The International Emergency Medicine Education Project (iem-student.org) has completed three years. As you may know, the iEM Education project aims to promote Emergency Medicine and provides copyright-free resources to students and educators around the world. Now we have reached more than 200 countries. We would like to thank again our contributors. Without them, such a project would not be possible. This experience has shown us once again how passionate our international EM community is to help and teach each other.
In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce alive activity series, Emergency Medicine PerspectivesofStudents Around the World. Our guests for the second session are Maryam Zadeh from Canada, Nawaf Alamri from Saudi Arabia, and Rebeca Barbara from Brazil, who are the leaders of the International Student Association of Emergency Medicine..
Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.
Here are the video and audio records of this session.
The great thing about going into emergency medicine (EM) is that it allows entry into the program at various points of your career. So whether you know right off the bat following your two foundations years or whether it takes you a couple of years to make a choice, there is a straight pathway into the speciality (give or take a bit more competition!).
Acute care common stem (ACCS)
The most common entry route into emergency medicine from your foundation years is through the Acute care common stem (ACCS). This will be a 3-year training program and so becomes your CT1-3 years. This will comprise four six-month rotations in Intensive care medicine (ICM), emergency medicine (EM), anesthesia, and acute medicine (AM). Following this, there will be a one-year focus on EM and pediatric emergency medicine (PEM). In terms of examinations, the major ones that need to be completed are the MCEM Part A before the CT3 year and the MCEM Parts B and C before progressing to higher specialty training (ST4).
Defined route of entry into EM training (DRE-EM)
If one doesn’t do the ACCS and decides they want to enter EM in their ST3 year, this can be done view the DRE-EM. For the two years before entry into the DRE-EM at ST3, you need to have a minimum of 2 years of experience in substantive EM posts (which exclude any done during your foundation years). In addition, one of these posts needs to have been in the UK in the previous four years. Examples of such posts could be a core trainee level in an ACCS specialty (anesthesia, EM, ICM, AM), which at the end of the pathway would give you a Certificate of Completion of Training (CCT), or in core surgical training, which would give you a Certificate of Eligibility for Specialist Registration by the combined program route (CESR CP). Your ST3 year following acceptance into the DRE-EM can take 18 to 24 months, depending on how quickly competencies are met to enter ST4.
Before entry into their ST4 years, trainees will be required to have completed the EM specialty-specific examinations before progressing into ST4:
• MCEM Part A or MRCS (Latter for DRE-EM trainees only)
• MCEM Parts B and C
At the end of this training, all trainees will be required to complete the FCEM exit example before their awarded their CCT.
Higher Specialty training (HST) in EM
This is one of the pathways into EM that can be taken following CT3/ST3. Entry at this point is by a selection through a national recruitment process. From this point, HST trainees can also apply for subspecialty training posts, such as PEM or prehospital emergency medicine. This training post doesn’t have to be full-time (i.e., done over two years instead of one year).
This simplified pathway can be seen in the figure below.
However, your route into EM isn’t always straightforward; you might be considering taking a detour, so it’s important to remember that there are backways into EM as well, and not everything will have been covered here! So make sure to check out the ACCS 2021 curriculum guide or the RCEM website for more details.
The International Emergency Medicine Education Project (iem-student.org) has completed three years. As you may know, the iEM Education project aims to promote Emergency Medicine and provides copyright-free resources to students and educators around the world. Now we have reached more than 200 countries. We would like to thank again our contributors. Without them, such a project would not be possible. This experience has shown us once again how passionate our international EM community is to help and teach each other.
In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce live activity series, Emergency Medicine PerspectivesofStudents Around the World. Our guests for the first session are Adebisi Adeyeye from Nigeria, Jonathan Kajjimu from Uganda, and Mohamed Hussein from Egypt, who are Student Council Leaders of the African Federation for Emergency Medicine.
Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.
Here are the video and audio records of this session.
In this episode of Coffee Chat With Emergency Medicine Experts, we discussed thing you should know before your first emergency department shift. Dr. Ana Paula Freitas, Dr. Gregor Prosen, Dr. Joe Bonney and Dr. Rasha Buhumaid were the guest speakers of this episode. Dr. Dr. Arif Alper Cevik was the hosts of this session.
