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
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
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.
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.
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on.
Often, junior doctors (including myself) find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures.
I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting.
These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
Breath sounds and pulses need to be checked in every patient!
Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
Always ask yourself what could the differential diagnosis be? How would you treat the patient?
Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
I recently have been working on a few different projects that have caused me to stop and reflect, “what is emergency medicine”. This specialty is very young within the house of medicine, compared to most other medical specialties. And while other specialties developed out of an attention to anatomical region or approach to diagnosis and treatment, emergency medicine has developed in large part to fill a gap in the healthcare workforce and address a specific needed skillset within healthcare systems.
Different health systems around the world have different structures and models of care. Some countries have developed robust primary health care systems with universal coverage for all citizens, while others have adopted alternative models of preventative and acute care. There is even greater diversity in how individuals seek and receive care for urgent and emergent health needs. The spectrum of the quality and availability of emergency care often varies within countries as well, contrasting highly populated urban centers against rural communities, or between different counties/provinces.
As a frame of reference, emergency medical care is any unscheduled episode of care for an acute health problem. It should be available 24 hours a day and systems should aim for patients to be dispositioned to inpatient units, taken to the operating room/theater, or discharged for outpatient care. Ideally, patients should spend less than 24 hours in the emergency ward, it is meant to be a short-term waypoint for diagnosis, treatment, and disposition. The skills and approach to emergency care are focused on the initial management, stabilization, and resuscitation of ill patients, as well as making targeted diagnostic and treatment decisions. Emergency care units shouldn’t be built to do any and all testing and treatment, but should complement other care pathways within the health system.
In much of the world the emergency ward is the most common entry point to hospitals and inpatient care. And specialized training in emergency medicine improves the quality of patient care with associated reductions in morbidity and mortality. Emergency medicine providers must be capable of treating all age groups, across undifferentiated and potentially routine or life-threatening patient presentations. And yet, there are days when an emergency medicine provider may not encounter any patients with a true life-threatening emergency, but rather may only see patients with a variety of complaints that exist here and now, and require attention to limit longer-term morbidity or mortality. Conversely, other days may have multiple critically-ill patients all at once. Usually, those attracted to emergency medicine enjoy the diversity of presentations, and it would seem almost no two days at work are the same.
As alluded to above, the emergency departments existed as a triage ward quite some time before the development of a specialized education and training in emergency medicine. And in many emergency care wards around the world today, patients are seen by students or junior doctors with little interest or training in emergent medical conditions. It is also important to remember that most emergency department patients are undifferentiated and evaluating a patient for causes of a single complaint requires a thorough history, exam, and targeted diagnostic testing. This skill set is how an emergency medicine provider can assess a patient who presents with chest pain and distinguish a myocardial infarction from a pulmonary embolism from musculoskeletal pain. To me, this is the real benefit of emergency medical education and specialized care: there are so many treatments and disposition pathways any singular chief complaint can lead to.
But, most anyone reading this post is likely familiar with the need for improved emergency care around the world. And as more countries recognize emergency medicine as a specialty and as more individuals decide to dedicate their career to providing high-quality emergency medical care, the global (and local) standards will continue to improve. An ever-growing body of evidence-based care continues to refine when and how we care for different conditions. And it’s so important that we continue to address the multitude of “unscheduled” health needs for our patients. Continue to adapt emergency medicine to your context and improve the care for your patients; as one of the most well-known EM-education podcasters often says: “what you do matters”.
As a medical student, presenting history and physical exam of a patient to the attending can be nerve-wracking. In the ED, physicians typically prefer an even more succinct presentation than usual, ideally less than 3 min. Case presentations are a great opportunity to show that you understand what the pertinent positives and negatives for the patient’s presenting complaint are and that you can summarize a large amount of information collected in an organized manner. Case presentations are your opportunity to impress your preceptor, so it is an important skill to master. It will also be the mode of communicating with the rest of the healthcare team throughout your career in medicine. Better communication = better patient care!
Before we get started, it is important to recognize that every physician may have their own preference for how they would like case presentations organized. Some prefer more details, and some prefer a specific order. Therefore, it is always a smart idea to ask your preceptor at the beginning of your ED shift if they have a preference for how they like cases to be presented.
The One Liner
State the patient’s name, age, sex, chief complaint, and any pertinent medical history. E.g., John Doe is a 16-year-old male with a history of eczema presenting with wheezing.
History of Presenting Illness (HPI)
include the details of the chief complaint, as well as any pertinent positives and negatives.
Why did this patient present to the ED today?
What are the details of the chief complaint? I.e. Onset, Duration, Progression, Alleviating and Aggravating Factors, Causes/Triggers, Changes with Position, etc.
For pain, it is helpful to describe OPQRSTU – Onset, Position, Quality, Radiation, Severity, Temporal, déjà vU (has it ever happened before).
Any associated symptoms
Any risk factors?
Any relevant past medical history (e.g. chronic conditions, hospitalizations, surgeries, etc.), family history, or social history (e.g. habits, living situation, alcohol consumption, smoking history, illicit drug usage)?
