Defibrillator: Clear!

Defibrillator clear
~ Jule Santos, Brasil ~ Leave a comment

So, this is your first day at your internship rotation in the Emergency Department. You see some movement in the resuscitation room, and someone shouts: CODE!

Then, you approach the team, excited to learn and help with cardiopulmonary resuscitation (CPR). The attending physician looks at you and asks: Do you know how to use the defibrillator?

What would your answer be?

Knowing the main functions of the defibrillator is essential but not enough; you need to get used to the model in your hospital to be able to help safely with an emergency.

Defibrillators are devices used to apply electrical energy manually or automatically. Their use is indicated for electrical cardioversion, defibrillation or as a transcutaneous pacemaker.

Later that day, another patient presents with unstable atrial fibrillation (AFib).

The attending suggests cardioverting the patient. Do you know how to prepare the defibrillator?

Defibrillation versus cardioversion

Both defibrillation and cardioversion are techniques in which an electrical current is applied to the patient, through a defibrillator, to reverse a cardiac arrhythmia.

Defibrillation

Defibrillation is a non-synchronized electrical discharge applied to the chest, which aims to depolarize all myocardial muscle fibres, thus literally restarting the heart, allowing the sinoatrial node to resume the generation and control of the heart rhythm, and reversing the severe arrhythmias. It is indicated for pulseless ventricular tachycardia and ventricular fibrillation during CPR.

Electrical Cardioversion

Electrical cardioversion is the application of shock in a synchronized way to ensure the electric discharge is released in the R wave, that is, in the refractory period because accidental delivery of the shock during the vulnerable period, that is, the T wave, can trigger VF. It is reserved for severe arrhythmias in unstable patients with a pulse. It can usually be an elective procedure.

Special Situations

Digital Intoxication

Digital intoxication can present with any type of tachyarrhythmia or bradyarrhythmia. Cardioversion in this situation is a relative contraindication, as digital makes the heart sensitive to electrical stimulation. Before considering cardioversion, correct all electrolyte imbalances, otherwise, the cardioversion can degenerate the rhythm to a VF.

Pacemaker / Implantable cardioverter-defibrillator (ICD)

Cardioversion can be performed, but with care. The inadequate technique can damage the generator, the conductive system, or the heart muscle, leading to dysfunction of the device. The blades must be positioned at least 12 cm away from the generator, preferably in the anteroposterior position. The lowest possible electrical charge must be used.

Pregnancy

Cardioversion can be used safely during pregnancy. The fetal beat should be monitored throughout the procedure.

Things To Consider

Keep your devices tested!

Working in the ED is not easy. This is the place where organization and preparation should be routine. Constant checking of materials and operation of the equipment must be the rule because the smallest detail can cause a difference in saving a life.

During adversity, it is necessary to remain calm, trying to not affect the reasoning and disposition of the team. It is an arduous job, it takes practice and a lot of effort. Errors can only be corrected after they are recognized and must have the right time to be exposed. It happens.

There is no time for despair, yelling and stress when it comes to CPR.

No conductive gel, what can we do?

The main guidelines regarding the use of the conductive gel used in the defibrillator paddles are:

  • Using the proper gel for this purpose is essential. The gel is an electrically conductive material that decreases the resistance to the flow of electric current between the paddle and the chest wall. The absence of conductive material can lead to the production of an arc that causes burns in the patient and the risk of explosion if there is an oxygen source very close, among others.
  • Avoid the use of gauze soaked in saline solution, as the excess serum can cause burns on the patient’s skin, but it is a reasonable option, in an emergency
  • Do not use the ultrasound gel
  • The preference is to use adhesive paddles that already come with their own conductive gel (but this is rare in Brazil).

Location recommended by Advanced Cardiac Life Support (ACLS)

Antero-lateral

One paddle is placed on the right side of the sternum, right below the clavicle and the other laterally where the cardiac appendix would be in the anterior or medial axillary line (V5-V6).

Adhesive paddles can also be placed in an anteroposterior position: The anterior one is placed in the cardiac appendage or precordial region, and the posterior one is placed on the back in the right or left infrascapular region.

During the shock, the provider must ensure that no one is in contact with the patient. A force of approximately 8k must be used to increase the contact of the paddles with the chest. Do not allow a continuous flow of oxygen over the patient’s chest to avoid accidents with sparks.

Complications

  • Electric arc (when electricity travels through the air between the electrodes and can cause explosive noises, burns and impair current delivery)
  • Electrical injuries in spectators
  • Risk of explosion if there is a continuous flow of oxygen during the shock
  • Burning of the skin by repeated shocks
  • Myocardial injury and post-defibrillation arrhythmias and myocardial stunning
  • Skeletal muscle injury
  • Fracture of thoracic vertebrae

References and Further Reading

  1. Sunde, K., Jacobs, I., Deakin, C. D., Hazinski, M. F., Kerber, R. E., Koster, R. W., Morrison, L. J., Nolan, J. P., Sayre, M. R., & Defibrillation Chapter Collaborators (2010). Part 6: Defibrillation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 81 Suppl 1, e71–e85. https://doi.org/10.1016/j.resuscitation.2010.08.025
  2. Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W., Drennan, I. R., Hirsch, K. G., Kudenchuk, P. J., Kurz, M. C., Lavonas, E. J., Morley, P. T., O’Neil, B. J., Peberdy, M. A., Rittenberger, J. C., Rodriguez, A. J., Sawyer, K. N., Berg, K. M., & Adult Basic and Advanced Life Support Writing Group (2020). Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142(16_suppl_2), S366–S468. https://doi.org/10.1161/CIR.0000000000000916
  3. Ionmhain, U. N. (2020). Defibrillation Basics. Life in The Fastlane. Retrieved April 26, 2020, from https://litfl.com/defibrillation-basics/
  4. Paradis, N. A., Halperin, H. R., Kern, K. B., Wenzel, V., & Chamberlain, D. A. (Eds.). (2007). Cardiac arrest: the science and practice of resuscitation medicine. Cambridge University Press.
  5. Nickson, C. (2020). Defibrillation Pads and Paddles. Life in The Fastlane. Retrieved April 26, 2020, from https://litfl.com/defibrillation-pads-and-paddles/
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Question Of The Day #49

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most likely cause of this patient’s condition?
  • A) Sympathomimetic toxicity
  • B) Heat exhaustion
  • C) Heat stroke
  • D) Thyroid storm

