Give Me A Headache!

Headache

by Matevz Privsek and Gregor Prosen, Slovenia

A 52-year old male comes to the ED with a severe headache. A triage nurse gives you his chart and says that his vital signs are normal, but he does not look well. You start to question the patient, and the following history is obtained: his headache started approximately six hours ago. He was working in his office when he started to feel squeezing-like sensation in his head. The pain has gotten worse since then, but it is still tolerable. It is independent of any physical activity or position. He already had a few similar episodes of this kind of headache in the past two years, but now the pain does not go away after aspirin as it did previously. He denies trauma as well as any associated symptoms, e.g. no visual disturbances, hearing loss, weakness, dizziness, stiff neck, loss of consciousness. He is otherwise a healthy, non-smoker, with no regular therapy or known allergies. His clinical exam is unremarkable. Conscious, GCS 15, alert and oriented, normal skin color. Blood pressure 135/82 mm Hg, pulse 78/min, 14 breaths/min, SpO2 99%, body temperature 36,4 °C. Neurologic exam shows no declines from normal, as well as the rest of the physical exam.

 

slovenia
Matev Privsek, Slovenia
Gregor Prosen, Slovenia

How many headache patients you may encounter today?

Touch Me

3-5% of all ED patients

So, theoretically, if your ED sees 300 patients a day. You have a chance to see 9-15 patients in 24 hours. Not bad! 3-5 in an 8 hours shift.
Answer

What is your diagnosis ?

You set up an intravenous cannula, draw blood for testing, and gave the patient some parenteral analgesics (metamizole 2.5 g, ketoprofen 100 mg) along with 500 ml of normal saline. You put him into the observation room. Lab results (complete blood count, basic biochemistry panel) came back in 2 hours and are completely normal. The patient now feels much better, with almost no headache at all. Repeated vital signs and clinical exam are again unremarkable. You explain to the patient that most likely he had a tension headache, warn him about red flags regarding headaches, and discharge him home with a prescription for peroral analgesics with a follow-up at his general physician.

GI Bleeding in 12 min

Gastrointestinal Bleeding​

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley, USA

A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to the Emergency Department (ED) with a complaint of vomiting bright red blood that began prior to arrival. He arrives actively vomiting; a significant amount of blood is noted in his emesis basin. He is now complaining of dizziness and appears pale.

Overview

Gastrointestinal bleeding (GIB) can be generalized into two categories based on the site of bleeding. Upper GIB (UGIB) is defined as any bleeding that occurs proximal to the ligament of Trietz near the terminal duodenum. Lower GIB (LGIB) is any bleeding that occurs distal to the ligament extending to the rectum. Most GIB seen in the ED is attributed to UGIB with an incidence of 90 per 100,000 population. LGIB, on the other hand, presents with a rate of 20 per 100,000 population. LGIB is more commonly seen in the elderly but has a wide range of presentations and causes. As a result, the approach to LGIB has been less standardized.

In a patient without kidney disease, a BUN to Creatinine ratio is an important parameter to decide UGIB presence.

What is the magic number of BUN/Cr ratio?

Touch Me

BUN/Cr

In a patient without kidney disease, a BUN to Creatinine ratio that is elevated to greater than or equal to 36 is strongly associated with UGIB.
Answer

Secure With Square Knot

Topic

Today, we just wanted to emphasize a vital part of the suturing procedure which is sometimes forgotten. This is square knot. Simple, easy and important. 

Problem

Suturing is one of the most common procedures performed by medical student/interns in the ED. Although they are learning by practicing under supervision, many of the medical schools and clerkship programs still may not have formal suturing training sessions. Therefore, there are various fundamental differences in wound closure techniques. 

Many physicians may ignore the importance of square knot.

What do we want?

In the wound closure, we want to gather two sides of the wound and ensure that they stay in that position until the healing occurs. So, we need to keep the wound edges in the exact position. Therefore, we use different wound closure techniques. Suturing is one of them. If we do not consider securing the stitch with the square knot, wound edges may be separated by time, and some cosmetic or infectious consequences happen. 

What to do?

Every physician should pay attention to use the square knot if they want to secure the wound edges in place.

One minute video

Here is a sample from our video archive.

Take EM Clerkship Seriously!

This chapter describes how and why important the emergency medicine clerkship is. Although it aims to reach medical student/interns, there are many lessons to learn for us, educators.