Review of Systems
Describe any other symptoms here.
Note that some ED physicians may not want a review of systems included in the oral case presentation if it does not include any additional pertinent information, but a review of systems should always be included in your written patient note.
if the patient states that they do not have any allergies, this can be recorded and/or stated as “NKDA” which stands for No Known Drug Allergies.
Physical Exam Findings
Start off by stating the most updated set of vitals.
Next, state the patient’s general appearance as this helps decide between sick vs. not sick. E.g., patient is alert, oriented, and in no apparent respiratory distress.
Then, delve into the pertinent details of the physical exam. E.g. for a cardiac complaint, it is important to include the specific details of the cardiovascular exam and respiratory exam, but not of all the other systems.
A brief overview of the other systems that a physical exam was conducted for can be useful, but be as concise as possible, and organize information in a head-to-toe fashion if needed. If there were no other findings, you can state that the remainder of the physical exam was unremarkable.
In 2-3 sentences, gather the main findings of your history and physical exam. Be sure to restate the initial one-liner sentence, other pertinent positives and negatives, and any important test results so far.
State your differential diagnosis for each problem.
Start off by stating what you think the most likely diagnosis is, and why you think it is the most likely.
Then, state any other likely diagnoses you are suspecting.
Lastly, state the deadly diagnoses that could be possible with this patient’s chief complaint. In some cases, this can be the first thing you may want to say. It is important to specify why you do or do not feel confident in ruling these out. E.g., in a baby presenting with fever of unknown origin, it is important to state why you are not (or are) suspecting meningitis, encephalitis, malignancy, or autoimmune conditions.
Many medical students will shy away from stating their impression of what could be going on in terms of differential diagnosis, but this is an important thing to attempt. Preceptors will appreciate your effort in synthesizing what could be going on and be impressed by it, even if your impression is incorrect. This is often what sets apart students that “meet expectations” vs. students that are considered “outstanding”.
What do you want to do next?
Plan includes anything from the tests you want to order (including repeat vitals, bloodwork, and imaging), immediate treatment (including analgesics and fluids), and referrals you want to make (including consults, admission/discharge plan, and referral to allied health professionals such as social work, speech-language pathology, occupational therapy, and physiotherapy).
Do not forget to take the patient’s social history into account when deciding what to do next.
Congrats – you have now completed your oral case presentation! This is a skill you will continue to develop with practice, so do not worry and keep working at it. It is also a good idea to always ask your preceptor for feedback on your case presentation once it is complete, as that will help you identify your strengths and weaknesses.
References and Further Reading
Davenport C, Honigman B, Druck J. The 3-minute emergency medicine medical student presentation: a variation on a theme. Acad Emerg Med. 2008 Jul;15(7):683-7. doi: 10.1111/j.1553-2712.2008.00145.x. PMID: 18691216.
Cough is one of the most common complaints presenting to any emergency physician or primary care practitioner – whether it is the chief complaint or an associated symptom. An acute cough is one that has been present for less than three weeks. In the era of COVID-19, a patient presenting with an acute cough can be alarming and scary. So, now more than ever, it is important to develop a strong diagnostic approach to the acute cough, which is largely a clinical diagnosis.
Differential Diagnosis of Acute Cough
*Indicates the most common causes of acute cough.
Symptoms / warning signs
Upper respiratory tract infection aka common cold*
Rhinorrhea, nasal obstruction, sneezing, scratchy/sore throat, malaise, headache, and no
signs of consolidation
Recent upper respiratory tract infection, and absence of COPD, and absence of high fever or other systemic signs
Fever, sore throat, nasal congestion, myalgia, headache, and no signs of consolidation
Fever, tachycardia, tachypnea, consolidation signs on respiratory exam, and mental status change in patients >75y old
Whooping cough and cough-emesis
Fever, non-productive cough, fatigue, dyspnea, and/or other less common symptoms such as sore throat, diarrhea, headache, skin rash, and anosmia
drip aka upper airway cough syndrome
Post-nasal drainage sensation, need to clear throat, and rhinorrhea
rhinitis aka hay fever
Itching and watering of eyes, rhinorrhea, pruritis
of a pre-existing chronic disease
Exacerbation of Asthma
History of episodic wheezing, non-productive cough, dyspnea, reversible air-flow obstruction, allergen exposure or triggered by exercise
Exacerbation of COPD
Smoking history, dyspnea, signs of obstruction on respiratory exam i.e. decreased
breath sounds, and irreversible air-flow obstruction
Exacerbation of CHF
Dyspnea, orthopnea, peripheral edema, gallop rhythm on cardiac exam, and elevated JVP
ACE inhibitor use
Non-productive cough, tickling or scratchy sensation in throat typically arising within 1 week of starting medication
reflux disorder (GERD)
Heartburn, regurgitation, dysphagia, and cough is more prominent at night
Other pulmonary causes
Clinical signs and symptoms of DVT, dyspnea, tachypnea, tachycardia, pleuritic chest pain,
immobilization for 3 or more days, surgery in the past 4 weeks, history of DVT/PE, hemoptysis, and malignancy with active treatment in the past 6 months
Smoking history, new change in cough, hemoptysis, dyspnea, night sweats, weight loss, and signs of focal obstruction on respiratory exam i.e. decreased breath
Foreign body aspiration
Dyspnea, inspiratory stridor, choking, and elevated risk in children
Acute inhalation injury
History of exposure to smoke (e.g. in firefighters, thermal burn victims) or chemicals (e.g. chlorine, ammonia)
Large volumes of purulent sputum, dyspnea, wheezing, and chest pain
Interstitial lung disease
Non-productive cough, dyspnea, fatigue, weight loss
Picture the scene: A 23-year-old female presents to the emergency department with a cough that has been ongoing for one week. What are your next steps?
