Attitudes, Behavior, and Comfort of Emergency Medicine Residents in Caring for LGBT Patients: What Do We Know?
This paper was written by some of the thought leaders in the Diversity, Equity and Inclusion realm in Emergency Medicine. Undergraduate medical education has minimal formal hours dedicated to LGBTQ+ health, and EM residency has even less. The authors wanted to assess EM resident comfort in caring for patients who identify as part of the LGBTQ+ community
An anonymous service was sent out to CORD and was then disseminated to the residents of the 167 ACGME accredited EM residencies. It was a 24-question survey based on a similar one given to medical students. Overall, a total of 319 residents responded to the survey, with the vast majority identifying as heterosexual and cisgender
The results seem at first to be contradictory. A majority of respondents (63.5%) were either comfortable or very comfortable in addressing the needs of LBGT patients. But when asked about specific behaviors related to providing care, there was more to the story. Only 17.3% of respondents always asked about sexual partner gender, 4.7% always asked about sexual orientation for an abdominal or genital complaint.
Perhaps more disturbing, the survey found that 10% of respondents had observed attending physicians make discriminatory or inappropriate comments about LGBT patients or staff, 2% of respondents were uncomfortable working alongside LGBT physicians, and 6% of respondents disagreed with the statement that LGBT patients deserve the same level of quality care as other patients.
This study was published in 2019. Despite some amazing advancement in the LGBT community, we obviously still have a long way to go. This study shows the need for more formalized and routine education regarding LGBT population health issues at both the undergraduate and graduate medical education levels. It also demonstrates that LGBT physicians still experience discrimination in the workplace, even within our specialty. Be kind, be compassionate, be understanding.
Moll J, Krieger P, Heron SL, Joyce C, Moreno-Walton L. Attitudes, Behavior, and Comfort of Emergency Medicine Residents in Caring for LGBT Patients: What Do We Know?. AEM Educ Train. 2019;3(2):129-135. Published 2019 Jan 21. doi:10.1002/aet2.10318
Category: Visual Diagnosis
Category: Visual Diagnosis
Category: Visual Diagnosis
Category: Visual Diagnosis
Keywords: patellofemoral, knee, pain (PubMed Search)
Bottom Line: In a recent meta-analysis the risk factors for patellofemoral syndrome are weak hip abduction strength, quadricep weakness in military recruits, and increased hip strength in adolescence.
PatelloFemoral Syndrome: Patellofemoral pain is not clearly understood and is believed to be multi-factorial. Numerous factors have been proposed including muscle weakness, damage to cartilage, patella maltracking, as well as others. Patient often complain of anterior knee that is aggravated by walking up and down stairs or squatting. Patellofemoral pain is extremely common. In the general population the annual prevalence for patellofemoral pain is approximately 22.7%, and in adolescents it is 28.9%.
Though commonly taught, the following have no evidence to support that they are a risk factor for patellofemoral syndrome: Age, Height, Weight, BMI, Body Fat or Q Angle of patella
Title: Mammalian meat allergy (alpha-gal syndrome) following tick bites
Author: Dan Gingold, MD, MPH
Development of IgE antibodies to the oligosaccharide galactose-alpha-1-3-galactose (alpha-gal) appears to be responsible for an acquired allergy to non-primate mammalian meat (i.e., beef and pork) and derived products. Antigen in the salivary apparatus of certain ticks (gross!!) can sensitize an IgE-mediated response to alpha-gal which is present in mammalian meat.
Symptoms are similar to other IgE-mediated hypersensitivity reactions, and can cause a delayed-onset reaction with hives, GI upset, or anaphylaxis after ingestion of red meat. Treatment with standard anti-histamines and epinephrine is effective. Individuals with no prior history of meat sensitivity can develop the syndrome at any age, often after exposure to the outdoors in tick-endemic areas. Skin and blood allergy testing can confirm the diagnosis. Symptoms can persist for years, but can recede over time if not exposed to further tick bites.
In the US, the primary tick responsible is Lone Star Tick (Amblyomma americanum), found primarily in the Eastern, Southeastern, and Midwestern US. Other tick species in Europe, Australia, and Asia have been found to induce the syndrome as well. Interestingly, there is a cross-reactivity with the monoclonal antibody Cetuximab (used to treat colorectal and head and neck cancers), an allergic reaction to which can also induce similar alpha-gal meat sensitivity.
Having first been described in 2009, the syndrome often goes unrecognized; increased physician awareness can inform the evaluation, diagnosis, and education of patients presenting to the ED with undifferentiated allergic reaction.
Khoury JK, Khoury NC, Schaefer D, Chitnis A, Hassen GW. A tick-acquired red meat allergy. Am J Emerg Med. 2018 Feb;36(2):341.e1-341.e3. doi: 10.1016/j.ajem.2017.10.044. Epub 2017 Oct 16. PMID: 29074067.
