UMEM Educational Pearls - Misc

Category: Misc

Title: Diagnostic Errors in the Emergency Department

Keywords: Errors (PubMed Search)

Posted: 4/14/2009 by Rob Rogers, MD (Updated: 2/23/2024)
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Diagnostic Errors in the Emergency Department

Believe it or not, there is actually a field of medicine that is devoted to examining how physicians think in clinical practice, i.e. how we make diagnostic decisions. Much of the work on this has been done by Pat Croskerry. This is extremely important for emergency physicians because we frequently have to make split second medical decisions with little to no information.

Why is this so important? If we can understand where errors are made, we can actually improve our own diagnostic skills and reduce our errors rates.

 

Some key pitfalls that we all fall victim to:

  • Bias-this refers to the chart that says under past medical history "fibromyalgia, interstitial cystitis, bipolar, chronic constipation." This type of chart has set us up to potentially miss a diagnosis because our thought processes shut down before we have even started. Ever miss a diagnosis or almost make a mistake because of your feelings about a patient (sometimes BEFORE seeing them)? This is bias. Being aware of this dangerous pitfall in practice is the first step in preventing bias-related mistakes.
  • Premature closure of the differential diagnosis-Now, we do this a lot in medicine. Some diagnosis falls in our lap (patient gives it to us, or a consultant tells us that is what it is) and we fail to r/o other things on our list. Key mistake we make is related to not considering other entities on the differential diagnosis. Take home point: Don't narrow the differential diagnosis until it is time to do so.

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Category: Misc

Title: G6PD Deficiency

Keywords: G6PD, Deficiency (PubMed Search)

Posted: 4/11/2009 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

Glucose-6-Phosphate Dehydrogenase Deficiency

  • G6PD Deficiency is a genetic disorder which can cause hemolytic anemia when people with the disorder come into contact with drugs, food and other substances which cause oxidative stress.
  • It is the most common genetic enzyme deficiency.
  • G6PD is an inherited disorder with over 400 different known variants.
  • Oxidative stress can cause the premature distruction of RBC's due to the lack of the enzyme reduced glutathione which G6PD helps produce.
  • Drugs that are at high risk for causing hemolytic anemia in those with G6PD deficiency are:
    • NSAIDS (Asprin, Tylenol, Ibuprophen)
    • Quinolones
    • Sulfa drugs
    • Drugs metabolized known to cause blood or liver related problems or hemolysis
    • Primaquine
    • Nitrofurantoin
    • Glyburide
    • Dapsone

Also make sure that you are not G6PD deficiency if you are eating with Hannibal Lecter as Fava beans and other legumes can also cause an episode of hemolysis.

A good reference for G6PD deficiency is http://g6pddeficiency.org/index.php



Category: Misc

Title: The Pearls and Pitfalls of Hyphema

Keywords: Hyphema IOP Ophthalmology (PubMed Search)

Posted: 2/11/2009 by Ben Lawner, DO (Updated: 2/23/2024)
Click here to contact Ben Lawner, DO

Hyphema is an urgent ophthalmologic condition. Due to the high risk of rebleeding and increased intra-ocular pressure, strict follow up with an ophthalmologist is warranted. SELECTED low grade hyphemas in reliable patients may be managed on an outpatient basis. Some pointers that may be helpful for the EM inservice exam: 

  • Measurement of intra-ocular pressure (IOP)  is crucial to proper treatment and prognosis.
  • Many drugs are available to lower IOP, these are generally used in association with opthalmologic consultation
    ->acetazolamide (has potential to "sickle" RBC's)
    ->aminocaproic acid
    ->B blockers
  • Hyphema > 5 days are associated with high incidence of synechiae formation
  • Avoid NSAIDs/ ASA
  • Eye patching,  HOB (head of bed) elevation recommended
  • Corneal bloodstaining indicates a poor prognosis
  • Incidence of rebleeding estimated at 30-40%
  • Graded from 0-IV. Grade IV hyphemas cover the entire anteror chamber; often called, "8 ball" or "blackball" hyphema. Grade 0=only visible on slit lamp.
  • Trauma is most common etiology
  • Low IOP and trauma? ---> Rule out globe rupture! 

General indications for "very urgent" ophthalmologic consultation:

  • Severely impaired visual acuity=greater rebleeding risk
  • Patient with known SCD or sickle cell trait
  • Visible blood staining of cornea
  • High grade, covering > 1/3 of anterior chamber
  • Delayed presentation (risk of synechiae / vision loss due to IOP) 

 

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Category: Misc

Title: Pitfalls in ED Teaching

Keywords: ED Teaching (PubMed Search)

Posted: 2/10/2009 by Rob Rogers, MD (Updated: 2/23/2024)
Click here to contact Rob Rogers, MD

Pitfalls in ED Teaching

One of the best ways to improve as a teacher is to understand what mistakes expert educators have made in the past.

