When the PERC Rule Fails
Kline et al developed a clinical decision tool based on parameters that could be obtained from a brief initial assessment to reasonably exclude the diagnosis of pulmonary embolism (PE) without the use of D-dimer in order to prevent unnecessary cost and the use of medical resources. 1 Many of us have used the Pulmonary Embolism Rule-out Criteria (PERC) rule by now, but we should be clear on what it includes. Are we using it appropriately? [+]
AMA: 2 high risk myths and misconceptions
Patients who leave the emergency department against medical advice (AMA) are at an increased risk of having a bad medical outcome, and can be a source of significant medicolegal risk to providers. Earlier we reviewed eight elements to address when signing a patient out AMA. There are two common myths regarding patients who leave AMA that can complicate an already difficult situation. [+]
Where is the pedagogy in flipped classrooms?
As you are aware there has been lots of discussion going on about the concept of flipping the classroom in education these days. ALiEM recently hosted a book club where Salman Khan’s book (The One World School House: Education Reimagined) was featured in a Google Hangout. Khan, an ex-hedge fund manager, started making videos to help his niece with her math homework years ago. These videos ended up on YouTube and became quite popular. It wasn’t until later with the help of Bill Gates that he formed The Khan Academy and popularized the concept of the flipped classroom. [+]
BISAP, EHMRG, ORT: 3 New Medical Scores You’ve Never Heard Of
Let’s face it. You’ve heard about the A-a gradient. And free water deficit. And even the APACHE-II score. But how useful are these in your daily practice? You don’t care that much if a patient has shunt physiology in the first case, nor exactly how much free water they’re lacking in the second. And in the third case, your clinical acumen is probably pretty good at predicting a sick patient’s mortality already. But what about the new medical scores of BISAP, EHMRG, and ORT? [+]
Blood Pressure Management in Adults (JNC 8 and ACEP Policy)
Hypertension is one of the most common conditions seen in primary care clinics and emergency departments (EDs). Frequently, patients are found to have asymptomatic hypertension and referred to EDs for management, despite the fact that rapidly lowering blood pressure is not necessary and may be harmful. Yet many clinics still refer these patients for emergent management. In December 2013, the Eighth Joint National Committee (JNC 8) published a new, open-access, evidence-based hypertension guideline in JAMA. They only cited randomized clinical control trials to answer three questions: Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? Does treatment with antihypertensive pharmacologic [+]
Buprenorphine and Acute Pain Management: The ED Perspective
Acute pain management in the ED is challenging. For patients on buprenorphine, it can be even more difficult. What if a patient on buprenorphine presents to the ED with a painful condition that requires a short course of opioid therapy? [+]
Serotonin Syndrome: Consider in the Older Patient with Altered Mental Status
What’s the first thing that pops into your head when you see an older woman presenting to the ED from a nursing facility with atraumatic altered mental status? If you’re like me, ‘UTI’ comes quickly to mind. I then banish the thought of a UTI and force myself to go through a worst-first differential diagnosis to exclude, either through the history and clinical assessment or through testing, more dangerous causes. This is a case of a 67-year-old woman with an unusual cause of altered mental status… and a UTI. [+]
ALiEM Bookclub Promo: Drive – The Surprising Truth About What Motivates Us
It was a few months into my simulation fellowship and I had been devoting a lot of my time to teaching at the medical school. I loved it. I find few things as fun as teaching students who are super motivated to learn. That got me thinking about why learning isn’t always that way. What is it about certain settings that foster a student’s passion to learn while others, that may be presenting the exact same content, cause the same group of students to grumble and disengage? [+]
MEdIC Series: The Case of the Terrible Teammate: Expert Review and Curated Commentary
The Case of the Terrible Teammate presented a conflict between a team of chief residents. Sarah got upset because David seemed to be shirking his responsibilities and getting her to do all of the work. While we provided a specific context for the case, interpersonal disagreements over the distribution of work may come up in any work arrangement that splits responsibility between two or more parties. When it does, how should we deal with it? This month Dr. Teresa Chan (@TChanMD) and I (@Brent_Thoma) explored this issue with insights from the ALiEM community and 3 experts. [+]
Is Pelvic Exam in the Emergency Department Useful?
Women with undifferentiated abdominal pain and/or vaginal bleeding commonly present to the emergency department. Many textbooks advocate for the pelvic exam as an essential part of the history and physical exam. Performance of the pelvic exam is time consuming to the physician and uncomfortable for the patient. It is with great regularity that emergency physicians make clinical decisions, based on information derived from the pelvic examination, but is this information reliable and does it effect the clinical plan of patients? [+]