You have a new patient!
Adam is a 76-year-old man who is brought to the emergency room by his family members, complaining of a lack of responsiveness and general lethargy. According to his family, Adam has been having increasing memory problems in the past year and has gotten lost while walking around his neighborhood multiple times. His personality has changed and becomes agitated easily. He is also becoming less attentive to personal hygiene, wearing dirty clothes for several days, and having several episodes of urinary incontinence. Today, his family members noted that he had fallen asleep multiple times and showed no interest in his food. He did not respond when addressed by name. At the time of presentation, he is conscious, but appears lethargic and uncooperative. He cannot tell where he is and does not seem to recognize his family members. His past medical history includes hypertension and hypercholesterolemia. He is taking amlodipine and simvastatin.
Vitals show a heart rate of 108 beats per minute, blood pressure 154/84 mmHg, temperature 36.7℃, respiratory rate 20 breaths per minute, and an oxygen saturation of 98% on room air. His Glasgow coma score is E4V4M6.
What do you need to know?
Importance
Dementia and delirium are two medical conditions that significantly impact the health and well-being of older adults and their families. In this case, Adam’s symptoms suggest that he may be experiencing one or both of these conditions, and it is important to understand their relevance in clinical practice.
Dementia is defined as an acquired global decline in cognitive function, affecting one’s memory, language, learning, and behavior without impairment of consciousness. Dementia is associated with a gradual, progressive decline. It is a leading cause of disability and dependence among older adults, with advancing age being one of the most significant risk factors [1]. With the global population aging, the number of individuals living with dementia is expected to rise significantly. The World Health Organisation estimates that 47 million people worldwide live with dementia, and this number is expected to triple by 2025 [2].
Delirium, conversely, is a clinical syndrome characterized by an acute state of confusion, inattention, and cognitive impairment. It can occur in people of any age, but is particularly common among the older population and hospitalized patients [1]. Delirium can wax and wane over time, unlike dementia, which is more progressive and persistent.
Dementia and delirium pose a tremendous burden not only on patients and caregivers, but also on our healthcare system and society. Therefore, understanding the significance of dementia and delirium is crucial in clinical practice. Identifying and managing these conditions early improves clinical outcomes and optimizes quality of life.
Epidemiology & Pathophysiology
Dementia is a condition that is more commonly seen in older individuals, with the incidence increasing from the age of 65. An exception is frontotemporal dementia, a rare type of dementia that is usually diagnosed from the age of 40 to 60. The most prevalent type of dementia is Alzheimer’s disease, which accounts for 60-80% of all cases. Other neurodegenerative dementias, such as vascular dementia, dementia due to Lewy bodies, Parkinson’s disease, and frontotemporal dementia, account for the remaining cases [3].
The underlying pathophysiology of dementia varies depending on the type and subtype, with most types involving damage to neurons and their connections in the brain. Abnormal protein accumulation is a common feature for many types of dementia, including amyloid and tau in Alzheimer’s disease, Lewy bodies with alpha-synuclein protein in Lewy body disease, and mutations causing the deposition of TDP-43 and tau proteins in frontotemporal dementia. Other factors, such as ischemic injury, HIV infection, and alcohol consumption, can also lead to cytotoxic processes in the brain and contribute to the development of dementia [4].
On the other hand, the epidemiology of delirium is more complex as it varies depending on age and underlying medical conditions. Although delirium is more prevalent in older individuals, with rates increasing after the age of 70, it is also common in younger patients suffering from chronic illnesses such as cardiovascular and renal comorbidities, dementia, or psychiatric illnesses [5].
The pathophysiology of delirium can result from various physiological and structural lesions in the brain. While its mechanisms are not fully understood, delirium can be caused by neurotransmitter imbalances, brain lesions involving the ascending reticular activating system, as well as disrupted blood-brain barrier function that causes the leakage of neurotoxic agents into the brain. Patients with impaired cholinergic transmission, such as those with Alzheimer’s disease, are particularly susceptible to delirium caused by medication use. Additionally, delirium can result from alcohol abuse, drug withdrawal, mental illnesses, psychosocial stress, and sleep deprivation [6].
Epidemiological and pathophysiological data on dementia and delirium allow physicians to identify individuals at risk and intervene appropriately. Since the development of dementia and delirium are multifactorial and the pathophysiology is variable among patients, evaluating and treating delirium and dementia is based on clinical gestalt and the presumed underlying cause.