Confirm the duration and timing of cough
Nature of cough, i.e. whooping, hemoptysis, and productive vs non-productive?
Presence of the following associated symptoms: fever, dyspnea, sore throat, headache, chest pain, heartburn, rhinorrhea, facial pressure/pain, nasal congestion, or weight loss
History of any chronic lung disease (i.e. asthma, COPD), allergies, CHF, or immunosuppression?
Medication history, i.e. ACE inhibitor use?
HEENT exam (head, eyes, ears, nose, and throat)
Cardiac exam, including JVP
Send for COVID-19 swab according to your hospital’s guidelines
Order CBC if suspecting infection
Order ABG if dyspnea present or life-threatening cause of acute cough suspected
Order sputum culture if suspecting bacterial pneumonia
Spirometry if need to differentiate between obstructive lung disease (e.g., asthma, COPD) and restrictive lung disease (e.g., interstitial lung disease)
Consider starting with a Chest X-ray if red flags for serious pathology are present >> dyspnea, hemoptysis, chest pain, weight loss, immunosuppression, significant smoking history, elderly or at risk of aspiration, tachypnea or hypoxemia, abnormal cardiac or respiratory exam, or sepsis.
If suspecting foreign body aspiration, need to order bronchoscopy
Please note that treatment of the conditions that may cause acute cough are not discussed in this blog post, but can be found through medical resources such as those in the references section. Treatment for acute cough often requires treating the underlying cause.
Boujaoude ZC, Pratter MR. Clinical approach to acute cough. Lung. 2010;188 Suppl 1(Suppl 1):S41-S46. doi:10.1007/s00408-009-9170-6
Holzinger F, Beck S, Dini L, Stöter C, Heintze C. The diagnosis and treatment of acute cough in adults. Dtsch Arztebl Int. 2014;111(20):356-363. doi:10.3238/arztebl.2014.0356
Madison JM, Irwin RS. Cough: A worldwide problem. Otolarynogol Clin North Am. 2010 Feb;43(1):1-13, vii.
A 78-year-old male, known case of Chronic Kidney Disease on maintenance hemodialysis, presented to the Emergency Department with dizziness and lethargy complaints about 2 days. He had missed his last hemodialysis session due to personal reasons. We could not elicit any further history details as was significantly dyspneic (no bystanders with him at the time of presentation). Hence, the patient was received in Bay 1 for immediate resuscitative measures. The patient was afebrile, conscious, and well oriented, but unable to communicate because of severe dyspnea.
HR – 142 beats/min BP – not recordable RR – 36 breaths/min SpO2 – poor tracing, intermittently showed 98% on room air (15 LO2 via Non Rebreathing Mask was initiated nevertheless)
He was immediately connected to a defibrillator in anticipation of possible synchronized cardioversion. Simultaneously, the cause of the possible rhythm was being evaluated for and a thorough examination was carried out. On examination, his lung fields were clear. His left arm AV Fistula had a feeble thrill on palpation.
In suspicion of hyperkalemia as the cause of VT, patient was immediately started on potassium reduction measures while the point of care ABG report was awaited. He was treated with salbutamol nebulization 10mg, sodium bicarbonate 50 ml IV and 10% calcium gluconate 10ml IV. In view of hemodynamic instability, he was also started on intravenous noradrenaline infusion.
As hyperkalemia was confirmed, the patient was also given 200 ml of 25% dextrose with 12 units of Rapid-acting insulin IV. With the above measures, the patient’s cardiac rhythm came to a sine wave pattern.
He was later taken up for emergency hemodialysis (HD) – Sustained Low Efficacy Dialysis (SLED) in the ICU, using a low potassium dialysate. Since his AV fistula was non-functioning, HD was done after placement of a femoral dialysis catheter. 2 hours into HD, the patient’s cardiac monitor showed a normal sinus rhythm. His hemodynamic status significantly improved. Noradrenaline infusion was gradually tapered and stopped by the end of the HD session, and repeat blood gas analysis and serum electrolytes showed improvement of all parameters.
The patient was discharged 2 days later, after another session of hemodialysis (through AV fistula) and a detailed cardiology evaluation (ECHO – LVH, normal EF).
For the Inquisitive Minds
The patient underwent a detailed POCUS evaluation, both in the ER and ICU. What findings do you expect to find on the RUSH examination for this patient?