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

Hyperthermia (or hypothermia) can cause altered mental status.  This patient arrives with altered mental status, severe hyperthermia, tachycardia, tachypnea, and hypotension.  The history of the patient running outside for exercise should raise concern for hyperthermia related to excess heat production due to overexertion.  This should narrow the differential diagnoses to heat exhaustion (Choice B) and heat stroke (Choice C).  Both heat exhaustion and heat stroke are marked by hyperthermia with temperatures often over 40ᵒC. Additional symptoms include weakness, nausea, vomiting, myalgias, syncope, and headache.  The differentiating factor between heat exhaustion and heat stroke is altered mental status and sweating.  Patients with heat exhaustion lack altered mental status and should still be able to thermoregulate through sweating.  On the contrary, heat stroke patients are more severely ill as they have altered mental status and can no longer thermoregulate with sweating.  The treatment in both conditions should be early and aggressive cooling measures.  This includes full body immersion in an ice bath, removal of clothes, and cold IV fluids.  Internal cooling with gastric, bladder, pleural, or peritoneal lavage with cold fluids can be done on more sick patients.  Antipyretic medications, like NSAIDs and paracetamol, have no benefit in patients with severe hyperthermia.  Evaluation for rhabdomyolysis, kidney failure, liver failure, sepsis, or other organ dysfunction should also be a part of the evaluation of hyperthermic patients.

Sympathomimetic toxicity (Choice A) is possible, but less likely as the skin is dry and the history of exercise outdoors.  Sympathomimetic toxicity manifests as diaphoresis, tachycardia, hypertension, hyperthermia, and sometimes altered mental status.  Thyroid storm (Choice D) is another possibility.  This diagnosis can also present with similar vital signs, hyperthermia, and altered mental status.  Again, the history of outdoor exercise should point more towards heat exhaustion vs heat stroke.

The diagnosis of this patient is heat stroke (Choice C) as he has altered mental status and lacks wet skin.

Correct Answer: C

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References

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Cerebral Venous Sinus Thrombosis

~ Sumaiya Hafiz, UAE ~ Leave a comment

One of the most frequent presentations in the ED is a patient complaining of headache. There is a wide range of differentials, such as mental illnesses to life threatening causes. Cavernous sinus thrombosis is amongst them, thus making it one of the main causes that need to be ruled in or out when a patient first presents to the ED with complaints of headache.

The most common presentation you may encounter or a presentation frequently asked in exams would be of a young female on oral contraceptive pills who presents with a headache and limb weakness. Although the list of differentials is long, cerebral venous thrombosis should definitely be kept amongst the top 3, as early diagnosis is key.

What is Cerebral Venous Thrombosis (CVT)?

CVT is the formation of a clot in the cerebral veins and the dural sinuses. The dural sinuses consist of the superior sagittal sinus, straight sinus, and transverse sinus. These are the sites commonly affected by clot formation. Rarely, it may present in cortical veins and jugular veins.

It is considered a type of stroke and is divided into three types: acute, subacute, and chronic.

Epidemiology and Risk Factors

Young patients between the ages of 20-50 years are most commonly affected, especially women of the age group are affected more compared to men.

People with factors contributing to Virchow’s Triad (stasis, endothelial injury, and hypercoagulability) are at a higher risk of getting affected. Other factors include – genetic disorders such as thrombophilia, APS – antiphospholipid syndrome, autoimmune disorders, malignancies, pregnant women, recent surgery, use of oral contraceptive pills, infections (most commonly sinusitis and meningitis), patients who recently underwent lumbar puncture, and catheterization of the jugular vein.

Anatomy

Cerebral veins are compromised of a deep and superficial system. The veins do not have valves. There are several connections between the veins of both systems and the sinuses.

Venous blood from cerebral veins drains into the major dural sinuses and the internal jugular vein. The superficial system mainly drains into the superior sagittal sinus and the lateral sinus.

https://radiologyassistant.nl/neuroradiology/sinus-thrombosis/cerebral-venous-thrombosis

Pathophysiology

How does it happen? The exact mechanism is unknown; however several studies propose the following theory: Thrombus formation in veins causes obstruction as the blood pools and raises pressure within the blood vessels and decreases CSF drainage. This CSF collection gives rise to intracranial hypertension and hydrocephalus, leading to the most common symptom patients present with – headache and stroke-like symptoms. Almost half of the cases have hemorrhagic transformation prior to treatment.

History and Physical Examination

The presentation is non-specific and may mimic other illnesses, making it one of the hardest to diagnose.

The history and physical examination findings depend on the extent of the thrombosis.

Some of the most common complaints in patients with CVT include-

  • Headache is the most common presentation – in the case of a patient complaining of sudden onset headache typical of subarachnoid hemorrhage, CVT should always be kept in mind as an uncommon yet possible cause.
  • Nausea, vomiting may also be present.
  • Seizures
  • Papilledema
  • Focal neurological deficits – weakness, gait, and visual abnormalities have all been reported
  • If the thrombosis extends to the jugular vein, there will be signs of multiple cranial nerve involvement :

Lesions in the superior sagittal sinus can present with seizures and motor dysfunction

Lesions in the left transverse sinus may cause patients to be aphasic

Lesions in the cavernous sinus could present with periorbital pain and visual changes

Lesions in deep venous sinuses may present with altered mental status

Differentials

  • Infections – meningitis, encephalitis
  • Trauma
  • Benign intracranial hypertension
  • 6th Cranial Nerve Palsy
  • Stroke
  • Cavernous sinus thrombosis

Investigations and Imaging

  • Full blood count – increased hemoglobin due to polycythemia, decreased platelet count, and increased white blood cell count are all important factors
  • In patients suspected to have hereditary hypercoagulable states, appropriate diagnostic tests may be done such as protein c and S deficiency, antiphospholipid syndrome, factor V Leiden
  • Lumbar puncture may be done if meningitis or encephalitis is suspected to be the cause
  • D-dimer level

Various imaging modalities are used to diagnose CVT, or the conditions leading to it. 

