EM-Bound Medical Students: Clinical Knowledge

Rotation Tune-Up: Arm yourself with clinical tools

In this series, we will be looking into commonly available tips and tricks, guidelines, algorithms, and clinical decision-making scores relevant to your clerkship rotation. Our goal is to augment your presentations on shift and set you up for success. We hope that you find this new series helpful as you embark on your journey to emergency medicine.

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine
Originally published in Jan 2024 EM Bound newsletter

The holiday season is a great time to raise a toast in cheers. However, we know there is a darker side to the celebration, especially the post holiday when the dark days of winter seem to stretch endlessly. Alcoholism is a disease that afflicts millions across the globe. In fact, alcohol abuse, alcoholism, and alcohol use disorder (AUD) kill over 3 million people each year and account for up to 6% of deaths globally. Within the United States, 95k people die each year from AUD. According to a 2019 NIH survey:

  • 85.6% of people 18 or older have reported that they drank alcohol at some point in their lifetime
    • 69.5% of this group reported that they drank in the past year
    • 54.9% (59.1% of men and 51.0 % of women in this age group) reported that they drank in the past month
  • 39.7% of 12- to 20-year-olds reported that they have had at least 1 drink in their lives. with 18.5% reported drinking alcohol in the past month (17.2% of males and 19.9% of females).

Alcohol intoxication is commonly seen within the ED. We must be thoughtful in our evaluation of the patient to identify any traumatic injuries that may have occurred while they were under the influence. Furthermore, as they await sobriety, we must keep an eye on signs of withdrawal. Obtaining a thorough history of alcoholism, frequency and volume of alcohol consumed, prior withdrawal history, and prior hospitalizations/ICU admissions can help guide your management of these patients. Your physical exam is also crucial in helping you identify signs of withdrawal.

The 4 stages of ETOH withdrawal occur at varying timing post-last drink, but generally are as follows:

  • At 6-12 Hours: Anxiety, anorexia, diaphoresis, gastrointestinal upset, hypertension, nausea, palpitations, tachycardia, tremors
  • At 12-24 Hours: Hallucinations: typically auditory, visual, or tactile in nature
  • At 24-48 Hours: Withdrawal seizures (generalized tonic-clonic seizures)
  • At 3-5 Days: Delirium-Tremens (profound confusion, autonomic hyperactivity, and cardiovascular collapse)

Check out this great one-page summary from EM Docs:

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a symptom-triggered therapy that is widely cited and utilized. This is used to help guide patient monitoring through frequent nursing assessment and management, including the use of benzodiazepines which are the mainstay treatment. In addition, in chronic alcoholic patients, thiamine and multivitamins should be given and any electrolyte abnormalities should be corrected (particularly hypomagnesemia). Finally, alcoholism should be considered a chronic disease. Check your biases at the door and approach these patients with compassion and empathy. Offer resources through your case manager or social worker to help your patient on the path to recovery. You could be the difference in life and death for these patients by your ability to discuss with them alcohol cessation.

Resources

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine
Originally published in Nov 2023 EM Bound newsletter

Thanksgiving is the perfect opportunity to gather with friends and family over a meal to enjoy each other. Its a time to indulge and slow down in a world that runs on 2x speed. However, it is also a challenging time for those with certain diseases such as diabetes and can lead to endocrine emergencies such as diabetic ketoacidosis (DKA).

Diabetic Ketoacidosis or DKA is due to an insulin deficiency resulting in a hyperglycemic acidosis state. The hallmark of this includes: glucose > 250 mg/dL, acidosis (pH < 7.3), ketosis. Due to the high glucose load in the bloodstream, there is a subsequent osmotic diuresis resulting in severe dehydration and depletion of important electrolytes such as sodium, calcium, magnesium, and phosphorus. Glucose metabolism is hindered due to the lack of insulin, resulting in fatty acid breakdown and production of ketones such as beta-hydroxybutyrate and acetoacetate.

DKA can be the presenting symptom of new onset diabetes, or due to trigger in those with a chronic insulin deficient state. Triggers can include medication non-adherence, steroid use, infection, substance use, stroke, myocardial infarction, pregnancy, pancreatitis, among others.

Here’s are some pearls and pitfalls to consider when approaching DKA.

Clinical Evaluation

  • History: Clues on history include the classic triad of polydipsia (increased thirst), polyphagia (increased hunger), and polyuria (increased urination). They may also experience fatigue, generalized weakness, nonspecific abdominal pain, nausea, vomiting.
  • Physical Exam: Ketosis may manifest as a fruity (acetone) odor to the breath. Kussmaul’s breathing of tachypnea and hyperpnea can also be seen. Dehydration can lead to dry mucous membranes, capillary refill >2 seconds, hypotension, tachycardia, altered mental status.

Diagnostics

  • Glucose: While in the majority of cases of DKA, the blood sugar are >250, beware of euglycemic DKA that can occur when patients are on specific medications such as SGLT2.
  • Venous blood gas: VBG has replaced arterial blood gas and can reveal the metabolic acidosis.
  • Electrolytes: The osmotic diuresis can lead to depletion of potassium. Repletion should be started PRIOR to starting insulin to prevent worsening hypokalemia after the insulin infusion. Sodium may also be affected due to delusional hyponatremia. You can correct for this using this MD calc app.
  • BUN/Cr: Creatinine may be elevated due to dehydration. Looking at the BUN/Cr ratio can help you determine if this is pre-renal and guide the fluid resuscitation.
  • UA: glucose and ketones will be seen spilled into the urine.
  • Ketones: Beta hydroxybutyrate >3.

Treatment

  • ABCs: As always in EM, ensure the patient is protecting their airway. Close monitoring of blood sugar and hydration status is important to guide treatment.
  • Fluids, fluids, fluids! Learn more from this ALiEM article, but fluid is the cornerstone of treatment. The patient is often markedly dehydrated. Isotonic fluids are crucial in the resuscitation of any patient in DKA.
  • Electrolyte repletion: As mentioned above, monitor and replete the electrolytes, especially K. Obtain an ECG to help give clues on any e- abnormalities by looking at the intervals and T waves.
  • Insulin: Keep it simple in DKA. Skip the insulin bolus primer, and start the insulin drip at 0.1-0.14 u/kg/hr. See the above post-it-pearl from our very own Dr. Lin.