The Importance of The Emergency Medicine Clerkship

by Linda Katirji, Farhad Aziz, Rob Rogers, USA

The Emergency Medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some programs may have an optional elective during the third year. Whether or not you plan to specialize in Emergency Medicine, the rotation is an important aspect of your medical education. The emergency room is a unique learning environment which is different than any other setting in the hospital. It provides clinical opportunities that are largely unavailable in other clerkships and rotations. During residency, many specialties will also spend a significant amount of time in the Emergency Department (ED). This may be within a structured EM rotation, or while admitting or seeing patients for a certain medical or surgical service. Therefore, it is important to gain an understanding of the flow of the ED as well as the particular thought process that must be employed with emergency department patients…

Hidden Facts!

Do you know"The Fishbowl Effect"

The Fisbowl Effect

Read a nice and short piece of paper of Sheldon Jacobson, MD
Read

Feel Responsible?

You may wonder "how to contribute"

Promoting Emergency Medicine and improving undergraduate Emergency Medicine education (UEME) are the responsibility of all of us. We believe that every academician, emergency physician, resident, intern, and the student has something to share with others, especially with who have limited resources. 

Well... There are many ways...

There are multiple ways to participate this global initiative. You can review the below options and contact us.

Update The Content

In 2020, there will be the second edition of the book/content for same platforms. We will update chapters. The priority to update the chapters will be given to original authors first. However, new authors and contributors can be the subject for this purpose.

Be A Section Editor

We have 22 sections in the book/content. Although we have section editors for some chapters, there is a need for more section editors.

Be An Author In The Book

Today, there are 130 topics/chapters in the book/content including quizzes. However, new chapters may be needed for 2020 (2nd) or  2022 (3rd) editions.

Be An Author In The Blog

The medicine is changing very fast, and content is becoming outdated over time. Furthermore, there are many important messages, topics, simple but important things we need to share with students/interns. Therefore, we open the blog section to emphasize some of them with short posts, screencasts, podcasts, infographics.

Be A Medical Image/Video Contributor

Finding freely available medical clinical pictures, videos, imaging pictures, etc. to use in the book formats is not easy. Actually, we recommend you to search on the internet and see the results. Although the internet is full of medical media, their quality, relevance, and permissions are not fully fit to use them in our chapters. Our authors tried their best to give original media and find the best freely available media options. However, there are a lot of media needed to provide a good resource for our trainees and educators in a complete package. Therefore, your contribution will be appreciated. We will use the image/video with your name (see example)

Be A Multiple Choice Question Contributor

One of the components of the project is providing a high-quality MCQ and different format questions to students in the chapters and separate quizzes.

Be a MOOC (Massive Open Online Course) Developer/Faculty for Medical Students/Interns

If you read the articles regarding emergency medicine clerkships in the world or if you travel the countries and discuss their undergraduate education with some of the local leaders, you easily recognize that there is a lot of gap between countries. Today, there are very few countries in the world has appropriately designed undergraduate emergency medicine education programs in their medical schools. The majority of the countries (even some developed ones) have no guideline, curriculum, enough resources (faculty members, etc.). This is one of the things we need to change as medical educators/enthusiasts. But, it will take decades. Until that time, we need to do something for undergraduate emergency medicine education globally. We need to provide some important aspects of the emergency medicine curriculum with well-designed modules and make it freely available. This will help to medical students/interns, first-year residents, clerkship directors who have limited resources. Therefore, two to three years time, we are planning to open these modules. If you eager to part of this, you are welcome.

As you see... There are many ways...

You reviewed the above options. 

If you feel responsible to improve international undergraduate emergency medicine education, this is your place. So,  please contact us, share your experience and resources with others.

We are looking forward to see you in the team

Elderly With Abdominal Pain!

Acute Mesenteric Ischemia

Rabind Antony Charles, Singapore

A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with diarrhea and vomiting. She says the pain is increasingly worse and has failed to respond to paracetamol and charcoal tablets. She has a history of hypertension, hyperlipidemia, and atrial fibrillation. She has no history of laparotomy. She is alert and oriented. However, she is in distress because of her abdominal pain. The pain score is 9 out of 10. Blood pressure: 96 over 56 mmHg, pulse rate: 125 (irregularly, irregular), respiratory rate 20, pulse oximetry: 98% on room air, tympanic temperature: 37.5 degrees Celsius. Heart sounds: (irregular) S1S2 positive. Lungs sounds are bilateral equal and clear. Abdominal exam reveals diffuse tenderness; it is worse in periumbilical region, no guarding, bowel sounds are sluggish. No scars or hernias noted. Per rectal exam: brown stool. ECG is given on the side.