  • CT Scan- hyperdensity in the lumen- dense clot sign & Empty delta sign (filling defect in the dural sinus)
  • CT Angio 
  • MRI
  • Magnetic Resonance Venogram (MRV)- Gold standard

1) Empty delta sign

https://radiopaedia.org/articles/empty-delta-sign-dural-venous-sinus-thrombosis

2) Dense clot sign

https://radiologyassistant.nl/neuroradiology/sinus-thrombosis/cerebral-venous-thrombosis

3) MRV of the Cerebral Venous System (Saposnik 2011)

https://coreem.net/core/cerebral-venous-thrombosis/

Treatment and Management

t is important to treat CVT, including its cause and complications. CVT treatment is quite similar to the treatment of stroke with the use of thrombolysis and anticoagulation. The treatment modalities have been controversial due to the risk of bleeding, but several studies conducted showed a much greater benefit of anticoagulation and thrombolysis in patients with CVT. Parenteral administration of Heparin or the use of Enoxaparin is preferred in the acute phase.

In patients who do not improve by anticoagulation treatment, thrombolytics are administered systemically or catheter directed. Common thrombolytics used are Tenecteplase and alteplase. After acute management, patients are prescribed warfarin for 3-6 months duration.

Treating the cause includes appropriate antibiotic coverage for infections, methods of lowering intracranial pressure, anticonvulsants for seizure control and care must be taken to prevent aspiration in patients with focal neurological deficits.

Prognosis

Death due to herniation is common, and decompressive surgery to prevent this has greatly reduced morbidity and mortality. The mortality associated with CVT is 5%.

Things To Consider

As the emergency physicians are the first ones to evaluate the patient, any patient who presents with stroke-like symptoms, headache – especially first occurrence and extremely painful, with a significant history of blood disorders or oral contraceptive use, CVT should be considered, and the appropriate tests must be ordered in order to make a timely diagnosis and begin management to prevent morbidity and mortality.

References and Further Reading

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Recent Blog Posts By Sumaiya Hafiz

Question Of The Day #48

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

  • A) Hypercarbic respiratory failure
  • B) Hypoxic respiratory failure
  • C) Opioid overdose
  • D) Sepsis

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The first step in managing this patient should be to treat the hypoxia with supplemental oxygen.  Prolonged hypoxia is dangerous and if left untreated, can cause brain damage.  Hypoxia can cause altered mental status, however, when this patient’s hypoxia is resolved, she remains somnolent and altered.  This should raise concern over an alternative etiology for the patient’s condition.      

The arterial blood gas demonstrates a low pH (acidosis), normal paO2, elevated paCO2 (hypercarbia), and a normal HCO3 (no metabolic compensation for acidosis).  The final interpretation of the ABG would be an acute respiratory acidosis without metabolic compensation.  Acute elevations of pCO2 can manifest as somnolence and altered mental status as seen in this patient.  This is known as hypercarbic or hypercapnic respiratory failure (Choice A).  This condition is caused by the inability to exhale CO2.  Risk factors include obstructive lung diseases (i.e., COPD), obesity, and obstructive sleep apnea.  Treatment involves treatment of hypoxia with supplemental oxygen, non-invasive positive pressure ventilation (i.e., BIPAP, CPAP, High Flow Nasal Cannula), and treatment of the underlying cause.

The patient’s arterial blood gas does not show hypoxic respiratory failure (Choice B).  Since treatment of the patient’s hypoxia does not improve the patient’s mental status, hypercarbic respiratory failure is more likely the underlying cause of the patient’s condition.  Opioid overdose (Choice C) can cause a similar ABG and patient presentation.  The normal size pupils and absent history of drug abuse makes this diagnosis less likely. Sepsis (Choice D) can trigger changes in mental status and cause respiratory failure, however, the absence of infectious symptoms and the presence of obesity and COPD support hypercarbic respiratory failure as the more likely underlying cause. 

Correct Answer: A

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References

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Imposter Syndrome In The Medical Field

~ Brenda Varriano, Canada ~ Leave a comment

Authors

Brenda Varriano and Matthew Welch

Part 1: Imposter Syndrome and Current Model (Brenda Varriano)

“You’re a genius.” I am sure many medical students heard this claim. While I am confident my peers are intellectually gifted, I still question my own acceptance. How did I make the cut-off, and do I really belong here?

Much of this self-deprivation stems from the concept of Imposter Syndrome (IS). IS is a psychological pattern in which an individual doubts their skills, talents or accomplishments and has a persistent fear of being exposed as a “fraud.” The concept of IS was first described in an article by Clance and Imes in 1978. However, it is likely that IS had been around before its appearance in the literature. Many highly respected individuals such as Meryl Streep and Albert Einstein have reported experiencing IS. (Buckland, 2017) IS is the opposite of the Dunning-Kruger effect, which is a cognitive bias in which an individual overestimates their ability. While it is possible that some physicians and medical students overestimate their ability, IS is something experienced by most of my peers and my mentors in the ED. Therefore, the goal of this article is to discuss IS, it’s prevalence in the medical field, the current model used to describe it, how it is identified, treated and what we can do at the individual level when there are no other solutions. This article is timed when IS is highest in many US Medical students, when we prepare for our STEP 1 Boards Examination, the most important exam in our medical career. Therefore, I invited my colleague Matthew Welch to co-author this article with me, as we navigate studying and avoid the negative implications of IS.

IS was first described by Clance and Imes in a group of high achieving women (Clance and Imes, 1978). The authors noted that no matter how accomplished these women had become, they mostly expressed feelings of inadequacy, and that they were not deserving of their successes (1978). Research from academic settings has built on the work of Imes and Clance, stating that IS has been associated with certain personality traits (Langford and Clance, 1993). Some of these traits included introversion and trait anxiety (1993). Moreover, IS has been linked to a desire to appear intelligent in front of one’s peers, a propensity to experience shame and is more common in those with a non-supportive family (1993). In a study of 2,612 medical students that attended Jefferson Medical College between 2002-2012; it was found that IS was highly linked to burn out (Villwock et. Al, 2016). Furthermore, there appears to be differences among gender in those who are impacted from IS (2016). Females appear to be more likely to experience IS compared to males, however, there is a high level of burnout in both males and females that suffer from IS (2016). Villwock purports that the reason for burn out in medical students may be due to the environment of a medical school, where shame-based learning, may be a contributor to IS (2016). In such an environment, students experiencing IS may be less likely to participate in medical learning and can experience psychological distress, which may be contributing to burnout (2016). A more recent study has supported findings from Villwock, stating that gender and institutional culture were associated with higher rates of IS, and as a result, led to high rates of burnout among physicians and physicians in training (Gottlieb, 2020).