Medical History
Dementia and delirium are two diagnoses that must be considered in elderly patients presenting with cognitive change to the emergency department. Differentiation between the two conditions is based on features noted in the history and physical examination. Table 1 lists symptoms that can help differentiate between the two conditions.
Delirium typically presents with sudden onset of impaired awareness, confusion, clouding of consciousness, and disturbances of perception (e.g., illusions or hallucinations). Delirium should be suspected when there is an acute deterioration in behavior, cognition, and daily functioning [7]. Delirious patients usually have short-term memory issues and may be disoriented by time and place. Abnormalities of cognition and behavior can fluctuate over brief periods. The level of awareness may range from hypervigilant and agitated to blunt and unreactive. The patient’s speech may be incoherent, nonsensical, or tense. The patient usually has no discernible focal neurological defect [8].
Dementia has various presentations according to the specific types, but symptoms often overlap. Alzheimer’s dementia, the most common type, presents with a history of a chronic, steady decline in cognitive ability, especially memory. It is often associated with difficulties in social relationships, activities of daily living, and work. During the early stages of dementia, clinical presentations can be quite subtle, and patients may try to hide their cognitive impairments [9].
Patients who present to the emergency department with symptoms of dementia are most likely in the later stages of disease progression. Acute presentation of dementia is possible in vascular dementia, and this subtype may present with symptoms of focal neurological deficit. Patients who are demented typically do not present with any impairment of consciousness. However, acute episodes of delirium can be superimposed on patients who have dementia. For example, Lewy body dementia can present with fluctuating levels of consciousness. Diagnosing uncommon variants poses a challenge to emergency physicians and is often done only after referral to a neurologist [10].
Obtaining a thorough history is essential in diagnosing delirium and dementia. Unfortunately, delirious or demented patients are often disoriented and cognitively impaired, resulting in the inability to provide accurate information about their condition. A detailed history should be obtained from family, caregivers, and healthcare staff (nurses, healthcare assistants, and other allied health professionals).
Important features to note during history are the onset of symptoms, factors that worsen or improve symptoms, drug or alcohol use, pre-existing endocrine or psychiatric disorders, exposure to toxins or traumatic injury, social history, and previous similar episodes of confusion or altered mental status. Drug history is particularly important as the use of drugs that impair cognition (e.g., analgesics, anticholinergics, psychotropic medications, and sedatives) may explain the presenting symptoms.
Determining the onset of symptoms, in particular, for patients with dementia, can be difficult due to the gradual nature of the disease. Questions like, “When did you first notice the memory loss?” and “How has the memory loss progressed since then?” can give a general idea on the patient’s current condition. The patient’s social history, especially work, educational history, and ability to conduct activities of daily living, can help establish a baseline for the patient.
Table 1: Key symptoms to look for to differentiate between delirium and dementia during history taking [11]
| Delirium | Dementia |
Onset | Acute | Insidious/chronic |
Course
| Fluctuating | Progressive |
Duration | Days to weeks | Months to years |
Consciousness
| Altered | Clear |
Alertness | Impaired | Normal, except for in severe cases of dementia |
Behaviour & Speech
| Agitated/withdrawn/ depressed/combination of symptoms | Intact early on |
Typical presentations of dementia of various type
Dementia manifests in various forms, each with distinct characteristic presentations. Alzheimer’s dementia typically involves memory loss, mood instability, apathy, and may include depressive or paranoid features. Additionally, patients may experience apraxia, anosognosia, sensory inattention, and progressive personality and intellectual deterioration. Vascular dementia, on the other hand, often has an abrupt onset with a stepwise deterioration and a fluctuating course. It is marked by slowed thinking, difficulties in organization, preserved personality and insight, and may include focal neurological deficits. Dementia with Lewy bodies is characterized by Parkinsonism, cognitive and alertness fluctuations, as well as visual hallucinations, delusions, and autonomic dysregulation. Frontotemporal dementia commonly occurs at a younger age, typically between 40 and 60 years, and is associated with early personality changes, disinhibition, and overactivity.
Physical Examination
The physical exam of the dementia and delirium patient starts with taking vital signs, assessing the airway, breathing, circulation, and performing a focused neurological exam. Calculating the Glasgow Coma Score (GCS) and checking blood glucose should be checked on all patients with behavioral or cognitive changes.
