Why Emergency Medicine?

Emergency Medicine in Brazil is still a small baby. In some states, it’s crawling, like here in Brasília. But even so, it already made my eyes shine. In Brasilia, we are moving to graduate the first group of emergency physicians. Several people were struggling for this to happen. And today, I’m going to talk a little about them, and why I decided to do emergency medicine, even though I’m still in the fourth year.

It is quite common for many medical students to have doubts about which residency to choose as if this decision were unique and definitive, and that weighs heavily. During the fellowship of an Airway course, I overheard one student from the last year say, “I have not yet found the specialty that makes my eyes shine.” And that made me think about how lucky I am because I’ve already found it. My intention here is not to make you choose Emergency Medicine as your only option, but to show you that the most serious patient needs the best doctor and the best treatment. It is to show you that the emergency department has to be ready for all the patients who can open through emergency doors, from the child to the elderly. And if you’re like me, who did not settle for a specialty that focused on only one part of the human body, you’re going to fall in love with the Emergency Medicine as well.

why emergency medicine 2
[BLS class offered by EMIG for medical freshmen] A great opportunity to improve knowledge, train and even teach!

I arrived at the emergency department of a hospital in the capital as a confused student, who still had no idea of my rotation. And whoever accepted me was the most fantastic doctor I could meet, no less than the boss of the state’s Emergency Medicine residency program. Well, I did not know that great detail of the time. But watching her play that “red room” was like watching an orchestra. Each bed is an instrument, which she commanded with mastery. I had never seen anything like it. She knew what she was doing. She was young and a strong woman. That by the standards of Brazil, borders the absurd, but there she was. In a public hospital, she was treating each patient as royalty. She maintained a firm posture, taught the students, and knew how to lead the team. It was beautiful to see. I knew that’s where I wanted to be; I knew I wanted to be at least 20% of the doctor she was. Despite the initial fear I had of her, little by little, she became my mentor. It was a big milestone in my life. She showed me what Emergency Medicine is and what is still going to be here in Brazil. And so, I was diving more and more into Emergency Medicine.

jule santos 2
Dra. Jule Santos
why emergency medicine 4
Rebeca is President of EMIG in Brasilia (LEM.DF : Emergency Medical League of the Federal District). They are medical students of different years who meet every two weeks for classes and practices focused on Emergency Medicine, with the help of doctors, teachers and proctors of different areas.

She taught me that the emergency department is not the messy garage entrance of a hospital. At least it should not. Here in Brazil, we face the overcrowding of emergency department and lack of resources. So an emergency physician here needs to be more than good, needs to be creative and resilient. However, generally in the country, the doctor who takes care of these patients is the most inexperienced. It’s usually the one who just got out of college and needs to work to earn money. And this needs to be changed. Some doctors saw this inconvenient situation and fought for it to be changed. But every change hurts, and it takes a lot of strength. Gradually, the movement grew. After several battles, Emergency Medicine managed to have an association of its own that finally took on the role of creating it. That’s why students with interest in the area are so valued, after all, it’s us who will keep this legacy.

jule santos 3
[Airway Management Course] Offered by "Emergencia Rules," blog by Jule Santos. Contact with residents and the participation of various events will open up several opportunities for you, such as assisting in the organization of for an important course for Emergency Medicine.

I also learned from her the importance of being humble and training whenever possible. After all, the best professionals in each area spend more hours training than acting. Perfecting your technique, strengthening your mindset, is a must in medicine. Train, study, and be humble to recognize that you don’t know everything. Being an emergency physician is having to deal with every situation. You don’t have to deliver a diagnosis now, but the patient has to be stabilized until someone else can take over. And to reach this level of saying to death “not today,” you need to study and train!

why emergency medicine 3
[Rebeca B. Rios and Jule Santos] On the poster it says: I am the person you will want on call the day you have a heart attack. A phrase from Jule's book: Born to be Wild

If you are a Brazilian medical student and interested in the area, here are some tips. Be part of an EMIG (Emergency Medicine Interest Group). Thus, you will have contact with residents and preceptors of the area. Engage in the different opportunities within the Emergency Medicine field that arise, such as events and courses. Look for the associations in Brazil, and also outside the country. Accompany shifts with an emergency physician, so you can feel a little of the specialty and understand what your day to day life will be like. After graduating from college, you must take the test for the Emergency Medicine Residency. The residency lasts three years and already exists in several Brazilian states. After three years of residency, you must take the specialty exam (title test), to become an Emergency Medicine specialist. And if you can find your Emergency Medicine mentor in college, know that your path will become clearer, know that you will enter a world where you can hardly get out, because that’s the Emergency Medicine. A world far beyond only the doors of the emergency department.

Dedicated to Jule Santos.

You May Also Like To Read

A Farmer’s Dilemma

Farmer's Dilemma

Case Presentation

It was a rainy night preceding my morning shift as a year 3 EM resident at one of our training centers in Abu Dhabi. The paramedics barged in with an agitated patient, who was found soaking wet in a farm field.

According to brief history that we got from the paramedics, the patient works at a farm and his boss found him collapsed, cold to touch and confused in the early morning hours. Paramedics also reported a confused, hypothermic, and tachycardic patient. They brought him directly to the ED, with no accompanying friends or family.

As we proceeded to resuscitate the patient, we noted that his initial vital signs did confirm hypothermia of 32 Celsius measured rectally, tachycardia, hypertension, and normal O2 saturation. We hooked him to the monitor, removed his wet clothing, gained IV access, started him on warm IV fluids, and covered him with blankets and a warming Bair Hugger (a warming blanket system).

Physical Exam

The patient was confused, agitated and uttering incomprehensive words, with a GCS of 11 (E3 V3 M5). I proceeded to examine him looking for more clues of why he was laying semiconscious under the rain all night. Systematic physical examination revealed pinpoint pupils, frothing and excessive salivations. Furthermore, diffuse mild crackles were noted on chest auscultation, and he was tachycardic with a regular rate and rhythm. Remaining physical exam was unremarkable, and a complete neurological exam was challenging.

Differential Diagnosis and Workup

Thinking of a broad differential diagnosis of altered mental status, systematic consideration of all possible etiologies similar to our patient presentation was reviewed. We have considered metabolic derangements, head trauma, CNS causes such as seizures and post-ictal status, infectious causes such as pneumonia or meningitis, and toxicologic causes, such as alcohol withdrawal, or medications overdose.

You may find useful this mnemonic for altered mental status!

ALTERED MENTAL STSTUS

Further management plan included giving him benzodiazepines for the agitation and possible post-ictal status. We collected basic blood work and proceeded for a head CT to rule out traumatic or atraumatic intracranial pathologies. Blood workup was inclusive of an alcohol level, Aspirin, Acetaminophen level, and a urine toxicology screen.

As the patient returned from the CT, he apparently had passed the copious amount of loose stools, that smelled surprisingly like garlic that studded the ED with its smell.

The head CT was normal, and most of his blood workup came back unremarkable. But, he remained confused and agitated as the benzodiazepines were wearing off and despite all the warming measures. ECG showed only sinus tachycardia, and a chest X-Ray was unremarkable.

smells like garlic!

