Should We Admit All Patients with Sternal Fractures?

By |Categories: Cardiovascular, Trauma|

The detection rate of sternal fractures following motor vehicle collisions and blunt trauma to the chest and abdomen has increased over the past decade.  The reason for this increase is most likely from the use of seat belts and better imaging modalities such as computed tomography (CT) in trauma patients. I can recall as a resident being told that any patient with a sternal fracture should be admitted to trauma because of the high likelihood of blunt cardiac injury and high mortality rate associated with this injury, but is this always true? […]

Child Whisperer Series: Breaking Bad News

By |Categories: Pediatrics|

The weekend after Thanksgiving, I received the following text from one of my friends: “Bella’s in the hospital. Her legs were hurting, they did tests… It’s leukemia.” Bella is one of my 8 year old daughter’s good friends. All of a sudden my professional world and personal world were colliding. As I looked up from my phone and at my daughter, one of my first thoughts was, how am I going to explain this to my daughter so that she isn’t terrified and understands leukemia? […]

Approach to Difficult Vascular Access

By |Categories: Cardiovascular, Critical Care/ Resus, Expert Peer Reviewed (Clinical)|

Intravenous (IV) access is a basic and invaluable skill for emergency physicians. For patients requiring rapid fluid resuscitation, airway management, or medication administration, the placement of one or more IV lines is absolutely essential. Most patients do well with a simple, landmark-based, blind placement of a superficial peripheral IV. However, we often encounter situations where this may be difficult or impossible to achieve, and so we all should have a repertoire of other sites and techniques to employ. […]

Applying to EM-Critical Care Medicine Fellowships: What you need to know

By |Categories: Critical Care/ Resus, Medical Education|

Emergency physicians (EPs) have been successfully training in and practicing critical care in the ICU for decades, though until recently board certification remained closed to EPs. In the last few years, however, we have seen monumental changes in training opportunities for EPs, including national standardization of training programs, and most importantly, the establishment of three distinct pathways to board certification. Though the details of some of these pathways are still being worked out, much more concrete arrangements have been reached in the last 6 months. If you are an EM resident interested in applying to critical care fellowships, this is [...]

The proper way to go Against Medical Advice (AMA): 8 Elements to Address

By |Categories: Medicolegal|Tags: |

Case Example: 42 y/o male presents with right lower quadrant abdominal pain and has significant tenderness at McBurney’s point on exam. While waiting for a CT scan to evaluate for possible appendicitis the patient rips out his IV and tells the nurse “I’m leaving, I don’t want to sit here all night, and you can’t make me stay.” The nurse pulls you out of another room and hands you the standard against medical advice (AMA) paperwork. […]

The HEART Score: A New ED Chest Pain Risk Stratification Score

By |Categories: Cardiovascular|

Chest pain is a common presentation complaint to the emergency department (ED) and has a wide range of etiologies including urgent diagnoses (i.e. acute coronary syndrome (ACS), pulmonary embolism, aortic dissection) and non-urgent diagnoses (i.e. musculoskeletal pain, gastroesophageal reflux disease (GERD), pericarditis). The challenge in the ED is to not only to identify high risk patients but also to identify patients who can be safely discharged home. Specifically, when dealing with ACS, dynamic ECG changes or positive cardiac biomarkers is pretty much a slam dunk admission in most cases, but a lack of these does not completely rule out ACS. [...]

Tramadol: When to avoid it

By |Categories: Tox & Medications|

Tramadol is a popular agent for the treatment of pain and offers an alternative to opioid therapy. Tramadol exerts its analgesic effects through weak stimulation of the mu opioid receptor as well as inhibiting the reuptake of serotonin and norepinephrine similar to some antidepressant medications. While tramadol may be an effective option for mild to moderate pain in otherwise healthy individuals, the following patients may benefit from an alternative analgesic selection. 1–4 […]

New Year’s Resolution: Let’s Dose Vancomycin Correctly in the ED

By |Categories: Tox & Medications|

Vancomycin remains one of our workhorse antimicrobials for treating infections caused by methicillin-resistant S. aureus (MRSA). As the incidence of MRSA infections continues to rise AND we are starting to see increasing minimum inhibitory concentrations (MIC) with vancomycin, it is paramount that we optimize its use, starting in the Emergency Department (ED). […]

Thank You ALiEM Expert Peer Reviewers

By |Categories: Expert Peer Review (Non-Clinical), Expert Peer Reviewed (Clinical)|

We would like to take this opportunity to thank those of you who took the time to take part in our exciting new Expert Peer Review series over the last 4 months of 2013.  Your contributions helped us roll out this ground breaking process, and we hope you all will continue to contribute to our peer review in the future.  […]

Why the Holidays Can Be Deadly

By |Categories: Cardiovascular, Geriatrics, Psychiatry, Tox & Medications|

The winter holiday season is a busy time in most EDs. Colder weather, respiratory infections, and many factors contribute to this. However Christmas Day and New Year’s Day in particular are two of the deadliest days of the year. Missed medications due to travel, delayed presentations because of a desire to stay home for family gatherings, increased stress, alcohol and substance abuse, travel, and drunk driving, are just a few of the things that can contribute to morbidity and mortality in patients of all ages, and particularly in older adults. If you are working this holiday season, here is a [...]