Category: FOAMed

The dose makes the poison: Coffee consumption, physiology and health impact

~ Brenda Varriano, Canada ~ Leave a comment

Introduction

As my alarm goes off at 4 am, I dread the day ahead. However, after countless sleepless nights since moving into a new city, I need to wake up early for my M3 orientation. Fortunately, I have caffeine at my disposal. So, reaching for my cup, I became inspired for my next wellness article, “Oh Sweet, Sweet nectar of the Gods.” For this article, I will start by sharing some statistics about coffee, followed by coffee processing, physiology, and, lastly, effects on the body.

In 2020, data from the national coffee association revealed that coffee consumption is up by 5% in the USA since 2015. The average American coffee drinker drinks over 3 cups of coffee a day. With coffee being a stimulant, it is no surprise that it is a favorite among physicians and medical students. Interestingly, one study reported that in-patient physicians were more likely to drink coffee and energy drinks than out-patient-based physicians. During orientation, the surgery director gave a piece of wisdom to the class of 2023. “Drink espresso. Less volume, more caffeine, less need to use the washroom after scrubbing in.”

Coffee Processing and Physiology

Given the high consumption rates of coffee, I want to start by appreciating the tremendous processing it must go through before we consume it. Coffee is derived from the Coffea (genus) shrub; the two most common species being canephora and arabica. First, coffee berries are handpicked, where the flesh is removed, and the seeds are left to ferment and dry. At this stage, the coffee is known as green coffee. Starbucks and other chains have started serving cold brews of coffee at this stage.

Interestingly, green coffee has the highest caffeine content. Second, comes the roasting stage, which impacts the amount of caffeine content and taste of coffee. The longer that coffee is roasted, the more moisture is lost and the less dense it becomes. As coffee is roasted, starches are broken down to simple sugars, high heat causes the breakdown of caffeine, and oils begin to develop. The oils contribute to coffee’s famous aroma. Finally, these beans are ground and brewed as they make their way into our cups. (Note: this is a very brief description, which does not cover decaf coffee)

Coffee is a stimulant, which has unique effects on the human body. Much of this content regarding coffee physiology shall be derived from a review by McLellan et al. 2016 and a sports podcast for those ortho heads: https://www.strongerbyscience.com/caffeine/#Adenosine_antagonism. First, coffee is considered a xanthine derivative with three methyl groups attached (scientific name-1,3,7-trimethylxanthine). This structure is similar to adenosine, explaining coffee’s action as an adenosine antagonist, meaning to inhibit the actions of adenosine at an adenosine receptor (figure 1). There are four adenosine receptors. By inhibiting different subtypes of adenosine receptors, caffeine can cause different effects. For example, adenosine receptors in the brain block the release of serotonin, dopamine, glutamate, and other neurotransmitters (less in the synapse). Caffeine blocks adenosine’s actions, thus increasing the amount of neurotransmitters in the synapse, explaining caffeine’s effects. For example, increased dopamine leads to an increased perception of reward. By altering glutamate levels, caffeine can even alter the seizure threshold. However, it is less straightforward than I am making it to sound since neurotransmitters can cause different effects in different brain regions.

Figure 1: The structure of caffeine vs. adenosine https://www.strongerbyscience.com/caffeine/#Adenosine_antagonism

Peripherally, coffee mainly acts as a sympathetic stimulant, see Figure 2. One mechanism is by stimulating your adrenal glands to secrete catecholamines which act on various organs in the body. Finally, the effects of caffeine vary, depending on individual caffeine metabolism. For example, metabolism differs between naïve or experienced caffeine consumers. Finally, the dose/timing of caffeine intake impacts metabolism. Literature suggests that absorption takes approximately 45 minutes, peak serum caffeine occurs after 15 minutes to 2 hours following ingestion, and finally, half-life ranges from 2.5-4.5 hours.

Figure 2: Impact of Coffee on the body (Van Dam et al., 2020)

Specific Effects

Coffee, while used as a stimulant, impacts our health more than we realize. A recent umbrella review by Poole et al. (2017) looked at the risks and benefits of coffee consumption based on the findings of over 200 meta-analyses. Coffee consumption was analyzed in the following conditions: high vs. Low consumption, any vs. none, and having an extra cup of coffee per day. Overall, coffee consumptions appeared to reduce the risk of all-cause mortality, cardiovascular mortality, and cardiovascular disease. Coffee consumption was also suggested to correlate with a reduced risk of cancer. These findings have been echoed in other studies. For example, a study in 2016 by Liebeskind et al. described the “coffee paradox.” In this study, high rates of coffee consumption were found to have a reduced risk of stroke, even in those who smoked. 