What do you think? What are the causes for this?

agents smells like garlic

phosphorus, tellurium, inorganic arsenicals and arsine gas, organophosphates, selenium, thallium, dimethyl sulfoxide
Learn More

The garlic smell did give us a lead though, we thought further of possible toxic agents that may give such a smell, along with a consistent similar clinical picture.

Case Management and Disposition

Collecting our clues once more, we had pinpoint pupils, frothing, salivation, wet lungs, vomiting and loose motions. Patient’s collective symptoms and signs indicated a Cholinergic Toxidrome, possibly due to Organophosphates ingestion.

The patient was already decontaminated with removal of all his clothes. All healthcare providers were equipped with personal protective equipment.

This was confirmed an hour later when his farm owner showed up with a Pesticides Bottle that he found near him in the early morning hours before calling an ambulance. Pesticide is shown in Figure. The content of the bottle is consistent with Organophosphates Toxicity, and hence his Cholinergic Toxidrome.

Pesticide Bottle Found Next To The Patient.
Pesticide Bottle Found Next To The Patient.

He was started on Atropine, and Pralidoxime, assessed and admitted to the ICU with arranged psychiatric consult to assess his suicidal ideations once he stabilizes.

Critical Thinking and Take-home Tips

A collection of symptoms and physical signs caused by a certain toxic agent.

Cholinergic
Anticholinergic
Sedative/Hypnotic
Sympatholytic
Sympathomimetics

Cholinergic toxicity represents a cholinesterase inhibitor poisoning. It results from the accumulation of excessive levels of acetylcholine in synapses. Clinical picture resulting from the Acetylcholine build up depends on the type of receptors that it stimulates and where is it found in the body. It can stimulate the nicotinic and muscarinic receptors. The balance of these stimulations reflects such clinical presentations.

Think of the symptoms that can be caused depending on the type of receptors affected by the buildup of acetylcholine.

Muscarinic Receptors – SLUDGE(M)

  • Salivation
  • Lacrimation
  • Urination
  • Diarrhea
  • Gastrointestinal pain
  • Emesis
  • Miosis

Nicotinic Receptors (NMJ) – MTWThF

  • Mydriasis/Muscle cramps
  • Tachycardia
  • Weakness
  • Twitching
  • Hypertension
  • Hyperglycemia
  • Fasciculations

These are called the Killers B’s which consist of Bradycardia, Bronchorrhea and Bronchospasm.

Decontamination should always be considered first in all cases with possible hazardous exposure from the patient and his environment to all health care providers in contact with him. All caregivers should wear appropriate personal protective equipment’s and make sure to remove all clothing and possible objects with the suspected contaminant.

Supportive care is a cornerstone to all unstable patients, make sure that they are monitored, with proper IV access and supplemental oxygen as needed.

Furthermore, airway management is lifesaving in similar patients, as bronchorrhea is one of the killer B’s and can lead to high fatality.

Antidotes such as Atropine and Pralidoxime in Cholinergic toxicity are paramount, as they help reverse the etiology, and prevent further worsening of the toxicity.

Make sure that such patients are admitted under needed specialty care with proper observation and reassessment for the patient.

Consult a toxicologist if feasible in your center to provide you with further management details and interventions that can help your patients better.

Conclusion

Organophosphates can be found in pesticides, chemical weapons such as nerve gases, and few medications as well such as neostigmine or edrophonium. They are highly lipid soluble making them easily absorbed via breathing and skin contact as well. Encountering similar patients, it is quite important to always be systematic in your approach, resuscitate your patient first, and make sure to use your history taking as feasible and physical examination to collect all the clues needed to narrow down your differentials and find the most appropriate treatment needed for your patient.

References and Further Reading

  1. Organophosphate toxicity on WikEM: https://www.wikem.org/wiki/Organophosphate_toxicity
  2. Das RN, Parajuli S. Cypermethrin poisoning and anti-cholinergic medication- a case report. Internet J Med Update. 2006;1:42–4.
  3. Aggarwal, Praveen et al. “Suicidal poisoning with cypermethrin: A clinical dilemma in the emergency department.” Journal of emergencies, trauma, and shock vol. 8,2 (2015): 123-5. doi:10.4103/0974-2700.145424
  4. Lekei EE, Ngowi AV, London L. Farmers’ knowledge, practices and injuries associated with pesticide exposure in rural farming villages in Tanzania. BMC Public Health. 2014;14:389. Published 2014 Apr 23. doi:10.1186/1471-2458-14-389

Suggested Chapters and Posts in iEM

Some Hints About Airway!

Some Hints About Airway!

Introduction

The airway is one of the most critical topics in the ER. Read everything about the airway; it is not a waste of time. Even if you have to spend one year just for airway, it is worth it. You will always be confident in dealing with whatever situation that might come to you. Although reading is essential, practicing and getting experience on airway issues is essential too. So, reading along with exposing many patients is a great combination to achieve good skills.

Build your own skills by reading then summarizing your own words. As long as it is correct and safe, the way accomplishing or securing the airway may not be important in many patients.

Here are some tips in airway management at the Emergency Department (ED)

I will mention some points that might help in the management of typical scenarios at the ED. They might look random, but trust me, it is the real deal.

  • Preparations

  • Attach the patient to monitor
  • Check the vitals,
  • Check saturation continuously,
  • Open IV lines (2x) and attach a bag of normal saline,
  • If the blood pressure is low use pressure cuff on the fluid’s bag,
  • If the patient maintains oxygenation don’t bag, just leave the mask on. Moreover, do not forget; bagging is not a safe procedure.
  • Your equipment’s; choose your tube size depending on the patient’s size, size of the laryngoscope
  • Make capnography ready
  • Call the respiratory therapist, if you don’t have one, you check the ventilation machine by yourself
  • Keep bougie on the side, and SUCTION! Doesn’t matter Yankuer or not anymore, as long as it takes away whatever is on your way. Don’t go too deep to avoid vomiting.
  • Raise the bed highest, keep the level of the patient up to your chest or even higher, the higher the better.
  • Have someone on your side in case you needed tracheal manipulation or pressure to facilitate the view.
  • Pay attention to hemodynamic parameters

  • Never intubate before knowing the blood pressure readings.
  • Never intubate with low blood pressure below 90 systolic.
  • Resuscitate then intubate.
  • Neutral hemodynamic resuscitation (some studies tried the use of paralytic agent alone, with local anesthetic on the glottis, the same idea as awake intubation, in case of hemodynamic instability to avoid the use of induction agents that might decrease hemodynamics). The risk of using multiple doses of an induction agent can cause hemodynamic instability.
  • However, if there is no contraindication, you can think of using ketamine to help boost the blood pressure.
  • Double the dose of your medication if the patient has low cardiac output. As with low cardiac output, the medication won’t reach fast; it might take longer than 4 min. There is no harm in increasing paralytic agents ONLY IF THE AIRWAY IS NOT DIFFICULT. Induction agents can be used as boluses also, but again be careful if the patient is unstable as it might worsen the condition.

