What you should know before your first ED shift

what you should know before your first ED shift

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 Buhumaid 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 ED shift work?

what you should know before your first ED shift
iEM Education Project Team

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

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sleep and shiftwork
Brenda Varriano, Canada

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

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Things You Should Know Before Your First ED Shift
Ibrahim Sarbay, Turkey

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

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Things you should know about wellness and emergency medicine

things you should know about wellness and emergency medicine

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?

things you should know about wellness and emergency medicine
iEM Education Project Team

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

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Coping with an Emotional Crisis
Sheza Qayyum, Canada

In the ED, we often see patients presenting amid an emotional crisis – whether it’s a panic attack, or a period of extreme anxiety or

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Who Takes Care of You While You Take Care of Others
Arthur Martins, Brasil

The COVID-19 Pandemic has changed our lives in so many ways that sometimes it is difficult to remember how life was without all these changes.

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Why Me? The Story of My Burnout - Part 3
Jule Santos, Brasil

The story continues from link (Part 2). I must take a deep breath. I must ask for help. The Self-Knowledge Path I could go away

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Why Me? The Story of My Burnout - Part 2
Jule Santos, Brasil

The story continues from link (Part 1) I had already been tired and sad. Now, I was also feeling wronged. The Dangers of Burnout It meant

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why me - the story of my burnout
Jule Santos, Brasil

This story starts like almost every other: I fell in love. The thing is, I LOVE heart attacks! I know this is a weird statement,

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Cite this article as: iEM Education Project Team, "Things you should know about wellness and emergency medicine," in International Emergency Medicine Education Project, September 29, 2021, https://iem-student.org/2021/09/29/wellness-and-emergency-medicine/, date accessed: December 4, 2021

iEM Image Feed: Star shape wound on forehead

iem image feed
Star shaped wound

A 17-year-old female patient presented to ED after hitting a metal piece on the wall.

How would you like to suture this patient?

Here is one clue!

Cite this article as: iEM Education Project Team, "iEM Image Feed: Star shape wound on forehead," in International Emergency Medicine Education Project, May 19, 2021, https://iem-student.org/2021/05/19/iem-image-feed-star-shaped-wound-on-forehead/, date accessed: December 4, 2021

iEM Image Feed: Scaphoid fracture

iem image feed
87 - Figure 6 - Fracture of the proximal pole of the scaphoid
  • Falling on an Out-Stretched Hand (FOOSH) is the most common mechanism of wrist injuries, with the wrist in extension.
  • Immature, weaker epiphyseal plate or metaphysis of the radius in children are more likely to sustain injuries, sparing the still-cartilaginous carpal bones.
  • Young adults with active lifestyles are more likely to be injured with greater forces.
  • In the elderly, especially in women with some degree of osteoporosis, distal radial metaphysis is more fragile resulting in Colles fracture.
  • “Anatomic snuffbox’’ on the dorsum of the wrist is an important landmark. Because the scaphoid is palpable with its triangle by styloid, extensor pollicis brevis tendon and the extensor pollicis longus tendon. Tenderness in this area may indicate a scaphoid fracture. The image above shows scaphoid fracture.
  • The examination should include assessment of neurovascular status motor and sensory function of the median, radial and ulnar nerves. Because acute median nerve compression is a common occurrence, the sensation of thumb and index fingers is important, especially with severely displaced fractures. In all injuries to the wrist, radial and ulnar pulses should be evaluated.

Further reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Scaphoid fracture," in International Emergency Medicine Education Project, May 12, 2021, https://iem-student.org/2021/05/12/iem-image-feed-scaphoid-fracture/, date accessed: December 4, 2021

iEM Image Feed: Penetrating eye injury

iem image feed

A 42 years old male, presents to the ED 1 hour after he was hammering a nail onto a wooden shelf, where the nail flew and strike his left open eye. In an attempt to help, his friend immediately removed the nail.

After that, he has been having severe sharp pain and blurry vision in his left eye.

On examination, the left eye had poor visual acuity, and he could only perceive light and movement. The pupil was fixed, dilated and non-reactive to light. Right eye examination was normal.

