Out of Proportion: Acute Leg Pain

Case Presentation

A 48-year-old male, with history of hypertension and diabetes and prior intravenous drug use (now on methadone) presents with acute onset right leg pain from his calf to the ankle, that woke him from sleep overnight. The pain has been constant, with no modifying or relieving factors. He hasn’t taken anything other than his daily dose of methadone. He hasn’t had any fevers or chills and denies any recent trauma or injuries.

Any thoughts on what else you might want to ask or know?

  • Any recent travel or prolonged immobilization?
  • Have you ever had a blood clot?
  • Are you on any blood thinners?
  • Have you used IV drugs recently?
  • Any numbness or weakness in your leg?
  • Any associated rash or color change?
  • Any back pain or abdominal pain? Any bowel or bladder incontinence?
  • Any recent antibiotics (or other medication changes)?
  • Have you ever had anything like this before?
[all of these are negative/normal]

Pause here -- what is your initial differential diagnosis looking like?

  • Deep vein thrombosis
  • Superficial vein thrombosis
  • Pyomyositis
  • Necrotizing fasciitis
  • Muscle sprain or tear
  • Arterial thromboembolism
  • Bakers cyst
  • Achilles tendonitis, Achilles tendon rupture

What are some key parts of your targeted physical exam?

  • VITAL SIGNS! [BP was slightly hypertensive, and he is slightly tachycardic, normothermic]
  • Neurologic exam of the affected extremity (motor and sensory)
  • Vascular exam of the affected extremity (femoral/popliteal/posterior tibialis/dorsalis pedis)
  • Musculoskeletal exam including ranging the hip, knee, ankle and palpating throughout the entire leg
  • Skin exam for signs of injury or rashes etc.
  • Consider a cardiopulmonary and abdominal exam, particularly the lower abdomen

On this patient’s exam, he was overall uncomfortable appearing and had slight tachycardia (110s, EKG shows normal sinus rhythm), normal cardiopulmonary exam, normal abdominal exam. He had a 2+ right femoral pulse and faintly palpable DP pulse that had a good biphasic waveform on doppler. His hip/knee/ankle all have painless range of motion. The compartments are soft in the upper and lower leg. He does have some diffuse calf tenderness and the medial aspect feels slightly cool compared to the contralateral side, but his foot is warm and well perfused. There isn’t any spot that is most tender. There is no rash, no crepitus, no bullae or bruising or other evidence of injury.

What diagnostic studies would you like to send?

  • CBC, BMP
  • CPK, lactate
  • DVT ultrasound?
  • Anything else?

What treatments would you like to provide?

  • Analgesia (mutli-modal)?
  • Maybe a bolus of IV fluids to help with the tachycardia?

The patient is having a lot of pain despite already getting NSAIDs, acetaminophen, and a dose of morphine. You decide to re-medicate the patient with more morphine and send him for DVT ultrasound. As soon as he gets back, he’s frustrated that you still haven’t treated his pain “at all” and he really does look uncomfortable and in a lot of pain.  You start to wonder if he’s faking it giving his history of IV drug use.

His DVT ultrasound comes back as normal. The lab work is also coming back and unrevealing. A normal CBC, metabolic panel, normal CPK, normal lactate. His pain is not really improving. You reexamine the leg, and the exam is unchanged. It really seems like his pain is out of proportion to the exam.

Pain is out of proportion to the exam should catch your attention every time. While we always need to keep malingering and less emergent causes for pain that seems to be more than expected in the back of our minds. But! Several emergent diagnoses have patients presenting in pain in a way that doesn’t fit what you can objectively identify as a cause. Diagnoses like compartment syndrome and mesenteric ischemia can be erroneously dismissed by emergency providers, and it is crucial you don’t just stop looking for the cause of pain out of proportion. In fact, it’s important you dig in deeper and rule out all potentially life and limb threatening causes.