The following is a short list of pitfalls offered from some of the great teachers in our specialty:

  • Trying to teach for too long: "Teaching less is more"-that is to say, more will be remembered if the teaching session is brief.
  • Trying to teach too much: Trying to Stick to one main point, the "Educational Hit and Run," and move on
  • Failure to be enthusiastic when you teach: You must have some enthusiasm when you teach. Students/Residents won't learn as much or be as enthusiastic about learning without your enthusiasm!


Category: Misc

Title: Feedback as a Teaching Tool

Keywords: Feedback, Teaching (PubMed Search)

Posted: 1/26/2009 by Rob Rogers, MD (Updated: 2/23/2024)
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Feedback as a Teaching Tool

Why do we, in general, stink at giving feedback?

  • We were never taught how to do it
  • We fear we will hurt someone's feelings
  • It's painful to give feedback

Consider a few quick pearls that will increase your success at giving valuable feedback:

  • Realize that learners (students/residents) crave feedback....proven in multiple studies
  • Feedback IS a powerful teaching tool and isn't just a way of evaluating someone.
  • Avoid at all cost, the phrase,"good job." Be specific about what you mean
  • Praise in public, perfect in private
  • Avoid the "complain syndrome" and don't fall victim to it. This refers to the phenomenon in which we complain about a behavior or trait and NEVER actuall tell the person. We have all done it. Set yourself apart from others by giving the learner the needed feedback.
  • Learners won't improve without feedback. Just like the Nike commercial says,"Just do it!"


Category: Misc

Title: Frostbite

Keywords: Frostbite, treatment (PubMed Search)

Posted: 1/24/2009 by Michael Bond, MD (Updated: 2/23/2024)
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FrostBite

Now that we are in the cold winter months, we are more likely to see patient with frostbite and hypothermia.  Here are some tips for treating frostbite.

  • Rapidly rewarm the affected body part.  Never attempt rewarming if there is risk of refreezing.
  • An appropriate warming technique tub of water at 40-42°C. Higher temperatures should be avoided secondary to the risk of burns. If a tub is not available, use warm wet packs at the same temperature.
  • It can take up to 40 minutes for the affected area to thaw.  Thawing is complete when the distal areas flush.
  • The only indication for early surgical intervention is debridement of blisters, necrotic tissue or fasciotomy if there is  compartment syndrome.
  • It often takes 1-3 months for frostbitten tissue to be declared viable. The affected area generally heals or shrivels and dries up without surgery. Amputation should be delayed as as long as possible. Early surgical consultation for amputation is rarely needed.

Adapted from Frostbite: Treatment and Medication by C. Crawfor Mechem, MD, MS, FACEP as posted on eMedicine.com.



Category: Misc

Title: EMS Pearls: Field Triage of Injured Patients and the MMWR

Keywords: EMS, trauma, injury, ISS, triage (PubMed Search)

Posted: 1/22/2009 by Ben Lawner, DO (Updated: 2/23/2024)
Click here to contact Ben Lawner, DO

BACKGROUND: 

For the first time since its publication, the centers for disease control has dedicated an entire issue of their Morbidity and Mortality Weekly Report to an emergency medical services topic. Vol 55 RR-1 reviews the, "Guidelines for Field Triage of Injured Patients." The report represents a consensus opinion of national experts in EMS, EM, and trauma care. It outlines which patients may be best served via transport to a trauma center.

CRITERION LINKED TO SEVERE INJURY  (Consider transport to nearest TRAUMA CENTER) 

  • GCS < 14, SBP < 90 mm Hg, RR < 10 or > 29 per minute (or less than 20 for infants) 
  • Penetrating wounds to neck, torso, head
  • Flail chest, two or more proximal long bone fractures
  • Proximal extremity amputation
  • Paralysis
  • Open or depressed skull fracture
  • Older patients on anticoagulation

From the MMWR: "The National Study on the Costs and Outcomes of Trauma identified a 25% reduction in mortality for severely injured patients who received care at a Level I trauma facility." 