Finally, a recent review published in the New England Journal of Medicine summarizes some of the consistent findings of coffee consumption and its effects on the human body (Van Dam et al., 2020). In the CNS, caffeine:

  1. Reduces fatigue, increases alertness, and improves vigilance (Note: caffeine does not compensate for chronic sleep deprivation!).
  2. Improves pain tolerance.
  3. Increases anxiety when >200 mg is consumed in one sitting or >400 mg is consumed in a day.

Caffeine withdrawal presents with headache, fatigue, and depressed mood 1-2 days after cessation of coffee consumption. Withdrawal effects last between 2-9 days. In addition, coffee toxicity (1.2g or higher) can lead to altered thought and speech, anxiety, insomnia, dysphoria, and cardiovascular toxicity—more on cardiovascular toxicity in peripheral effects. I briefly mention it here, as it is part of the toxicity presentation. 

Peripherally, coffee intake increases epinephrine release by stimulating the adrenal glands and subsequently increases blood pressure transiently, as tolerance develops over time. Coffee intake (non-toxic levels) can reduce the risk of cardiovascular disease (see coffee paradox above). Coffee may potentially improve metabolism and reduce appetite, thus causing minimal effects on weight loss. Coffee may also decrease insulin sensitivity with short-term use (long-term use counteracts these effects). Furthermore, breakdown products of coffee may act as an antioxidant and protect against reactive oxidative species (ROS). Finally, coffee has been reported to reduce the risk of mortality from any cause. 

Conclusion

Coffee is a staple among many households, including our patients. Though used as a stimulant, coffee can have many physiological effects, many being beneficial. However, there can be too much of a good thing. Too much coffee can increase the risk of agitation, anxiety, insomnia, and arrhythmias. Coffee is a tool, but it is our job to use it wisely and educate patients that may be at risk of too much caffeine consumption.

References and Further Reading

  1. de Melo Pereira, G. V., de Carvalho Neto, D. P., Júnior, A. I. M., do Prado, F. G., Pagnoncelli, M. G. B., Karp, S. G., & Soccol, C. R. (2020). Chemical composition and health properties of coffee and coffee by-products. In Advances in food and nutrition research (Vol. 91, pp. 65-96). Academic Press.
  2. International Coffee Organization. The Current State of the Global Coffee Trade. Coffee Trade Stats. (2016). Retrieved from: http://www.ico.org/monthly_coffee_trade_stats.asp.
  3. Kummer, C. (2003). The joy of coffee: the essential guide to buying, brewing, and enjoying. Houghton Mifflin Harcourt.
  4. Liebeskind, D. S., Sanossian, N., Fu, K. A., Wang, H. J., & Arab, L. (2016). The coffee paradox in stroke: Increased consumption linked with fewer strokes. Nutritional neuroscience, 19(9), 406-413.
  5. McLellan, T. M., Caldwell, J. A., & Lieberman, H. R. (2016). A review of caffeine’s effects on cognitive, physical, and occupational performance. Neuroscience & Biobehavioral Reviews, 71, 294-312.
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Can I Eat This? – A Helpful Guide To Plant Toxicology

~ Mohammad Anzal Rehman, UAE ~ Leave a comment

Not only is identification of toxic plants from their gross appearance a commonly tested topic in Emergency Medicine Board Exams, it is a necessary skill for doctors operating in institutions where an established Toxicology division does not exist or where the opinion of a specialist in the field is not immediately available.

This is the third part in a series of blog posts dedicated to providing you with original mnemonics and visual aids that serve to highlight a few classes of common toxic plants prominent for both their inclusion in academic assessment as well as their prevalence in the community. These memory tools will attempt to highlight key features in the identification of well-known toxic plant species and are designed to aid clinicians from various regions of the globe as well as hone the skills of aspiring toxicologists.

Picture the Scene

A 67-year-old man, known to have dementia secondary to Alzheimer’s disease, was brought to the Emergency Department with complaints of abdominal pain and 3 episodes of vomiting after being found by his grandson consuming some roots and leaves from a ‘berry-looking plant’ he had found in a local garden. Following the vomiting, the patient was lethargic, diaphoretic and had an ataxic gait, which prompted the family to bring him to the ED.