Here is a great video summarizing hemodynamic issues in airway management

  • Intubation and beyond

  • Use direct laryngoscopy first, use the old school equipment to keep your skills fresh, but keep the video laryngoscope ready on the side. Some experts recommends using video laryngoscope blade for direct laryngoscope and if you need, just look to the screen.
  • Still failed multiple trials with the laryngoscope? Consider difficult airway. One of the recommendations is to “leave the tube in the esophagus and insert another tube; the other opening is definitely the trachea.” By the way, there are tools to understand the difficulty of the airway, so know and use it.
iEM-infographic-pearls-airway - Assessing Airway Difficulty
  • Rapid Sequence Intubation (RSI) and Delayed RSI: Delayed RSI used mainly in the ICU, and many authors hate this term. However, there is no harm if the patient is maintaining oxygenation, you can give a sedative and look before proceeding to RSI. Just don’t call this approach “RSI.”
  • Rocuronium or Succinylcholine; both will paralyze the patient; it is not about which one is better; it depends on the type of airway you are dealing with. If it is a difficult airway, you do not want to use rocuronium and end up bagging the patient for one hour. Using a short-acting agent is a smart move.
  • However, if it is easy, use it as it would help in paralyzing the patient for an hour, but doesn’t mean the patient is fine, do not forget analgesia/sedation!
  • The tube is in, yay! Good for you, but your work is not done yet. All of us been through the situation where we jump into the airway, insert the tube and leave. This is not a skill lab; it is a real patient. The patient is not moving does not mean he is fine, you paralyzed him but he can still feel. Insert the tube, attach capnography, bag, auscultate, make sure of the level of the tube’s depth, order x-ray STAT then start analgesia/sedation infusion! No matter how naive you are or had a blackout, use midazolam and fentanyl! However, please learn other options too, because different patients may require different agents.
  • Propofol infusion, the bright side of Propofol is its analgesic and sedative effect, although it has a high risk of causing hypotension.
  • The dilemma of which medication to use, as for induction or paralyzing. No one can tell you that one medication is better than the other. Read everything about each medication, understand it, then you make your own mixture.

As long as you keep reading, and updating your knowledge, with of course practice and exposure to different type of situations, you will always know how to deal with every situation.

Further Reading

A Case Of Cyanide Poisoning From Vitamin B17

Since their advent in the 1930s, ‘vitamin pills’ have shown a steady rise in both variety and consumption patterns in patients. Guided by the promise of a healthier lifestyle and overall wellness, the use of vitamin supplements has become increasingly commonplace and you would be hard-pressed to find a patient who isn’t on some form of regular vitamin. Most of these nutritional adjuncts are either indicated for chronic conditions or, at the very least, harmless additions to daily regimens and do not usually warrant a second thought when described during patient encounters in the ED. However, not all supplements are as benign as they might seem. The following case report details the events that unfolded when a 45-year-old male patient accidentally ingested more tablets than were indicated for a vitamin he had purchased online.

Case Presentation

A 45-year-old male presented to the Emergency Department with complaints of fatigue, shortness of breath and anxiety following a possible over-ingestion of vitamin supplement tablets. As per the patient, he ordered a bottle of vitamin supplements online and admitted to misreading the instructions on the label. Instead of the recommended one tablet per day dose, he reported taking eight tablets for the first time earlier that morning. The tablets were bought without the need for prescription and, according to the patient’s research, were meant to be “good for promoting long life and preventing cancer.” Upon arrival to the ED, the patient was visibly anxious and mildly diaphoretic, stating that “I know I took too many tablets. Am I going to be okay?”

Physical Exam

Examination revealed a tired-looking patient with vital signs significant only for mild tachycardia of 105 and spO2 95% on room air. Otherwise, physical exam was normal. 

ABG

The initial ABG and preliminary lab tests revealed no significant findings, mildly elevated lactate of 1.8, for which the patient was placed on fluids with observation.

Being a particularly busy shift at the Emergency Department, the patient’s presentation coupled with his history of seemingly harmless vitamin ingestion, did not produce an immediate cause for concern. Nevertheless, he was monitored frequently until his investigations returned, during which time he remained clinically stable and without any subjective complaint besides a persistent feeling of fatigue.

A second ABG was performed and, despite the fluids, demonstrated a rise in his lactate levels to 2.6. By this time, the patient’s companion had made their way to the hospital, carrying with them the bottle of pills he reported he took prior to the onset of his symptoms. The bottle of supplements was filled to about ¾ of its capacity, with the label indicating that each capsule contained 250mg of Vitamin B17.

Given the persistence of fatigue and rising lactate, the physician decided to perform an internet search on whether any adverse effects were linked to the over-ingestion of vitamin B17. While most sources claimed the supplement was relatively safe, with many ayurvedic webpages praising the vitamin’s numerous benefits, it was soon found that the vitamin had been shown in studies to be associated with the development of cyanide toxicity when taken in large amounts.

However, this toxicity apparently only seldom manifested in individuals who only consumed vitamin B17. Instead, the cases of cyanide toxicities observed occurred more frequently in groups of patients who had concomitant consumption of Vitamin C.

Returning back to the patient, further history taking revealed that the patient had, in fact, consumed vitamin C for the past one month after he had about flu and had failed to mention it earlier as it had ‘slipped his mind at the time.’ Considering the risks evident in the patient’s ingestion history and his worsening fatigue (at 30 minutes after the ED arrival, the patient had now become increasingly somnolent with profuse diaphoresis, maintaining O2 saturation at 94-96% on room air), the decision was made to manage the patient as a case of cyanide toxicity and hydroxycobalamin was administered.

What is Vitamin B17?

Vitamin B17, also known as Amygdalin, is a naturally occurring chemical compound that is found most famously in the seeds of fruits such as apricots, bitter almonds, apples, peaches and plum (1). At the molecular level, amygdalin is formed as a chemical combination of Glucose, Benzaldehyde and Cyanide. The cyanide component in amygdalin can be released by the action of Beta-Glucosidase and Emulsin- both of which are not present in human tissues. However, microorganisms present in human intestinal linings have been found to possess similar enzymes that effectively promote cyanide release from the Amygdalin compound. The resulting cyanide toxicity is therefore almost 40 times more toxic by the oral route when compared with IV injection of the compound (2).

A modified form of amygdalin has been available under the brand name ‘Laetrile’ since the early 1950s as an alternative treatment to fight cancer, though most studies have failed to show any such benefit in humans (3). While the US FDA continues to insist on the drug’s obvious cyanogenic effects, there exist numerous advocates promoting the potential benefits of taking Amygdalin. Despite years of regulation on the original Laetrile supplement, unregulated forms of Amygdalin (or Vitamin B17 as it is often called) continue to circulate the market and are available in most outlets without the need for a prescription.

Since the toxicity of amygdalin depends on intestinal conversion, peak levels of cyanide are usually reached at around 2 hours post-ingestion. A curious phenomenon was evidenced in studies which found that the conversion of amygdalin to cyanide in vitro was further accelerated when amygdalin was ingested with foods containing beta-glucuronidase (such as bean sprouts, peaches, celery, and carrots) or with a concurrent intake of high doses of vitamin C (4,5).

Cyanide Toxicity - Principles & Management

Oral intake of 500 mg of amygdalin may contain up to 30 mg of cyanide (6). A minimum lethal dose of cyanide is approximately 50 mg or 0.5 mg/kg body weight (7). Our patient had ingested eight 250mg tablets, totaling 2000mg of amygdalin, thereby exposing him to a dose of cyanide well above the lethal dose.