Crispell G, Commins SP, Archer-Hartman SA, Choudhary S, Dharmarajan G, Azadi P, Karim S. Discovery of Alpha-Gal-Containing Antigens in North American Tick Species Believed to Induce Red Meat Allergy. Front Immunol. 2019 May 17;10:1056. doi: 10.3389/fimmu.2019.01056. PMID: 31156631; PMCID: PMC6533943.
Category: Infectious Disease
Keywords: HIV, Medications (PubMed Search)
Category: Airway Management
Keywords: Patient, centered, communication (PubMed Search)
Keywords: geriatrics, orthopaedic, fractur (PubMed Search)
Therefore, pain medications must be dosed carefully, which runs the risk of underdosing. Pain medications can also contribute to delerium, and decreased functional status.
Keywords: Rotation, Fracture, Phalanx (PubMed Search)
Remember to evaluate for any rotational deformity when evaluating patients with a phalanx fracture.
The easiest way to do this is to have the patient flex all their fingers. They should all point to the scaphoid. If a finger deviates or overlaps another finger there is a rotational deformity. One should also make sure that all the nailbeds align.
This video shows how to evaluate for rotation https://www.youtube.com/watch?v=Dhp25UVn7RQ
Even if the finger is reduced otherwise, persistent rotational deformities should be referred to a hand surgeon for consideration of corrective surgery.
Keywords: anesthetic, orthopedics, wound (PubMed Search)
When caring for a patient with a laceration we often do lcoal infiltration prior to suturing but remember the benefits of regional nerve blocks
Benefits of Regional Nerve Blocks
Quick reminder of properities of common anesthetic
|Anesthetic||Onset of Action||Duration of Action|| Max Dose |
| Max Dose |
|Bupivicaine||Seconds +||> 6 hrs||2mg/kg||3mg/kg|
Final reminder: There is no evidence that epinephrine causes necrosis and it can be used safely in digital blocks. Duration of action is max 90 minutes. Even individuals that have injected themselves with EpiPens into their hands have not had any long term sequelue or necrosis seen. Vast majority required no treatment at all.
Keywords: C-Spine Clearance, altered mental status (PubMed Search)
Keywords: PPI, Gi bleed (PubMed Search)
Continuous vs intermittent dosing of PPIs in bleeding peptic ulcer disease
There continues to be debate as to the optimal dose, frequency, and route of proton pump inhibitors (PPIs) in bleeding ulcers, especially prior to endoscopy. Multiple guidelines including from the American Journal of Gastroenterology continue to recommend continuous dosing of PPIs.1,2,3 However, multiple studies appear to show at least non-inferiority when compared with intermittent dosing of PPIs.
The most frequently cited study for non-inferiority is a meta-analysis of 13 randomized control trials by Sachar et al. which evaluated PPI use in patients presenting with upper GI bleeds who were endoscopically found to have a bleeding gastric or duodenal ulcer with high risk features (active bleeding, non-bleeding visible vessel, or adherent clot)4. There was non-inferiority of intermittent dosing in rebleeding, need for repeat endoscopy/surgery, RBC transfusions, and mortality with a non-statistically significant trend towards superiority of intermittent dosing.
However, the patients were only randomized to continuous vs intermittent dosing AFTER endoscopic treatment. In addition, the dosing regimen of intermittent dosing was quite variable.
Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.
In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.
Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571
Keywords: dental pain, ibuprofen, acetaminophen (PubMed Search)
Category: Visual Diagnosis
Keywords: Green urine, diuretic (PubMed Search)
75 y/o M is brought in by EMS after he fell off the light rail and hit his head. In the ED he is A&Ox3, and is asking for a urinal. Two minutes later the tech comes running to show you the following:
What is the cause of this patients Jolly Rancher Green Apple looking urine sample?
Pamabrom side effect. Patient admitted to taking an “over the counter diuretic” called Diurex. The generic name is pamabrom. Pamabrom is a xanthine diuretic with only modest diuretic effect. It is marked mostly for weight loss to lose “water weight” and for relief of bloating during menstruation. A common side effect of the pills is a blue, green or golden discoloration of the urine. The capsules do not have the same side effect. The side effect is otherwise harmless and will disappear after stopping the diurex.
Keywords: pain, extremity (PubMed Search)
A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen. The study looked at adults with fractures and sprains and randomized them to one of four groups.
Pain relief was similar in all groups.
With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.
Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov 7;318(17):1661-1667. doi: 10.1001/jama.2017.16190.
Have your wondered what you should do with patients that you suspect have infectious diarrhea. Well the IDSA has updated their 2001 guidelines for the management of infectious diarrhea. The TAKE HOME Points are:
You can find all the recommendations at https://academic.oup.com/cid/article/doi/10.1093/cid/cix669/4557073/2017-Infectious-Diseases-Society-of-America
Keywords: nursemaid, elbow (PubMed Search)
Take Home Points:
The Hyperpronation Method: This reduction technique for a nursemaid's elbow (radial head subluxation) has been found to have better first attempt success than classic supination/flexion technique and less painful. (Pediatrics July '98).
Click here to see a video of the technique https://youtu.be/-0ROu4hCXwQ?t=1m15s