His previous ECHO report (done 1 month ago) mentioned left ventricular hypertrophy and normal ejection fraction. So what would be the reason behind the POCUS findings? Is it reversible?
Why was the AV fistula non-functioning at the time of presentation? When would it have started to function again?
Despite not having hypoxia, this patient was given supplemental oxygen. Did he really require it, and if so, what was the rationale?
What was the necessity for carrying out SLED for this patient?
Why was this patient not immediately cardioverted in the ER?
If this patient had gone into cardiac arrest, what drugs would you have given for management of hyperkalemia?
How differently would you have managed this patient?
Please give your answers and comments into "leave a reply" area below.
Kawasaki disease (KD), or mucocutaneous lymph nodes syndrome is an immune-mediated inflammation in the walls of medium-sized arteries throughout the body. It’s complications result in the coronary arteries expanding, heart attacks, and premature death.
As the leading cause of heart disease in North American and Japanese children, KD continues to bewilder clinicians and researchers – even in the midst of a global pandemic. Possible links to SARS-CoV2 has even stirred uneasiness in patients, and physicians making diagnoses.
Beginning in Victorian-era England, a young boy presented to the doctor’s office with symptoms suggestive of scarlet fever; however, noticing heart disease in this child was just baffling. Despite being unaware of this rare disease, it was beyond physicians at the time; since then, progress has been limited as clinicians still fail to comprehend the disease’s root cause.
Dating back to 1874, KD was discovered by Samuel Gee while he was dissecting the cadaver of a seven-year-old boy.
He noticed something strange, “The pericardium was natural. The heart natural in size, and the valves healthy. The coronary arteries were dilated into aneurysms at three places, namely, at the apex of the heart a small aneurysm the size of a pea; at the base of the right ventricle, close to the tip of the right auricular appendix, and near to the mouth of one of the coronary arteries, another aneurysm of the same size; and at the back of the heart, at the base of the ventricles, and in the sulcus between the ventricles, a third aneurysm the size of a horse bean. These aneurysms contained small recent clots, quite loose. The aorta near the valves, and the aortic cusp of the mitral valve, presented specks of atheroma.”
From his autopsy, evident was that Gee found aneurysms in the coronary arteries running across the surface of the boy’s heart. He then placed the specimen in a jar and provided it to the Barts Pathology Museum in London. Little did he know, that his specimen marked evidence of the earliest recorded case of KD and sparked worldwide medical curiosity. Unfortunately, when physicians 100 years later were hoping to retrieve samples from the specimen containing the boy’s heart, they were informed that it was missing.
A few years later, the disease was recognized in 1967 by the Japanese physician, Tomikasu Kawasaki. Although some researchers claimed the virus was unknown, others stated KD resulted from a bacterial or fungal toxin. The windborne theory suggested that the disease was seasonal, and as such, the direction of the swaying wind played a role in infection. Others stated that since children’s immune systems are still developing and since they have just lost the protective antibodies from their mothers, they are susceptible to infection. Therefore, in Asian American household’s diets rich in soy put Asian children at greater risk due to the isoflavones. In the 1980s, the Center for Disease Control and Prevention (CDC) suspected chemicals as the cause of KD, inferring that disease stems from agents that trigger an overreaction of the patient’s immune system. No one knew exactly what the mechanism or cause of KD was, although many scientists speculated some theories.
Over the last decade, significant progress toward understanding the pathogenesis, history, and therapeutic interventions of KD has been fruitful. Treatment aimed at the intravenous infusion of gamma globulin antibodies derived from the plasma of blood donations has helped children recover. In contrast, other therapies of corticosteroids for immunoglobulin-resistant patients and tumor inhibitors such as etanercept, infliximab, and cyclosporin A have been other medications providing relief.
The most significant clinical debate was over the possible link between the rash and the cardiac complications seen in Asian American children. Factors responsible for KD were introduced into Japan after World War II and re-emerged in a more virulent form spreading through the industrialized Western world. Advancements in medicine, improvements in healthcare, and, notably, the use of antibiotics reduced the burden of rash and fever illnesses significantly allowing KD to be recognized as a distinct clinical entity.
Nonetheless, the enigma pervades even during the COVID19 pandemic; this time, more pressing as the ever-elusive cause of KD that troubles children’s hearts affects physicians’ sleep and worries parents’ minds. Although the story of Kawasaki disease began decades ago when a young boy’s heart was locked inside a glass specimen, its ending is still being crafted. By the time the heart is found again at the museum, and placed safely for visitors treasuring ancient history, what further knowledge and progress will the scientific community have achieved? How far will humanity have come to find answers to KD and fill in the perplexing missing piece of the puzzle?
For now, there are no answers, but the enigma continues…
Burns, Jane C., and Howard I. Kushner. “Kawasaki Disease: A Brief History.” American Academy of Pediatrics, 2000, DOI: 10.1542/peds.106.2.e27 pediatrics.aappublications.org/content/pediatrics/106/2/e27.full.pdf.
One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.
Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.
Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.
While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.
