Winner 2008

winner-2008Congratulations to Dr. Allison Loynd, PGY-1 Emergency Medicine Resident at Detroit Receiving Hospital.  Over the course of 5-months, Dr. Loynd’s perseverance kept her at the top of the leader board.  After falling to second place mid-contest, Dr. Loynd stayed focused and swept the final six weeks with a string of correct answers.  Dr. Loynd answered correctly in 13 of the 15 questions.  Nice work!

Receiving will come back on-line January 5, 2009.  In the interim, please get in touch with me if you would like to help out with the site or contribute some of your ideas (tech skills not necessary).  Email me at arosh@med.wayne.edu

Happy New Year!!

Answer Tracings Vol 1.2

Winners

Allison Loynd          Marjan Siadat       Richard Gordon

David Mishkin         Brian Kern

Case

ecg2

ECG Interpertation

  • anterolateral wall STEMI
  • ST-elevation in leads I, AVL and precordial leads V2-V6.
  • Evolving Q waves are seen in several leads.

There is, in addition, complete heart block (CHB). The atrial rate is 125 bpm, while the ventricles are beating at 52 bpm. The arrows in ECG#2 show P waves (except the 8th P wave, which is buried in a QRS complex) marching through the QRS complexes.

Remember: you have AV dissociation but NOT CHB if the atria and ventricles are dissociated BUT the ventricular rate is FASTER than the atrial rate.

Discussion

CHB occurs in about 5% of STEMIs. When it occurs in association with anterior wall MI, the prognosis is grave with mortality as high as 70-80%. This apparently is not causally related to the CHB itself but reflects that large MIs, which have worse outcomes, are more likely to have associated CHB.

In this case the patient was taken rapidly from the ED to the cath lab, where the LAD was found to have a proximal ruptured plaque with thrombus resulting in a 99% stenosis. This was successfully stented. A large troponin leak peaked at >22.78.

Although complete heart block with STEMI is generally considered to be an indication for at last temporary pacemaker placement, in this case after stenting the heart block resolved and it was felt that the patient did not need a pacemaker.

Echocardiogram on the 2nd hospital day showed a small LV cavity with concentric hypertrophy, severe hypokinesis of the mid
to distal and anterior septal wall, and akinesis of the apex. Ejection Fraction was 35%.

The patient was discharged home on the 4th hospital day.

Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department.  Topics chosesn are dervied from the EM Model for Resident Education. Cases are prepared by Dr. William Berk.

Tracings Vol 1.2

A 79-year-old Bangladeshi man arrived in the ED via private car.  He describes having chest pain for 4 hours that is worse on the left side than the right. He speaks no English and it is impossible to immediately obtain a more detailed recent history.  His past medical history includes Type 2 diabetes and a  “thyroid problem.” His medications include glipizide 5 mg once daily and levothyroxine 50 mcg once daily. On exam, his BP is 154/71 mm Hg, P 62 beats per minute, R 18 breaths per minute, and T 96.7. He is alert and as far as can be ascertained, oriented. There are no other significant exam findings.
A 12-lead ECG was obtained as seen below.

ecg1

Questions:

1.  What is your ECG interpretation?
2.  What is your disease differential diagnosis?
3.  What would you do?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department.  Topics are derived from the EM Model for Resident Education. Cases are prepard by Dr. William Berk.

Answer quizzER 1.5

quizzER Winners:

Eric Tosh                Allison Loynd             Marjan Siadat

Julie Nguyen          Maria Pak                   Gloria Kuhn

Brian Kern              Richard Gordon        Rob Klever

Last Week’s Question

The answer is d.

The most useful diagnostic test obtainable in a suspected CO poisoning is a COHb level. Normal levels range from 0 to 5%, as CO is a natural by-product of the metabolism of porphyrins. COHb levels average 6% in one-pack-per-day smokers. CO poisoning should be suspected when multiple patients, usually in the same family, present with flu-like symptoms, and were exposed to products of combustion (e.g., home heaters/generators). This most commonly occurs in colder, winter months. The mainstay of treatment is the delivery of O2. Hyperbaric O2 is usually used for patients with COHb levels greater than 25%.

______________________
(a) Lead toxicity is mainly a disease of children resulting from ingestion of lead-based paints. Adults can be exposed to lead in a variety of occupational circumstances such as welders, glassmakers and scrap metal workers. There is no classic presentation of lead toxicity. Therefore, high suspicion and a thorough history are critical. The diagnosis is made by an elevated whole blood lead level. (b) CO poisoning is often confused for a viral syndrome. Patients with influenza usually present to the ED with high fever. (c) Malingering is the intentional production of false or exaggerated symptoms motivated by external incentives. (e) A lumbar puncture is used to diagnose meningitis, which may present with headache, nausea, and fatigue.

Here is an excellent review article from the New England Journal of Medicine on carbon monoxide poisoning

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

quizzER Vol 1.5

A 43-year-old woman presents to the ED in the state of Michigan with a 1-week history of intermittent headache, nausea, and fatigue. She was seen at her private doctor’s office 1-week ago along with her husband and children, who also have similar symptoms. They were diagnosed with a viral syndrome and told to increase their fluid intake. She states that the symptoms began approximately one week after Thanksgiving. The symptoms are worse in the morning and improve while she is at work. Her BP is 123/75 mm Hg, HR is 83 beats per minute, temperature is 98.9°F, and O2 saturation is 98% on room air. Physical exam is unremarkable. You suspect her first diagnosis was incorrect. Which of the following is the most appropriate next step to confirm your suspicion?
a. Order a mono spot test
b. Perform a nasal pharyngeal swab to test for influenza
c. Consult psychiatry to evaluate for malingering
d. Order a carboxyhemoglobin (COHb) level
e. Order a lead level

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Mini-me

mini-me

Welcome to the my inaugural posting of pediatric EM potpouri.  This blog will eventually take better shape (hopefully with your feedback), but for now it is just an amorphous blob of my thoughts from the smaller gentler side of the ER.