Table 2 lists the key signs of differentiating delirium and dementia. Key features such as acute onset, fluctuations in awareness, orientation, and consciousness, cognitive decline, and potential sensory disruptions can help distinguish delirium from dementia. This includes declining memory function, language ability, and judgment. When in doubt, the general rule of thumb is to assume the patient is having an episode of delirium and try to rule out the common causes. This rule can be applied even for patients with known psychiatric illnesses like depression and dementia, as they are also susceptible to delirium superimposed on their existing condition.
Table 2: Key signs to look for to differentiate between delirium and dementia during physical exam [11]
| Delirium | Dementia |
Conscious level | Abnormal | Normal |
Psychomotor changes | Increased/decreased | Often normal |
Reversibility of symptoms | Reversible usually | Irreversible |
On neurological examination, look for signs of stroke, parkinsonism, gait abnormalities, and abnormal eye movements. Dementia caused by Alzheimer’s disease generally has no sensory or motor deficits. Whereas for delirium, it is essential to identify any co-existing neurological disorders that may cause a presentation of delirium. Special tests for gait, daily living, and cognitive function assessment should be done to assess the severity of the patient’s condition. A thorough physical examination of other systems should also be conducted to look for signs of encephalopathy and drug and alcohol abuse.
Use the physical exam to help identify any exacerbations of an underlying medical illness (e.g., signs of diabetic ketoacidosis in a diabetic patient) and to evaluate for signs that may reveal an underlying cause. For example, a high fever, low blood pressure, rapid or slow heart rate, difficulty breathing, severe pain, or malaise may indicate delirium caused by an infection, sepsis, or shock that requires immediate medical attention. Severe thirst, nausea, and vomiting may indicate dehydration or electrolyte disturbances that should be promptly treated. Signs of unresponsiveness, difficulty breathing, or seizures may indicate intracranial bleeding or alcohol or drug intoxication. Since these conditions can cause delirium and have symptoms that overlap with dementia, it is important to prioritize and appropriately manage these urgent and life-threatening cases [12].
Alternative Diagnoses
Table 3 shows alternative diagnoses to consider when evaluating for dementia and delirium. In patients presenting with altered cognitive levels, life-threatening causes that need to be ruled out include hypoglycemia, electrolyte abnormalities such as hyponatremia and hyperkalemia, dehydration, stroke, intoxication/overdose, encephalopathy, cerebral infection, sepsis, and shock.
Psychiatric disorders such as psychosis, schizophrenia, and depression are among the list of differential diagnoses that could present with similar symptoms. Frequently, in patients with delirium, they do not have any previous history of psychiatric illness. In delirium, hallucinations and illusions are acute or subacute and fluctuate over time. In addition, the patient has impaired memory, orientation, and judgment, as well as clouding of consciousness. Elderly patients with a depressed mood, hopelessness, and suicidal ideation may be suffering from “pseudodementia” (false dementia). When the symptoms of depression are treated, the dementia-like condition usually resolves itself [13].
Investigations, such as bloodwork, toxicology screening, biochemical tests, and imaging can help determine a delirium patient’s underlying cause and identify an alternative diagnosis. Investigations to consider are listed below under “Acing diagnostic testing.”
Table 3: Alternative diagnoses of altered cognitive level [14]
Central nervous system: brain abscess, cerebral neoplasm, encephalitis, intracranial haemorrhage, meningitis, normal pressure hydrocephalus, variant Creutzfeldt-Jakob Disease and bovine spongiform encephalopathy |
Electrolyte: hyper/hypocalcemia, hyperkalemia, hyper/hyponatremia |
Dehydration |
Environmental: heat stroke, snake bite |
Infective: sepsis, rabies, malaria |
Metabolic: diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic coma, hypoglycemia, hypothyroidism, uremia, hepatic encephalopathy |
Nutrition deficiency: folate, thiamine (Wernicke encephalopathy), vitamin B12, |
Poisoning: amphetamine, anticholinergic, antidepressant, cocaine, hallucinogen, lithium, tricyclic antidepressant, valproate, withdrawal |
Psychiatric: depression, psychosis |
Transient global amnesia |
Acing Diagnostic Testing
Initial Investigations
Complete Blood Count with Differential: This test is critical for assessing overall health and detecting a variety of conditions, such as infections, anemia, and blood disorders. The differential component provides a breakdown of different types of white blood cells, which can help to identify specific types of infections (e.g., bacterial or viral) and help diagnose other hematological disorders like leukemias or other abnormalities in blood cell production.