819.2 - eye penetran trauma 2 -siedel sign

Further reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Penetrating eye injury," in International Emergency Medicine Education Project, April 28, 2021, https://iem-student.org/2021/04/28/iem-image-feed-penetrating-eye-injury/, date accessed: December 4, 2021

iEM Image Feed: Gallbladder Stone

iem image feed

A 35-year-old woman presents to the emergency department with right upper quadrant pain of two hours duration. She awoke several hours after eating a large meal. Based on increasing pain and nausea she presents for evaluation. She denies vomiting, fever or dysuria. Her past history is notable for diet-controlled type II diabetes, dyslipidemia, and essential hypertension. Her BMI is 33. Her only medication is lisinopril 10 mg daily. She has never had surgery. Her social history is unremarkable. She neither drinks alcohol nor uses tobacco. She has begun to diet and reports recent weight loss.

Her temperature is 37ºC, blood pressure: 110/70 mmHg, pulse: 90 beats per minute. Physical exam reveals an overweight female in mild distress secondary to right upper quadrant pain. She cannot find a position of comfort and describes the pain as similar to labor pains. Pertinent exam findings include: chest exam normal, cardiac exam normal, abdominal exam demonstrates normal bowel sounds and no rebound in any quadrant. She has guarding to inspiration with palpation over the gallbladder (positive Murphy’s sign). Rectal exam normal, stool is hemoccult negative for blood. Pertinent lab values: glucose 110 mg/dl, alkaline phosphatase 120 U/L, alanine aminotransferase (ALT) 25 U/L, aspartate aminotransferase (AST) 25 U/L, gamma glutamyl transferase (GGT) 20 U/L, direct bilirubin 0.1 mg/dL, total bilirubin 0.5 mg/dL, lipase 20 U/L.

The emergency physician performs a focused right upper quadrant ultrasound and finds gallstones without associated gallbladder wall thickening or pericholecystic fluid. In addition, the patient has a “sonographic Murphy sign”: there is maximal abdominal tenderness when the ultrasound probe is pressed over the visualized gallbladder.

79 - gall bladder stone

Further reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Gallbladder Stone," in International Emergency Medicine Education Project, April 21, 2021, https://iem-student.org/2021/04/21/iem-image-feed/, date accessed: December 4, 2021

iEM Image Feed: Viscus perforation

iem image feed

A 35 years old previously healthy gentleman presented to the Emergency Department with a sudden-onset severe and diffuse abdominal pain which started an hour ago. Chest X-ray was ordered; what do you see?

Abdominal pain is one of the commonest ED presentations. Like acute MI, AAA rupture, or DKA, viscus perforation should be in our worst-case scenario list. The image shows free air under the diaphragm.

The expected hints for this type of patient are a history of peptic/duodenal ulcer disease, severe abdominal pain that patients do not want to move, and a rigid and very tender abdomen, which any palpation gives much pain to the patient. 

We need to remember that this situation is a surgical emergency. There are some steps that we need to do immediately for this patient.

  1. Proper history and examination
  2. Attaching to monitor and following vital signs and intervene if necessary to normalize them
  3. Opening 2 large-bore IV lines and fluid resuscitation as needed
  4. IV pain medication
  5. IV antibiotics
  6. Stopping oral ingestion and placing NG tube
  7. Contact surgery
  8. Sending basic biochemistry lab, coagulation profile, blood type and cross, CBC, which will be asked by surgery soon. 
  9. Arranging transfer to the OR
887.1 - viscus perforation

Abdominal pain is one of the commonest ED presentations. Like acute MI, AAA rupture, or DKA, viscus perforation should be in our worst-case scenario list. The image shows free air under the diaphragm.

887.2 - viscus perforation

The expected hints for this type of patient are a history of peptic/duodenal ulcer disease, severe abdominal pain that patients do not want to move, and a rigid and very tender abdomen, which any palpation gives much pain to the patient. 

We need to remember that this situation is a surgical emergency. There are some steps that we need to do immediately for this patient.

  1. Proper history and examination
  2. Attaching to monitor and following vital signs and intervene if necessary to normalize them
  3. Opening 2 large-bore IV lines and fluid resuscitation as needed
  4. IV pain medication
  5. IV antibiotics
  6. Stopping oral ingestion and placing NG tube
  7. Contact surgery
  8. Sending basic biochemistry lab, coagulation profile, blood type and cross, CBC, which will be asked by surgery soon. 
  9. Arranging transfer to the OR

Additional reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Viscus perforation," in International Emergency Medicine Education Project, April 14, 2021, https://iem-student.org/2021/04/14/viscus-perforation/, date accessed: December 4, 2021

iEM Image Feed: Plateau Fracture

iem image feed

A 60-year-old man known to have DM type 2 was brought by the family as a camel hit his knee. He was not able to walk on it at the scene and in ED. It was swollen with no open wound.