In this case, the pain was recalcitrant to multiple doses of IV opiates and several other modes of treatment. The patient was getting so frustrated that he pulled out his IV and threatened to leave the ED. After talking with him further, he agreed to stay and a new IV was placed, more pain medication given, and a CTA with lower extremity run-off was performed, which showed the acute thrombus of the proximal popliteal artery, just below the level of the knee.

He was started on a heparin infusion and vascular surgery was consulted; the patient was admitted from the ED and taken for thrombectomy. No source of embolism was identified, and his occlusion was presumed to be thrombotic (most commonly from a ruptured atheromatous plaque leading to activation of the coagulation cascade), with particular attention to his history of diabetes and hypertension raising his risk for this. He had a fair amount of collateralization from other arteries around the occlusion, such that his foot wasn’t cold, and he had a doppler-able DP pulse. 

Remember

Go with your gut and don’t minimize pain that is out of proportion to the exam. Keep hunting for a reasonable explanation or you may miss a life or limb threatening cause of an atypical emergency presentation.

Further Reading

Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

Read More »

Acute Mesenteric Ischemia

by Rabind Antony Charles Case Presentation A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with

Read More »

Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Read More »
Cite this article as: J. Austin Lee, USA, "Out of Proportion: Acute Leg Pain," in International Emergency Medicine Education Project, October 18, 2021, https://iem-student.org/2021/10/18/acute-leg-pain/, date accessed: October 18, 2021

What is Emergency Medicine?

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”.  

Cite this article as: J. Austin Lee, USA, "What is Emergency Medicine?," in International Emergency Medicine Education Project, May 3, 2021, https://iem-student.org/2021/05/03/what-is-emergency-medicine/, date accessed: October 18, 2021

Recent Blog Posts By John Austin Lee

Local Anaesthetic Toxicity (LAST)

Local Anesthetic Toxicity (LAST)

Think about the number of times a month you use a local anaesthetic; maybe not every day, but I know there are a lot of emergency department shifts when I use a local anaesthetic. The uses and applications for local anaesthesia abound: wound care and laceration closure, pain control with painful procedures like a paracentesis or lumbar puncture, and targeted regional anaesthesia blocks after a broken hip. It is important to know and understand a bit more about this commonly used class of drug given how often we use them in emergency medicine, including the recommended dosing, signs of toxicity, and treatment of toxicity.

Local anaesthetics fall into two divisions, based on their chemical structure:

  • the Esters (have one i): procaine, cocaine, tetracaine, chloroprocaine, etc
  • the Amides (have two i’s): lidocaine, bupivacaine, mepivacaine, prilocaine, ropivacaine, etc

Effect

These drugs have their effect as sodium-channel blocking medications with variable durations of action. Interestingly, 1% diphenhydramine has also been used as a local anaesthetic since the 1930s, given its sodium channel blocking mechanism. Local anaesthetics can be administered with other drugs, namely epinephrine, to help increase the duration of action and minimize the spread of the anaesthetic from the site of injection.

Maximum Dose

The safe maximal dose for the local anaesthetics is based on patient weight and correlates to the risk of systemic toxicity. The maximally safe dose of two common local anaesthetics is detailed below, and as you can see, the use of epinephrine allows for an increased dose of local anaesthetic injection.

Max dose without Epi Max dose with Epi Duration of Action
Lidocaine
4.5 mg/kg
7 mg/kg
0.5 - 1.5 hours
Bupivacaine
3 mg/kg
3 mg/kg
6-8 hours

Usage abd Absorbtion

Absorption into the bloodstream of a local anaesthetic can occur when the drug is injected directly into the bloodstream. Still, it can also occur in highly vascular areas or near neurovascular bundles in locations such as intracostal, epidural, and the brachial plexus. Local anaesthetic systemic toxicity (LAST) occurs when there are elevated circulating levels of local anaesthetic and occurs within minutes of injection. As you may know, lidocaine is used intravenously as an antiarrhythmic drug, and cocaine when used (or abused) systemically can cause numerous systemic effects and a sympathomimetic toxidrome. Bupivacaine is the most commonly discussed cause of LAST, and extra care should be taken when utilizing this for local anaesthesia.