Electrolyte Panel: The electrolyte panel is essential for assessing the balance of minerals in the body, such as sodium, potassium, calcium, and chloride. Disturbances in these levels can indicate a variety of issues. For instance, hyponatremia (low sodium) can be a sign of dehydration or kidney dysfunction, while hyperkalemia (high potassium) could indicate kidney failure or metabolic acidosis. These imbalances can have significant effects on muscle function, nerve transmission, and overall cellular processes.
Liver Function Test: Liver function tests are crucial in diagnosing liver diseases such as hepatitis, cirrhosis, and alcoholic liver disease, as well as conditions like hepatic encephalopathy. These tests measure the levels of enzymes, proteins, and substances like bilirubin, which indicate how well the liver is working. Abnormal results may suggest liver damage, bile duct obstruction, or liver dysfunction that can lead to brain symptoms, especially in severe cases of hepatic encephalopathy.
Renal Function Test: This test evaluates how well the kidneys are filtering waste from the blood. It includes measurements like serum creatinine and blood urea nitrogen (BUN), which are key indicators of kidney function. Elevated levels may suggest renal failure, and abnormalities in these values can also help diagnose uremia, a condition where kidney dysfunction leads to the accumulation of waste products in the blood, potentially affecting multiple organ systems.
Blood Sugar: Blood sugar levels are measured to rule out conditions like hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). In patients with diabetes, particularly in cases of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHNS), these levels can be critically elevated and require immediate treatment. Monitoring blood sugar is essential for managing and preventing complications related to these conditions.
Urine Dipstick: The urine dipstick test is a quick and convenient method for identifying potential urinary tract infections (UTIs), which are a common cause of sepsis in elderly patients. It can detect substances like white blood cells, nitrites, and protein in the urine, all of which suggest infection or inflammation. Early detection of UTIs is crucial, as they can quickly progress to sepsis if untreated.
Chest X-ray: A chest X-ray is an important imaging tool for identifying lung consolidation, a hallmark of chest infections such as pneumonia. Pneumonia is another common cause of sepsis, particularly in elderly patients with weakened immune systems. The X-ray can also help detect other lung-related issues like fluid accumulation, pulmonary edema, or lung tumors that could complicate the clinical picture.
CT Scan of the Brain: A CT scan of the brain is used to identify structural abnormalities, including the presence of tumors, stroke, or brain hemorrhages. It is also used to detect cerebral atrophy (shrinkage of brain tissue) and ventricular enlargement, which can be indicative of conditions like dementia. This imaging modality is important in diagnosing neurological disorders and guiding further management for patients with cognitive or neurological impairments.
Further Investigations If A Differential Is Suspected
Urine and Blood Toxicology: This test is performed to detect the presence of drugs, alcohol, or other toxic substances in the body. Toxicology screens can identify intentional or unintentional overdoses, exposure to toxic substances, and drug or alcohol misuse. In cases of altered mental status or cognitive impairment, toxicology testing helps to rule out substance-induced confusion or delirium, which can mimic other medical or psychiatric conditions.
Thyroid Function Test: Thyroid hormones play a significant role in regulating metabolism and overall brain function. Abnormal thyroid function, whether hypothyroidism (underactive thyroid) or hyperthyroidism (overactive thyroid), can lead to symptoms of cognitive impairment, mood changes, and lethargy. A thyroid function test measures levels of thyroid hormones (such as TSH, T3, and T4) to determine if an imbalance is contributing to the patient’s cognitive or neurological symptoms, which can be reversible with appropriate treatment.
Vitamin B12 and Folate Levels: Both Vitamin B12 and folate are essential for nerve function and the production of red blood cells. A deficiency in either of these vitamins can lead to cognitive impairment, memory loss, and other neurological symptoms. Vitamin B12 deficiency, in particular, is known to cause a condition called subacute combined degeneration of the spinal cord and brain, which can lead to irreversible damage if left untreated. Checking these levels helps to rule out nutritional deficiencies as a potentially treatable cause of cognitive decline.