Figure 1: Clance’s (1985) model of the Imposter Cycle, as depicted in Sakulku & Alexander (2011).

To date, the concept of IS is based around the imposter cycle (Sakulku, 2011), as depicted in figure 1. The imposter cycle describes the theory behind IS, and the futile cycle between accomplishments and feelings of inadequacy. First an individual has a goal, which leads to anxiety, self-doubt and worry. In order to achieve this goal, the individual describes either procrastination or over preparedness. Once achieving the goal, the individual attributes it to luck if they had procrastinated to achieve it or effort if they had over-prepared. Despite the method to achieve the goal, accomplishment of the goal does not result in positive feedback, but leads to feelings of fraudulence, self-doubt, depression and anxiety.

Part 2: Solutions and Pitfalls (Matthew Welch)

My name is Matthew Welch, I am a second-year student at the Central Michigan College of Medicine. I am the first in my family to obtain a college education. Subsequently, the topic of IS is quite personal. In reviewing the literature, it has become apparent that the pitfalls and solutions to IS should be divided into three distinct categories: (1) Personal actions (2) Institutional actions (3) Actions for peers. Table 1 summarizes our findings regarding both the solutions and the pitfalls within each category.

Table 1: A summary of solutions and pitfalls of addressing IS in medical students divided into three categories based on the literature: (1) Personal actions (2) Institutional actions (3) Actions for peers.

Within the category of self, the consensus seems to be that a focus on one’s own mindfulness and emotional regulation can be successful in combating IS. I began a personal mindfulness meditation practice during my M1 year, and my experience aligns with the literature. By practicing mindfulness meditation for 10 minutes daily, I have noticed a dramatic difference in my ability to recognize and soothe my feelings of inadequacy. Beyond my anecdotal experience, research has shown that daily mindful practice leads to a significant reduction in activity within the amygdala, the brain’s stress center (Kral, 2019).

The strengths and weaknesses of institutional contributions to IS is vast. One theme that remains steady among all the literature however, is the effect of transitional periods. For example, IS seems to be higher during periods of transition from one life “chapter” to another. As anyone in medicine can attest, the years of training to become a physician often feel like a series of transitional periods. Beginning in undergraduate education, we transition into preclinical years, followed by clinical years and residency where expectations of our competency are continually increased.  After residency we are independent and expected to have an all-encompassing grasp on the vast information, we spent our entire medical education acquiring. While every step of this path is necessary for educating physicians, softening the harsh transition from one step to the next may be an area to explore solutions to the IS epidemic in medicine.

Finally, the subject of how our behavior affects our peers can be best summarized by a quote from Dr. Edward Hundert, Dean of Medical education at Harvard University;

Hundert likens this to a duck swimming in a swift current. On the water’s surface, the duck sits serenely, floating without effort, while below it is paddling furiously.

Miller, 2020

To help our peers, we must stop masking our own feelings of insecurity with blind confidence. Despite research showing rates of IS in medical students being somewhere in the range of 40% (Villwock, 2016). Any medical student will tell you that number is larger than reality. Moreover, the worst part of IS is the feeling of isolation. Therefore, as medical students, residents, and practicing physicians, we should be willing to admit that we are equally impacted by IS. While I frame this as a personal issue, I also recognize that medical education is designed to breed this behavior. We are constantly told that we are the “best-of-the-best,” and while some schools have moved to pass-fail curriculums, many of us are still continually ranked against our peers, even if inconspicuous in nature. This mentality can have a negative impact on student wellness in the classroom and beyond.

Finally, in the United States, it has only been recently announced that our score on the USMLE Step 1 examination has been altered to a pass fail. For example, previously if you scored below the 96th percentile, specialties such as dermatology/neurosurgery are no longer feasible options. While Brenda and I still must take part in this Hunger Games practice, I am happy that we are the last class to do so. In reducing the burden of the Step 1 examination, I believe we are supporting the mental wellbeing of students. However, IS still exists, and future discussions are warranted to reduce its impact and support the well-being of medical students and physicians at any stage in their career.

Acknowledgments

A special thanks to my colleague Matthew, who worked with me on this paper, which I believe is a particularly important topic in medicine. Please join me for my next article.

References and Further Reading

  • Atherley A, Meeuwissen SNE. Time for change: Overcoming perpetual feelings of inadequacy and silenced struggles in medicine. Med Educ. 2020;54(2):92-94. doi:10.1111/medu.14030Buckland, F. (2018). Feeling like an imposter? You can escape this confidence sapping syndrome. The Guardian, Health and Wellbeing, 1–8.
  • Clance, P. R., & Imes, S. A. (1978). The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241–247. https://doi.org/10.1037/h0086006
  • Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine, 81(4), 354–373. https://doi.org/10.1097/00001888-200604000-00009
  • Ingraham, B. L., Lerner, R., Nagai, A. K., & Shepard, J. D. (2001). Letters to the editor. Society, 38(2), A5–A6. https://doi.org/10.1007/s12115-001-1047-0
  • Jensen, D. M. (2018). 肌肉作为内分泌和旁分泌器官 HHS Public Access. Physiology & Behavior, 176(1), 1570–1573. https://doi.org/10.1038/s41395-018-0061-4.
  • Klassen, R. M., & Klassen, J. R. L. (2018). Self-efficacy beliefs of medical students: a critical review. Perspectives on Medical Education, 7(2), 76–82. https://doi.org/10.1007/s40037-018-0411-3
  • Ladonna, K. A., Ginsburg, S., & Watling, C. (2018). “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals about the Imposter Syndrome in Medicine. Academic Medicine, 93(5), 763–768. https://doi.org/10.1097/ACM.0000000000002046
  • Langford, J., & Clance, P. R. (1993). The impostor phenomenon: Recent research findings regarding dynamics, personality and family patterns and their implications for treatment. Psychotherapy, 30(3), 495–501. https://doi.org/10.1037/0033-3204.30.3.495
  • Miller, J. (2020). Tailored for Perfection. Harvard Medicine Magazine, 1–40. https://hms.harvard.edu/magazine/skin/tailored-perfection
  • Sakulku, J. (2019). Impostor Phenomenon. Encyclopedia of Personality and Individual Differences, 1–5. https://doi.org/10.1007/978-3-319-28099-8_2332-1
  • Villwock, J. A., Sobin, L. B., Koester, L. A., & Harris, T. M. (2016). Impostor syndrome and burnout among American medical students: a pilot study. International Journal of Medical Education, 7, 364–369. https://doi.org/10.5116/ijme.5801.eac4
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Recent Blog Posts By Brenda Varriano