Dr. Ana Paula Freitas, Dr. Gregor Prosen, Dr. Joe Bonney and Dr. Rasha Buhumaidshared their experiences and lessons learned during their career. We believe medical students and junior EM trainees can learn many from this episode.
Want More on ED shift work?
In this episode of Coffee Chat With Emergency Medicine Experts, we discussed thing you should know before your first emergency department shift. Dr. Ana Paula
The emergency department is open 24/7, meaning that most ED physicians experience shift work. Shift work means that service is provided around the clock, whether
I recently posted a question to the Twitterverse: “Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be
In this episode of Coffee Chat With Emergency Medicine Experts, we discussed wellness and emergency medicine for medical students. Dr. Tracy Sanson, Dr. Al’ai Alvarez were the guest speakers of this episode. Dr. Janis Tupesis and Dr. Arif Alper Cevik were the co-hosts of this unique session.
Dr. Sanson and Dr. Alvarez shared their experiences and lessons learned during their career. We believe medical students and junior EM trainees can learn many from this episode.
Want More on Wellness?
Author: Brenda Varriano Guest Author: Jason M White What is Burnout? Most of us have experienced some component of Burnout in one shape or another.
In this episode of Coffee Chat With Emergency Medicine Experts, we discussed wellness and emergency medicine for medical students. Dr. Tracy Sanson, Dr. Al’ai Alvarez
Emergency medicine (EM) is a young specialty globally. Its origins can be traced back to the 1960s. As we move forward into the future, in 2019, approximately 82 countries worldwide (out of 194 countries) have recognized EM as a separate specialty. Emergency care systems in these countries are at various stages of development.
However, the mere fact that the specialty is recognized in a certain country does not mean that a modern model of EM clinical practice has been widely adopted throughout the said country. Many challenges remain in the face of the more widespread adoption of modern EM.
By far, the most important challenge in the face of any health care system is human resources. Highly trained personnel are a requirement to operate any system regardless of material resource capacity. You can have the most sophisticated machines readily available, but without the staff to utilize these machines, they will just sit in a dark corner, slowly gathering dust.
Potential causes of human resource limitation in emergency medicine
In countries where EM does not have a strong presence, it struggles to recruit medical graduates into its ranks. Students are deterred from the specialty because of misinformation and a fundamental lack of understanding of the unique role EM plays in a larger health care system. This deprives the specialty of a diversity that could have been harnessed to help the specialty achieve its maximum potential.
Thus, it is imperative that students be ‘engaged’ to ensure a correct exposure to EM. At the very least, you will have educated students, whether or not they ultimately decide to pursue EM as a specialty, on the importance of the role of EM. This has the potential added benefit of removing a lot of future interdepartmental resistance and greatly enhancing the motivation to ensure efficient collaboration between EM and other consulting specialties.
The building blocks of student engagement
The Clerkship
Student engagement can take multiple forms. For example, the basis for a student’s introduction to any specialty is usually the specialty’s clerkship during a medical education curriculum. This is ideally the foundation of any attempt to expose students to EM. However, many schools do not yet have an emergency medicine clerkship embedded in their curriculum. This is a gap that can be temporarily bridged using tailored FOAMEd products that are contextually relevant.
The Interest Group
“Building Blocks” by André Hofmeister is licensed with CC BY-SA 2.0.
The next ‘building block’ is an extracurricular exposure to emergency medicine through a student interest group at their local institution. This allows students to explore emergency medicine in a more relaxed, non-didactic setting. This also presents the opportunity to network with EM faculty and other students that are interested in emergency medicine. It can additionally be an introduction to some soft skills such as leadership, presentation, and interpersonal skills. However, students at schools that do not have academic departments of EM face an inability to use this building block(and the previous block as well).
The ‘Student Council’
The final building block in student engagement would be a student section in the national (or international) emergency medicine organization. The advantages of this block are that it can precede all the other blocks and that its reach is very wide. It can, in a way, be the panacea to limited exposure to EM. A student section(or council) can also serve as the ‘interest group’ for students without access to one. This allows students to greatly enhance their leadership skills on a national scale. It also provides them with a front seat to both witness and contributes to the development effort.