Ok, I admit that chest pain in a 40-year-old makes me want to  vomit, but vomit in a 4-year-old can also give a lot of EM docs chest pain.

Today I’m gonna give some tips on examining kids.  I hate to overcook a cliché, but pediatrics is not medicine for “little adults”.  And beyond knowledge of their unique physiology, anyone who treats children needs to have a bag of tricks to help with their evaluation.  Some folks are born with the magic touch,  but even if butterfly stickers and funny voices aren’t your thing, using these tricks can help you get a better physical exam. (By the way, I think pediatrics may be the last bastion of good physical exam skills–since we think long and hard  before ordering tests that may cause unnecessary irradiation or needle  sticks).

Top 5 approaches to examine the frightened child

1.  Start far away

Children are in touch with their primitive instincts.  When you enter to find a frightened face, just pretend you happened upon a wild tiger and avoid any threatening moves.  No eye contact, no babbling baby noises, take a few steps back, and maybe even turn your back to them.  After they get acclimated they will be pissed that you are ignoring them, and fear will be replaced by curiosity about you.  That’s when you make your move!

2.  Share and play nice

If you are not sure what is scaring the child, take time to find out.   White coats are already passé in peds, but stethoscopes and otoscopes are still around to scare the crap out of kids.  Change the familiar script by doing something novel with your stethoscope.  Take it off your neck, place it on your leg, or the table, or parents leg.  Hand it to the child. Once they see it as a toy,  see if they’ll let you (or mom) hold it to their chest.  Putting it in your  ears is the last move you make, and hopefully by then they no longer feel  threatened.

3.  Back down

When the tears start welling up, some people assume the war is lost  and just go for broke: pinning the child down, and forcing an exam.  Sure,  that is sometimes necessary, but it is usually an inadequate exam and things get missed or unnecessary workup results.  When you see a child startle, my advice is to act more startled, back away, put down your stethoscope and cower in the far corner.  The child will often become curious about this weak creature that it scared away and you then get a second pass to come in for a smoother landing.  If you smell fear the moment you open the door, then just turn  around a close it (confuses the crap out of ’em).  You can then reenter while they are in a “cry refractory” daze of confusion.

4.  Head to toe? no no no

Ok, most people know this one cold.  But at the risk of stating the  obvious, save the invasive stuff for last (things in ears, things in throats,  pushing on bellies, opening diapers.  My exam changes every time depending on  what the child lets me do first.  Try and get your auscultating in early  while the child is cooperative and quiet.

5.  Crinkle paper

I don’t know why, but kids love the sound of crinkled paper, and no  paper crinkles better than the bargain sheets that cover our exam tables.   Grab a piece, smush it up, throw it around.  Distraction is your best friend  when it comes to kids.

Ok that’s it for now.   In my next post, I’ll go over some tricks for pediatric access IV access/phlebotomy.

Thanks for reading, and please send me your questions, critiques, ideas, and suggestions for what else you’d like to see here.

-Oren

Mini-mə is an educational resource that highlights the essentials in pediatric emergency medicine care. Each entry will focus on ways you can improve your practice in pediatric emergency medicine.

Interview: Dr Lewis Goldfrank

Dr. Goldfrank is Professor and Chair of the Emergency Department at NYU/Bellevue Hospital Center and Director of the New York City Poison Control Center.  Dr. Goldfrank is a dedicated phyisican who has spent most of his career caring for the underserved population of New York City.  He is a civil rights activist and is committed to social justice.

Receiving: You have been practicing Emergency Medicine for more than three decades, what are some of the biggest changes you have seen?

LG: The development of academic departments, EM residencies, exceptional fellowships, devotion to academicity, the exceptional quality of faculty, resident, and students.

Receiving: What are some of the toughest issues we currently face in the medical profession?

LG: Lack of universal healthcare, inadequate access to primary care, corruption of the pharmaceutical and device industries in collusion with physicians.

Receiving: How did you first become interested in toxicology?

LG: The overwhelming demands in the ED population, environmental toxins, unintentional and intentional exposures and their vast societal implication all come to ED. Someone needed to study and develop responses.- antidotes,education and management strategies.

Receiving: Some of your recent work has been in disaster preparedness; are we prepared?

LG: We are integrating efforts, collaborating with more people than ever before and thinking about the unthinkable – all that makes us better prepared.

Receiving: You recently visited the African country of Guinea; how has that experience reshaped any of your views in Emergency Medicine?

LG: We are creating educational exchanges for faculty, nurses, residents, fellows and students so that young people can have a global educational perspective. The developing world must address problems that we no longer address – working together is a unique intellectual experience. The intellectual exchange includes members of many of the schools of NYU – Public Policy, Dentistry, Nursing, Medicine, Public Health. The opportunities for learning are unmatched.

Receiving: How can Emergency Physicians improve society?

LG: We must find jobs that make a difference to human beings. Achieving improved societal understanding of health and working with our communities, offers us the capacity to feel useful every day.

Receiving: Who is your role model?

LG: Probably no one individual – a composite of values and skills represented by Upton Sinclair, Pete Seeger , Albert Camus and Linus Pauling.

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.