Upon arrival to the ED, patient looks tired and restless. Vital signs reveal the following:

BP 78/43                   HR 50                           RR 12                           Temp 37.7 C

You start IV fluids, obtain a Point-of-Care venous blood gas and order an ECG and laboratory investigations for the patient. The BP improves slightly up to 80/50, and the venous blood gas shows no significant acid/base disturbance, Sodium of 137 mEq/L, Potassium of 3.7 mEq/L, Hgb of 12.6 g/dL and Lactate 1.4. All other parameters seem to also fall within normal limits. The ECG, however, revealed a widened QRS. As you bring the rhythm strip to your Attending Physician, you hear the patient’s cardiac monitor beep and notice similar, but wider QRS intervals at a faster rate on the screen. You recognize the rhythm as Ventricular Tachycardia.

Recognizing the patient to be in shock with a persistently low blood pressure and a cardiac rhythm of ventricular tachycardia, you decide to perform synchronized electrical cardioversion. After delivery of shock, the patient’s rhythm converts to sinus rhythm. Your Attending Physician arrives with some additional family members who brought with them the berries the patient had reportedly ingested (Figure 1).

Figure 1- Photograph of the berry-like fruit ingested by the patient, identified later as a species of yew

Overview of Taxus Yew Toxicity

The poisonous nature of the Yew (Taxus spp.) has been attributed to taxine alkaloids present in all parts of the plant except the scarlet ‘berry’. The mechanism of toxicity from taxine alkaloids centers on their ability to antagonize sodium as well as calcium channels, primarily acting on cardiac myocytes. [1,2]

While most ingestions are accidental, with non-significant complaints reported, serious fatal outcomes can often be encountered when large amounts of the plant are consumed, usually with suicidal intent. [3]

Typical symptoms post-ingestion range from gastrointestinal complaints such as nausea and abdominal pain, but can easily progress to neurologic complaints of paresthesias and ataxias, along with the dreaded cardiovascular manifestations of bradycardia, conduction delays, wide-complex ventricular dysrhythmias that can cause rapid and fatal instability.

Unfortunately, no specific antidote exists to counter the effect of taxine alkaloids. Ventricular dysrhythmias causing instability are preferably controlled through cardioversion as per ACLS guidelines, though this admittedly treats the effect rather than the cause. [4] Anti-arrhythmic agents have not been shown to have a significant impact on management. Some limited reports show no benefit from hemodialysis,[5] but some promise of Extracorporeal life support with Membrane Oxygenation (ECMO)[6,7] in treating Yew berry poisoning, making management largely reactionary rather than targeted.

Identifying Plants with Sodium Channel Actions

Yew berry (Taxine alkaloid) poisonings can be grouped with other toxic plant species solely due to their common mechanism of action on the sodium channel. Three major plant types that are often encountered in literature are highlighted below:[8]

  1. Aconitum spp., commonly referred to by names such as monkshood, wolfsbane and helmet flower: Contain aconitine and other similar alkaloids that prevent inactivation of voltage-gated sodium channels in cardiac and CNS cells, producing both neurological (paresthesias, weakness, seizures) and cardiovascular (hypotension, bradycardia) effects.
  2. Taxine spp., commonly referred to as Yew plants: Contain taxine alkaloids as highlighted above, with actions of sodium and calcium channel blockade, producing effects primarily on the cardiovascular system, with chances of severe ventricular dysrhythmias and cardiac arrest.
  3. Rhododendron spp., commonly referred to as death camas, azalea and mountain laurel: Contain grayanotoxins that can be concentrated in honey (‘mad honey’), with actions propagated by binding to sodium channels, resulting in sustained depolarization and an increased vagal tone. This results in cardiovascular effects as with the other plants above (bradydysrhythmias, hypotension) as well as symptoms of diaphoresis, hypersalivation and dizziness/syncope.

Plant Identification

As you may notice, all of the above species have two things in common: they all act on the sodium channel and they all can manifest as hypotension and bradydysrhythmia.

Visual identification of these plants can then be made easier by correlating their appearance with the cartoon image below.