Conclusion
It is vital to prioritize student engagement on the development agenda. This will ensure that the EM community can rely on a steady stream of young energies that can keep on carrying the fire. Hopefully, this will accelerate the adoption of organized emergency care worldwide.
In countries where EM is completely absent, it falls unto other countries where EM has taken the time to mature to harness the spirit of Ubuntu and to empower their fellow humans to take control of their own development. Then and only then can we ensure equitable access to high-quality, safe emergency care for ALL.
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on.
Often, junior doctors (including myself) find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures.
I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting.
These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
Breath sounds and pulses need to be checked in every patient!
Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
Always ask yourself what could the differential diagnosis be? How would you treat the patient?
Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
I recently have been working on a few different projects that have caused me to stop and reflect, “what is emergency medicine”. This specialty is very young within the house of medicine, compared to most other medical specialties. And while other specialties developed out of an attention to anatomical region or approach to diagnosis and treatment, emergency medicine has developed in large part to fill a gap in the healthcare workforce and address a specific needed skillset within healthcare systems.
Different health systems around the world have different structures and models of care. Some countries have developed robust primary health care systems with universal coverage for all citizens, while others have adopted alternative models of preventative and acute care. There is even greater diversity in how individuals seek and receive care for urgent and emergent health needs. The spectrum of the quality and availability of emergency care often varies within countries as well, contrasting highly populated urban centers against rural communities, or between different counties/provinces.
As a frame of reference, emergency medical care is any unscheduled episode of care for an acute health problem. It should be available 24 hours a day and systems should aim for patients to be dispositioned to inpatient units, taken to the operating room/theater, or discharged for outpatient care. Ideally, patients should spend less than 24 hours in the emergency ward, it is meant to be a short-term waypoint for diagnosis, treatment, and disposition. The skills and approach to emergency care are focused on the initial management, stabilization, and resuscitation of ill patients, as well as making targeted diagnostic and treatment decisions. Emergency care units shouldn’t be built to do any and all testing and treatment, but should complement other care pathways within the health system.
In much of the world the emergency ward is the most common entry point to hospitals and inpatient care. And specialized training in emergency medicine improves the quality of patient care with associated reductions in morbidity and mortality. Emergency medicine providers must be capable of treating all age groups, across undifferentiated and potentially routine or life-threatening patient presentations. And yet, there are days when an emergency medicine provider may not encounter any patients with a true life-threatening emergency, but rather may only see patients with a variety of complaints that exist here and now, and require attention to limit longer-term morbidity or mortality. Conversely, other days may have multiple critically-ill patients all at once. Usually, those attracted to emergency medicine enjoy the diversity of presentations, and it would seem almost no two days at work are the same.
As alluded to above, the emergency departments existed as a triage ward quite some time before the development of a specialized education and training in emergency medicine. And in many emergency care wards around the world today, patients are seen by students or junior doctors with little interest or training in emergent medical conditions. It is also important to remember that most emergency department patients are undifferentiated and evaluating a patient for causes of a single complaint requires a thorough history, exam, and targeted diagnostic testing. This skill set is how an emergency medicine provider can assess a patient who presents with chest pain and distinguish a myocardial infarction from a pulmonary embolism from musculoskeletal pain. To me, this is the real benefit of emergency medical education and specialized care: there are so many treatments and disposition pathways any singular chief complaint can lead to.
But, most anyone reading this post is likely familiar with the need for improved emergency care around the world. And as more countries recognize emergency medicine as a specialty and as more individuals decide to dedicate their career to providing high-quality emergency medical care, the global (and local) standards will continue to improve. An ever-growing body of evidence-based care continues to refine when and how we care for different conditions. And it’s so important that we continue to address the multitude of “unscheduled” health needs for our patients. Continue to adapt emergency medicine to your context and improve the care for your patients; as one of the most well-known EM-education podcasters often says: “what you do matters”.
As a medical student, presenting history and physical exam of a patient to the attending can be nerve-wracking. In the ED, physicians typically prefer an even more succinct presentation than usual, ideally less than 3 min. Case presentations are a great opportunity to show that you understand what the pertinent positives and negatives for the patient’s presenting complaint are and that you can summarize a large amount of information collected in an organized manner. Case presentations are your opportunity to impress your preceptor, so it is an important skill to master. It will also be the mode of communicating with the rest of the healthcare team throughout your career in medicine. Better communication = better patient care!