Bacteriology and Viral Detection: Infection-related causes of cognitive impairment or altered mental status may be identified through bacteriology and virology testing. This typically involves blood and urine microscopy, as well as culture tests to detect bacterial, viral, or other pathogenic organisms. Infections, especially in elderly or immunocompromised patients, can lead to sepsis or encephalitis, which can significantly impact cognitive function. Identifying and treating an underlying infection can prevent further deterioration and improve cognitive outcomes.
Risk Stratification
Cognitive assessment tools help identify and grade abnormal cognitive performances. They can also be integrated into the emergency medicine physical exam to screen patients for mild cognitive impairment or dementia.
Instead of an extended mental status examination or formal neuropsychological testing, more focused screening tools are more relevant and feasible for use in the emergency department [15]. Examples of screening tools validated for use in the emergency department include the abbreviated mental test score (AMTS) and its abbreviated four-item version (AMT4), the mini-mental state examination (MMSE), and the Montreal Cognitive Assessment (MoCA). They assess a broad range of cognitive domains, including memory, language, and orientation. These tests are designed to be administered in 15 minutes or less and have pre-determined cut-off scores to help distinguish patients with normal cognitive function and those with impaired cognitive function [16].
These screening tools are intended to help screen individuals who may require more extensive neurological assessments. They should only be used as a reference and must be integrated with history and physical examination findings for a holistic approach. Multiple factors, such as altered mood, disorientation, and education level, can affect the accuracy of these screening tools.
Table 4: Abbreviated mental test score four-item version (AMT4)
Ask the patient to state each of the following. A score less than 4 should prompt further cognitive screening. | |
Age | Correct (+1) / Incorrect (0) |
Date of birth | Correct (+1) / Incorrect (0) |
Place | Correct (+1) / Incorrect (0) |
Year | Correct (+1) / Incorrect (0) |
Management
The ABCDE approach is used for the initial management of patients with cognitive changes, behavioral changes, and alterations in consciousness, which may be present in delirium or dementia.
The acute management of dementia and delirium is variable and depends on the patient’s underlying medical conditions and presenting symptoms. The main goal of managing dementia and delirium in the emergency department is to identify and treat any life-threatening underlying causes. Based on the patient’s signs and symptoms, a thorough history, physical exam, and pertinent investigations should be ordered. Patient and staff safety should also be prioritized, as these patients may be aggressive and combative.
Obtaining investigations to evaluate for the underlying cause may be hindered by the patient’s aggressive and combative state. If this is the case, the first attempt is to calm the patient and de-escalate the situation verbally. If unsuccessful, chemical sedation should be considered for the safety of the patient and the healthcare staff. Examples of chemical sedation used in an emergency department setting include benzodiazepines, antipsychotics, and dexmedetomidine [17,18]. Close monitoring is necessary after the patient is sedated. Sedatives should be used only when necessary, as they have the potential to worsen delirium and disorientation.
Physical restraints and environmental seclusion are other adjunctive treatments for agitated delirium or dementia patients. However, their use should be weighed with the psychological and physical risks they may cause (e.g., emotional distress, skin and soft tissue injuries, orthopedic injuries, rhabdomyolysis, etc.). Alternative methods of managing agitation should always be attempted prior to physical restraint, such as explaining your desire to care for the patient, orienting the confused patient to his or her surroundings, using verbal de-escalation techniques, providing psychosocial support, and relocating to a calm and quiet environment, if possible [19].
Special Patient Groups
Most patients presenting with delirium and/or dementia are elderly patients. Younger patients (<60 years) presenting with delirium or patients who have rapidly progressing dementia may require extensive evaluation to discover the underlying cause. Further investigations could include lumbar puncture, electroencephalography, advanced neuroimaging, neuropsychological, and genetic testing [20]. Regardless of age, the most common causes of early-onset dementia are still Alzheimer’s disease, vascular dementia, and frontotemporal dementia [21].
When To Admit This Patient
Admission of dementia and delirious patients depends on various factors, including the severity of symptoms, comorbidities, and safety concerns. Patients who present with acute changes in their mental status, such as sudden confusion or agitation, should be further assessed for any underlying medical conditions and often require hospitalization. Delirious patients, particularly those with severe symptoms or who are at risk of harming themselves and others, should also be admitted until stabilized. Ultimately, the decision to admit dementia and delirious patients in an emergency department setting should be based on a comprehensive evaluation of the patient’s medical history, current symptoms, and risk factors.