Rabind Antony Charles

What is the mortality risk?

Touch Me

Mortality

rates can be between 60-80% especially in patients with greater than a 24-hour delay in diagnosis or presentation
Answer

Did You Encounter Poisoned Patient Today?

frog

"Approach to poisoned patients" is one of the core EM clerkship topics!

Poisonings

Harajeshwar Kohli and Ziad Kazzi, USA

An 18-year-old, previously healthy female, presents to the Emergency Department with nausea, vomiting, and tremors. She states 45 minutes ago she ingested an unknown number of diphenhydramine tablets (25 mg) in a suicidal gesture. Past Medical History: Depression, Medications: none. Social History: As per family member, she does not smoke or use illicit drugs. She is single and unemployed. Vital Signs: HR 110 bpm, BP 151/92 mmHg, RR 20 / min, Temp 38.5 degrees Celsius. Physical Exam: General Appearance: Mild distress, awake, appears to be hallucinating. Eyes: Dilated pupils bilaterally but reactive. Cardiovascular: Tachycardic, normal sounds, and no murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, non-distended, decreased bowel sounds. Neurologic: Normal motor power, normal cranial nerves, normal cerebellar exam, alert and oriented to self. Not oriented to location or date. Attention level waxes and wanes. Skin: warm, dry, no rash. Musculoskeletal: No deformities, no clonus, normal deep tendon reflexes.

Drugs Causing Anticholinergic Toxidrome

Touch Me

Most Common

Tricyclic Antidepressants, Diphenhydramine, Antihistamines, Jimson Weed, and Atropine
Answer

Have you never seen Jimson Weed?

Touch Me

Is this AAA going to be ruptured?

AAA rupture

Abdominal Aortic Aneurysm (AAA)

Lit Sin Quek

A 75-year-old obese man comes to the emergency department. He has history COPD, hypertension. He is a smoker and on regular follow-up with primary care. He describes sudden onset severe flank and back pain for past 2 hours. He denies any chest pain or dyspnea. He informs the physician about his chronic abdominal pain. His initial vital signs are HR 98 bpm, RR 24/min, BP 190/105 mmHg, T 36.9C. His examination revealed mild abdominal pain without rigidity or rebound tenderness. Bedside ultrasonography performed and the result is shown on the side.

What is the risk of rupture?

Touch Me

Risk of Rupture

increases with emphysema, smoking, hypertension. Regarding Powell’s (2003, 2007) study aneurisms above 5.5 cm have 9.4% to 32.4% rupture risk in one year.
Answer

Unbearable Attraction of Emergency Medicine

Where This Attraction Come From?

Emergency Medicine! It is maybe the most desired specialty all around the world. Countries are rapidly changing their systems to modern emergency medical care. Residency trained emergency physicians are the cornerstone of this change across the globe. Today, more than 65 countries have recognized Emergency Medicine specialty. The demand is still so big, and all systems are facing to Emergency Physician shortage. However, it is not the reason why thousands of students/interns apply for a single position every year. 

This summer many new Emergency Medicine residents will start their new career. They are the winners! They chose the best specialty ever. They chose to be the advocate for their patients. They chose the challenge themselves to save a life, many lives. 

Want to understand more “why?” We have 3 chapter to share with you. You may prefer to read or listen. Every medical student and intern should know these facts; the facts that make our specialty unique. 

Emergency Medicine: A Unique Specialty

Will Sanderson, Danny Cuevas,
and Rob Rogers

Imagine walking into the hospital to start your day – ambulances are blaring, the waiting room is clamoring, babies are crying…

Choosing the Emergency Medicine As A Career

C. James Holliman

The specialty of Emergency Medicine (EM) is a great career choice for medical students and interns. In August 2013, I celebrated my 30th year in full-time EM clinical practice…

Thinking Like an Emergency Physician

Joe Lex

Why are we different? How do we differentiate ourselves from other specialties of medicine? We work in a different environment in different hours and with different patients more than any other specialty. Our motto is “Anyone, anything, anytime.”

Core EM Clerkship Topics

Continue reading “Core EM Clerkship Topics”