Ask
Before we get started, it is important to recognize that every physician may have their own preference for how they would like case presentations organized. Some prefer more details, and some prefer a specific order. Therefore, it is always a smart idea to ask your preceptor at the beginning of your ED shift if they have a preference for how they like cases to be presented.
The One Liner
State the patient’s name, age, sex, chief complaint, and any pertinent medical history. E.g., John Doe is a 16-year-old male with a history of eczema presenting with wheezing.
History of Presenting Illness (HPI)
include the details of the chief complaint, as well as any pertinent positives and negatives.
Why did this patient present to the ED today?
What are the details of the chief complaint? I.e. Onset, Duration, Progression, Alleviating and Aggravating Factors, Causes/Triggers, Changes with Position, etc.
For pain, it is helpful to describe OPQRSTU – Onset, Position, Quality, Radiation, Severity, Temporal, déjà vU (has it ever happened before).
Any associated symptoms
Any risk factors?
Any relevant past medical history (e.g. chronic conditions, hospitalizations, surgeries, etc.), family history, or social history (e.g. habits, living situation, alcohol consumption, smoking history, illicit drug usage)?
Review of Systems
Describe any other symptoms here.
Note that some ED physicians may not want a review of systems included in the oral case presentation if it does not include any additional pertinent information, but a review of systems should always be included in your written patient note.
Medications
Allergies
if the patient states that they do not have any allergies, this can be recorded and/or stated as “NKDA” which stands for No Known Drug Allergies.
Physical Exam Findings
Start off by stating the most updated set of vitals.
Next, state the patient’s general appearance as this helps decide between sick vs. not sick. E.g., patient is alert, oriented, and in no apparent respiratory distress.
Then, delve into the pertinent details of the physical exam. E.g. for a cardiac complaint, it is important to include the specific details of the cardiovascular exam and respiratory exam, but not of all the other systems.
A brief overview of the other systems that a physical exam was conducted for can be useful, but be as concise as possible, and organize information in a head-to-toe fashion if needed. If there were no other findings, you can state that the remainder of the physical exam was unremarkable.
Summary
In 2-3 sentences, gather the main findings of your history and physical exam. Be sure to restate the initial one-liner sentence, other pertinent positives and negatives, and any important test results so far.
Impression/Assessment
State your differential diagnosis for each problem.
Start off by stating what you think the most likely diagnosis is, and why you think it is the most likely.
Then, state any other likely diagnoses you are suspecting.
Lastly, state the deadly diagnoses that could be possible with this patient’s chief complaint. In some cases, this can be the first thing you may want to say. It is important to specify why you do or do not feel confident in ruling these out. E.g., in a baby presenting with fever of unknown origin, it is important to state why you are not (or are) suspecting meningitis, encephalitis, malignancy, or autoimmune conditions.
Many medical students will shy away from stating their impression of what could be going on in terms of differential diagnosis, but this is an important thing to attempt. Preceptors will appreciate your effort in synthesizing what could be going on and be impressed by it, even if your impression is incorrect. This is often what sets apart students that “meet expectations” vs. students that are considered “outstanding”.
Plan
What do you want to do next?
Plan includes anything from the tests you want to order (including repeat vitals, bloodwork, and imaging), immediate treatment (including analgesics and fluids), and referrals you want to make (including consults, admission/discharge plan, and referral to allied health professionals such as social work, speech-language pathology, occupational therapy, and physiotherapy).
Do not forget to take the patient’s social history into account when deciding what to do next.
Congrats – you have now completed your oral case presentation! This is a skill you will continue to develop with practice, so do not worry and keep working at it. It is also a good idea to always ask your preceptor for feedback on your case presentation once it is complete, as that will help you identify your strengths and weaknesses.
References and Further Reading
Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008 Jul;15(7):683-7. doi: 10.1111/j.1553-2712.2008.00145.x. PMID: 18691216.
Cough is one of the most common complaints presenting to any emergency physician or primary care practitioner – whether it is the chief complaint or an associated symptom. An acute cough is one that has been present for less than three weeks. In the era of COVID-19, a patient presenting with an acute cough can be alarming and scary. So, now more than ever, it is important to develop a strong diagnostic approach to the acute cough, which is largely a clinical diagnosis.