Resources

EM Docs: DKA
Core EM: DKA
Dont Forget the Bubbles: Diabetic Ketoacidosis
ALiEM: AIR Series Endocrine – 2021

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine;

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine

Originally published in Nov 2023 EM Bound newsletter

Pancreatitis is not an uncommon disease that we see in the emergency department. Often, the diagnostic workup includes determining if the pancreatitis is due to biliary disease as this is the most common cause. Other causes of pancreatitis include alcohol use, high triglycerides, trauma, other causes of obstruction, and even scorpion bite! Here’s a great mnemonic to help you remember: “I Get Smashed” from Knowmedge.

For diagnosis, serum lipase 3x the upper limit of normal serves as the cutoff for the diagnosis. But how do you decide who’s sick or not sick? Some clinical guidelines are available, including Ranson’s criteria, the Harmless Acute Pancreatitis Score (HAPS), and the Bedside Index of Severity in Acute Pancreatitis (BISAP) Score. One of the limitations of Ranson’s criteria is that it requires 48-hour lab tests, including an ABG. This is not helpful in the ED. The HAP Score has three criteria: peritonitis, creatinine, and hematocrit. Given the subjective nature of the first criteria, this scoring guideline is less reliable. However, a score of 0 according to this guideline suggests “no pancreatic necrosis, need for dialysis, artificial ventilation or fatal outcome.”

The BISAP Score offers another risk stratification for patients with acute pancreatitis.

  • B is for BUN >25 mg/dl
  • I is for having impaired mental status (or how I remember as intoxication)
  • S is for having >2 SIRS Criteria
  • A is for age >60
  • P for the presence of pleural effusion

Scoring Sytem

Patients with a BISAP SCORE of 0 had <1% risk of mortality>So next time you see a patient with pancreatitis, be sure to mention the BISAP score and help it guide you regarding the level of care needed for the patient.

Originally published in Nov 2023 EM Bound newsletter

One of the lasting lessons that my attendings imparted to me as I walked away from being a senior resident and jumped into becoming an attending was that I should always “trust, but verify.” This saying is often used to express the relationship between senior physicians and trainees (even residents and medical students). However, it truly applies to all that we do in the Emergency Department. In particular, I try to tell all learners who rotate with us to always read their own radiologic images.

Even a quick glimpse can buy you time as you spot the rib fractures that push you towards a CT scan or the small bowel obstruction that gets you on the phone with the surgeon sooner. You should start to develop a habit of looking at X-rays, CT scans, and even ultrasound images instead of just waiting for a read. Unfortunately, there is no standardized curriculum for emergency radiology that you can expect in residency. Some programs may have partnerships with the radiologist at their shop, but most learning is piece-meal during conference or clinical shifts. Still, with purposeful and deliberate practice, you can develop a comfort level that can impact not just your clinical practice but your patients’ care.

To be clear, it’s not about being better than the radiologist– that is a misguided goal and would require focused years of training which our radiology colleagues obtain to help us in the ED. Instead, it’s about approaching the care you holistically provide patients so that you can show true ownership of your patients as a medical student and resident. We dread the read that states ‘please clinically correlate’ yet this is the advantage we have as we look at the images. Even if you aren’t spot on with the correct interpretation, the thought process of interpreting the images with the clinical context you have will strengthen your understanding of the patient in front of you.

So, where can you start?

  • Seeing is believing: Make it a point to review images for patients you are taking care of in or outside of the ED, even if you already know the diagnosis. Create a mental model for what this finding looks like with your own clinical correlation.
  • Understand the limits: No test is perfect, so its important to understand the limitations of the imaging you are engaging with. What can CT find better than an X-ray? What can MRI add? An excellent way to do this is to understand the different modalities. Check out this primer on Radiology Basics for medical students.
  • Know what you don’t know: Make a list of “can’t miss” radiologic findings and review cases through Google image search and using online case repositories like Radiopaedia. This website provides medical student lectures for Learning Radiology, including a “Must-See” for medical students review.

Resources

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine

Originally published in Sept 2023 EM Bound newsletter

There’s no question trauma resuscitations get every medical student rotating in the ED excited. The adrenaline rush, the controlled chaos, and the opportunity to do interventions that immediately show response. As a medical student, however, I can imagine how stressful it can be to assert yourself to be part of the X-teams.

Pre-work

  • At the beginning of your shift, let your senior resident or attending know you want to be part of trauma resuscitation. This could mean doing the trauma survey or doing the eFAST exam.
  • When the trauma run down happens, ensure that critical equipment are in the trauma bay, including the ultrasound machine.
  • Remind your resident or attending which role you want to take during the evaluation of this patient.

During the resuscitation

  • Introduce yourself to the patient. Reassure them that they are safe and that you are there to help them.
  • Make your voice heard. Remember to speak up if you are leading the trauma survey. Yours is the voice that must clearly be heard by the team leader and the nurse documenting the survey. You got this!
  • Be systematic. Move from Airway to Breathing to Circulation. Remember that patient’s HR and BP are part of the circulation, including whether the patient is pale, diaphoretic, or clammy. Comment on this.
  • Practice calculating GCS on non-trauma patients. The more you do this, the more you will remember the elements of the GCS.
  • POCUS is your friend. Delegate the eFAST exam if you are doing the survey, or if you are doing the eFAST exam, clearly state whether each step is positive or negative.
  • Some variations exist in doing the trauma survey. Places where more patients present as blunt trauma often do the secondary survey before they roll the patient. That’s OK. However, for penetrating trauma, make sure you are deliberate about rolling the patient as part of Exposure during the primary survey.
    • Finish the eFAST before rolling patients with blunt abdominal trauma, as fluid tends to move around with rolling and can cause false-negative results. If you must roll first, roll to the right to increase the sensitivity of the eFAST.
  • Summarize. At the end of the survey, summarize pertinent positives. Offer your suggestions for further workup–CT scan, x-rays, etc.