1) Lethal Triad also known as The Trauma Triad of Death Hypothermia + Coagulopathy + Metabolic Acidosis
COVID-19 pandemic has caused drastic changes in personal and educational lives of medical students, who hold a unique position between being a student and a part of the health care workforce (1). The role of senior medical students who are on the brink of becoming licenced physicians, in particular, have been discussed thoroughly by experts from the perspective of safety, education and the need for skilled workforce. As the discussions continue, medical students got to stay home – as it should be, in my opinion – at least in most countries. Remote learning became the primary training modality all in a sudden.
Remote learning, even though the safest option, is not free of problems. Studying from home and continuing daily routine require a strong determination, especially when people have a lot on their minds. But most of all, clinical and procedural skills are hard, if not impossible, to translate into online learning. Medical students need alternative methods to physical practice of clinical and procedural skills, other than reading instructions and watching procedural videos. Mental practice may offer a solution for medical students who want to sharpen or at least retain procedural skills at home.
What is Mental Practice?
Mental practice refers to the introspective rehearsal or visualisation of psychomotor skills (2). It has been called many names including ‘‘imaginary practice,’’ ‘‘covert rehearsal,’’ ‘‘conceptualization,’’ or ‘‘mental imagery rehearsal’.’ It has been researched extensively in sports literature and is shown to provide both cognitive and motivational benefits (3). Can it do the same trick for medical training, though? At this point, being sceptical is perfectly normal. Let’s look into the literature.
The History of Mental Practice
Surprisingly, even as early as the 1900s, the scientists were discussing the effect of ideational elements in motor learning (4). In the 1930s, pioneer researchers had already experimented on rats that were deprived of kinesthetic impulses by sectioning of the cervical cord and discovered that even they could not run the maze as perfectly as normal rats in terms of motor skills, they still learned it (5, 6, 7). They asserted that kinesthetic impulses were neither sufficient nor necessary in learning of the motor skill. A few years later in 1940, researchers observed ideational clues helped human subjects to learn basic motor skills making fewer attempts, committing fewer errors, and spending less time (8). Subsequent studies tested mental practice against the physical in basketball free throws, dart games, and ring toss (9, 10). All reached the same conclusion: Mental practice was effective, even about as effective as physical practice in learning of motor skills.
What About Medical Training?
Experiments on the use of mental practice in the area of medical training started a few decades later. One of the first studies examined the use of mental practice in the pelvic examination. The students who did 5-minute audio-guided mental practices before and after the physical practice on a model performed significantly better at skill examination (11). Research in this area has gained momentum recently. Mental practice was shown to facilitate medical students’ learning of suturing, venipuncture, cricothyroidotomy, and lumbar puncture (12-15). In some studies, it performed as effective as physical practice, and superior to studying text (12, 16).
The evidence shows that mental practice can be a strong and free learning tool. It can serve as a satisfactory substitute for physical practice in the days of the pandemic, which forces medical students to stay at home. But, let’s not get ahead of ourselves. Mental practice does not provide all of the answers. Remember the rats: They still needed motor practice to run perfectly and as fast as normal rats (7). In other words, you still need the train your muscles to operate smoothly what you have learned. Even after years of mental practice, one could never score a free throw if he or she is lacking the muscle strength to make the ball reach the basket. Admittedly, most medical procedures do not require large motor skills or much strength, but they still demand well-trained small muscles. However, until the world figures out how to put a medical student and a simulator together in the same room safely, the mental practice seems like a solid way of learning new procedures.
Whether you are an optimist, a pessimist, or a strict realist is likely to impact how you would project potential effects of COVID on the post-COVID world.
I would argue that from the medical-practical perspective, the three attitudes above are not mutually exclusive. As we often conclude when reading pro- and con- arguments for a new legislature, unrefined reality allows for enough mixed data and scattered observations upon which to base and justify either stance.
My approach here is more of realistic anticipation: what changes to our global emergency care practice environment may result from what we are experiencing today? Undoubtedly, such changes will affect trainees a lot more than seasoned EM providers.
While by no means a new thing, Telemedicine has advanced exponentially over the last few months and has come to the forefront of medical care in terms of its scope, breadth, and practical applications.
I am what my spouse would call “technologically challenged” (if she were to put it kindly). Yet even a tech-doofus (me) has had to dabble in Telehealth over the last few weeks – both inside my ED and to reach patients thousands of miles away.
TAKE-HOME: The earlier and the more you get exposed to Telemedicine, the smoother your future tele-practice will be. Telemedicine to EM today is sort of like what Ultrasound was to EM twenty years ago. I see an EM Telemedicine fellowship coming your way.
Local Resource Preparedness
Everyone now realizes that you need to have tucked away but keep readily available roughly two N-95 masks per healthcare worker per day for three hundred and sixty-five days, amen.
Which changes in how entire healthcare systems are financed are necessary is a huge comprehensive topic. But point-preparedness, as in being ready at the actual place where you and I live and work locally, is a much easier thing to wrap our heads around and become directly involved in.