Cyanide has a famously dangerous mechanism of toxicity. It binds to the ferric ion on cytochrome oxidase in mitochondria and blocks the electron transport chain, thus halting oxidative metabolism and leading to cell death by interfering with mitochondrial oxygen utilization leading to cell death, hypoxia and lactic acidosis (8). Mild to moderate cases of cyanide toxicity manifest as tachycardia, headache, confusion, nausea, and weakness. Severe cases may present with cyanosis, coma, convulsions, cardiac arrhythmias, cardiac arrest, and death.

Treatment involves addressing the patient’s vitals, oxygen saturation and acidosis as well as administering the appropriate antidote as detailed in the Table below. A sequence of these medications can be incorporated or hydroxycobalamin can be administered alone, as was done in the case above.

Cyanide Toxicity Medication

Medication

Dosage

Mechanism of Action

Notes

Amyl Nitrite pearls
0.3mL (1 amp) inhaled prior to establishing IV
Induces methemoglobinemia (binds cyanide)
First component of cyanide kit Discontinue once IV started
Sodium Nitrite
300mg (10 mg/kg) IV over 3-5 minutes
Induces methemoglobinemia (binds cyanide)
Second component of cyanide kit Do NOT use if suspected concurrent Carbon Monoxide poisoning
Sodium Thiosulfate
12.5 g IV over 10-20 minutes
Binds cyanide to form thiocyanate (less toxic) which is excreted in urine
Third component of cyanide kit
Hydroxycobalamin
5 g IV over 15 minutes
Binds cyanide to form cyanocobalamin (Vitamin B12) which is excreted in urine
Can be used as a single agent May cause transient hypertension

Conclusion

As with most cases of toxic ingestion, the key to effective management is appropriate stabilization followed by rapid identification of the potential toxicity through focused history taking and physical examination of the patient. In cases such as the one outlined above, where the ingested agent is unfamiliar but poses a potential threat, efforts should be made to probe deeper into the potential side effects, interactions and toxicities of such drugs and the Poison Control Center contacted immediately when and where available to expedite successful treatment of affected patients.

For our patient, the decision to administer hydroxycobalamin was followed by admission to the ICU with serial investigations done to monitor for any metabolic derangements. The patient showed remarkable improvement in his symptoms over the course of 24 hours and was eventually discharged in a stable condition.

References and Further Reading

  1. National Center for Biotechnology Information. PubChem Compound Database; CID=656516,
  2. https://pubchem.ncbi.nlm.nih.gov/compound/656516
    http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+hsdb:@term+@DOCNO+3559
  3. Laetrile (Vitamin B17 or Amygdalin): Benefits, Myths and Food Sources, https://www.healthline.com/nutrition/laetrile-vitamin-b17
  4. Bromley J., Hughes B. G. M., Leong D. C. S., Buckley N. A. Life-threatening interaction between complementary medicines: Cyanide toxicity following ingestion of amygdalin and vitamin C. Annals of Pharmacotherapy. 2005;39(9):1566–1569. doi: 10.1345/aph.1E634
  5. Conjoint use of laetrile and megadoses of ascorbic acid in cancer treatment: possible side effects, 1979 Sep;5(9):995-7, PMID: 522711
  6. Newton G. W., Schmidt E. S., Lewis J. P., Conn E., Lawrence R. Amygdalin toxicity studies in rats predict chronic cyanide poisoning in humans. Western Journal of Medicine. 1981;134(2):97–103.
  7. Shragg T. A., Albertson T. E., Fisher C. J., Jr. Cyanide poisoning after bitter almond ingestion. Western Journal of Medicine. 1982;136(1):65–69
  8. Physician Beware: Severe Cyanide Toxicity from Amygdalin Tablets Ingestion- 2017; 2017: 4289527, DOI: 10.1155/2017/4289527

Adventures on the Annapurna Circuit

For this blog entry, I want to share two issues I encountered while traveling in Nepal, just shy of my graduation from medical school: acute mountain sickness (AMS) and responding to a wilderness medicine incident as a medical trainee.

There is nothing more glorious

There is nothing more glorious than the period just after finishing medical school and before residency! For me, the highlight was being able to hike in Nepal. With the long travel time from Canada, and the multi-day itineraries most hikes necessitate, the post-grad period seemed like the ideal opportunity to make my dream of visiting the Himalayas come true.

Courtesy of Helene Morakis
Courtesy of Helene Morakis

I wrote my medical licensing exam, hopped on a flight and got ready to soak up the change of pace. While traveling, I found time to relax, (tried my best to) practice mindfulness and experienced the incredible kindness of Nepali people. Traveling was the perfect recharge that now has me geared up and excited for residency.

Annapurna Circuit

A few weeks before leaving for my travels, I began researching the Annapurna Circuit (APC). Having grown up at a staggering 240m above sea level in the Canadian prairies, I felt threatened by the Thorong La pass, which at 5416m is the highest part of the trek. My highest previous experience at altitude was 4200 meters, where I (unfortunately) developed Acute Mountain Sickness (AMS). My history of having AMS and following a typical itinerary for the APC put me at moderate risk for AMS(1). I decided to heed the Wilderness Medicine Society’s recommendation to take acetazolamide 125mg every 12 hours as prophylaxis(1).

Table reproduced from Luks, A. M. et. al 2019

While on the trek, I overheard many myths about AMS and sensed a general reluctance to take acetazolamide as prophylaxis(2). Himalayan Rescue Association does free daily teaching about AMS on the APC in Manang and on the Everest Base Camp trek as well(3). As we moved to higher altitudes, many guest houses and Annapurna Conservation Area Project outposts had accurate information about AMS and its consequences (High Altitude Pulmonary Edema and High Altitude Cerebral Edema). Surprisingly, despite this teaching and the availability of acetazolamide on the trail for purchase, there are still hikers that routinely require evacuation due to AMS, some by helicopter.

On the day before crossing the Thorong La Pass, I stopped for lunch with some trekking mates at Thorong Phedi (4538m). A few minutes passed before someone came into the guesthouse, visibly worried, requesting help from a doctor. It took me a few seconds (and my friends practically lifting me off my seat) to register that I could help! I was thankful to be hiking with an experienced nurse and we went to see the hiker together.

We were asked to see a fit hiker in his 60’s whose foot had been the victim of a rockslide. I clarified my training as a fourth-year medical student before asking details about the mechanism of injury and his past medical history. The hiker and his family were concerned and asked me to “rule out” a fracture. With positive Ottawa Ankle Rules findings, I wished for an X-Ray machine to rule out a clinically significant fracture(4). Keeping in mind there was no road access – the nearest road before the camp was in Manang (3500m, 15km away) or in Muktinath (3800m, 16km away) after the pass – the only ways out were by donkey or helicopter.