Question Of The Day #47

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) 1000mL bolus of 0.9% NaCl
  • B) 25g of IV dextrose
  • C) 1mg of IV naloxone
  • D) 100mg of IV thiamine

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The initial approach to all Emergency Department patients, especially those with abnormal vital signs, should include a primary survey (“ABCs”, or Airway, Breathing, Circulation).  This patient is breathing independently but at a significantly reduced rate and is hypoxic.  Hypoxia should prompt the administration of supplemental oxygen to the patient and reassessment of the SpO2.  The patient’s reduced respiratory rate, lethargy, and bilateral miosis (constricted pupils) should strongly hint at the possibility of opioid overdose.  Although the patient is lethargic and hypoxic, establishing a definitive airway (endotracheal intubation) should be avoided until after the antidote to opioid overdose is administered.  Naloxone is a mu-opioid receptor antagonist and functions as the antidote to opioid overdose.

 

Administration of 1000mL of 0.9% NaCl (Choice A) is unlikely to fix the patient’s clinical condition.  The patient needs naloxone to improve respiratory status.  25g of IV dextrose (Choice B) would be helpful if this patient’s altered mental status was from hypoglycemia.  A normal glucose level is provided in the question stem.  100mg of IV thiamine (Choice D) may be helpful in the case of Wernicke-Korsakoff Syndrome, a state of thiamine deficiency often associated with malnutrition and alcohol abuse.  Wernicke-Korsakoff Syndrome presents with vision disturbances, ataxia, and confusion.  Typically, this syndrome does not present with severe lethargy or depressed mental status as is seen in this patient.

The best next step in management is 1mg of IV naloxone (Choice C).  If given appropriately, naloxone can prevent the need for intubation.  Naloxone has a very short onset to action (~1min).  If suspicion for opioid overdose is high and there is an inadequate respiratory response after a single naloxone dose, repeat doses of naloxone are appropriate.  Naloxone can be administered in repeat boluses every 3-minutes to a total dose of 10mg IV.  Patients who respond appropriately to naloxone should be observed for recurrent respiratory depression as naloxone is cleared.  Need for repeat doses of naloxone indicates the need for a continuous naloxone infusion and hospital admission.  The typical infusion dose is 2/3 the “wake-up” dose given over 1 hour as a continuous infusion.  For example, if the patient responded to 1mg IV initially, the continuous infusion dose would be 0.6mg/hour of IV naloxone.

Correct Answer: C

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References

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Autism in the Emergency Department

~ Ibrahim Sarbay, Turkey ~ Leave a comment

An Emergency Department (ED) is undoubtedly one of the most complex and chaotic places on earth where every individual can visit, regardless of age, gender, socioeconomic status, and existing conditions. Patients with autism may also visit EDs with any medical complaints. So, as Emergency Medicine physicians, what can we do to provide them the best health care possible? Of course, there is no limit to what we can individually do to help them, but it may be a good start to think about our EDs’ conditions and find the ways to improve them to serve ALL patients best.

About Autism

The Word “Autism” is derived from Greek autos (“self”) and  -ισμός (-ismós) (“-ism”) and was used for the first time by psychiatrist Eugen Bleuler in 1908. He used it to describe a schizophrenic patient who had withdrawn into his own world. Until the 1970s, many scientists confused autism with mental retardation and psychosis and blamed the parents for their lack of parental skills. “A morbid self-admiration and withdrawal within the self” was the definition of Autism in this time period. In the 1970s Autism correctly described at last as “conditions characterized by challenges with social skills, repetitive behaviors, speech, and nonverbal communication” and autism and schizophrenia were recognized as completely different conditions. Treatment modalities in autism have undergone a dramatic shift with the help of this level of awareness – from pain and punishment to behavioral therapies.

In 2013, the American Psychiatric Association merged four distinct autism diagnoses (autistic disorder, childhood disintegrative disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS), and Asperger syndrome) into one diagnosis: Autism spectrum disorder (ASD). (1)

Society’s Perspective

The fact that individuals with autism experience various difficulties in communication may cause them and their relatives to be “labeled” and encounter many problems throughout their lives, from education to transportation, from neighborhood relations to social life. It has been shown in various studies that families of individuals with autism are exposed to high levels of stress.

The general view and attitude of society are included in a wide spectrum of negative behaviors such as pitying, excluding, avoiding, and harming the individual with autism.

Why It’s Important to Be Cautious?

The average number of ED visits is nearly 30 percent higher for children with ASD, and their experience is generally far from good. In a comprehensive literature review, it was found that young patients (aged 0-17 years) with ASD were up to 30 times more likely to present to the ED, were likely to have repeat visits, and more likely to be admitted to the hospital. (2)

Caregivers of children with ASD are more likely to report “difficulty utilizing services, lack of shared decision making and care coordination, and adverse family impact”. (3)

Because of language and learning problems, children with ASD may have difficulty understanding hospital procedures and medical tests, which can increase their already high-stress levels. In addition, ED personnel often do not have enough knowledge about the special needs of patients with ASD. (4)

Early mortality is markedly increased in ASD due to a multitude of medical conditions. This is particularly important in ASD as it may indicate insufficient awareness of comorbid diseases, misdiagnosis, and mistreatment in the health system, in addition to the increased susceptibility to various diseases.

In a population-based cohort study, it was shown that the risk of death due to all diseases examined increased compared to the normal population. (5) In another study, all major psychiatric disorders, immune system disorders, nearly all medical conditions (including epilepsy, obesity, dyslipidemia, hypertension, and diabetes), suicide attempt and rarer conditions such as stroke and Parkinson’s was found to be significantly more common among adults with autism. (6)

These results indicate that physicians working in all medical specialties should have a better level of knowledge about ASD.

Remember These Words: See – Hear – Feel – Speak

There are many recommendations in various sources regarding the clinical approach to patients with ASD in the ED (7-10). In this article, I will be content with introducing a highly memorable 4-step system, which was developed by Samet and Luterman in order to facilitate patient-centered encounters with pediatric patients with ASD: (11)

Before examining a patient with ASD presenting to your ED, immediately think of these words: See – Hear – Feel – Speak.