EXTRAS: 

The remainder of the report details the triage decision making process, explains trauma center capabilities, and provides an interesting and detailed review of trauma transport criteria. Link to the current issue is attached.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm

 

 

 



Category: Misc

Title: Teaching in the Emergency Department

Keywords: Teaching, Emergency Department (PubMed Search)

Posted: 1/20/2009 by Rob Rogers, MD (Updated: 2/23/2024)
Click here to contact Rob Rogers, MD

Teaching in the Emergency Department

Effective ways to teach in the ED:

  • Limit the amount of time you spend teaching (more teaching does not = more learning)....Take Home Point: teach a quick pearl about a case and move on. Dont belabor the point and keep teaching for 5-10 minutes. You will loose the learner.
  • Make teaching points applicable to the patient. Theoretical stuff is fine but no one cares about the Krebs cycle or ATP.
  • Teach "on the fly" (teach as good teaching moments come up on each case). "Board talks" are nice but are often times not practical in a busy ED.
  • Above all, be enthusiastic...without this all teaching will be ineffective

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Category: Misc

Title: Glucometers

Keywords: Glucometer, Accuracy (PubMed Search)

Posted: 11/15/2008 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

The glucometer is one of the devices that we quickly reach for in the management of our unresponsive patients, diabetics and in the critically ill.  Recently, I noticed that our Roche Accu-Check has a big sticker on the case stating that results could be affected by therapies that alter the metabolism of galactose, maltose, and xylose.  Since this was a big hole in my fund of knowledge I decided to look up what else affects the accuracy of glucometers.

 Now, Dr. Winters already warned used about the inaccuracy of bedside glucometer readings in the critically ill, but what about the patient that is not septic and/or in shock.

Substances/Drugs that have been reported to affect the accuracy of glucometers are:

  • Levodopa
  • Dopamine
  • Mannitol
  • Acetaminophen
  • Severe lipemia
  • Severe unconguted bilirubin
  • Elevated Uric Acid
  • Maltose (present in immunoglobin products)
  • Patient on peritoneal dialysis secondary to Icodextrin
  • Ascorbic Acid (Vitamin C)

Anemia also results in higher values, and a capillary blood sample can differ from venous blood by as much as 70mg/dL.

Most errors are more significant when dealing with hypoglycemia. 

So the moral of the story is be careful with a bedside glucometer when the reading is low, as the venous blood sample sent to the lab may return even lower.  Error on the side of treating the patient with glucose.

 

 

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Category: Misc

Title: High Altitude Illnesses

Keywords: high altitude illness (PubMed Search)

Posted: 11/1/2008 by Michael Bond, MD (Updated: 2/23/2024)
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High altitude illnesses is typically called Acute mountain sickness (AMS) and is associated with two major complications high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).

Symptoms associated with AMS are headache, fatigue, nausea and vomiting, anorexia and insomia. Cough, Cyanosis, hypoxia, and dyspnea are associated with HAPE.  HACE is associated with progressive neurologic symptoms and can lead to ataxia and coma.

Factors that increase your risk for altitude illnesses are:

  • Rate of ascent
  • Elevation obtained
  • Exertion on arrival to elevation
  • Duration at that altitude
  • Recent URI
  • Previous symptoms of AMS


Category: Misc

Title: Severe Hypothyroidism or Myxedema Coma

Keywords: Hypothyroidism, Myxedema, Treatment (PubMed Search)

Posted: 10/11/2008 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

Severe Hypothyroidism or Myxedema Coma

  • Mortality rate has been as high as 80% now 15-20% with aggressive treatment
  • Some common symptoms are:
    • Constipation
    • Depression
    • Lethargy
    • Dry, Brittle hair or Alopecia
    • Weight Gain
    • Cold Intolerance
    • Weight Gain
  • Treatment consists of:
    • Rule out aggravating cause (i.e.: infection)
    • Start IV levothyroxine dosing
      • Initial dose 400-500 mcg (Helps to saturate the thyroid receptors)
      • Daily dose 100 mcg/day
    • Consider starting Dexamethasone or doing a Cortisol stimulation test
      • Patients may also have adrenal insufficiency from primary pituitary failure or may have secondary adrenal suppression due to the severe hypothyroidism.  If dexamethasone is not provided they may develop severe adrenal insufficiency once you kick start their metabolism.


Category: Misc

Title: SVC Syndrome...when to suspect

Keywords: superior vena cava, svc syndrome (PubMed Search)

Posted: 5/20/2008 by Rob Rogers, MD (Updated: 2/23/2024)
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Superior Vana Cava Synrome....when to suspect

 

Two common causes of SVC syndrome include thrombus (secondary to CV catheters) and lung tumors/lymphoma

Consider this diagnosis in patients with a history of cancer and/or who have a central line in place and the complaint of facial swelling. Patients may not look swollen to you.