Below is a great summary of primary survey. Trauma resuscitations are exciting and anxiety-inducing for medical students. With practice, you can showcase your medical knowledge, composure under stress, and team-based performance in one clinical setting.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine

Originally published in Aug 2023 EM Bound newsletter

Chest pain is one of the most common chief complaints you’ll encounter in the emergency department. The emergent differential diagnosis is broad, ranging from STEMI to dissections to PE to Boerhaave’s. The HEART score is a helpful tool to risk stratify the likelihood for major cardiac events (MACE) in the next six weeks within this chief complaint.

The genius behind the HEART score focuses on critical attributes of the patient’s history, symptoms, and clinical data. You can easily calculate the HEART Score using MDCalc.

H is for history:

  • Despite what many believe is answered by gestalt, the criteria for choosing “Slightly suspicious” vs. “Highly suspicious” is clear.
  • We know from prior research that particular history portends a higher likelihood of a cardiac-related disease process. These symptoms include “Retrosternal pain, pressure, radiation to the jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, and patient recognizes symptoms.” We also know that the alternative portends likelihood for other diagnoses: “well localized, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation.”
  • Having a mostly high-risk history gets 2 points or “highly” suspicious, whereas having more alternative symptoms gets 0, or the designation of “slightly suspicious.” A mix of the two gets you 1, or “moderately” suspicious.

E is for EKG:

  • This is a lot easier to interpret: 0 for normal, 2 for “Significant ST-segment deviation without LBBB, LVH, or digoxin,” and 1 for nonspecific changes.

A is for Age:

  • Scoring is 0 for <45>≥ 65 as 2, and everything else in between, 1.

R is for risk factors:

  • This includes the traditional coronary artery disease (CAD) risk factors: “HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65).”
    Again, the scoring here is easy. 0 for no risk factors, 2 for 3 or more risk factors, and 1 for 1-2 risk factors.

T is for troponin using local sensitivity and cutoffs.

EM and the house of medicine are familiar with the HEART score, and appropriately using it helps us understand whether or not you can apply this to your patient. So next time you present a patient with chest pain, consider using the HEART score in your presentation to let your team know you understand the components for the 6-week prediction of MACE in your patient.

To take the HEART Score to the next level, here are several JournalFeed articles to consider regarding the nuances of applying this clinical decision-making score:

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in July 2023 EM Bound newsletter

July is here! Congratulations! It’s a momentous time of the year. Welcome!

“Accept that you are imperfect and always will be. Your quest is not to perfect yourself, but to better your imperfect self.” – Eric Greitens in Resilience

This quote reminds me of the growth mindset and our role in bettering ourselves. It also normalizes that while there may be unrealistic expectations of always doing well in medical school, we also acknowledge that challenges are part of your training. We don’t expect you to know everything, nor do we expect you to show up to your clerkship able to do every EM procedure. In fact, as a faculty, I still find myself not knowing exactly what my patients have. And that’s ok. Our job as emergency physicians is to think of the worst things, emergencies, and to anticipate how we would address this or the next best steps to help our patients. It is not our job to provide final diagnoses–this is often just a bonus.

With that, I recently learned this perspective from one of our med students: think of yourself as a tourist. As a tourist, you’re not expected to know the lay of the land. Be curious. And even if you think you already know what’s going on with your patient, stay open-minded and see how else you can improve their visit in the ED–through diagnostics, through procedures, or simply by acknowledging their suffering and being there for them.

Another perspective is the difference between having to vs. wanting to do something. For example, “I have to do a neuro exam” is very different from “I want to do a neuro exam.” As the pendulum swings to the “I want to” narrative, you’ll realize you’ll be a lot more motivated, and tasks become less of a chore.

So, we ask that you try your best. At the same time, take care of yourself. Find moments when you can recharge. Hydrate. Eat. Take that bathroom break. Breathe.

“Real achievement doesn’t happen overnight. At the end of each day, ask yourself whether you were better than the day before.” —Daniel H. Pink in Drive: The Surprising Truth About What Motivates Us

Lastly, be on the edge. Push yourself when you’re on shift to be a little uncomfortable. Being too comfortable does not allow for growth; being too uncomfortable can be dangerous or paralyzing. The edge is the most productive place to be. Small changes make a difference.

I do not doubt that starting your new clerkship will push you to be on this edge. It’s hard to know sometimes if what you’re feeling is an appropriate amount of challenge or if it’s too much. Ask around. Talk to your colleagues and friends. Talk to your mentor or your clerkship director. You don’t have to go through this alone.

We want you to thrive in your rotation/acting internship.

Illustration by Dr. Moises Gallegos

Here’s the top chief complaints (Great video: Patient Presentations in Emergency Medicine)

  • Abdominal pain
  • Altered mental status
  • Back pain
  • Chest pain
  • Fever
  • Headache
  • Musculoskeletal injury, trauma, and wound care
  • Nausea and vomiting
  • Shortness of breath
  • Sore throat

If you want to do a procedure, you should know the steps! When your team is doing a procedure, you can chime in on landmarks and the steps to demonstrate that you know the drill. This will help you earn their confidence and give you more opportunities to do procedures during your Sub-I. Check out the CDEM: Procedural Skills.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford University
Originally published in May 2023 EM Bound newsletter

Even though it’s been several years since the first shift of my intern year, I remember it vividly. In the whirlwind of emotion that accompanied the start of residency, I remember a common feeling in those first few weeks being that of inertia. I wanted to do something, but didn’t always know right away how to best do it.

Calling consults were some of the moments that made me pause. Fortunately, I had senior residents that imparted their experience with how to best communicate issues of patient care.

Phone calls in EM, in addition to the common difficulties of communicating complex matters over telephone, are made more challenging by the fact that, often, the patient presentation is still developing and rapidly changing. In addition to the clinical acumen that is required for managing acutely ill or injured patients in the ED, it is a critical skill to be able to communicate with consulting services. As you prepare for your away rotations, or the first shift of your intern year, it’ll be helpful to think about how to approach speaking with consulting services.

Here are some tips:

Introductions are key.

Make sure you state your name and role clearly. “Hello, thanks for calling back. My name is Moises, I’m an intern working in the ED today.” Similarly, make sure to ask for the other person’s name. Simply addressing someone by their name can build collegiality. In addition, you’ll need the consultant’s name for documentation purposes.