TAKE-HOME: Find others like you, cooperate, get involved, and make your voices and opinions heard and count. We do not know when the Penguin flu or SARS-5 will hit us, but surely they will and with a vengeance. There is a tacit hope we will be smarter and more prepared next time.
I do not know if golf practice makes you better at playing basketball or swimming at karate. But I do know that we have become so specialized, it is almost like there are hand specialists nowadays who will only deal with the left index finger.
COVID has shown all of us that it is not helpful to only possess knowledge and skills within the comfort zone of your specialty or sub-specialty.
As an EM doc, I have been okay with my ventilator and ARDS management skills. But the last few weeks have been extraordinary in reading up on anything from the forgotten basics of epidemiology and virology to palliative care. And that’s a good habit of keeping up for the future.
TAKE-HOME: Get out of your profession’s shell and encourage others to do the same. EM standing for Everything Medicine has never been more true. We are kind of lucky that way.
Sorting Out The Trash In Medical Literature
It is one thing to be able to verbally shred a New England or a Lancet paper at a leisurely journal club; it is quite another to be able to apply new (or old) reported research to clinical practice without harming anyone.
In the times of YouTube anxieties and misinformation, the latter task becomes even more crucial yet difficult. COVID controversies ranging from antimalarials to early intubation are a prime example.
But the good news with COVID is that I think we have just been handed the requirement for a free refresher course on how to appraise medical literature critically. We have to do this under pressure, without much time, and, arguably, fighting with our own natural inclination that “to do something is better than doing nothing.”
TAKE-HOME: Less YouTube, more journal clubs. Our relatively young standard of evidence-based medicine is being tested worldwide like never before. Let us wish for it to perform well and withstand all the temptations. And yes, you do need to become a pro with this one.
Patient Privacy and Empty EDs - As They Were Intended?
These points are controversial. But with medical information privacy requirements being loosened in many locations and with fewer non-COVID patients going to EDs, it is a valid question to ask: is right now how things should have always been?
Whether certain patients do not belong to an ED is a complex topic. Finding the golden middle between protecting confidential patient information and enabling providers to reach and treat patients most efficiently is likewise easier said than done.
For now, I am just inviting you to think about it.
TAKE-HOME: It may be that things will never go back to how they were. Perhaps we have all overdid it with patient privacy laws that, for a long time, had trumped basic common sense. It may also prove that no one will suffer a dire consequence because they chose to call a doctor via video rather than to drive to an ED. Keep a lookout for good data.
Viruses In Focus
After decades and billions poured into research, we finally have stuff against HIV. Hepatitis and the herpes families are the two runners up, plus we developed a few effective vaccines like the MMR – but that’s about it really.
So much time and focus have gone into killing bacteria, we have somewhat neglected the other big guy. Until now.
TAKE-HOME: Nobel price winner Joshua Lederberg once said that “The single biggest threat to man’s continued dominance on this planet is the virus.” You will likely be practicing during an era of unprecedented anti-viral efforts. Just like with bacteria, we may not succeed all the way. But as long as we do not all turn into zombies, it’s okay.
The Cure For The Common Burnout
Emotional exhaustion may indeed be the key factor in professional burnout for emergency care providers. But other factors contribute as well – including feeling unappreciated or not needed, and work seems routine and mundane.
We now have COVID, which has reignited the fire for many EM providers, no matter how deep are those post-N95 facial marks. Otherwise, why would one fly to New York or elsewhere right now “to help”?
Frontline medicine certainly takes its toll on you. But hardly anyone in our specialty should feel not needed or unappreciated anymore.
TAKE-HOME: Wake up and go to bed humbled, proud, and lucky to be able to do this work.
The few changes I have listed come from a very long list. Whether they will prove to be overwhelmingly positive remains to be seen. Of course, future benefits do not negate the tremendous harm and suffering the pandemic has already brought and will continue to bring in the months to come.
But one thing is for sure: COVID is not the last time we are dealing with something like this. What your attitude and knowledge will be then, is up to you.
In this post, we are sharing an announcement with you. One of our contributors, Dr. Emilie Calvello Hynes has something to share with you. Here is her message.
The Global Emergency Care Initiative has created and maintained its Emergency Care Pathways since 2018 on AgileMD in collaboration with the African Federation of Emergency Medicine. We have recently updated and expanded guidance to reflect COVID-19 care in low and middle-income countries.
If you have colleagues in other countries who could use curated, clinical support in a single source that is updated daily, please consider letting them know about this resource. A flyer attached to aid in dissemination.
We welcome your thoughts and the ability to disseminate this resource further.
The AFEM/GECI Emergency Care Pathways were launched in 2018 to provide an “at the bedside” reference to help standardized emergency care for common presentations of acute illness for healthcare workers working with limited resources.
The pathways are available online/offline, available via an app or in printable form. The pathways integrate WHO Emergency Care Checklists, updated AFEM Handbook recommendations, WHO Essential Medication Lists and accepted international standards (e.g. Helping Babies Breathe, MSF Guidelines) as a summary reference of best-practice care. The pathways have been peer-reviewed and tagged for differing levels of possible interventions based on resources. The Emergency Care Pathways are meant to be applied after the initial assessment and management taught by the WHO BEC.
