dementia as well as a long list of other medical problems, you notice no known advanced directive, and see that her daughter lives out of state but is available via phone. Have you been here? Seen this patient? If you have worked in emergency medicine long enough you certainly have. The tool outlined below is designed to help you know what to do in these difficult situations.

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By Kei Ouchi, MD|2020-05-31T19:05:01-07:00May 25, 2020|Palliative Care|

Work Grief: A Primer for Emergency Medicine Providers

Heartbreaking patient situations are the backbone of Emergency Medicine. Whether it’s a new cancer diagnosis, telling a family member that their loved one has died, or the creeping dread that a mistake that we’ve made will negatively impact one of our patients, we all experience extraordinary stress in our day-to-day clinical practice. Most clinicians are not tasked with routinely sharing news about the violent, unexpected, and horrific life-changing situations that occur in the emergency department, and yet we are given so few tools to help us manage this firehose of grief. This article is intended to share some of the best practices of grief management with clinicians who are immersed in grief, even if unawares.

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By Kai Romero, MD|2020-05-22T12:34:22-07:00May 22, 2020|Palliative Care, Wellness|

Production and use of free open access medical education resources (FOAM) has had a meteoric rise over the last decade.^1–4 ALiEM works hard to produce content, disseminate knowledge, and consolidate resources in a democratic and accessible way. However, we recognize that FOAM comes with its own limitations:

Blogs are distinct, individual, and decentralized. How can we search for topic-specific content?
FOAM doesn’t often have peer review. How can we assess quality and accuracy?
FOAM is produced on an as-needed basis. How do we achieve curricular comprehensiveness?

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By Andrew Grock, MD|2020-05-28T12:37:11-07:00May 20, 2020|Genitourinary, Renal|

Tricks of the Trade Book: Pre-order release of first 500 copies

Will there be a return to book publishing in this era of digital information chaos and overload? We believe so. We are proud to announce “Tricks of the Trade in Emergency Medicine: Where Experience, Ingenuity, and Evidence Intersect.” Being our own publishers (ALiEM Publishing) and selling through a print-on-demand bookstore has allowed us to design the book with full creative license. In stark contrast to our blog and other digital-based projects, we aimed to create a hardback, full-color book that you can read on a lazy Sunday afternoon, give as a graduation gift, or look delightful on your coffee table. We hope these tips spark your own creativity on how you can better improve your troubleshooting abilities on your next Emergency Department shift.