Sign and Symptoms of LAST

Signs and symptoms of LAST predominate in the central nervous system and the cardiovascular system. CNS symptoms can include oral/perioral numbness, paresthesia, restlessness, tinnitus, fasciculations/tremors, seizures, decreased level of consciousness, and/or apnea. Cardiovascular symptoms can include: hypertension and tachycardia though more commonly vasodilation and hypotension, sinus bradycardia, AV blocs, conduction defects (notably: long PR and QRS), ventricular dysrhythmias, cardiovascular collapse, and/or cardiac arrest.

The differential diagnosis for LAST includes anaphylaxis (rare with amides), other sodium channel blockers (antihistamines, TCAs, cocaine, antimalarials), and anxiety. However, the timing nearly immediately following local anaesthetic administration should help one to hone in on the diagnosis.

Management

If a patient develops LAST, ACLS protocols should be followed. Furthermore, lipid emulsion (Intralipid) is the treatment that will help bind the anaesthetic in the bloodstream. While this medication is not on the WHO essential medication list, in a patient with LAST, Intralipid should be administered if available. Dosing is a 1.5 mL/kg bolus (standard dose of 100mL for 70kg patient), followed by a 0.25-0.5 mL/kg/min infusion until the patient is hemodynamically stable (and for at least 10 minutes).

How To Decrease Risk of LAST

A few strategies to minimizing the risk of causing harm to your patients when using local anaesthetics: 
 
  • know the maximum dose your patient can receive
  • know the dose you’re giving by dose (milligrams) and how that correlates to drug volume (mg/mL)
  • aspirate prior to injection(s) to ensure you are not in a blood vessel
  • consider using point of care ultrasound to ensure needle location

References and Further Reading

Cite this article as: J. Austin Lee, USA, "Local Anaesthetic Toxicity (LAST)," in International Emergency Medicine Education Project, November 23, 2020, https://iem-student.org/2020/11/23/local-anaesthetic-toxicity/, date accessed: October 18, 2021

More Posts By Dr. Lee

COVID-19; Reflecting on a Globalized Response

COVID-19; Reflecting on a Globalized Response

As I write this is, it has been 200 days since the first reports in China came out regarding an unspecified viral illness in Wuhan, China. What is now the pandemic of COVID-19 has spread around the world, and in history books and our collective memory, the year 2020 will forever be closely associated with this virus. There have been nearly 14 million confirmed cases around the world and nearly 600,000 known deaths from COVID-19. Some countries have done incredibly well with containment measures, while others continue to see case counts grow every day.

It has been fascinating to see how the outbreak has had different impacts in communities around the world, including how local and global responses have efficiently controlled or been unable to contain this novel public health problem. Prevention and mitigation strategies continue to form the foundation of public health management of this outbreak. The capacity for any country or locality to provide the most invasive supportive care is widely variable, and even when it is available mechanical ventilation is certainly not a panacea as COVID-19 case-survival rates in those being mechanically ventilated have been low (from 14% to 25%).

At the core of the variable outcomes seems to be a mix of sociological issues: a mix of personal beliefs, geography, politics, socio-economics and health infrastructure which lead to vastly different outcomes around the globe.

The accumulation of more epidemiological data over the past 200 days has improved our collective understanding of the COVID-19 virus, as today we have improved models and a better understanding of the rates of asymptomatic carriers (estimated at 40%) and mortality rates (1.4%-15.4%). Yet still, uncertainties and local variability (even within countries) have made an accurate calculation of the COVID-19 basic reproductive number (R0; the number of people who are infected by a single disease carrier) difficult. In the early stage of the outbreak in Wuhan, R0 calculation ranged from 1.4-5.7, and some have suggested that instead of single R0 value, modellers should consider using ongoing contact tracing to gain a better range of transmissibility values.