From a wilderness medicine standpoint, the injury was by all measures considered stable and the patient did not require an evacuation [reproduced from Isaac & Johnson 2013](5):

  • No deformity or instability on exam

  • No sense of instability reported by patient

  • Able to move and weight bear after accident

  • Distal circulation, sensation, movement (CSM) intact

  • Slow onset of swelling

  • Pain proportional to apparent injury

After a discussion with the patient, we decided that treating the injury as “stable” was reasonable and accepted the risk of delaying healing of a potential fracture. I recommended 24 hours of rest, ice (which kept the patient’s family busy fetching snow!), and elevation. I gave them ibuprofen to be administered on a regular schedule and instructed them to monitor CSM and plan an evacuation if there were any signs of impairment. I told the patient to continue the hike the following day if the pain did not increase with activity and to obtain medical follow up once they had returned to the city.

In hindsight, I recognized that I should have documented the encounter. I had written down the dosing of ibuprofen for the family, but I did not write a detailed SOAP (subjective, objective, assessment and plan) note. Properly documenting wilderness medicine encounters was a skill I learned in Advanced Wilderness Life Support. When we met the patient, he was generally well other than his foot injury. What if the patient’s condition worsened? What if the family forgot the plan in the stress of the situation?

I also found myself wondering about this patient long after I had left them. Reflecting upon this, I recognized that it is easier to “discharge” someone from an urban Canadian ED, where I have had most of my clinical experience because I know they can access good care if things change. The huge potential on the trail for loss to follow up made documentation much more vital in this case.

Later on, I pondered about the potential legal ramifications of helping this hiker. In Ontario, Good Samaritan laws protect health care professionals who provide first aid(6). From my understanding, there are no similar laws in Nepal, and there have been calls to define the rights and duties of those who witness or are requested to aid with an injury in the country(7).

In Nepal, I had a much-needed change of pace from medical school and plenty of time for reflection. I was inspired to see many organizations work together to educate guides, locals and hikers about AMS and hope to spend some time volunteering at the Himalayan Rescue Association in the future. Even after wilderness medicine training, being asked to provide first aid on the trail as a soon to be medical graduate caught me by surprise. I was happy to help and be able to have an approach to the patient in a low resource setting – and now recognize the importance of documentation.

I would like to hear your comments on this article: any experiences dealing with AMS, tips and tricks for musculoskeletal injuries in the wilderness setting, advice for navigating giving medical treatment outside of a hospital as a trainee or anything you would have done differently.

Courtesy of Helene Morakis

References

  1. Luks, A. M., Auerbach, P. S., Freer, L., Grissom, C. K., Keyes, L. E., McIntosh, S. E., … Hackett, P. H. (2019). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update. Wilderness & Environmental Medicine. https://doi.org/10.1016/j.wem.2019.04.006
  2. Kilner, T., & Mukerji, S. (2010). Acute mountain sickness prophylaxis: Knowledge, attitudes, & behaviours in the Everest region of Nepal. Travel Medicine and Infectious Disease, 8(6), 395–400. https://doi.org/https://doi.org/10.1016/j.tmaid.2010.09.004
  3. Himalayan Rescue Association. (2019). [online] Available at https://himalayanrescue.org.np/ [Accessed 30 Jun. 2019].
  4. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992; 21:384–90.
  5. Isaac, J. E., & Johnson, D. E. (2013). Chapter 13: Musculoskeletal Injury. In Wilderness and Rescue Medicine (pp. 84–85). Burlington, MA: Jones & Bartlett Learning.
  6. Good Samaritan Act, Government of Ontario (2001). Retrieved from the Ontario e-Laws website: https://www.ontario.ca/laws/statute/01g02
  7. Pandey, S. (2014). Good Samaritans. [online] The Kathmandu Post. Available at: https://kathmandupost.ekantipur.com/news/2014-07-13/good-samaritans.html [Accessed 30 Jun. 2019].

Further Reading

Clinical Video: abnormal hand twitching

Case Presentation

A 43-year-old female presented with altered mental status (GCS of 10/15) and abnormal twitching of hand. Reported to have a long-standing history of constipation and had been on laxatives. POC electrolytes showed Sodium: 110 mmol/L, Potassium: 3.5 mmol/L and Calcium: 0.71 mmol/L. The case managed as symptomatic euvolemic hyponatremia, hypocalcemia, and SIADHS.

Symptoms of hypocalcemia

Numbness and/or tingling of the hands, feet, or lips, muscle cramps, muscle spasms, seizures, facial twitching, muscle weakness, lightheadedness, and bradycardia.

Symptoms of hyponatremia

Nausea and vomiting, headache, confusion, loss of energy, drowsiness and fatigue, restlessness and irritability. muscle weakness, spasms or cramps, seizures, coma.

At the presentation time of the patient, you may not know these muscle spasms are because of hypocalcemia and hyponatremia’s similar symptoms. So, laboratory tests can clarify the diagnosis. However, in this case, both (Ca and Na) are low. So, you treat both. 

In addition

There are two findings related to hypocalcemia which worth to mention. Chvostek’s sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve. Trousseau’s sign is carpopedal spasm caused by inflating the blood pressure cuff to a level above systolic pressure for 3 minutes. This video shows both findings.

Do you need more free clinical images or videos for your exams or presentations? Please visit iEM clinical image and video archive in Flickr and YouTube!

Clinical Image: rhabdomyosarcoma?

862.1 - rhabdomyosarcoma 1

A 35-year-old male with a seven-month history of right supraclavicular mass. No compressive symptoms. Clinical and Xray interpretation was soft tissue rhabdomyosarcoma.

862.2 - rhabdomyosarcoma 2
862.3 - rhabdomyosarcoma 3

Rhabdomyosarcoma is one of the aggressive and malignant cancers of skeletal (striated) muscle cells. The cases are mostly young, particularly below age 18. It may arise from al body regions. However, head and neck, urinary and reproductive system, extremities are common locations.

Do you need more free clinical images or videos for your exams or presentations? Please visit iEM clinical image and video archive in Flickr and YouTube!

Venous blood gas analysis: Less arterial punctures!

Introduction

Blood gas analysis is probably one of the most used tests for diagnosis and therapeutic guidance in the emergency departments (EDs) and intensive care units (ICUs).

The evaluation of arterial blood gas (ABG) analysis is commonly used to estimate acid-base status, oxygenation and concentration of carbon dioxide (CO2) in critically ill patients. However, arterial blood (AB) may be difficult to obtain due to weak pulses or movement of the patient. Furthermore, because the thick walls and their innervation, it is more painful for the patient.

Therefore, venous blood gas (VBG) analysis is an alternative to estimate pH and other values in a quicker and easier way.

Venous blood gas analysis

Venous blood (VB) can be obtained from different places. You should always consider the location and the sampling method to interpret the results.

Figure 1 - Types of samples and locations for extraction

VBG analysis is an alternative for ABG in situations of low peripheral perfusion such as shock states of any etiology.

VBG has been studied in critically ill patients as an alternative in patients who do not have a central venous catheter (CVC) (Tavakol, 2013; Byrne, 2014). If a tourniquet is used to facilitate venous puncture, it should be released approximately a minute before the extraction in order to avoid changes induced by ischemia. (Cengiz, 2009). However, VB is preferred from a CVC given its higher correlation with AB. The values obtained from a VBG and an ABG are interchangeable in clinical practice, in both central VB (Malinoski, 2005; Walkey, 2010; Mallat, 2015) and peripheral VB (Malatesha, 2007; Chu, 2003; Kelly, 2001), except for the values of oxygen saturation (SaO2) and partial pressure of oxygen (PaO2).