In addition, the app serves as a repository for open access commonly reference texts, useful protocols, forms and links. The pathways have been updated to reflect useful at the bedside guidance for clinicians during the COVID-19 pandemic. Resources and clinical guidance are updated almost daily. The links include ACEP guidance, AFEM, WHO, Partners in Health and any other resources we think would be helpful to clinicians practicing in LMICs.
It’s 2 AM, and the Pediatric Emergency Department (ED) at a community hospital in New York is overflowing with children and caregivers. A young Nigerian boy is being transported down the center of a hallway, past a long line of doors to patient rooms. The porter is calm and walks briskly, determined to bring this boy to get immediate care. The boy winces, his hands outstretched next to him, rigid, and frozen in space, and while he is seated in the wheelchair, his legs bent at the knees are thin frames, held in place with his feet planted on the wheelchair pedestals. He is afraid to move any of his extremities; tears are rolling down his face; he is fighting the urge to grimace and furrow his brow. He cries how much it hurts to move. He knows he needs help. Behind him, his mother follows close holding a one-year-old baby in her arms, and behind her, five other young children aged 3 through to thirteen stream in. There is quiet concern on all of their faces. The older siblings have seen this before. We learn that he has Sickle Cell Disease (SCD). He has been in excruciating pain for the past 4 hours and is now presenting with dactylitis. This case has not been the first in this ED, and like other EDs across the United States and in the world, the number of cases presenting with SCD will increase.
Sickle Cell Disease (SCD)
SCD is a condition that causes red blood cells to morph from a biconcave dumbbell-shaped disc, into a rigid semi-circular shape. This disease is inherited genetically by receiving two sickle genes, one from each parent and risk for complications are attributed to a variety of factors, including deoxygenation, dehydration. It is most common in African Americans as well as Latinos and people of Middle Eastern, Indian, Asian and Mediterranean backgrounds. In the United States, SCD is the most common genetic blood disorder and affects approximately 100,000 Americans(1) and although babies are screened at birth, management plans vary with the degree of disease progression and exacerbation severity, as well as with the availability of resources and education.
Why Emergency Physicians need to be Familiar with SCD
SCD affects both pediatric and adult patients, and it has been reported that patients between the ages of 18 to 30 years old have increased emergency department utilization. A major reason for this is due to the transition by young adults from pediatric to adult care in the management of SCD, and this population is simultaneously also learning to navigate the health care system and community resources (pediatric to adult care, insurance, independent decision making, housing, education, workforce) as discussed further below(2). In addition, the use of community health workers is important as they can act as liaisons between the health care systems and patients to disseminate information and resources. However, despite the awareness of the disproportionate use of the ED among patients with SCD, the social factors that impact care remain unknown(3) and more research and investigation is needed to understand this patient population.
Often when a complication or crisis occurs in patients with SCD, patients seek immediate care in the Emergency Department. Included in the potential list of complications include infections, such as those with encapsulated bacteria; sepsis; stroke; splenic sequestration, and early treatment is essential in managing patients. Of these complaints, the emergent cases to be aware of in the ED include vaso-occlusive crisis and pain, sickle cell anemia (SCA)(4) central nervous system such as stroke, and acute chest syndrome (ACS), where ACS due to blocked capillaries in the lungs, may be caused by infections, asthma exacerbations and/or pulmonary embolisms, and is the leading cause of morbidity in patients with SCD. Further, the Emergency Severity Index (ESI) Version 4 triage system, commonly used in the majority of EDs in the United States, suggest that patients with SCD be triaged as ESI level 2, indicating a very high priority, and that rapid placement be facilitated(5).
Although the discussion of complications of SCD including the presentation and management is a complex topic, and will be covered in detail in future posts, information and algorithms for clinicians are available online for reference. One such resource is a treatment algorithm that acts as a how-to guide for SCD and is available online in the Annals of Emergency Medicine(6). This approach is based on the point-of-care hemoglobin level, and discusses issues such as myonecrosis, aplastic crisis, ACS.
Pain in SCD
When tissues and organs are not adequately perfused with oxygen, in part due to the sickled shape of RBCs, tissue damage and death can occur. Patient management of vaso-occulusive crisis and pain varies by practices and the medications available for use around the world, however it is important to note that pain in patients with SCD is often extreme and may require treatment with opioids. In a response to the American Society of Hematology (ASH) draft recommendations to Sickle Cell Disease-Related Pain in May 2019(7), emDOCs.net published a response to the drafted recommendations and offered insight to pain management and includes an algorithm(8). The insight provided is essential in decreasing the suffering experienced by patients during an SCD crisis, and notes the use of Dilaudid, Ketamine, Dexmedetomidine, and Lidocaine. Further, the understanding of limiting the use of NSAIDS due to impaired renal function caused by the disease is also outlined in the response.