Tips
Although patients come with isolated injuries, we always have to make sure that they do not have other injury findings. Therefore, approaching systematically to the patient is important. At this moment, please remember primary and secondary surveys of multiple trauma. The animal attacks may create multiple injuries on patients, and they should be evaluated as multiply injured patients. After you ruled our multiple or life, organ, extremity threatening injury, you can deep dive into isolated injuries. In this case, knee injury after a direct hit.

Of course, inspection and palpation are essential in every extremity injury. Evaluating the patient for neurovascular problems and range of motions are applied in almost every extremity trauma. But sometimes, clinical presentations or findings can be subtle and you may need a better tool. In these case, we recommend using Ottawa Knee Rules.

The image shows tibia plateau fracture on AP knee x-ray.

885.1 plateau fracture
885.2 plateau fracture copy

Additional reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Plateau Fracture," in International Emergency Medicine Education Project, April 7, 2021, https://iem-student.org/2021/04/07/plateau-fracture/, date accessed: December 4, 2021

iEM Image Feed: Radius and Ulna Fracture

iem image feed radius and ulna fracture
radius and ulna fracture

Her father brought a 9-year-old girl due to deformed right extremity. He was playing at home and fell from a hight on his hand. No open wounds. No past medical and surgical. Vaccination: up to date.

Examination: radial pulse is intact. He can move the fingers but with limitation due to pain. Sensation is normal. The X-ray showed both radius and ulna fracture. The patient underwent procedural sedation with IV ketamine, and the reduction was made with ortho oncall.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Radius and Ulna Fracture," in International Emergency Medicine Education Project, March 31, 2021, https://iem-student.org/2021/03/31/radius-and-ulna-fracture/, date accessed: December 4, 2021

iEM Image Feed: Humerus Shaft Fracture

image feed
humerus fracture
humerus fracture 2

The EMS brought a 39-year man as his right upper extremity was stuck in a machine in a factory where he works. He came with deformity and severe pain in his right arm. Pain management was given. He received tetanus toxoid as well. X-ray shows oblique humeral shaft fracture with shortening and angulation. He underwent procedural sedation to reduce it.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Humerus Shaft Fracture," in International Emergency Medicine Education Project, March 17, 2021, https://iem-student.org/2021/03/17/humerus-shaft-fracture/, date accessed: December 4, 2021

iEM Image Feed: Mandibular Fracture

image feed
mandibular fracture

A 39-year-old woman presented to ED with mouth pain. She was cleaning the bathroom and suddenly slipped and fell. She hit her mandible with the floor. She was able to speak minimally—no avulsed teeth. She had teeth 23 and 24 subluxations.

This is a high energy impact trauma. Ensure that you evaluate the patient systematically for trauma and not forget to pay attention to a neck injury. Violence, assault, partner abuse should be in your mind. Specific mandibular and panoramic imaging may give excellent views for diagnosis. In some cases, CT may be necessary to evaluate the maxillofacial injury. Besides, know the teeth universal numbering. If you see this kind of damage in the examination, always rule out an alveolar fracture.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Mandibular Fracture," in International Emergency Medicine Education Project, March 3, 2021, https://iem-student.org/2021/03/03/mandibular-fracture/, date accessed: December 4, 2021

iEM Image Feed: Camel Bite

iem image feed camel bite
camel bite injury

EMS brought a 24-year-old man due to camel bite happened while feeding the camel in the early morning. The injury was basically on the right arm and forearm. No other injuries, vitally stable.

Students should know the following while taking care of these patients.

  1. Systematic evaluation of the patient – remember ATLS, primary and secondary survey.
  2. Focused neurologic and vascular examination.
  3. Exposing the wound and ordering an x-ray
  4. Wound cleaning and management
  5. Be aware of fracture – Open Fracture!
  6. Antibiotic coverage and tetanus toxoid/IG
  7. For open fractures – Look for Gustilo-Anderson Classification and choose appropriate antibiotics.  
  8. Do not forget – pain medication.
Cite this article as: iEM Education Project Team, "iEM Image Feed: Camel Bite," in International Emergency Medicine Education Project, February 10, 2021, https://iem-student.org/2021/02/10/camel-bite/, date accessed: December 4, 2021