VB Central VB Peripheral

pH

0.03 – 0.05 below arterial values
0.02 – 0.04 below arterial values

PCO2

4 – 5 mmHg above arterial values
3 – 8 mmHg above arterial values

HCO3

Minimal variation
1 – 2 mEq/L above arterial values

PaO2 / SaO2

No correlation
No correlation

Table 1 – Correlation between venous blood gases and arterial blood gases

Mixed VB (obtained from a pulmonary artery catheter) gives similar results to the values obtained from a CVC. (Ladakis, 2001; Tsaousi, 2010). One should be cautious when interpreting VBG, it has to be always correlated to the clinical state of the patient and if it is necessary, it should be confirmed with an ABG.

Central venous gas analysis

Central VBG analysis allows us to assess the metabolic state of a patient with a good correlation with ABG. Even though central VB is not adequate to assess oxygenation efficacy, this can be estimated by pulse oximetry. Likewise, central VBG analysis gives us central venous oxygen saturation (SatvO2), which is a very sensitive marker of the respiratory, hemodynamic and metabolic homeostatic variations. (Gattinoni, 2017).

Any change in the pulmonary, hemodynamic, metabolic or oxygen transport functions will affect SatvO2. In other words, when we assess SatvO2 value, we are analyzing the result of the interaction between all its determinants:

1) Oxygen input (respiratory system)
2) Oxygen transport (hemoglobin)
3) Oxygen availability DO2 (cardiac output)
4) Oxygen consumption VO2 (tissues).

Gasometric assessment of a central VB sample and its relation with the pulse oximetry will provide us with more information than an ABG analysis.

Global tissue perfusion

In recent year it has been shown that the difference between the value of CO2 obtained from mixed venous blood or central venous blood sample and the value of CO2 obtained from an arterial blood sample is correlated with an increased anaerobic cellular metabolism when the result shows values above 6mmHg. This increase in the veno-arterial CO2 difference is given by an increase of hydrogen in plasma coming from the intracellular environment because of anaerobic metabolism; these hydrogen molecules are buffered in plasma and metabolized to CO2. The causes of the increase in the veno-arterial CO2 difference are mainly due to hypoperfusion secondary to the inadequate cardiac output of mitochondrial dysfunction. (Ospina-Tascón, 2016). Likewise, the quotient of the veno-arterial CO2 difference and the arterio-venous O2 difference has been related with higher accuracy of the tissue perfusion status.

Conclusion

During the assessment of critically ill patients, the analysis of blood gases stands up as a fundamental step in the process of attention. A VBG analysis and SpO2 can give us enough information to make decisions even if there is no ABG analysis available, besides being easy to obtain a sample, implies less pain and less punctures in general. An indication of taking an AB sample is to assess tissue perfusion in severely ill patients.

References

Byrne AL, Bennett M, Chatterji R, Symons R, Pace NL, Thomas PS. Peripheral venous and arterial blood gas analysis in adults: are they comparable? A systematic review and meta analysis. Respirology. 2014 Feb;19(2):168-175. doi: 10.1111/resp.12225. Epub 2014 Jan 3. Review. PubMed PMID: 24383789.

Cengiz M, Ulker P, Meiselman HJ, Baskurt OK. Influence of tourniquet application on venous blood sampling for serum chemistry, hematological parameters, leukocyte activation and erythrocyte mechanical properties. Clin Chem Lab Med. 2009;47(6):769-76. doi: 10.1515/CCLM.2009.157. PubMed PMID: 19426141.

Gattinoni L, Pesenti A, Matthay M. Understanding blood gas analysis. Intensive Care Med. 2018 Jan;44(1):91-93. doi: 10.1007/s00134-017-4824-y. Epub 2017 May 11. PubMed PMID: 28497267.

Ladakis C, Myrianthefs P, Karabinis A, Karatzas G, Dosios T, Fildissis G, Gogas J, Baltopoulos G. Central venous and mixed venous oxygen saturation in critically ill patients. Respiration. 2001;68(3):279-85. PubMed PMID: 11416249.

Malatesha G, Singh NK, Bharija A, Rehani B, Goel A. Comparison of arterial and venous pH, bicarbonate, PCO2 and PO2 in initial emergency department assessment.  Emerg Med J. 2007 Aug;24(8):569-71. PubMed PMID: 17652681; PubMed Central PMCID:  PMC2660085.

Malinoski DJ, Todd SR, Slone S, Mullins RJ, Schreiber MA. Correlation of central venous and arterial blood gas measurements in mechanically ventilated trauma patients. Arch Surg. 2005 Nov;140(11):1122-5. PubMed PMID: 16342377.

Mallat J, Lazkani A, Lemyze M, Pepy F, Meddour M, Gasan G, Temime J, Vangrunderbeeck N, Tronchon L, Thevenin D. Repeatability of blood gas parameters, PCO2 gap, and PCO2 gap to arterial-to-venous oxygen content difference in critically ill adult patients. Medicine (Baltimore). 2015 Jan;94(3):e415. doi: 10.1097/MD.0000000000000415. PubMed PMID: 25621691; PubMed Central PMCID: PMC4602629.

Ospina-Tascón GA, Hernández G, Cecconi M. Understanding the venous-arterial CO(2) to arterial-venous O(2) content difference ratio. Intensive Care Med. 2016  Nov;42(11):1801-1804. Epub 2016 Feb 12. Review. PubMed PMID: 26873834.

Tavakol K, Ghahramanpoori B, Fararouei M. Prediction of Arterial Blood pH and Partial Pressure of Carbon dioxide from Venous Blood Samples in Patients Receiving Mechanical Ventilation. J Med Signals Sens. 2013 Jul;3(3):180-4. PubMed PMID: 24672766; PubMed Central PMCID: PMC3959008.

Walkey AJ, Farber HW, O’Donnell C, Cabral H, Eagan JS, Philippides GJ. The accuracy of the central venous blood gas for acid-base monitoring. J Intensive Care Med. 2010 Mar-Apr;25(2):104-10. doi: 10.1177/0885066609356164. Epub 2009 Dec 16. PubMed PMID: 20018607.

Further Reading

Self-Directed Learning

  • Diagnose your learning needs

    What I don’t know? What is important for me to know? i.e., “I’m not confident enough to quickly read and interpret an ECG with acute conditions - I think this is important to know.”

  • Formulate your learning goals

    What I expect to learn on this rotation? i.e., “I want to learn how to read an ECG in the ED effectively.”i.e., “I’m not confident enough to quickly read and interpret an ECG with acute conditions - I think this is important to know.”

  • Explore resources

    What resources are available for me to learn? Are there lectures available? FOAMed? i.e., “The medical staff are accessible, there are weekly ECG case discussions at the ED and FOAMed resources as the ECG library in the LITFL.”

  • Choose the learning strategies

    What is the best method for me? i.e., “I have a good visual memory, I may find it easier to take a look at the ECG library and then to discuss with my professor when the cases show up.”