Differential Diagnosis of Acute Cough
*Indicates the most common causes of acute cough.
Cause
Example
Symptoms / warning signs
Infectious
(viral/bacterial)
Upper respiratory tract infection aka common cold*
Rhinorrhea, nasal obstruction, sneezing, scratchy/sore throat, malaise, headache, and no
signs of consolidation
Acute bronchitis*
Recent upper respiratory tract infection, and absence of COPD, and absence of high fever or other systemic signs
Influenza
Fever, sore throat, nasal congestion, myalgia, headache, and no signs of consolidation
Pneumonia*
Fever, tachycardia, tachypnea, consolidation signs on respiratory exam, and mental status change in patients >75y old
Pertussis
Whooping cough and cough-emesis
COVID-19
Fever, non-productive cough, fatigue, dyspnea, and/or other less common symptoms such as sore throat, diarrhea, headache, skin rash, and anosmia
Post-nasal
drip aka upper airway cough syndrome
Post-nasal drainage sensation, need to clear throat, and rhinorrhea
Allergic
rhinitis aka hay fever
Itching and watering of eyes, rhinorrhea, pruritis
Exacerbation
of a pre-existing chronic disease
Exacerbation of Asthma
History of episodic wheezing, non-productive cough, dyspnea, reversible air-flow obstruction, allergen exposure or triggered by exercise
Exacerbation of COPD
Smoking history, dyspnea, signs of obstruction on respiratory exam i.e. decreased
breath sounds, and irreversible air-flow obstruction
Exacerbation of CHF
Dyspnea, orthopnea, peripheral edema, gallop rhythm on cardiac exam, and elevated JVP
Drug-induced
ACE inhibitor use
Non-productive cough, tickling or scratchy sensation in throat typically arising within 1 week of starting medication
Gastroesophageal
reflux disorder (GERD)
Heartburn, regurgitation, dysphagia, and cough is more prominent at night
Other pulmonary causes
Pulmonary embolism
Clinical signs and symptoms of DVT, dyspnea, tachypnea, tachycardia, pleuritic chest pain,
immobilization for 3 or more days, surgery in the past 4 weeks, history of DVT/PE, hemoptysis, and malignancy with active treatment in the past 6 months
Lung cancer
Smoking history, new change in cough, hemoptysis, dyspnea, night sweats, weight loss, and signs of focal obstruction on respiratory exam i.e. decreased breath
sounds
Foreign body aspiration
Dyspnea, inspiratory stridor, choking, and elevated risk in children
Acute inhalation injury
History of exposure to smoke (e.g. in firefighters, thermal burn victims) or chemicals (e.g. chlorine, ammonia)
Bronchiectasis
Large volumes of purulent sputum, dyspnea, wheezing, and chest pain
Interstitial lung disease
Non-productive cough, dyspnea, fatigue, weight loss
Picture the scene: A 23-year-old female presents to the emergency department with a cough that has been ongoing for one week. What are your next steps?
History
Confirm the duration and timing of cough
Nature of cough, i.e. whooping, hemoptysis, and productive vs non-productive?
Presence of the following associated symptoms: fever, dyspnea, sore throat, headache, chest pain, heartburn, rhinorrhea, facial pressure/pain, nasal congestion, or weight loss
History of any chronic lung disease (i.e. asthma, COPD), allergies, CHF, or immunosuppression?
Smoking history?
Medication history, i.e. ACE inhibitor use?
Physical Exam
Vitals
HEENT exam (head, eyes, ears, nose, and throat)
Respiratory exam
Cardiac exam, including JVP
Laboratory Tests
Send for COVID-19 swab according to your hospital’s guidelines
Order CBC if suspecting infection
Order ABG if dyspnea present or life-threatening cause of acute cough suspected
Order sputum culture if suspecting bacterial pneumonia
Spirometry if need to differentiate between obstructive lung disease (e.g., asthma, COPD) and restrictive lung disease (e.g., interstitial lung disease)
Imaging
Consider starting with a Chest X-ray if red flags for serious pathology are present >> dyspnea, hemoptysis, chest pain, weight loss, immunosuppression, significant smoking history, elderly or at risk of aspiration, tachypnea or hypoxemia, abnormal cardiac or respiratory exam, or sepsis.