Know your patient.

It doesn’t have to be that you know every detail by memory, but if you won’t be by your computer you should know enough to introduce the patient and question while you make your way back. If possible, have the chart in front of you so that you can accurately tell the story and quickly confirm things that are asked of you.

What’s the consult for?

If you’re calling a consultant, it’s important to have a clear and directed consult request. Let them know this at the beginning so that they can frame the information they are being told. “Hello, thanks for calling back. I am calling to consult you on a patient with a hand infection concerning for flexor tenosynovitis.”

Summarize and close the loop.

When the conversation over the phone is wrapping up, close the loop with any recommendations that were given and confirm the next steps. OK, well it sounds like you’ll be a little while since you’re in the OR with another patient, but you recommend starting ceftriaxone and vancomycin given the high degree of concern. You’d like to evaluate the patient in the ED to decide whether they can go to the floor or straight to the OR. Thanks, we’ll see you here shortly.”

The art of the EM phone call is developed over time. It requires tailoring patient information to the needs of that moment, minimizing extraneous information. While calls may not always go smoothly, remember to always remain professional and consider the best interest of the patient.

Check out this great infographic from EMRA on Effective Consultation In Emergency Medicine and the 5 C’s Model!

Resources

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine
Originally published in March 2023 EM Bound newsletter

Abdominal pain is a common chief complaint accounting for up to 10% of the presentations to the ED. As such, developing a systematic approach to abdominal pain can help ensure efficient workup. Check out these pearls for the history, physical exam to help guide the workup of these patients.

History

  • Begin with the history: History alone can lead to the correct diagnosis in 76% of cases. The history and physical exam together can help you to determine organic vs. non-organic causes in up to 79% of patients. Bottom line: take a careful history each and every time.
  • Timing: Insidious or gradual onset should make you think of an inflammatory or infectious cause, while acute onset should raise alarms of a vascular etiology or potential bowel perforation.

Physical Exam

  • Location: Ask the patient to raise their gown to point to where the pain is located. This can help you gain additional history and reveal any skin findings (ecchymosis, distension, surgical scars, wounds, etc).
  • Special maneuvers:
    • RUQ pain: Murphy sign: asking the patient to take in and hold a deep breath while palpating the right subcostal area. This is suggestive of cholecystitis.
      RLQ pain:
    • McBurney point tenderness: tenderness to palpation at McBurney’s point (two-thirds the distance between the umbilicus and anterior superior iliac spine)
    • Rovsign sign: pain felt in the right lower abdomen upon palpation of the left side of the abdomen
    • Obturator sign: pain that is elicited in a supine patient by internally and externally rotating the flexed right hip
    • Psoas sign: having the patient lie on his or her left side while the right thigh is flexed backward
  • Peritoneal signs: There are many tests that can help you understand if the patient has what we call peritoneal signs or concerns for a surgical abdomen. A few examples of tests to determine if peritonitis is present are the stethoscope test (press down while auscultating to distract patient and see if the pain is elicited on the removal of pressure) or the cough test.
  • Additional reading

Check out this great table of differential diagnosis based on quadrants (EM Docs)

Resources

Sree Natesan, MD
Associate Program Director
Duke Emergency Medicine
Originally published in Feb 2023 EM Bound newsletter

Low back pain is among the most common presenting complaints in the ED. A systematic approach to evaluating these patients can help you identify life-threatening etiologies and provide efficient and effective care. Cauda equina syndrome (CES), is a true emergency, which is due to compression of the distal lumbar and sacral nerve roots and can lead to significant neurologic compromise in a matter of hours.

Can’t Miss emergent pathologies include:

  1. Cord compression from cancer, herniated disc, trauma
  2. Infections such as osteomyelitis, discitis, or spinal epidural abscess (SEA)
  3. Fracture from trauma or pathologic from malignancy
  4. Mimics (Vascular) such as leaking/ruptured AAA, retroperitoneal bleed, and spinal epidural hematoma

History pearls

  • Key pieces include: onset, duration, mechanism of injury, and associated symptoms (fever, chills, night sweats, associated neuro symptoms)
  • Obtaining a thorough history of risk factors is key such as IV drug use, malignancy history, trauma history
  • The “classic triad” of fever, back pain, and neurologic deficits on your boards mean the patient has a spinal epidural abscess (SEA). However, in clinical practice, they may not have all three present.
    • Identifying risk factors can help you to figure out how suspicious you should be on this emergent diagnosis (IV drug use being the most common risk factor)

Physical exam pearls

  • A thorough exam should start with palpation of the spinous processes and soft tissue for tenderness
  • Be systematic in your neurologic exam: For all patients with back pain, check strength, sensation, reflexes, coordination, and gait.
  • Be aware and check for signs of spinal cord compression
    • Bladder distension (early sign): New urinary retention (Post void residual >100ml) is abnormal; may also present with urinary incontinence from bladder overflow
    • Saddle anesthesia: numbness in groin/inner thighs & perineal region
    • Digital rectal exam: evaluate for decreased rectal tone or new fecal incontinence
    • Motor deficits not localized to a single nerve root

Red flag symptoms

Here’s a great way to remember from REBELEM. Think TUNA FISH with a few additions:

Management

  • Labs: If you are considering an inflammatory or infectious etiology: obtain an ESR, CRP, CBC, and blood cultures (if SEA is on differential)
    If ESR/CRP/WBC are elevated: consider MRI
  • Imaging
    • Routine imaging is not recommended for nonspecific low back pain (as per American College of Physicians (ACP) / American Pain Society)
    • Reserve imaging for patients with concerns for cord compression, trauma, or infection when suggested based of history and physical examination
    • MRI: Preferred imaging. Obtain an immediate MRI if:
      • Suspect acute spinal cord compromise
      • High suspicion of infection
      • High suspicion of metastatic disease/pathologic fracture
    • CT imaging: If history and physical exam of thoracolumbar trauma suggests high risk for structural injury, obtain plain film or CT.
      • Signs of injury with Focal pain or tenderness over the spine – palpable step off – overlying hematoma
      • Neurologic deficit consistent with thoracolumbar injury

Treatment

  • Emergent spine consult for evaluation is indicated if there are signs of cord compression
  • For infection, broad-spectrum IV antibiotics should be started. The patient will need a spine and infectious disease consultations and admission
  • For nonspecific back pain, conservative treatment symptomatic pain management with acetaminophen or NSAIDs (if no contraindication) physical therapy, exercise.