In addition, make sure to look at their necks and chest wall-presence of asymmetric, prominent veins should prompt consideration for this diagnosis. 

A useful clinical tool is to look at the patient's driver's license (assuming they have one) and compare to their appearance on presentation.

Workup in most cases will involve a CT of the chest.

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Category: Misc

Title: Acute Leukemia

Keywords: Leukemia (PubMed Search)

Posted: 4/28/2008 by Rob Rogers, MD (Updated: 2/23/2024)
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Suspected Acute Leukemia in the ED

 Key ED Interventions for patients with astronomically high WBC counts:

  • Usually talking about WBC counts over 200,000 or so (can be lower in lymphocytic leukemia)
  • Hydrate aggressively
  • Avoid PRBC transfusions as blood products will increase the patient's cytocrit (combination of WBC, platelets, and RBC) and predispose to organ malperfusion. This may lead to WBC (or blast) sludging in the microcirculation and may result in CNS bleeds. 
  • Obviously, call for help immediately! Get a hematologist on the line quickly
  • Assume the patient already has Tumor Lysis Syndrome and administer Allopurinol in a dose of 300 mg orally.
  • Obtain a uric acid level, and if high, give an intravenous infusion of Rasburicase-eliminates preformed uric acid released from leukemia cell lysis. Renal failure results from high uric acid levels. We have this medication at University.
  • The treatment of choice is initiation of definitive chemotherapy....clearly not an option for us in the ED. You can also do leukapheresis (where you take out WBC)....also not an option unless you have a special catheter and a perfusionist/nurse. BUT, you can take off a unit or two of blood (phlebotomy). This will potentially lower the patient's cytocrit. 


Category: Misc

Title: Neutropenic Fever-Pearls and Pitfalls

Keywords: Fever (PubMed Search)

Posted: 3/31/2008 by Rob Rogers, MD (Updated: 2/23/2024)
Click here to contact Rob Rogers, MD

Neutropenic Fever

A few pearls about neutropenic fever:

  • Usually occurs a few weeks after chemotherapy (14-21 days)
  • Defined as a fever in the setting of rapidly declining neutrophil count
  • Patients who report fever at home but who are not febrile in the ED should be treated as if they are neutropenic
  • ANC=absolute neutrophil count. Calculated by adding neutrophils and bands together
  • Classification of neutropenia, use the ANC to calculate:  Mild: 1000-1500 cells/mm3, Moderate 500-1000 cells/mm3, and Severe Less than 500 cells/mm3.
  • Mortality rate increases as the ANC drops to below 500 and the duration of neutropenia. These people die of overhwhelming bacterial infections/sepsis.
  • Treatment: #1 Consider the diagnosis, #2 Broad spectrum antibiotic coverage: Imipenem, or Pip/Tazo, or Cefipime. Consider adding Vanc if the patient has a line, looks ill or is hypotensive, or if the patient has been on a fluoroquinolone.

#1 Pitfall:

  • Not initiating broad spectrum antibiotic coverage fast enough. These patients can crash very rapidly.
  • Patients do not have to be febrile in the ED to be diagnosed with this. Their report of fever is enough.
  • Mortality rates drop the faster big gun antibiotics are given. Don't be skimpy and give Unasyn. Use the big bad boys like single agent Pip/Tazo (4.5 grams, not 3.375), Cefipime, etc. Have a low threshold for adding Vancomycin.

IDSA Guidelines on Neutropenic Fever, 2002. New Guidelines coming Summer 2008!

 



Category: Misc

Title: Oncologic Emergencies-SVC Syndrome

Keywords: Oncologic, Emergency, SVC Syndrome (PubMed Search)

Posted: 3/3/2008 by Rob Rogers, MD (Updated: 2/23/2024)
Click here to contact Rob Rogers, MD

Clinical Presentation of SVC Syndrome

SVC syndrome (caused either by tumor or thrombosis of the SVC) classically presents with facial swelling, arm swelling, and dilated chest wall veins. The problem in the real world is that often times the manifestaions are a bit more subtle.