We have seen how prevention strategies such as hand-washing, face-masking, and physical distancing can impact local and disseminated disease spread. While many communities have come together through a collective approach to lock-downs and universal masking measures, other localities have struggled to get adequate levels of citizen compliance. Others have struggled with obtaining testing supplies. Certain political systems allow for streamlined and unified directives while others have made it difficult to provide adequate centralized coordination.

As the COVID-19 pandemic has spread to almost every country in the world, outbreaks are smoldering in much of the global south. While the United States continues to see rising numbers of cases with numerous states confronting ongoing daily record high incident cases, other countries such as Brazil are seeing similar upward trends. At the global level, the curve of daily incident cases seemed to have “flattened” and held steady through much of April and into May with aggressive seemingly worldwide measures. However, since the last days of May, global incident cases have been again steadily increasing. This is likely due to a variety of reasons but is linked, at least in part, to efforts to reopen economies and return to pre-pandemic routines and lifestyles.

covid-19 daily cases
Source: Johns Hopkins University Coronavirus Resource Center https://coronavirus.jhu.edu/map.html, accessed July 17, 2020

As an American citizen and a physician with training in public health, it has been both interesting and frustrating to see the how some countries (including my own) have had deficiencies in dealing with testing and basic prevention (such as mandatory universal masking). While I don’t want to engage in political rhetoric or cast blame in any one place, I do think it is instructive to point out that in the United States (or anywhere else for that matter) the sociological factors of personal preferences and autonomy, geography, and local politics have had an overwhelming influence in determining the progress of the pandemic.

Quarantining has always been a unique problem that sits at the intersection of personal autonomy and communal wellbeing, and is implemented and respected by citizens in different ways around the world. It would seem, at least anecdotally, that cultures with an emphasis on personal independence and autonomous choice have had greater difficulty with containment or in obtaining high levels of compliance with masking and distancing measures, even when compared to other localities with similar socio-economic situations.

These sociological factors are key to responding to and managing any epidemic health concern. We have come to see that in our globalized world, our ability and desire to work together towards a common goal, even at the cost of personal sacrifice, will determine our ability to control both the COVID-19 pandemic and the next health crisis of the future.

Public health education and communication, it would seem, is at the crux to getting collective buy-in and global participation.

Unfortunately, as with so many things these days, such issues can be easily politicized and cause fractured and disparate approaches to response. In our globalized world, this coronavirus outbreak is unlikely to be the last public health crisis we must face as a worldwide community.

As thoughts turn towards what is to come, from vaccine development and distribution to numerous long-term economic impacts, we are not nearing the end of this outbreak yet.

The incidence curve is growing, and there is much work left to be done. My hope is that as we move into the second half of 2020, our global community can continue to find ways to improve communication and coordination in order to come together to approach and control this pandemic collectively. The fate of this outbreak, and likely the next, hangs in the balance.

Cite this article as: J. Austin Lee, USA, "COVID-19; Reflecting on a Globalized Response," in International Emergency Medicine Education Project, August 3, 2020, https://iem-student.org/2020/08/03/covid-19-reflecting-on-a-globalized-response/, date accessed: October 18, 2021

Trauma and Public Health

Trauma is a leading cause of preventable morbidity and mortality. Each reader will have a different context regarding what causes traumatic injuries locally, from different types of motor vehicles, various weapons or security concerns, unique household and workplace injuries, among others. There are several generalizable public health level considerations that we can all benefit from.

Traumatic injuries occur “at the organic level, resulting from acute exposure to energy (mechanical, thermal, electrical, etc.) in amounts that exceed the threshold of physiologic tolerance” [1]. Historically, humans have viewed traumatic injuries as “accidents”; it’s even what we often call them. This view has made trauma a neglected subset of public health focus and funding, though more recently, there has been an increased recognition from public health entities that traumatic injuries are often preventable and treatable [1].