Step 1: See – Remove non-essential visual stimuli. Dim the lights if possible, or try to place the patient in a dimmer room in the ED. Eliminate flickering lights like old fluorescents and avoid fluorescent lighting altogether if possible. Move active flashing lights or monitors out of the patient’s direct visual field.

Step 2: Hear- Remove excessive auditory stimuli before interacting. Turn off any unnecessary alarms or beeps from devices in the room, mute the TV, and move the patient to the least noisy room in the ED, if possible.

Step 3: Feel- Ask both the patient and care providers if they have any textures, which they find calming or agitating. Patients with ASD may have specific tactile stimuli they find soothing or aggravating.

Step 4: Speak – Say aloud in simple language to the patient everything you are doing before and as you are doing it. Ideally, speak directly in front of the patient’s plain view, because they may have difficulty with localizing the sounds.

Conclusion

It is possible to provide better healthcare to individuals with ASD through better training of health workers and structural changes to the EDs.

In this long journey to perfection, the first step could be increasing our awareness.

Because they deserve the best.

References

  1. Autism Speaks, What Is Autism?, Accessed June 4, 2021,  https://www.autismspeaks.org/what-autism
  2. Lytle S, Hunt A, Moratschek S, Hall-Mennes M, Sajatovic M. Youth With Autism Spectrum Disorder in the Emergency Department. J Clin Psychiatry. Published online June 27, 2018. doi:10.4088/jcp.17r11506
  3. IBCCES . Autism and the Emergency Department (ED): Why it’s Important. IBCCES. Published June 5, 2020. Accessed April 4, 2021. https://ibcces.org/blog/2020/06/05/autism-and-the-emergency-department-ed-why-its-important/
  4. When a Psychiatric Crisis Hits: Children with Autism in the Emergency Room. SPARK. Accessed April 4, 2021. https://sparkforautism.org/discover_article/when-a-psychiatric-crisis-hits-children-with-autism-in-the-emergency-room/
  5. Hirvikoski T, Mittendorfer-Rutz E, Boman M, Larsson H, Lichtenstein P, Bölte S. Premature mortality in autism spectrum disorder. Br J Psychiatry. Published online March 2016:232-238. doi:10.1192/bjp.bp.114.160192
  6. Croen LA, Zerbo O, Qian Y, et al. The health status of adults on the autism spectrum. Autism. Published online April 24, 2015:814-823. doi:10.1177/1362361315577517
  7. Taylor K, Cadman E, Burkitt S, Langseth A. G338(P) Improving the emergency department experience for children with autism, and their families. In: Association of Paediatric Emergency Medicine. BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health; 2018. doi:10.1136/archdischild-2018-rcpch.328
  8. Kirsch SF, Meryash DL, González-Arévalo B. Determinants of Parent Satisfaction with Emergency or Urgent Care When the Patient Has Autism. J Dev Behav Pediatr. Published online June 2018:365-375. doi:10.1097/dbp.0000000000000573
  9. Giarelli E, Nocera R, Turchi R, Hardie TL, Pagano R, Yuan C. Sensory Stimuli as Obstacles to Emergency Care for Children With Autism Spectrum Disorder. Advanced Emergency Nursing Journal. Published online April 2014:145-163. doi:10.1097/tme.0000000000000013
  10. Nicholas DB, Muskat B, Zwaigenbaum L, et al. Patient- and Family-Centered Care in the Emergency Department for Children With Autism. Pediatrics. Published online April 2020:S93-S98. doi:10.1542/peds.2019-1895l
  11. Samet D, Luterman S. See-Hear-Feel-Speak. Pediatric Emergency Care. Published online February 2019:157-159. doi:10.1097/pec.0000000000001734

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Question Of The Day #46

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) 1000mL of IV 0.9% NaCl
  • B) Noncontrast CT scan of head
  • C) 25g of IV dextrose
  • D) 150mL of 3% NaCl

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The serum chemistry results provided show elevated BUN and Creatinine with a BUN/Cr ratio of 21.3.  A BUN/Cr ratio greater than 20 indicates decreased perfusion to the kidneys, also known as pre-renal azotemia, which can indicate dehydration, hypovolemia, or shock.  The serum chemistry also shows a severely low sodium level.  Hyponatremia can present with a variety of symptoms, including weakness, fatigue, myalgias, nausea, vomiting, headaches, altered mental status, focal neurologic deficits, seizures, or coma.  Hyponatremia can be acute or chronic, asymptomatic or symptomatic, and mild or severe.  Sodium levels below 120 mEq/L are severely low.  Neurologic symptoms, such as seizures, altered mental status, and focal neurologic deficits, are also considered severe.  Treatment should be based on patient symptoms, rather than the sodium level, as it can be difficult to assess how acute or chronic the hyponatremia state is on initial evaluation.  The presence of any severe neurologic symptoms as is seen in this scenario should prompt administration of hypertonic saline (3% NaCl).  This allows for rapid correction of serum sodium levels, which should in turn relieve the neurologic symptoms.  A 100-150mL IV bolus of 3% NaCl can be given a second time if symptoms continue after 5-10 minutes.  

Typically, hyponatremia should be corrected slowly to avoid central pontine myelinolysis.  Increases in sodium greater than 8mEq/L per 24hours should be avoided for this reason.  However, in the case of neurologic symptoms, rapid correction of sodium is opted for to prevent further damage.

Administration of “normal saline”, or 1000mL of IV 0.9% NaCl (Choice A), can increase the sodium level.  However, normal saline is not concentrated enough to rapidly increase the serum sodium to terminate neurologic symptoms.  A noncontrast CT scan of the head (Choice B) is a reasonable investigation for this altered patient, but hypertonic saline should be administered first if hyponatremia is known.  Administration of 25mg IV dextrose (Choice C), also known as “D50”, would be helpful in a patient with hypoglycemia and altered mental status. However, this patient is not hypoglycemic.

Administration of hypertonic saline (Choice D) is the best next step in this patient with severe hyponatremia and neurologic symptoms.

Correct Answer: D

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References

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Student Engagement is a Priority on the Development Agenda

~ Mohamed Hussein, Egypt ~ Leave a comment

Introduction

Emergency medicine (EM) is a young specialty globally. Its origins can be traced back to the 1960s. As we move forward into the future, in 2019, approximately 82 countries worldwide (out of 194 countries) have recognized EM as a separate specialty. Emergency care systems in these countries are at various stages of development.