If suspecting foreign body aspiration, need to order bronchoscopy
Please note that treatment of the conditions that may cause acute cough are not discussed in this blog post, but can be found through medical resources such as those in the references section. Treatment for acute cough often requires treating the underlying cause.
References
Boujaoude ZC, Pratter MR. Clinical approach to acute cough. Lung. 2010;188 Suppl 1(Suppl 1):S41-S46. doi:10.1007/s00408-009-9170-6
Holzinger F, Beck S, Dini L, Stöter C, Heintze C. The diagnosis and treatment of acute cough in adults. Dtsch Arztebl Int. 2014;111(20):356-363. doi:10.3238/arztebl.2014.0356
Madison JM, Irwin RS. Cough: A worldwide problem. Otolarynogol Clin North Am. 2010 Feb;43(1):1-13, vii.
A 78-year-old male, known case of Chronic Kidney Disease on maintenance hemodialysis, presented to the Emergency Department with dizziness and lethargy complaints about 2 days. He had missed his last hemodialysis session due to personal reasons. We could not elicit any further history details as was significantly dyspneic (no bystanders with him at the time of presentation). Hence, the patient was received in Bay 1 for immediate resuscitative measures. The patient was afebrile, conscious, and well oriented, but unable to communicate because of severe dyspnea.
Vitals
HR – 142 beats/min BP – not recordable RR – 36 breaths/min SpO2 – poor tracing, intermittently showed 98% on room air (15 LO2 via Non Rebreathing Mask was initiated nevertheless)
ECG
Monomorphic ventricular tachycardia
He was immediately connected to a defibrillator in anticipation of possible synchronized cardioversion. Simultaneously, the cause of the possible rhythm was being evaluated for and a thorough examination was carried out. On examination, his lung fields were clear. His left arm AV Fistula had a feeble thrill on palpation.
In suspicion of hyperkalemia as the cause of VT, patient was immediately started on potassium reduction measures while the point of care ABG report was awaited. He was treated with salbutamol nebulization 10mg, sodium bicarbonate 50 ml IV and 10% calcium gluconate 10ml IV. In view of hemodynamic instability, he was also started on intravenous noradrenaline infusion.
As hyperkalemia was confirmed, the patient was also given 200 ml of 25% dextrose with 12 units of Rapid-acting insulin IV. With the above measures, the patient’s cardiac rhythm came to a sine wave pattern.
He was later taken up for emergency hemodialysis (HD) – Sustained Low Efficacy Dialysis (SLED) in the ICU, using a low potassium dialysate. Since his AV fistula was non-functioning, HD was done after placement of a femoral dialysis catheter. 2 hours into HD, the patient’s cardiac monitor showed a normal sinus rhythm. His hemodynamic status significantly improved. Noradrenaline infusion was gradually tapered and stopped by the end of the HD session, and repeat blood gas analysis and serum electrolytes showed improvement of all parameters.
The patient was discharged 2 days later, after another session of hemodialysis (through AV fistula) and a detailed cardiology evaluation (ECHO – LVH, normal EF).
For the Inquisitive Minds
The patient underwent a detailed POCUS evaluation, both in the ER and ICU. What findings do you expect to find on the RUSH examination for this patient?
His previous ECHO report (done 1 month ago) mentioned left ventricular hypertrophy and normal ejection fraction. So what would be the reason behind the POCUS findings? Is it reversible?
Why was the AV fistula non-functioning at the time of presentation? When would it have started to function again?
Despite not having hypoxia, this patient was given supplemental oxygen. Did he really require it, and if so, what was the rationale?
What was the necessity for carrying out SLED for this patient?
Why was this patient not immediately cardioverted in the ER?
If this patient had gone into cardiac arrest, what drugs would you have given for management of hyperkalemia?
How differently would you have managed this patient?
Please give your answers and comments into "leave a reply" area below.
Kawasaki disease (KD), or mucocutaneous lymph nodes syndrome is an immune-mediated inflammation in the walls of medium-sized arteries throughout the body. It’s complications result in the coronary arteries expanding, heart attacks, and premature death.