Every year, more than 5 million people die from injury, which is a mortality rate of more than 1.5 times that of HIV, tuberculosis, and malaria combined [2]. Beyond deaths, nearly one billion people sustain injuries that require health care each year from around the globe [3]. Notably, for every death from injury, there are 20–50 nonfatal injuries that result in some disability [4]. Further, the morbidity from trauma is often long-lasting and impacts the quality of life, productivity, and the financial security of individuals, families, and entire communities [5].

Of the 5 million annual trauma deaths, an estimated 1.3 million people are killed in road traffic crashes each year, and projections indicate these will likely increase by another 65% over the coming two decades [6]. Common throughout the world, pedestrians and two-wheel vehicle users are at greater risk of injury and death than vehicle occupants [7]. As vehicles like cars and trucks are owned and operated by more individuals around the world, such projections make logical sense.

After a traumatic injury occurs, the aim is the progress of a patient through a continuum of trauma care, as represented in the below figure:

Yet, such systems and continuums of care lack around the world. In one 2017 review of trauma systems from around the globe, Dijkink et al. found only 9 of 23 high incomes countries had well-defined and documented national trauma systems. Very few low and middle income (LMIC) countries had a formal trauma system or trauma registry [9]. Of note, most injuries occur in low-income and middle-income countries, and most trauma care research comes from high-income countries [10].

In their review of LMICs developing trauma care system, Reynolds et al. identified several common strengths, including training, prehospital systems, and organization, but also found weaknesses in LMICs’ lack of focus on performing quality-improvement, costing, rehabilitation, and policy around trauma care [10].

Each context, even within countries, has a unique set of advantages and barriers, ranging from well-developed to non-existent: EMS systems, in-hospital diagnosis and treatment, and rehabilitation care. Estimates derived from the Global Burden of Disease data suggest that nearly 2 million lives could be saved every year if case fatality rates among seriously injured persons in low- and middle-income countries were similar to those achieved in high-income countries [10,11].

Moving towards such improvements is a monumental task that requires stepwise action. One tool that can help is something I have written about previously: the World Health Organization’s Basic Emergency Care course. The multi-day course curriculum has been developed to teach a high-yield approach to emergent health problems systematically. The course focuses on triage interventions for treating trauma, breathing, shock, and altered mental status. This framework for knowledge and skills can help to improve the acute care of a traumatic injury in almost any location.

I strongly encourage every reader to take a few minutes to consider what are the local causes of traumatic injury, to think about how your current trauma care system is both doing well and where it needs help. I would ask that you think about what ways you could focus on this crucial public health issue and find ways either through education, advocacy, or otherwise, to improve the health of your local and global community.

References

  1. Krug et al. The global burden of injuries. Am J Public Health. 2000 Apr;90(4):523-6. DOI: 10.2105/ajph.90.4.523.
  2. World Health Organization, 2014. Injuries and Violence: The Facts. Geneva: WHO
  3. Haagsma et al. 2016. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj. Prev. 22(1): 3–18
  4. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. 2015. Essential Surgery: Disease Control Priorities, Vol. 1. Washington, DC: Int. Bank Reconstr. Dev./World Bank. 3rd ed.
  5. Wesson HKH, Boikhutso N, Bachani AM, Hofman KJ, Hyder AA. 2014. The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence. Health Policy Plan. 29(6): 795–808.
  6. Global Road Safety Facility (2014) Transport for health: the global burden of disease from motorized road transport. Washington, DC, The World Bank.
  7. Jayanth Paniker, et al. Global trauma: the great divide. SICOT J. 2015; 1: 19. Published online 2015 Jul 21. doi: 10.1051/sicotj/2015019.
  8. National Academy of Sciences, Committee on Military Trauma Care’s Learning Health System; Health and Medicine Division. Berwick D, Downey A, Cornett E, editors. Washington (DC): National Academies Press (US); 2016 Sep. https://doi.org/10.17226/23511
  9. Dijkink S et al. Trauma systems around the world: A systematic overview. J Trauma Acute Care Surg. 2017 Nov;83(5):917-925. doi: 10.1097/TA.0000000000001633
  10. Reynolds TA et al. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health. 2017 Mar 20;38:507-532. doi: 10.1146/annurev-publhealth-032315-021412. Epub 2017 Jan 11.
  11. Mock C, Joshipura M, Arreola-Risa C, Quansah R. 2012. An estimate of the number of lives that could be saved through improvements in trauma care globally. World J. Surg. 36(5): 959–63.