However, the mere fact that the specialty is recognized in a certain country does not mean that a modern model of EM clinical practice has been widely adopted throughout the said country. Many challenges remain in the face of the more widespread adoption of modern EM.

By far, the most important challenge in the face of any health care system is human resources. Highly trained personnel are a requirement to operate any system regardless of material resource capacity. You can have the most sophisticated machines readily available, but without the staff to utilize these machines, they will just sit in a dark corner, slowly gathering dust.

Potential causes of human resource limitation in emergency medicine

In countries where EM does not have a strong presence, it struggles to recruit medical graduates into its ranks. Students are deterred from the specialty because of misinformation and a fundamental lack of understanding of the unique role EM plays in a larger health care system. This deprives the specialty of a diversity that could have been harnessed to help the specialty achieve its maximum potential.

Thus, it is imperative that students be ‘engaged’ to ensure a correct exposure to EM. At the very least, you will have educated students, whether or not they ultimately decide to pursue EM as a specialty, on the importance of the role of EM. This has the potential added benefit of removing a lot of future interdepartmental resistance and greatly enhancing the motivation to ensure efficient collaboration between EM and other consulting specialties.

The building blocks of student engagement

The Clerkship

Student engagement can take multiple forms. For example, the basis for a student’s introduction to any specialty is usually the specialty’s clerkship during a medical education curriculum. This is ideally the foundation of any attempt to expose students to EM. However, many schools do not yet have an emergency medicine clerkship embedded in their curriculum. This is a gap that can be temporarily bridged using tailored FOAMEd products that are contextually relevant.

 

The Interest Group

building blocks
“Building Blocks” by André Hofmeister is licensed with CC BY-SA 2.0.

The next ‘building block’ is an extracurricular exposure to emergency medicine through a student interest group at their local institution. This allows students to explore emergency medicine in a more relaxed, non-didactic setting. This also presents the opportunity to network with EM faculty and other students that are interested in emergency medicine. It can additionally be an introduction to some soft skills such as leadership, presentation, and interpersonal skills. However, students at schools that do not have academic departments of EM face an inability to use this building block(and the previous block as well).

 

The ‘Student Council’

The final building block in student engagement would be a student section in the national (or international) emergency medicine organization. The advantages of this block are that it can precede all the other blocks and that its reach is very wide. It can, in a way, be the panacea to limited exposure to EM. A student section(or council) can also serve as the ‘interest group’ for students without access to one. This allows students to greatly enhance their leadership skills on a national scale. It also provides them with a front seat to both witness and contributes to the development effort.

Conclusion

It is vital to prioritize student engagement on the development agenda. This will ensure that the EM community can rely on a steady stream of young energies that can keep on carrying the fire. Hopefully, this will accelerate the adoption of organized emergency care worldwide.

In countries where EM is completely absent, it falls unto other countries where EM has taken the time to mature to harness the spirit of Ubuntu and to empower their fellow humans to take control of their own development. Then and only then can we ensure equitable access to high-quality, safe emergency care for ALL.

Further Reading(or watching):

Countries Recognize Emergency Medicine as a Specialty

The Importance of The Emergency Medicine Clerkship

Question Of The Day #45

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Administer IM haloperidol
  • B) Endotracheal intubation
  • C) Roll patient to lateral decubitus position and suction the airway
  • D) Obtain a 12-lead EKG

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

This patient’s altered mental status is likely due to a post-ictal state after a first-time seizure.  A seizure occurs when the brain is in a state of neuronal hyperactivity.  First time seizures can be caused by a variety of factors, such as hypoxia, hyperthermia, hypoglycemia, traumatic brain injury, brain tumors, meningitis, encephalitis, hyponatremia, or alcohol withdrawal.  It can sometimes be difficult to differentiate a seizure from a syncopal episode.  Both conditions cause loss of consciousness and both may include body convulsions.  Details that support a diagnosis of seizure over syncope include bowel or bowel incontinence, tongue biting, and confusion after regaining consciousness (post-ictal state).

Management of a patient having a seizure should focus initially on the ABCs (Airway-Breathing-Circulation) and terminating the seizure.  This involves first repositioning the patient to prevent aspiration.  A common maneuver is rolling the patient in the lateral decubitus position, performing a jaw thrust, and suctioning the airway (Choice C).  Administration of IM haloperidol (Choice A) is unlikely to terminate the seizure as it is an antipsychotic, not an antiepileptic medication.  Obtaining a 12-lead EKG (Choice D) is an important aspect of evaluating a patient with a potential seizure, however, the next best step in this seizing patient should focus on the ABCs and terminating the seizure.  Endotracheal intubation (Choice B) may be necessary in this patient to protect the airway, but patient repositioning (Choice C) and antiepileptic (i.e., benzodiazepines) administration are important initial steps prior to considering intubation.  The best next step in this scenario is Choice C.

 Correct Answer: C

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References

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Special Considerations for Homeless Patients in the Emergency Department

~ Helena Halasz, Hungary ~ Leave a comment

The emergency department is often the first place that a homeless patient steps into to seek medical aid, and as such, the special considerations in the care of this particularly vulnerable patient population is an important discussion for aspiring emergency medicine physicians.

In 2017, a YaleGlobal article estimated that there were approximately 1.5 million homeless people worldwide, which made up 2% of the global population at the time. In the same report, they noted that an estimated 1.6 billion people lacked “adequate housing,” which unfortunately has no specific definition and thus varies from country to country, as well as from study to study.1

Nevertheless, it is apparent that the numbers are staggering. For an in-depth overview of the statistics relating to homeless on a global scale, Wikipedia offers a list of countries by homeless population, linked here.2 Many of these individuals do not have easy access to maintenance healthcare and end up resorting to emergency services for both acute and non-acute issues.