Management of pain in pediatric patients with SCA and vaso-occulsive pain also varies according to hospital and individual provider practices, and scientific investigation and patient research is needed to provide proper care to this population. An example includes a study by PECARN addressing the use of a normal saline bolus in pediatric emergency departments found an association with poorer pain control(9). Identifying and implementing results from research studies is important in understanding and managing SCD in both adult and pediatric patients.
Emergency Physicians around the world should be aware of strategies for identifying SCD, and management, specifically in areas around the world where refugees from countries with SCD prevalence is common. Countries where refugees and migrants are commonly are known to disembark, such as those in southern Europe(10) and certain areas in the United States and Canada would benefit from in-depth analysis of the issue and could allow for appropriate and accessible health care to vulnerable populations, as well as educate providers who are unexposed to managing emergencies in SCD patients while setting in place integrated and individual health plans away from emergency room dependence(11). In developing countries with SCD populations, such as Nigeria, there is a high prevalence of pediatric emergency cases, and the proper management of the disease as well as policy and hospital organization for high volume and off-hour admissions, may reduce hospital stays(12). Further, the self-efficacy of adult patients with SCD, from education, pro-active efforts, understanding of disease management, also can allow for decreased ED visits and hospitalizations for pain(13).
Investigations, Resources, Education
A number of investigative studies, clinical trials and research is being conducted around the world for a better understanding of SCD, including patient care in adult and pediatric patients, genetic factors, supportive services, associated co-morbidities, and search for cures. Investigations around the world include collaborations and information sharing between academic researchers, patients, clinical providers, and health care providers and officials around the world.
The National Heart, Lung, and Blood Institute hosted a series of Webinars in September 2018, during Sickle Cell awareness month from experts in blood science and sickle science research and are available to watch for free online(14). Some of the key highlights from two of the webinars: Serving the Sickle Cell Disease Community Here and Abroad; Sickle Cell Transitional Care from Childhood to Adulthood, are discussed here.
Webinar Overview Serving the Sickle Cell Disease Community Here and Abroad Presented by Dr. Keith Hoots, Director of Division of Blood Diseases and Resources, NHLBI
Prevalence of the disease is so much larger in Africa than most places in the world. There are as many babies born with SCD born in Nigeria there are babies born with SCD, by estimate, as there almost are total people with SCD in the United States.
There is a need to share research and practices in the developed world with the developing world.
Three New Research Initiatives in Africa:
The Sickle Pan-African Research Consortium (SPARCO) Overview: The study sites for this research include East Africa (Tanzania), West Africa (Ghana, Nigeria) and central Africa (Cameroon, Democratic Republic of Congo) with the goal to later include 20 sites in 15 countries. SPARCO’s aim is to develop an SCD database, standards of care, and strengthen research investigation.
Sickle Cell Disease Genomics of Africa (SickleGenAfrica) Overview: The purpose is to develop strategies to predict, prevent and treat organ damage in SCD and to investigate biomarkers associated with the development of organ damage, including molecules released during red blood cell damage in sub-Saharan African populations.
Webinar Overview: Sickle Cell Transitional Care from Childhood to Adulthood Part 1 Presented by Dr. David Wong, MD, FAAP, Medical Officer, Office of Minority Health
SCD is no longer a childhood disease. Young adults are at a higher risk for hospitalization due to illness and pain.
Treatment and management examples in childhood include annual transcranial dopplers to assess for risk of stroke; vaccinations; hydroxyurea; L-glutamine; opioids for pain management; penicillin prophylaxis; RBC transfusions; water intake to avoid exacerbations due to dehydration; splenectomy. The cure available is bone marrow transplant.
Prior to July 2017, Hydroxyurea was the only FDA approved therapy for 20 It is used in adults and children. It has been shown to reduces hospital admissions, pain crisis, and ACS however barriers to hydroxyurea use exist. These include difficulty with communicating the use to patients and caregivers, issues with frequent monitoring, lack of adherence, lack of provider knowledge and comfort with its use.
Community Health Workers (CHWs) are key players in effective patient care. CHW can provide information affected by social and health determinants from local economic and environmental (housing, employment), local communities (families, safety, support), activities (learn, work, play, move, shop), lifestyles (alcohol, drugs, smoking, sexual health, physical activity, and individual needs (age, genetics). CHW are experts in condition-specific information and navigating complex health systems, including accessing care in a medical home (the approach to providing comprehensive care). This is particularly important when care is not always contained or organized by one organization, where care should be accessible, continuous, comprehensive, family-oriented, coordinated, compassionate and culturally competent. Pediatric medical home principles include family-centered partnerships, community-based systems, transition care, value. Interventions for education such as warning signs and treatment options and links to care are important.
The SCD Newborn screening program, and the Sickle Cell Disease Treatment Demonstration Program for patients who solely rely on the ED for SCD care, aid the care options for patients with SCD.
Follow this iEM story for part two which will include information on adult and pediatric management of SCD in the ED, as well as an overview of four NHLBI webinars: Holistic Health and Sickle Cell Disease A Focus on Mental and Behavioral Health; Genetic Therapies in Sickle Cell Disease; Bone Marrow Transplants, Other Therapies, and Sickle Cell; Improvement Initiatives and Ongoing Research.