 

Cite this article as: J. Austin Lee, USA, "Trauma and Public Health," in International Emergency Medicine Education Project, May 11, 2020, https://iem-student.org/2020/05/11/trauma-and-public-health/, date accessed: October 18, 2021

Basic Emergency Care (BEC): A New Global Health Framework

BEC WHO

Experienced emergency medicine providers know the ins and outs of how to approach and assess any patient of any age with a critical illness. As has been discussed previously on this blog, the need to rapidly identify and manage sick and dying patients requires a systematic approach. When a new patient arrives for care, or alternatively when a patient decompensates and gets acutely sicker, the emergency medicine provider is tasked with systematically identifying and treating such conditions.

Because most trauma and critical care approaches and training modules were developed and implemented in high-income, resource-rich contexts, there has long been a need for a systematic approach to critically ill patients in lower-income settings.

Over the past several years, the World Health Organization, the International Committee of the Red Cross/Red Crescent, and the International Federation for Emergency Medicine have been working together to develop and create a training course to aid frontline providers in managing acute illness and acute injury in resource-limited contexts.

BEC in Uganda 2
Zambian BEC course facilitators Hassan, Alex, Chipoya (doctors), and Irene (nurse) demonstrate how to safely move an injured patient.

Since 2018, the World Health Organization’s Basic Emergency Care course has been developed and refined as a way to teach a systematic, high-yield approach to urgent and emergent health problems. Using both triage and interventional strategies, the course trains participants to be prepared to deal with a variety of critical illnesses, with a focus on trauma, breathing, shock, and altered mental status.

The BEC course is generally given as a 4 to 6-day course to individuals working in healthcare systems around the world. The BEC course is intended for individuals who might be able to or expected to provide emergent patient care, including students, trainees, nurses, physicians, and even pre-hospital or inpatient care providers, among others. This course is not only intended for emergency medicine physicians, but for all types of locally appropriate providers.

The BEC course participants first learn about the ABCDE approach to ill patients, with a recurring emphasis on obtaining a focused patient history using the SAMPLE mnemonic. These skills are crucial and can be applied to almost any patient in any context.

BEC in Uganda
Tanzanian BEC course facilitators, Suzie (nurse) and Juma (doctor) demonstrate infant resuscitation.

The knowledge gained around ABCDEs and the SAMPLE histories are then applied across the four main care modules in the course, which are: trauma, breathing, shock, and altered mental status. As has been pointed out by others, before any patient goes from alive to dead, they usually pass through the framework of one of these four critical care modules. The hypoglycemic patient develops altered mentation, or the patient with pneumonia develops respiratory distress. As such, lifesaving interventions at these crucial action points can truly save lives.

Each day of the 5-day training course generally has a mix of lectures, group discussions, case scenarios, and hands-on skills stations. The freely available WHO BEC Handbook can help one to better understand the course structure and content.

It should be noted that the BEC course does presume the participant has a very basic but pre-existing knowledge of some of the following: basic human anatomy, basic history taking, basic physical examination skills including vital signs auscultation and abdominal exam, use of a glucometer, and the use of intravenous and intramuscular medications.

In several locations around the world, after the completion of the 5-day course, a Training of the Trainers course has been given, where top course participants and other health system leaders come together to learn how to teach the BEC course. As such, there is a goal for developing and cultivating both local leadership regarding the skills and knowledge around care during critical illness. Subsequently, a locally perpetual training around BEC can take root and become the new standard of emergency care.