Resources

 

Eddie Charles Michael Garcia, MD
Clinical Assistant Professor, Emergency Medicine
Stanford University School of Medicine
Originally published in Nov 2022 EM Bound newsletter

What is medical toxicology?

Toxicology is a subspecialty for the management of poisonings, overdoses, drug interactions, envenomations, and occupational exposures.

But, what is medical toxicology really?

Toxicology is the nerdy side of emergency medicine. Toxicologists love rare cases, trivia, and, possibly, even basic science! If you give a toxicologist a chance to talk, they will. Toxicology rounds produce thoughtful discussions about both critically ill and seemingly routine patients, all while in the acute setting of the emergency department.

What is a toxicology rotation like?

Just as an ultrasound rotation allows a learner to use 45 minutes to perform an ultrasound, a toxicology rotation slows the rapid pace of the emergency department to think through syndromes more in-depth. There are three main models for rotations, depending on what the institution has to offer. Very often, aspects from each of these models will be combined for an elective with a full toxicology experience.

  • The state’s poison center: This might be the most common toxicology elective available. You will spend your time consulting remotely for any calls that come into the poison center. Rounds will be similar to “workroom rounding,” where cases are discussed, but a patient is not physically seen.
  • A toxicology consult service: This is an experience similar to any inpatient consult service. Yes, you heard me right. Inpatient teams are consulting an emergency medicine specialty!
  • An emergency department-based service: You may meet in the emergency department with the team to wait for poisoned patients or to discuss toxicology-related subjects. When the weather is nice, you might sit outside on the grass and discuss mushrooms. Maybe you even go home early!

Who might be part of the toxicology team?

Like most medical teams, you will find attendings, fellows, residents, and medical students. There may be pharmacists, pharmacy residents, and pharmacy students as well. Although toxicology is primarily an emergency medicine subspecialty, you may have attendings and fellows previously trained in pediatrics, internal medicine, or occupational medicine.

What are the benefits of a toxicology rotation?

  • Poisoned patients represent some of the sickest of the sick patients in the emergency department. Many inpatient consults come from the Intensive Care Unit because of the higher level of care these patients require.
  • Toxicology will broaden your differential building dramatically. Never again will you have a differential diagnosis without at least one toxicology diagnosis on it!
  • Even if you decide not to go into emergency medicine, toxicology is relevant to all medical fields.
  • It never hurts to get test questions right. Toxicology is always a big part of emergency medicine exams, so learning to identify toxidromes can help you clinically and on your test!

Tips for a toxicology rotation

  • You will likely be provided a small toxicology handbook of common poisons and antidotes. Read it! Most chapters can be read in just 3 minutes, so it is an easy way to prepare for rounds.
  • You may find yourself suddenly lost during rounds. Don’t be afraid to ask questions. I guarantee you that the resident sitting next to you also needs a refresher on Michaelis-Menton’s kinetics.
  • Embrace the diversity of the team. Partner with a pharmacy student to approach difficult cases with greater cumulative knowledge.

Resources

Rebekah Burns, MD & Anita A. Thomas, MD MPH
Assistant Professors, Emergency Medicine
Seattle Children’s Hospital
Originally published in July 2022 EM Bound newsletter

Does that toddler cry the moment they see you? No idea where to start with a baby? Consider these 8 tips for the pediatric emergency department exam.

  1. Show them you’re nice: Developing rapport with caregivers helps the child feel comfortable with you as well. When interacting with the child, make eye contact, sit or kneel down, and speak in a soothing voice using age-appropriate terms. Little humans care about social pleasantries, too.
  2. Break the ice: For verbal children, ask them a few questions. See that dirty, ragged stuffed dog? That is their best friend. Ask them what its name is and see how it is feeling today. Use your stethoscope to listen to their stuffy or perform an abdominal exam on it first. If nothing else, the child might be very confused which can be a great distraction….
  3. Observation is key: If you suspect a child might be fussy with an exam, observe the child from afar and walk by the room several times, noting observations, and practicing a doorway differential.
    • You can get a good sense of sick versus not sick by observing how the child interacts with the people and environment around them.
    • Work of breathing can be observed (with the shirt off) from across the room.
    • While children, especially babies, and toddlers may not be able to cooperate with a neuro exam, they are constantly showing us what they are capable of.
    • Watch how they move different parts. What is their gait like? Are they crawling all over the bed performing death-defying acrobatics? Do they respond to audio and visual cues?
    • When trying to localize pain in a baby or toddler, ask parents to press over areas of concern. There is a high likelihood that the patient will cry out of anxiety/fear when you approach making it hard to distinguish cries from pain from cries from stranger-danger.
  4. Distract, distract, distract: You know all those flashing lights and small toys the pediatricians keep attached to their badges and stethoscopes? We don’t hang onto them because we like flair. Distraction helps children with painful procedures, and it will help with your exam as well. Have the parents blow bubbles or use a toy that flashes some lights. Screens are also an amazing distraction. For older children complaining of pain, distracting them with conversation or a show might help you figure out how significant their pain might be.
  5. Do the exam in an order that makes sense for that patient: Try to listen to their heart and lungs before the child starts screaming, but then use that moment of crying to look in the posterior oropharynx. Doing an ear exam on a toddler or NP suctioning on an infant may result in tears- save these until the end. If the child has abdominal pain, do other parts of the exam before pushing on their belly. Save the genitourinary exam until the end after you have built more trust with the child, and always utilize a chaperone.
  6. Don’t ask for permission, give choices: Avoid asking yes/no questions if the patient doesn’t really get a choice. Instead of asking the 3-year-old who is on the brink of tears if you can look in their ears, ask which ear you can look in first. Kids are constantly struggling for control and granting them some power when possible may help make the exam go more smoothly.
  7. Positioning: Often young children will feel most comfortable while being held by their parents. Trying to stick a speculum in the ear of a flailing child will fail and might lead to ear canal injury that will be traumatic for all involved. Have an adult hold the child in a seated position facing the parent with one arm around the child’s back and the other around their front holding the child’s head to their chest or shoulder. See here for an example.
  8. Ask the parents: If a child appears extremely anxious, especially if they have sensory processing difficulties such as autism spectrum disorder, ask their caregiver what helps them calm down or feel safer. Engage the parents in the distraction and exam. Parents appreciate being involved in their child’s medical care, and positive interactions with parents reflect well on the child.