The patient who is coming to the emergency department for a chronic presentation of Alzheimer’s dementia could be discharged if life-threatening conditions have been ruled out and home safety is not a concern. They should be referred to an outpatient primary care doctor or a geriatrician for follow-up and prescription medications to manage behavioral symptoms. Be sure to educate the patient’s family members on the diagnosis and to monitor for any new or worsening symptoms that may require urgent medical attention. Advise the family on managing certain scenarios, prioritizing the patient’s basic daily needs, addressing any medical concerns, and maintaining patient and family safety. Refer the patient to a geriatric community support program, if available.
Revisiting Your Patient
Adam’s initial vital signs are stable, and you have decided to continue his management in the consultation room. His history of cognitive and behavioral change over the past year is consistent with dementia. However, his acute presentation of impaired consciousness level and disorientation raises your suspicion of concurrent delirium from an underlying medical condition. Collateral history from the family indicates that Adam lives with his wife, who is 85 years old and limited in her ability to assist Adam with his daily needs. Focused drug and alcohol history is unrevealing.
Further neurological exams do not identify any focal neurological signs or gait disturbance. Physical examinations of the cardiovascular, respiratory, and abdomen are unremarkable. Blood glucose is within the normal range. Due to his disorientation, his Glasgow coma score is 14 (E4/V4/M6).
You consider using AMT4 to screen for cognitive impairment. He can recall his age and date of birth and tell where he is, but he fails to tell us the current year. You establish that he has delirium with impaired alertness and likely an underlying cognitive impairment.
You decide to conduct further investigation to look for potential underlying causes, especially those which may prompt immediate treatment. You arrange blood tests, including complete blood count, electrolytes, liver, and renal function tests, in consideration of potential sepsis, electrolyte disturbance, and acute organ failure. You arrange a CT brain to rule out any acute cerebral hemorrhage and space-occupying lesion. Chest X-ray and ECG are performed, as well. As you order these investigations, you consider that the patient may become agitated and uncooperative during these tests, so you review options for chemical sedation should they be needed.
You discuss openly with Adam and his family on his diagnosis of delirium and likely dementia. Your preliminary investigations show a urinary tract infection; one dose of intravenous antibiotics has been ordered. You suggest admitting Adam for monitoring and investigations due to safety concerns and his inability to care for himself due to his recent rapid decline. You discuss the importance of appropriate follow-up care and geriatric resources specializing in dementia. The patient is admitted to the general medical floor for further testing and monitoring.
Authors
Lo Lucian Simeon
Lucian Lo is a medical student at The Chinese University of Hong Kong. An avid enthusiast of emergency medicine and humanitarian work, he hopes to one day combine his two great passions as a front-line healthcare professional in conflict and disaster zones. He is a certified Advanced Medical Life Support Provider and Youth Mental Health First Aid Provider. In addition, he has led and organized multiple medical service projects in Hong Kong, Nepal, and Thailand. In regard to emergency medicine, his interests include trauma care, intensive care medicine, and pre-hospital emergency medicine.
Ngai Oona Wing Yan
Oona Ngai is a medical student at The Chinese University of Hong Kong with a passion for emergency medicine and humanitarian work. She has organized and participated in various volunteer services for vulnerable communities in Hong Kong, including the homeless, refugees, and domestic helpers. Oona is also a St. John’s certified Advanced Medical Life Support Provider and aspires to better equip herself with the necessary skills and knowledge to provide effective medical care in emergency situations. In addition, she has published a life story book on rare diseases to raise awareness and advocate for those in need.
Lo Yat Hei
Dr. Lo Yat Hei is an emergency physician who is trained and grew up in Hong Kong. He now serves at the Accident and Emergency Department of Prince of Wales Hospital and teaches at the Accident and Emergency Medicine Academic Unit of the Chinese University of Hong Kong. When not practicing medicine, he enjoys gardening, ceramics and playing mahjong.
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References
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Reviewed and Edited By
Joseph Ciano, DO, MPH, MS
Dr. Ciano is a board-certified attending emergency medicine physician from New York, USA. He works in the Department of Emergency Medicine and Global Health at the Hospital of the University of Pennsylvania. Dr. Ciano’s global work focuses on capacity building and medical education and training in low-middle income countries. He is thrilled to collaborate with the iEM Education Project in creating free educational content for medical trainees and physicians.
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