Early research by Tenner et al., among others, into the efficacy and impact of the BEC course is showing that indeed, the WHO BEC course is both effective and helpful. For those who are interested in either taking the course, or in becoming a certified trainer, you can contact your national or local emergency medicine leaders and ask for times and locations near you where there may be the opportunity to take this incredibly valuable and impactful course. One such BEC and follow-on training of the trainer course will be taking place in Rwanda in March of 2020; to contribute financially to this Rwandan effort, consider a small donation: here.

References

  • Tenner AG, Sawe HR, Amato S, et al. Results from a World Health Organization pilot of the Basic Emergency Care Course in Sub Saharan Africa. PLoS One. 2019;14(11):e0224257. Published 2019 Nov 13. doi:10.1371/journal.pone.0224257 – pdf link
Cite this article as: J. Austin Lee, USA, "Basic Emergency Care (BEC): A New Global Health Framework," in International Emergency Medicine Education Project, February 17, 2020, https://iem-student.org/2020/02/17/basic-emergency-care/, date accessed: October 18, 2021

The 2018 Global Emergency Medicine Literature Review

The 2018 Global Emergency Medicine Literature Review

The Global Emergency Medicine Literature Review Group

The Global Emergency Medicine Literature Review Group (https://gemlrgroup.wixsite.com/mysite) is a team of students and physicians from around the world that work together each year to review and highlight the published literature related the practice of emergency medicine in resource-constrained settings. The Global Emergency Medicine Literature Review (GEMLR) started in 2005 and has been published annually (you can review past editions of the GEMLR: here, https://www.ncbi.nlm.nih.gov/pubmed/?term=gemlr).  

Annual Systematic Review

The review group completes their annual systematic review of scholarly work around international emergency medicine, which screens for and then reviews relevant peer-reviewed and gray literature. The authors of this years review note that the term international emergency medicine is quite subjective, but the research of interest is generally related to “the practice and development of emergency medicine in settings without the robust or mature systems commonly seen in resource-rich western countries.”

The 2018 Review

The 2018 review was just recently published online in Academic Emergency Medicine (https://www.ncbi.nlm.nih.gov/pubmed/31313411), and this edition was put together by a team of 7 editors, 5 editorial board members, and 27 reviewers (of note, I was one of the reviewers for 2018). Interestingly, a number of reviewers are tasked with reviewing literature in other languages with which that reviewer is fluent in order to include any relevant studies from around the world. Articles are screened for appropriateness and then grouped into three main categories: the development of emergency medicine, disaster and humanitarian response, and emergency care in resource-limited settings.
 

The GEMLR group screened over 19,000 articles for the 2018 review, and of these 517 were found to be of appropriate quality and content for a full review. Each screened article is then obtained in full-text format and both categorized and scored by two independent reviewers. This edition of the GEMLR found the screened articles fell into each category as follows: 15% in the development of emergency medicine, 25% in disaster and humanitarian response, and 60% in emergency care in resource-limited settings. After scoring, a total of 25 articles (approximately 5% of all of the scored literature is selected for a full summary and critique. This year’s publication included the full summary and the critical appraisal of each of the highest-scoring articles in Supplement 7. 

The 2018 GEMLR authors found that this year’s edition included “studies and reviews focusing on pediatric infections, several new and traditionally under-represented topics, and landscape reviews that may help guide clinical care in new settings represented the majority of top-scoring articles. A shortage of articles related to the development of EM as a specialty was identified.”

The body of published work around international emergency medicine continues to grow; 7.3% more studies were identified as compared to 2017. I would encourage you to looking through the most recently published GEMLR reviews to find content areas that are currently gaps in the peer-reviewed literature and consider finding ways to help prepare and publish relevant work. The great news is that the body of work in international emergency medicine is expanding.

Ongoing Scholar Work Around International Emergency Medicine

This and other recent GEMLR publications are a great resource and can be a really helpful starting point in looking at ongoing scholarly work around international EM. This is also a great resource to consider as content to be used in your next journal club. I strongly recommend you take a look at this year’s publication and then go look at a few of the articles; there is a lot of great work being done and published!