As the leading cause of heart disease in North American and Japanese children, KD continues to bewilder clinicians and researchers – even in the midst of a global pandemic. Possible links to SARS-CoV2 has even stirred uneasiness in patients, and physicians making diagnoses.
Beginning in Victorian-era England, a young boy presented to the doctor’s office with symptoms suggestive of scarlet fever; however, noticing heart disease in this child was just baffling. Despite being unaware of this rare disease, it was beyond physicians at the time; since then, progress has been limited as clinicians still fail to comprehend the disease’s root cause.
Dating back to 1874, KD was discovered by Samuel Gee while he was dissecting the cadaver of a seven-year-old boy.
He noticed something strange, “The pericardium was natural. The heart natural in size, and the valves healthy. The coronary arteries were dilated into aneurysms at three places, namely, at the apex of the heart a small aneurysm the size of a pea; at the base of the right ventricle, close to the tip of the right auricular appendix, and near to the mouth of one of the coronary arteries, another aneurysm of the same size; and at the back of the heart, at the base of the ventricles, and in the sulcus between the ventricles, a third aneurysm the size of a horse bean. These aneurysms contained small recent clots, quite loose. The aorta near the valves, and the aortic cusp of the mitral valve, presented specks of atheroma.”
From his autopsy, evident was that Gee found aneurysms in the coronary arteries running across the surface of the boy’s heart. He then placed the specimen in a jar and provided it to the Barts Pathology Museum in London. Little did he know, that his specimen marked evidence of the earliest recorded case of KD and sparked worldwide medical curiosity. Unfortunately, when physicians 100 years later were hoping to retrieve samples from the specimen containing the boy’s heart, they were informed that it was missing.
A few years later, the disease was recognized in 1967 by the Japanese physician, Tomikasu Kawasaki. Although some researchers claimed the virus was unknown, others stated KD resulted from a bacterial or fungal toxin. The windborne theory suggested that the disease was seasonal, and as such, the direction of the swaying wind played a role in infection. Others stated that since children’s immune systems are still developing and since they have just lost the protective antibodies from their mothers, they are susceptible to infection. Therefore, in Asian American household’s diets rich in soy put Asian children at greater risk due to the isoflavones. In the 1980s, the Center for Disease Control and Prevention (CDC) suspected chemicals as the cause of KD, inferring that disease stems from agents that trigger an overreaction of the patient’s immune system. No one knew exactly what the mechanism or cause of KD was, although many scientists speculated some theories.
Over the last decade, significant progress toward understanding the pathogenesis, history, and therapeutic interventions of KD has been fruitful. Treatment aimed at the intravenous infusion of gamma globulin antibodies derived from the plasma of blood donations has helped children recover. In contrast, other therapies of corticosteroids for immunoglobulin-resistant patients and tumor inhibitors such as etanercept, infliximab, and cyclosporin A have been other medications providing relief.
The most significant clinical debate was over the possible link between the rash and the cardiac complications seen in Asian American children. Factors responsible for KD were introduced into Japan after World War II and re-emerged in a more virulent form spreading through the industrialized Western world. Advancements in medicine, improvements in healthcare, and, notably, the use of antibiotics reduced the burden of rash and fever illnesses significantly allowing KD to be recognized as a distinct clinical entity.
Nonetheless, the enigma pervades even during the COVID19 pandemic; this time, more pressing as the ever-elusive cause of KD that troubles children’s hearts affects physicians’ sleep and worries parents’ minds. Although the story of Kawasaki disease began decades ago when a young boy’s heart was locked inside a glass specimen, its ending is still being crafted. By the time the heart is found again at the museum, and placed safely for visitors treasuring ancient history, what further knowledge and progress will the scientific community have achieved? How far will humanity have come to find answers to KD and fill in the perplexing missing piece of the puzzle?
For now, there are no answers, but the enigma continues…
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References and Further Reading
Burns, Jane C., and Howard I. Kushner. “Kawasaki Disease: A Brief History.” American Academy of Pediatrics, 2000, DOI: 10.1542/peds.106.2.e27 pediatrics.aappublications.org/content/pediatrics/106/2/e27.full.pdf.