Some SVC syndrome pearls:

  • Consider the diagnosis in patients with a generalized complaint of facial swelling or "fullness," particularly if they have an indwelling catheter in place.
  • Consider in patients who complain there face is swollen or red (plethoric) in the morning, or who notice this when their arms are raised (Pemberton's sign)
  • The diagnosis is usually established by CT.
  • Patients with SVC syndrome and the complaint of hoarseness or headache should make you nervous, as these symptoms may indicate laryngeal and cerebral edema.
  • The importance of examining the neck and chest in ED patients cannot be overemphasized. Often the one clue that leads to the diagnosis is prominent and asymetric neck, upper chest, or shoulder veins.
  • Treatment: For tumor related SVC syndrome-head elevation, possibly steroids, radiation therapy (along with biopsy if no cancer diagnosis established); For thrombotic-related SVC syndrome-anticoagulation, Interventional Radiology consult for lytics/stent

 



Category: Misc

Title: Coding and Billing Pearls

Keywords: Coding, Billing, Reimburshment (PubMed Search)

Posted: 12/16/2007 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

The insurance companies are always trying to down code our visits so that they can save money, and unless we diagnosis the patients with the appropriate jargon it can cost us a lot of money.  Here are some coding suggestions as written by Sharon Nicks, President and CEO of Nicks & Associates in EP Monthly .

 

Diagnosis
Consider Diagnosising  It this, if the condition fits
Esophagitis
  • Acute Chest Pain
U.R.I.
  • Acute febrille illness with cough
  • Acute tracheobronchitis
Gastroenteritis
  • Acute severe abdominal pain
  • Acute dehydration (volume depletion) secondary to nausea/vomiting
  • Electrolyte imbalance
 Flu/Viral Ilness
  • Acute viremia
  • Acute febrile illness
 Musculoskeletal Pain
  • Acute cervical pain
  • Acute chest wall syndrome
  • Acute strain or pain to a specific (i.e: lumbar) due to a MVA or fall
Otitis Media
  • Acute febrile illness secondary to acute otitis media
  • Otalagia

 

The moral of this pearl is try to use words like Acute, Severe, Sudden, Serious, Distress, Pain, or Fever so that it is clearer to the insurance companies that the patient warranted a visit to a physician (i.e.: an ED) before their PCP could see them in a week.



Category: Misc

Title: Changes to the educational list format

Keywords: administrative, notice, admin, tech (PubMed Search)

Posted: 10/4/2007 by Dan Lemkin, MD, MS (Updated: 2/23/2024)
Click here to contact Dan Lemkin, MD, MS

I have made some improvements to the educational pearl interface. This required recoding several sections to change the text formatting from plain text to html...

Why do you care?

Well, many email clients will block html, or messages that have lots of capitals, decorations, etc...

Our first priority is to get you the information and beat anti-spam auto-filtering. If you notice that you are not getting the educational emails. 
If it still doesn't work, send me an email. If many people are having problems, I will revert to the old system of text entry... But if this works, hopefully it will make the messages easier to read.
Notes to authors
  • Do not use a lot of colors like this post
  • Do not use allcaps, lots of bolding, etc...
thanks
dan

Category: Misc

Title: Medical Management Ureteral Stones

Keywords: Ureteral, stone, tamsulosin, management (PubMed Search)

Posted: 7/21/2007 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

Medical Management of Ureteral Stones Tamsulosin (Flomax ) has been shown to help increase the passage of ureteral calculi. According to a metaanalysis compared to patients receiving conservative therapy only, patients receiving conservative therapy plus α -blockers were 44% more likely to spontaneously expel the stones (RR 1.44, 95% CI 1.31 to 1.59, p0.001), and stone expulsion incidence increased significantly (RD 0.28, 95% CI 0.22 to 0.34, p0.001). Mechanism of action: Alpha blockage results in ureteral smooth muscle relaxtion and subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen. Erturhan S. Erbagci A. Yagci F. Celik M. Solakhan M. Sarica K. Comparative evaluation of efficacy of use of tamsulosin and/or tolterodine for medical treatment of distal ureteral stones. [Comparative Study. Journal Article. Randomized Controlled Trial] Urology. 69(4):633-6, 2007 Apr. Parsons JK. Hergan LA. Sakamoto K. Lakin C. Efficacy of alpha-blockers for the treatment of ureteral stones. [Journal Article. Meta-Analysis] Journal of Urology. 177(3):983-7; discussion 987, 2007 Mar.

Category: Misc

Title: Test of new education blog/listserv

Keywords: Listserv, mailing list, test (PubMed Search)

Posted: 7/10/2007 by Dan Lemkin, MD, MS (Emailed: 7/8/2007) (Updated: 2/23/2024)
Click here to contact Dan Lemkin, MD, MS

I am redesigning the way the educational pearls are sent. You will still receive them via email to the education list. This will not change. What will change, is that a record will be available for review on the website in the residency --> pearls section. Currently you can browse the posts as the come in. In the very near future, you will be able to search by keywords and review several pearls at once. This should serve as a really handy review tool. Please bear with me as I test the email system to ensure it comes across ok. thanks dan