  • Evaluate the outcomes

    Did I achieve my goals? i.e., “At the end of my rotation, I can successfully identify major acute conditions on an ECG.” After thinking about the outcomes you had and the goals you have achieved, you can identify your needs and establish learning goals once again.

The technique can sound quite simple – and it is! The hard part is to have it on your mind when you are about to start a new clinical rotation or observership, but it becomes part of your routine with a little time.

Reference

Education Theory Made Practical: Volume 1; Published by Academic Life in Emergency Medicine, San Francisco, California, USA, 2017  chap 7, pgs 59 – 69

Learning Experiences in the ED

Introduction

Every student, regardless of the area and grade, should have recognized that the process of learning is different depending on the environment and the situation. For medical students, it very often depends on the clinical rotation, the type of structure of the hospital and the epidemiologic profile of the population in the area. Thinking about the Emergency Department (ED), we have critical patients, urgent measures to be taken and no much time to have second thoughts, all of this in a very dynamic – sometimes chaotic – environment.

What is the evidence on Medical Education in the ED? How can we improve our experience as a student in such context? Is it possible to have – and give – good feedback? These are some of the points we are discussing in this article, which features a quick conversation with one of the most incredible and enthusiastic emergency physicians I ever know – and who has taught me a lot.

Juliana is an Emergency Physician. I had the pleasure to learn from her with in the field, as well as attending some of her brilliant lectures for the EMIG which I’m part of. She work as an emergency physician in São Paulo and th coordinator of the “Basic and Advanced Airway Digital Course."

What are the singularities you see when giving and receiving feedback in Emergency Department?

“It’s a very dynamic environment and, sometimes, the moment for feedback can be completely ignored if the opportunity is not taken at the right time since the room can always become even more chaotic. For me, one of the greatest advantages is that everything is happening here and now, and the learner can be observed and taught closely. However, this could be a problem if the learner feels insecure while being watched, or if the professor interferes too much during the procedure or the history taking and examination.”

How do you think learning takes place in this environment? Is it possible to learn and teach with each case without disturbing the emergency dynamics?

As I said earlier, although it is a very dynamic environment, I see an emergency department as a valuable environment for the teaching-learning process because we can take advantage from each case in its entirety (from the evaluation to the outcome) or in key situations, important for that learner. Also, the fact that the patient is right there, requiring interventions, instigates the student to want to participate, take action and understand what is going on. Another thing I like very much about teaching in this environment is how we can be very practical in exemplifying and exercising the ED mindset, developing in the learner the clinical reasoning of the emergency, which, as we know, operates in a different logic.”

With the recognition of the specialty in Brazil, what can change in relation to the teaching and mentoring in the emergency department?

“I think the change that many of us are already experiencing is to have emergency medicine specialists in these settings, which qualifies the teaching of mindset and the purpose of acute and severe patient care.”

What tips would you give to students who go through emergency medicine internships to learn more and better?

“One exercise I often do with my students is to always think not about what the patient has, but what he needs. In many cases, the definitive diagnosis is absolutely secondary in immediate care. That is the mindset. Another important point is to observe the emergency room like an orchestra, which the emergency physician is there to conduct: how do we organize physical space? What should I solve first? What patient needs most of my attention right now? What people from the multidisciplinary team are fundamental there? these are skills that we develop with practice, sometimes even without noticing, but when we pay attention to all of this we understand the complexity of the critical care, of the specialty, and the potential that the emergency medicine has in changing patient’s outcomes.”

And for teachers and residents, what tips would you give to improve students learning from the ED routine?

“Everything that shows up is an opportunity for learning, including an empty room, without patients: if you knew how much students don’t know about the physical organization of the room, support materials and ventilators, monitors, defibrillators, multi-professional teams and so on, we would not feel moments without patients as idle time. So I wanted to tell you never to let go of these moments. Another thing that is poorly discussed by us, but that in the Emergency Medicine is essential: health policies, emergency departments situation, organization of health structures. Emergency medicine is an excellent thermometer to measure the efficiency of the system and, if we stop and think a little, to discuss and debate the context that we are inserted (even without all the answers), we develop a more critical and interested generation, not only in Emergency Medicine but in improving the system as a whole.”

iEM Monthly – June 2019

Welcome to the iEM Education Project Monthly Newsletter. We will share the achievements, information about top posts, chapters, activities and future plans of the project.

Around the Globe

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Collaborative Work

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Downloads

ICEM2019

ICEM2019 was one of the very successful conferences of IFEM. Korean Emergency Medicine Society showed incredible organizational leadership and successfully organized such a big event for the world of emergency medicine.

Although there is a lot to talk about South Korean hospitality, foods and the Seoul city, we’d like to give some exciting numbers and highlights from the conference. There were 2725 attendees from 72 countries at the conference. 116 (4%) of the attendees were from middle and low-income countries. It is quite a high number if we compare to other ICEMs. Korean society did an outstanding job by offering discounted or free registration option for these countries. However, it is still 4%, and if we want to improve emergency medicine around the globe, we need to increase this number too. Australia was the country which had the highest attendees after South Korea, 173 and 1555, respectively. According to the conference scientific secretary, the longest registered attendee name was “Annuar Muhammad Zuljimal Bin Osman” from Malaysia. The first registrant was from USA, Eugene Kim. Highest group registration was Korean Fire Agency with 193 attendees. The youngest kid in the conference was 14 months old. Total scientific minutes were 12,030 in 29 topics. Siti Nasrina Yahaya presented 12 presentations at the conference, which is the highest number. Application of the conference downloaded 2,198 times. In 4 days, over 50 news released in media. There were 134 organizing committee members and 120 staff. The next conference ICEM2020 will be in Buenos Aires, Argentina (http://www.icem2020.net).

MOOC

One of the new project of the iEM is free massive open online course (MOOC) of Emergency Medicine for medical students who do not have structured Emergency Medicine training in their medical schools. The project aiming to create an adjustable course for different needs and various lengths. The content will be created under the guidance of the new IFEM undergraduate curriculum. 

The IFEM Core Curriculum and Education committee and IFEM Board gave us a green light to move forward to develop a MOOC and its certification process. 

IFEM Awards

The IFEM awards ceremony was held in the leadership dinner in Seoul during the ICEM2019. Melanie Stander, Vice-President of the IFEM and Prof. James Ducharme, President of the IFEM presented the awards right after the Gautam Bodiwala’s presentation regarding the history of IFEM awards. There are three awards of IFEM; Gautam Bodiwala Lifetime Achievement Award, IFEM Humanitarian Award, Order of IFEM Award. This year Gautam Bodiwala Lifetime Achievement Award was given to Prof. James Holliman. He is one of the significant figures of international emergency medicine who helped the development of emergency medicine in many countries. IFEM Humanitarian Award was given to the Korean Society of Emergency Medicine and Prof. Elisabeth M. Molyneux from Royal Collge of Emergency Medicine, UK. Order of IFEM Award entitles the recipients to use Fellow of the International Federation for Emergency Medicine (FIFEM). This year award was given to Prof. Lisa Moreno-Walton from American Academy of Emergency Medicine (AAEM president-elect), Prof. Anthony Lawler and Assoc/Prof. Sally McCarthy from Australasian College of Emergency Medicine, Prof. Arif Alper Cevik from Emergency Medicine Association of Turkey, Dr. Clifford Mann from the Royal Collge of Emergency Medicine, UK, and Dr. Lau Fei Lung from Hong Kong College of Emergency Medicine.