Resource

Sree Natesan, MD
Associate Program Director
Duke University Emergency Medicine
Originally published in May 2022 EM Bound newsletter

Stroke recognition is one of the most time-sensitive diagnoses we must make in Emergency Medicine. The common mantra is time is brain: early recognition and treatment can help provide the best outcome for our patients. Here are a few pearls to help you rock your presentation and diagnosis and help save your patient’s life!

History Pearls

  • Timing: The key part of the history is identifying the last known normal (LKN). This will help determine if the patient is a t-PA candidate. The goal is door-to-needle goal is
  • Past Medical/Surgical History: Obtaining a rapid history of risk factors for stroke (i.e. hypertension, diabetes, atrial fibrillation, prior ischemic or hemorrhagic stroke, etc) can help your team figure out if the patient is having a stroke. Figuring out if the patient has
  • Medications: Getting an accurate list of the patient’s medications is key, especially if they are on any anticoagulation such as NOACs, or Warfarin. If they are, please ask the last time they took the medication to see if this is truly a contraindication to t-PA.
  • EMS Report: If the patient presents by EMS, typically the above information is already obtained. Ask the EMS about fingerstick glucose, initial vitals including blood pressure, and if there is family available.

Physical Exam Pearls

  • Vital Signs: Obtaining a recent set of vitals is important. There are certain criteria that must be met in order for the patient to be a t-PA candidate, including blood pressure.
  • Neuro Exam: Being systematic in your assessment of the neurologic exam is crucial to localizing the lesion in the brain and determining if t-PA is an option for treatment.
    • Severity: Speaking a standardized language (in this case the NIH Stroke Scale) can help you communicate better with the neurologist and better understand the severity of the stroke.
    • Repeat assessments: Serial neuro exams using the NIHSS can help you to determine if the patient’s condition is improving or worsening.
    • Localizing the lesion: Here’s a great summary slide from GrepMed.

Management Pearls

  • Fingerstick Glucose: There are many mimics to stroke that must be ruled out quickly. A fingerstick glucose can help determine if hypoglycemia or hyperglycemia are contributing to the patient’s presentation.
  • Blood Pressure Management: For patients who are eligible for IV t-PA therapy, it is recommended that the BP be maintained below 185/110 mmHg during the infusion and 180/105 mmHg for the following 24 h. Various medications can be used including Labetalol and Hydralazine as IV push medications. Close monitoring is important through frequent vital sign assessments.
  • Imaging: The first choice of imaging in all patients with suspected acute stroke is the non-contrast head CT to ensure no hemorrhagic bleed and to identify signs of ischemic stroke. Although diffusion-weighted MRI is considered more sensitive, it is not recommended (or cost-effective) to have routine use of this in all patients. MRI is the choice if the CT is negative and the presentation is unclear as it may lead to management change.
  • IV t-PA: IV t-PA should be administered to all eligible acute stroke patients within 3 hours of LKN and to a more selective group of eligible acute stroke patients (based on ECASS III exclusion criteria) within 4.5 hours of the LKN. While the decision is complex with the need to consider absolute and relative contraindications, here is a sweet and simple summary from EMDocs on IV t-PA vs. Thrombectomy.
    TPA management

Resources

Sree Natesan, MD
Associate Program Director
Duke University Emergency Medicine
Originally published in April 2022 EM Bound newsletter

Headaches (H/A) are a common presentation to the Emergency Department. You may feel your own head ache as you try to figure out what the differential diagnosis and plan should be for the patient you are caring for in the ED. Having a systematic approach to these patients can help you in your efficiency and accuracy in obtaining the right clues to lead you to the diagnosis. Here are some pearls:

History

A thorough history can help you elicit the etiology of the H/A. Here are a few considerations:

  • Onset: The onset of the H/A can really be the best place to start. Sudden onset, “thunderclap” can suggest a vascular etiology. A more gradual course may suggest an infectious or inflammatory etiology, whereas a progressive headache or neuro symptoms may suggest a malignancy etiology.
  • Character: While a lot of patients will say they are having the “worst headache of their life,” not all of them are having a subarachnoid hemorrhage (SAH). Asking questions such as “what number was the pain when it started, what is the pain level now,” or “did it come on gradually versus all of a sudden” can help you learn more. Another question is asking “when did you have a headache this bad” can gather the idea if this is the worst headache or not. A careful history is important.
  • Associated symptoms: Its key to do a good ROS. If the patient is having fever and neck stiffness, then meningitis would jump up on the DDx. If the patient is having an aura and photophobia, then migraine may be the culprit.

Physical Exam

Your exam is key to helping to elucidate the working DDx and guide your workup. Here are a few pearls to make sure you focus on when your patient presents with H/A:

  • Eye Exam: A fundoscopic exam looking for papilledema can help you figure out if your patient has increased intracranial pressure (ICP) in processes such as Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) or space occupying lesions like meningiomas, glioblastomas, metastatic disease).
  • Neuro Exam: You can localize the lesion (if one is present), based on your neurologic exam! It really is a map to the brain. Ensuring a thorough neuro exam means cranial nerves, strength, sensation, and reflexes. Cerebellar testing looking for nystagmus, abnormal finger-to-nose, heel-to-shin, or gait is important.

Diagnostic/Therapeutics

The workup for H/A is really dependent on your thoughts on what the leading diagnosis is. For example, if you are worried about an infection, a lumbar puncture to analyze the fluid would be important. If your patient may have Pseuodotumor, an opening (and closing!) pressure from the spinal tap is key to the diagnosis. If you are worried about malignancy, imaging will be helpful (such as CT or MRI).