Numerous studies have shown that homeless patients are generally high utilizers of emergency services; according to the Center for Disease Control in the United States, there was an annual average of 42 ED visits per 100 non-homeless people between 2015-2018, compared to an average of 203 ED visits per 100 homeless persons in the same timeframe.3

So the question becomes: what are some of the special considerations that we, as emergency medical staff, should be weighing when treating homeless patients? Here are some tips:

  1. Start thinking about disposition early, and, if your facility has access to them, get social workers involved as soon as possible. Take into consideration the closing time(s) of nearby shelters, and plan accordingly.
  2. Discuss and document your patient’s social history thoroughly; this can not only help whatever further research that may be conducted but also help build better rapport with your patient. Ask whether they live in a shelter or on the street, for how long, transportation needs, etc., and be sure to document key findings.
  3. Evaluate ability to perform activities of daily living, assess the level of functional independence and ambulatory capabilities.
  4. Provide clothing, food, warm blankets, and mobility devices, when appropriate.
  5. Assess access to follow-up healthcare. Familiarize yourself with the resources available: what are the organizations in your area that might be of help? Are there non-profits that work explicitly with the homeless population?
  6. Discuss any potential substance abuse and attempt counseling.*

* In the United States, consider obtaining an x-waiver, which would allow you to prescribe buprenorphine. For more information about the significance of the x-waiver and information on how to obtain one online for free, click here.

  1. Prepare discharge papers with clear, easy-to-understand instructions for follow-up and care. Avoid medical jargon and use comprehensible language; one recommendation suggests keeping language to a fifth-grader level.

Areas of improvement:

Each institution that deals with homeless patients will likely have its own protocols in place for its management. It is helpful to get acquainted with these protocols and to look around your emergency department to see if there is any room for improvement.

Below are some of the interventions which were undertaken, many of which ultimately showed a reduction in re-presentation and ED utilization, and could lead to an increase in patient satisfaction.

  • transition of care: a review examining the effect of various interventions in discharging homeless patients found that all three studied categories (those being case management, individualized care plans, and information sharing) had a modest impact, with varying degrees of success based on different studies.4
  • dedicated homeless clinics: a single-center study in 2020 found that a dedicated homeless clinic initiative reduced ED disposition failures and inappropriate ED visits, defined as seeking care for non-emergent conditions.5
  • transportation considerations: while some hospitals are able to subsidize travel costs (taxi vouchers, shuttle service, etc.), that might not be possible at all institutions, so alternatives should be considered.

[A 2012 community-based participatory research approach was undertaken to understand how homeless patients (n = 98) reflected on their care. Of the patients surveyed, 42% mentioned that there had been no discussion of transportation, while 11% noted that they had slept on the street the night after discharge.6 This goes to show how important it is to discuss disposition early and thoroughly.]

  • adding social determinants into electronic medical record-keeping systems: a paper reflected on the changes, such as adding fields for social determinants to the electronic health record (EHR) system, that were undertaken in Hawaii, USA.7 Some institutions tag their homeless patients in a certain way, but making changes at the EHR level could help integrate social needs into clinical care across multiple providers.

References and Further Reading

  1. Chamie J. As Cities Grow Worldwide, So Do the Numbers of Homeless. YaleGlobal Online. https://truthout.org/articles/as-cities-grow-worldwide-so-do-the-numbers-of-homeless/. Published 2017. Accessed June 8, 2021.
  2. Wikipedia. List of countries by homeless population. Wikipedia. https://en.wikipedia.org/wiki/List_of_countries_by_homeless_population#cite_note-1. Accessed June 8, 2021.
  3. QuickStats: Rate of Emergency Department (ED) Visits, by Homeless Status and Geographic Region — National Hospital Ambulatory Medical Care Survey. MMWR Morb Mortal Wkly Rep. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a8.htm. Published 2020. Accessed June 8, 2021.
  4. Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Reducing frequent visits to the emergency department:A systematic review of interventions. PLoS One. 2015;10(4):1-18. doi:10.1371/journal.pone.0123660
  5. Holmes CT, Holmes KA, MacDonald A, et al. Dedicated homeless clinics reduce inappropriate emergency department utilization. J Am Coll Emerg Physicians Open. 2020;1(5):829-836. doi:10.1002/emp2.12054
  6. Greysen SR, Allen R, Lucas GI, Wang EA, Rosenthal MS. Understanding transitions in care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. J Gen Intern Med. 2012;27(11):1484-1491. doi:10.1007/s11606-012-2117-2
  7. Trinacty CM, LaWall E, Ashton M, Taira D, Seto TB, Sentell T. Adding Social Determinants in the Electronic Health Record in Clinical Care in Hawai’i: Supporting Community-Clinical Linkages in Patient Care. Hawaii J Med Public Health. 2019;78(6 Suppl 1):46-51. http://www.ncbi.nlm.nih.gov/pubmed/31285969http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC6603884.

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Question Of The Day #44

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next investigation to confirm this patient’s diagnosis?

  • A) Lumbar puncture
  • B) 12-lead EKG
  • C) MRI of brain
  • D) Noncontrast CT scan of head

This patient presents to the Emergency Department with altered mental status.  This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.

ALTERED MENTAL STATUS

The information provided indicates that the patient’s headache was maximal at onset, severe, associated with vomiting, and led to a deteriorating mental status ultimately requiring intubation.  This history is very concerning for intracranial bleeding, especially subarachnoid hemorrhage (SAH).  The majority of atraumatic SAHs are caused by the rupture of a saccular aneurysm.  This causes the leakage of blood into the subarachnoid space.  Symptoms of a SAH are sudden onset headache that is maximal intensity at onset (“thunderclap headache”), syncope, vomiting, seizures, and any neurological deficits.  Risk factors for SAH are age over 50years-old, family history of SAH, alcohol abuse, tobacco smoking, Marfan Syndrome, Ehlers-Danlos Syndrome, and Polycystic Kidney Disease.  Diagnosis of SAH takes into account the patient’s history, physical exam, and risk factors. 

Patients that arrive in the Emergency Department under 6hours since symptom onset should initially get a noncontrast CT scan of the head (Choice D).  When a noncontrast head CT is performed in this time window, its sensitivity reaches 98-100%.  Noncontrast head CTs performed within the first 24hrs since headache onset have a sensitivity of about 90%.  Patients with signs and symptoms concerning for SAH who have a negative CT head should get a lumbar puncture (Choice A) to evaluate for xanthochromia.  This is especially important if the patient’s symptoms have been for over 6 hours.  A 12-lead EKG (Choice B) can show ST and T wave changes, but an EKG alone cannot be used to make a diagnosis of SAH.  A brain MRI (Choice C) can make the diagnosis of SAH, but a CT scan would be preferred due to greater CT scan accessibility, cost, and the shorter time of this imaging test.  The best next investigation would be a noncontrast CT of the head (Choice D).

Correct Answer: D

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References

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