FIFEM Awardees – Lisa Moreno-Walton, Anthony Lawler, Sall McCarthy, Arif Alper Cevik, Lau Fei Lung, Taj Hassan (On behalf of Clifford Mann)

Arif Alper Cevik (FIFEM) and James Holliman (Gautam Bodiwala Lifetime Achievement Award)

Arif Alper Cevik who is the founder and director of iEM Education Project, was a fellow in International Emergency Medicine Fellowship Program in PennState University, Milton S. Hershey Medical Center which where Prof. James Holliman was a director. Both met in Vancouver, BC during the 7th ICEM conference in 1998, and their willingness to help and improve emergency medicine around the globe was a common topic in their discussion. But there is another common thing between them. They both born on the same day, 20th December. 

Blog Authors

There are two new blog authors joined our team in June, AlHanouv from KSA and Rebeca from Brazil. We welcome both of them. To see full blog authors team please click this link – https://iem-student.org/iem-blog-authors/

AlHanouv

KSA

I recently finished Emergency Medicine residency in KSA and continuing my training on Master of Healthcare Administration. From my little experience in working and studying Emergency Medicine, I have to admit that having such projects made things more easier and enjoyable. By using different ways of sharing knowledge, this has made a big difference in Physicians practices also in their confidence in being updated and discussing topics anywhere at anytime with everyone you can imagine. We can all benefit from each other by trying our best to find new ways in sharing/explaining knowledge in a more smoother way.

rebeca barbara rios

BRAZIL

I am a student at the end of the 3rd year of medicine, in Brasilia, capital of Brazil. I already contribute to ISAEM, with translations in FOAMed and also assisting in matters related to the national embassy. I am also Academic Coordinator of ABRAMEDE, the Brazilian Association of Emergency Medicine.

Blog Posts

We published 11 posts during June 2019. The article “Countries Recognizing Emergency Medicine As A Specialty” is the top read article in June, again. It reached 2426 views. 

Top Countries by Views

The iEM platform reached to 166 countries around the globe. In June, top countries by views are given below. 

Lover’s Fracture

A 35-year-old construction worker was brought in by the ambulance to the Emergency Department. He was reported to have fallen from scaffolding at the height of approximately 4 meters and landed onto the concrete floor below feet first. He was found conscious by paramedics but in obvious pain, holding his right leg. Upon initial examination in the ED, the patient remains vitally stable but complains of severe, persistent pain in his right ankle and heel. After adequate analgesia, an X-ray of the right ankle and foot revealed signs of a calcaneal "Lover’s" fracture (Figure 1).

Figure 1
Figure 1: Image courtesy of Annelies van der Plas, and J.L. Bloem - http://www.startradiology.com/internships/general-surgery/ankle/x-ankle/

Calcaneal Fractures

Before we begin our discussion on calcaneal fractures, it is important to highlight the major anatomical structures visible on a standard X-ray of the ankle and foot.

Figure 2
calcaneus and foot anatomy

Figure 2 shows a lateral x-ray of the right ankle, demonstrating the calcaneus as the bone – commonly referred to as the heel – that makes up the majority of the hindfoot.

As would be expected, the size and position of the calcaneus predispose the bone to various forms of injury. A calcaneal fracture is most often sustained after a road traffic accident or a fall from significant height onto the feet as was the case with our patient. Due to the mechanism of injury, it is often colloquially dubbed as “Lover’s fracture” or the “Don Juan fracture”(1).

Epidemiology

Among fractures of the hindfoot, calcaneal fractures comprise 50-60% of all tarsal bone fractures (2). These fractures are usually intra-articular (3) and occur more commonly in young men aged between 20 and 40 years. Diseases which decrease bone density, such as osteoporosis, invariably increase the risk for development of the fracture when injury occurs.

Patient evaluation

Patients with calcaneal fractures will often present in severe pain, though they may not always be able to localize the exact source for their pain. Swelling at the ankle or heel along with bruising (ecchymosis) can also be expected. Due to the mechanism of fall, injury usually occurs bilaterally. Most patients are unable to bear any weight onto the affected limb.

The lower extremity or extremities in question should undergo a thorough neurovascular exam, as diminished pulses distal to the injury (dorsalis pedis) could indicate arterial compromise and mandate aggressive investigation with angiography or Doppler scanning. Though the gold standard for diagnosing calcaneal fractures remains a CT scan, a plain film X-ray is usually obtained first which should include an Antero-Posterior (AP), a lateral, and an oblique view.

Bohler’s Angle and Critical Angle of Gissane

Historically, physicians would measure Bohler’s angle and the critical angle of Gissane in cases where a calcaneal fracture was not clearly evident on a plain X-ray. Outlined in Figure 3, a calcaneal fracture would be suspected if Bohler’s angle was below 20 degrees or the critical angle of Gissane was noted to be more than 140 degrees. Bohler’s angle was found to be a lot more diagnostically reliable when compared to the critical angle of Gissane (4). However, both these methods of diagnosis are now considered obsolete and the same research that studied that utility of the angles found that Emergency Physicians were able to accurately identify calcaneal fractures approximately 98% of the time without the measurement of either angle.

Figure 3
853 - bohler angle - calcaneus
854 - Gissane angle- calcaneus

Figure 3- Bohler’s Angle and Critical angle of Gissane

Management

The goal of initial management in the Emergency Department is centered on adequate pain relief, immobilization and wound care (including antibiotics when there are signs of a contaminated wound). [See the link for open fractures and antibiotic choices.]

An important point to note is that the mechanism of injury in calcaneal fractures (namely fall from height) is a form of axial loading. The energy from landing on the ground will often be transmitted up through the body, usually to the spine causing compression fractures of the vertebrae. The patient, however, may not complain about pain in other areas due to the overwhelming and distracting pain in the calcaneus. Therefore, all calcaneal fractures should be managed with a high index of suspicion for associated injuries.

Other potential complications include compartment syndrome, wound infection, malunion and osteomyelitis. All patients diagnosed to have calcaneal fractures should be managed by a multidisciplinary team that includes an Orthopedic Surgeon to ensure definitive management and repair of the fracture.

Take Home Points

  • High energy impact with axial loading, usually from a road traffic accident or a fall from height should raise suspicion of a calcaneal fracture.

  • Perform a thorough evaluation of the site of injury and suspect associated injuries (check the spine and remember to check the other foot for concomitant injury).

  • Maintain adequate analgesia (these fractures hurt!) and involve the Orthopedic Surgeon as soon as the diagnosis is made.

References and Further Reading

  1. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names? Radiographics. 2004;24 (4): 1009-27. doi:10.1148/rg.244045015
  2. Davis D, Newton EJ. Calcaneus Fractures. [Updated 2019 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  3. Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471
  4. Jason R. K., Eric A. G., Gail H. B., Curt B. H. & Frank L. Boehler’s angle and the critical angle of gissane are of limited use in diagnosing calcaneus fractures in the ED. American Journal of Emergency Medicine. 24, 423–427 (2006)