Check out this great algorithm from GrepMed that can help guide you through your DDx:

Resources

Sree Natesan, MD
Associate Program Director
Duke University Emergency Medicine
Originally published in March 2022 EM Bound newsletter

The undifferentiated patient is the norm in Emergency Medicine. It is up to us, as EM physicians, to be the detectives to figure out the clues to solve the case and get to the definitive diagnosis and treatment. Because of this, the history, physical exam, and collateral information are crucial to success. This is especially true in patients who come in with an unknown toxic ingestion.

A toxidrome is a syndrome (set of symptoms) caused by specific medications or toxins. Understanding the toxidromes and implicated medications/drugs can help lead you to the correct management.

While there are many types, the 5 big ones to know (and respective meds/drugs that cause this toxidrome) are:

  • Anticholinergic: low potency antipsychotics, Acetylcholine (ACh) receptor antagonist (Atropine, Ipratropium, Scopolamine), Oxybutynin
  • Cholinergic: ACh receptor agonists (pilocarpine), AChEIs (organophosphates, phyostigmine)
  • Opioid: Fentanyl, Heroine, Hydromorphone, Hydrocodone, Methadone, Morphine, Oxycodone
  • Sympathomimetic: Amphetamine (Adderall), Cocaine, Epinephrine, Methylphenidate (Ritalin)
  • Sedative-Hypnotic: Antihistamines (Benadryl), Benzodiazepines (Lorazepam/Ativan, Diazepam/Valium, Midazolam/Versed), Barbiturates, “Z-drugs” (zopiclone, zolpidem)

A few pro tips regarding the evaluation of the undifferentiated tox patient:

  • Get collateral ASAP: If EMS is dropping off the patient, ask if there were any pills or bottles nearby. Did they notice any drug paraphernalia or alcohol bottles? What was the patient’s initial vitals and physical exam? This information can help you understand the scene the patient is coming from and start narrowing your differential.
  • Undress the patient: This can help you look for any patches or drugs that may be concealed. Additionally, you can do a thorough physical exam.
  • EKGs are key: Many medications can cause derangements in the ECG. For example, an R prime, or shark tooth appearance can be seen in a TCA overdose. Methadone, Cocaine, and other medications can prolong the Qtc. Sodium blockade can result from medications like phenytoin. Thus, getting an EKG to evaluate for rate and intervals is key.
  • Physical Exam: While often a lost art in the world of CT, Ultrasounds, and technology, in toxicology, your exam can help narrow down your DDx. Here’s a great chart to help you figure out what toxidrome the patient.

The mainstay treatment for toxidromes is early recognition and management. Like much in EM, ABCs come first with securing the airway if necessary. Seizures are typically managed with Benzodiazepines (Lorazepam). Doing your thorough history, PE, and EKG can then help you tailor the remainder of your management. For example, if the patient has pinpoint pupils, slowed respirations, AMS– you would order Narcan while ensuring the patient’s airway is intact. If the patient is diaphoretic, with dilated pupils, tachycardia, and hypertensive– you may be thinking the patient is sympathomimetic and start treatment with benzos and fluids.

Remember to be systematic in your approach. Gather information early, do a thorough physical exam, and reassess frequently. Below are some great Toxicology resources and cards to help as quick references. Finally, remember that Poison Control is a great member of the team to help guide your treatment.

Resources

Sree Natesan, MD
Associate Program Director
Duke University Emergency Medicine
Originally published in March 2022 EM Bound newsletter

I may be dating myself as I write this. Rather, I know I am. But bear with me- I started my career in medicine over 20 years ago as a unit secretary at a prestigious hospital on the general medicine floor. I remember sitting at the desk entering orders (yes! At that time, secretaries had to input all the physician orders?!?) wondering how these doctors knew what to order. Thus, my journey to medicine truly accelerated with my changing majors for pre-med from biology to a bachelor’s in nursing. I accepted a job as a registered nurse on a Cardiothoracic ICU/Stepdown Unit as a new graduate. What I didn’t realize, aside from how much experience I would get in procedures (i.e., calculating cardiac output from Swan Ganz catheters, pulling out large-bore chest tubes, and resuscitating immediate post-op patients who would have typically gone to a PACU but in our community hospital came straight up to the ICU for us to do this work) was how important ECG interpretation truly was.

As you can imagine, post-operative cardiac surgery patients love to go into arrhythmias. From atrial fibrillation to heart blocks, to scary rhythms like ventricular tachycardia, early recognition is key for patient safety and treatment. A surprising part of my orientation was that I would need to interpret the ECG, call my CT surgeon and have him use my interpretation to order medications. Times and practices have changed since then, but in knowing the impact of my reads, I had to become OCD on my approach to ECG.

Here are a few hints and pro-tips:

  • Have a systematic approach to ECGs: This means, read it the same way each time. Don’t jump around, but be intentional in how you interpret it. This will keep you from missing anything.
  • Trust but verify the machine’s read at the top: As a learner, ignore the top of the ECG. Calculate your rate and intervals. You can then look at the top and see if they match up to similar ranges of what is reported.
  • Know when to get help: Although the ECG is typically handed to a senior resident or attending, if you are given an ECG, make sure to review this with a senior member of your team. Not only does this allow you to learn from them, but it also ensures that no acute emergent pathology is missed.