Although applications to be a reviewer for the 2019 review have just recently closed, keep your eyes on the GEMLR team (@gemlrgroup) for the latest in IEM research, and for the opportunity to join the GEMLR team for next year.

Cite this article as: J. Austin Lee, USA, "The 2018 Global Emergency Medicine Literature Review," in International Emergency Medicine Education Project, August 20, 2019, https://iem-student.org/2019/08/20/the-2018-global-emergency-medicine-literature-review/, date accessed: October 18, 2021

Key Resources for Emergency Medicine Providers

One of the essential skills an emergency medicine provider can develop is knowing what resources are available and correctly and efficiently utilizing those resources in your time of need.

You need to know where your ultrasound and associated supplies are stored to quickly perform a FAST exam as soon as a trauma patient arrives. You need to know who your general surgeon on call is and how to contact them, in order to get your newly diagnosed case of appendicitis admitted and to the operating room. Most of your patients may not individually need a bedside ultrasound or surgical consultation, but when you have a patient who does need it, you have to be ready to mobilize these resources quickly.

Likewise, you need to learn about and develop a system for how to look up answers when you have clinical questions about diagnosis and treatment of both common and rare presentations of emergency medicine cases. One of the hardest things about emergency medicine is never knowing what you will take care of next, including relatively rare disease processes, particularly those you haven’t seen before or studied in a long time. While many folks may refer back to hard-copy printed textbooks for reference when these clinical questions of “what do I do next” arise, an increasing number of incredibly useful resources are available online and can improve your efficiency in both learning outside of the hospital as well as calling upon them during a busy shift to answer the “what next” conundrum.

Outlined below are a number of resources I have found helpful, and you might as well. Some of these are paid while many are free, and all should be available digital formats. As the world of online medical education continues to grow, you may find others, including this website, have the answers you need, when you need them. Finding answers to your questions when you most need it is a really valuable skill that will enhance your clinical practice.

UpToDate

UpToDate requires a subscription but may be available for some individuals for free through institutional logins. Despite its relatively high price, this is my favorite resource and is great for questions around diagnosis (including differential diagnosis) and treatment recommendations. A phone application is also incredibly helpful on the go.

Orthobullets

Orthobullets is a great quick reference for injuries and orthopedic complaints. For example, they can give you guidance on the recommended management of a specific fracture. Most everything an EM provider would need is accessible for free, though there are paid portions of the website.

Radiopaedia

Radiopaedia is incredibly helpful when looking for the best radiologic study to answer your clinical question, and can also provide guidance in interpreting imaging once it has been obtained. They also have lots of example images that show both normal and pathologic findings, which is really helpful when trying to analyze imaging studies.

Below is a list of other websites that you might consider using, particularly for an emergency medicine perspective on important EM topics. Please remember that many of these sites are in a blog format and individual blog posts will vary in their level of scientific evidence with a base in peer-reviewed literature versus an author’s opinion and practice. Most all will utilize references in their posts and can help you delineate what content is following the standard practice versus a newly developing opinion or approach. Some of the best online EM content to consider:

Although there are dozens and dozens of podcasts that contain valuable content in emergency medicine, the standard-bearer has been EM:RAP. Though this resource requires a subscription, it does come with a native phone application and is free for EMRA members as a part of your membership, and their C3 (continuous core content) series is great for the highest yield topics in emergency medicine. Also, the Crackcast series systematically walks through Rosens and is a great adjunct or review tool.

Lastly, consider hardcopy or electronic versions of the foundational textbooks of emergency medicine: Rosen’s and Tintinalli’s. Also, the procedural textbooks ​Roberts & Hedges, or Reichman’s Emergency Medicine Procedures, cover all procedures, from basic to complex, that are within the scope of the practice of emergency medicine.

Cite this article as: J. Austin Lee, USA, "Key Resources for Emergency Medicine Providers," in International Emergency Medicine Education Project, May 24, 2019, https://iem-student.org/2019/05/24/key-resources-for-emergency-medicine-providers/, date accessed: October 18, 2021