Here’s my favorite systematic approach to ECG interpretation:

  • Rate: This is how fast or slow the patient heart rate is beating. Normal should be 60-100 beats per min (bpm). There are a few ways to figure this out.
    • Option 1 (Cardiac Ruler or Sequence Method): Find the R wave: Count using the following numbers: 300-150-100-75-60-50 until you hit the next R wave. Note: This can only be used on regular rhythms and not on irregular rhythms
    • Option 2 (Six Second Rule): Count 6 seconds of ECG tracing (i.e., 30 big boxes). Next, count the number of R waves that appear within that 6 second period. Finally, multiply by 10 and that will give you the rate. Note: this can be used for regular and irregular rhythms.
  • Rhythm: Is the rhythm regular (the QRS complex comes at regular or same-timed intervals) or irregular (there is no pattern to the QRS complexes)?
  • Axis: A simple way to do this is to look at lead I and aVF and observe the main direction of the QRS complex.
    • If Lead I represents is upward and aVF is downward, this is LEFT axis. (ie: the complexes are Leaving each other = Left axis)
    • If Lead I is downward and Lead aVF is upward, this is RIGHT axis. (i.e., the complexes are Reaching for each other = Right axis)
  • Intervals: Specifically, what are your PR interval (3-5 boxes or 120-200ms), QRS complex (80-100ms), and QTc (350–450 ms in males and 360–460 ms in females).
  • Abnormalities of contiguous leads: I call this ‘cardiac vessel distribution’ because much like our brains where a clot in a specific vessel or area of the brain causes specific deficits/symptoms resulting in a stroke, the same is true with the heart. Here are the cliff notes:

  • STEMI and Reciprocal changes (PAILS): In assessing for ST elevations, it is also important to look for reciprocal changes. That is, upward reflection in one area of the EKG should have a reciprocal downward direction on the other side of the energy vector (I know, Physics!). The PAILS mnemonic is handy so that if you have a Posterior lead ST elevation, there should be ST depressions in the Anterior leads, the next letter after P in PAILS. Therefore, for Anterior lead ST elevations, you should see an Inferior lead ST depression (PAILS).

Now put these tips into action to hone your ECG skills. Below are some great resources to help you on your journey.

Resources

Sree Natesan, MD
Associate Program Director
Duke University Emergency Medicine
Originally published in Jan 2022 EM Bound newsletter

We love working in the ER because of the rapid pace, breadth of diagnoses, variable patient acuity, and volume. We possess the ability to task-switch innumerable times a shift effortlessly. We enjoy exercising our skill in the art of leadership through our interactions with multiple members of our team (nurses, techs, consultants) in order to provide quality patient care. However, the same chaotic environment we thrive in can also lead to deterioration in our ability to speak clearly and effectively. Communication is the crucial key to developing rapport quickly with patients and being able to unlock the pertinent history and physical exam findings to determine the correct differential diagnosis. It is also critical in allowing us to share treatment options and deliver news (both good and bad) to our patients and their families.

Here are a few pro-tips that can help you master the art of communication:

  1. Seek to listen before you speak: We all have heard that physicians interrupt our patients within mere seconds of asking a question. In order to hear the answers from our patients, we must first listen. Not only will this help you develop rapport, but it can also help give information you may not have thought to inquire about.
  2. Don’t underestimate the value of the history and physical exam: As mentioned in our previous newsletter, the majority of the diagnoses (80-85%)  can be reached via the history and physical alone. So instead of thinking of all the labs and imaging you may need to order, focus on developing a rapport and work with your patients by asking the right questions to get to the diagnosis. If you leave the room not knowing what your DDx should be, turn around and go back and ask some more questions to help you figure it out!
  3. Don’t underestimate the power of collateral: While the patient is our primary source of information, the surrounding community (i.e., the family, skilled nursing facility, power of attorney) can help give a broader picture of the concerns that have brought the patient to the ER. This is especially crucial for our patients who suffer from mental health diseases or dementia. Pick up the phone and call for additional information- this can actually help save you time in the long run!
  4. Lose the jargon: While we are taught a brand new language in medical school (called medicine), we must be thoughtful on how we convey this same information to our patients. Use clear and simple explanations. Avoid medical jargon, and pause to allow for questions to clarify any confusion. The ‘Teach Back’ method works great in having your patient repeat back what you have explained to identify any gaps that exist.
  5. Practice the ‘Difficult Conversations’ with someone you trust: We will touch base on this in future newsletters but we will all have difficult news we must convey to our patients (or their families) during our careers. We must recognize how fragile the situation is and transformative it will be to the receiver (particularly when telling someone of a death, or life-altering diagnosis). As such, it is helpful to practice with a trusted friend or colleague the delivery of such news, so you can learn the words to convey empathy and compassion. Use your time in med school to observe attendings and residents delivering this news so you can learn from them.
  6. Pose the clinical question to your consultant: Consultants are busy seeing patients throughout the ER as well as balancing other duties. We must help them be successful by clearly communicating the clinical question we would like answered. Putting this question upfront during the call can help provide a frame for the consultant to hear the story.

Communication is an art form that we can grow and build upon. Take time to reflect on interactions that went well and those you wish had gone better. By doing so, you can gain perspective on areas that can be improved and gain skills to open any locks that exist through the keys of communication.

Siobhan Thomas-Smith, MD
Caitlin Crumm, MD, MS
Anita Thomas MD, MPH
Pediatric Emergency Medicine
University of Washington/Seattle Children’s Hospital
Originally published in Jan 2022 EM Bound newsletter

Child abuse or non-accidental trauma (NAT) is a common issue seen in emergency departments nationwide. As emergency medicine physicians, it is important to identify signs of NAT in order to protect our young patient population.

Fast Facts

  • 1 in 7 children in the US experienced child abuse and neglect in the last year.
  • Many adults report historical childhood sexual and physical abuse, with some studies showing as high as a 20-30% prevalence. In 2019 alone, over 1800 children died of abuse in the US.
  • Child abuse and neglect + other adverse childhood experiences (ACEs) = poor health outcomes (MI, stroke, overall mortality), PTSD, and toxic stress → this leads to memory, attention, and executive functioning issues.

Special considerations

  • Have a low threshold for further investigation if there are concerning findings regardless of how “appropriate” parents might seem
  • Consider NAT in nonmobile, nonverbal, and developmentally delayed kids in particular as they are at high risk.
  • Look for bruising or deformity on every child with a complete head-to-toe exam.
  • Remember- Kids that don’t cruise, rarely bruise! Be worried when non-mobile children have bruising, fractures, or burns.

High-risk findings concerning for NAT

Remember, if you’re worried about child abuse, discuss it with your ED’s social worker and child abuse team.

Resources

Sreeja Natesan, MD

Sreeja Natesan, MD

Editor-in-Chief, ALiEM EM Bound Newsletter
Section Editor, ALiEM Medical Student Home Page
Associate Residency Program Director
Assistant Professor, Duke University