References and Further Reading

  1. Wilson, C. R., Sauer, J., & Hooser, S. B. (2001). Taxines: a review of the mechanism and toxicity of yew (Taxus spp.) alkaloids. Toxicon : official journal of the International Society on Toxinology, 39(2-3), 175–185. https://doi.org/10.1016/s0041-0101(00)00146-x
  2. Jones, R., Jones, J., Causer, J., Ewins, D., Goenka, N., & Joseph, F. (2011). Yew tree poisoning: a near-fatal lesson from history. Clinical medicine (London, England), 11(2), 173–175. https://doi.org/10.7861/clinmedicine.11-2-173
  3. Labossiere, A. W., & Thompson, D. F. (2018). Clinical Toxicology of Yew Poisoning. The Annals of pharmacotherapy, 52(6), 591–599. https://doi.org/10.1177/1060028017754225
  4. Nelson LS, Shih RD, Balick MJ. Handbook of Poisonous and Injurious Plants. 2nd ed. New York, NY: Springer/New York Botanical Garden; 2007:288-290
  5. Dahlqvist M, Venzin R, König S, et al. Haemodialysis in Taxus baccata poisoning: a case report. QJM. 2012;105(4):359-361.
  6. Panzeri C, Bacis G, Ferri F, et al. Extracorporeal life support in severe Taxus baccata poisoning. Clin Toxicol. 2010;48(5):463-465.
  7. Soumagne N, Chauvet S, Chatellier D, Robert R, Charrière JM, Menu P. Treatment of yew leaf intoxication with extracorporeal circulation. Am J Emerg Med. 2011;29(3):354.e5-6.
  8. Lim, C.S., Aks, S.E. (2017), ‘Chapter 158 – Plants, Mushrooms and Herbal Medications’, Rosen’s emergency medicine 9th edition, Pg. 1957 – 1973
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Cognitive load theory and its applications in emergency medicine education

~ Nada Radulovic, Canada ~ Leave a comment

Throughout my medical education thus far, I have been very drawn to simulation and cognitive load research related to emergency medicine. This has provided me with an appreciation for the applications of cognitive load theory to diverse areas within the specialty, including medical education.

What is cognitive load?

The cognitive load theory was developed in the late 1980s and explores the ways in which the amount of mental effort affects your working memory, and subsequently, learning (1). Specifically, learning involves processing sensory stimuli through various forms of memory, until the stimuli are encoded into your long-term memory. When the working memory capacity is surpassed, the ability to acquire or learn new information can become limited and may lead to poor performance or errors. Since the development of this theory, research in this area has been expanding to enhance instructional design to optimize learning.

Fig. 1. The basic structure of memory, extending from sensory input to encoding of long-term memory (obtained from Mancinetti et al. (2019)) - (2)

Objective and subjective measures of cognitive load

Global collaborative and independent research initiatives have identified an array of objective physiologic measures (e.g. pupillometry, heart rate, galvanic skin response and EEG parameters), subjective psychometric measures (e.g. Paas, NASA Task Load Index (NASA-TLX)) and secondary task measures that are indicative of an individual’s cognitive load (3). Current research has been investigating the validity of these physiologic metrics beyond a controlled laboratory setting, in order to determine accurate measures that can be applied within dynamic and real-life settings. This can potentially allow us to monitor learners’ cognitive load in real-time and adjust teaching strategies accordingly to optimize learning.

Fig. 2. NASA-TLX cognitive load scale (obtained from Shively, J, NASA-Ames Research Center (2016)) and the Paas rating scale (obtained from Paas et al. (2008)) - (4-5)

Applications of cognitive load theory to emergency medicine education

A paper by Croskerry (2014) highlighted various factors that can influence cognitive load in the emergency department setting and lead to clinical errors, including overcrowding, and fatigue and circadian dyssynchronization secondary to shiftwork (6). Of relevance, a previous post on emDocs explored numerous strategies for emergency providers to mitigate some of this cognitive load (link here: http://www.emdocs.net/cognitiveload/). Furthermore, experienced emergency physicians have developed strategies to better manage their cognitive resources, effectively reducing their cognitive load relative to trainees in similar clinical scenarios. Therefore, there are many ways in which cognitive load theory can be implicated in emergency medicine and used to not only enhance the functional and spatial design of the emergency department, but to also optimize simulation training and other areas of learning for emergency medicine trainees. For example, Johannessen et al. (2019) evaluated the association between physiologic measures and the Paas scale in trauma team leaders using wearable technology during the resuscitation response, in order to better understand cognitive load expression in emergency physicians during traumas (7). Additionally, another study used galvanic skin response, heart rate and a modified Paas scale to assess the “Beat the Stress Fool” protocol in reducing mental effort during clinical simulation (7). Fraser et al. (2018) investigated the link between the cognitive load theory and debriefing simulations. Specifically, they evaluated whether the categorization of mental loads during debriefing can improve learning of this vital and complex skill, and they additionally discussed strategies to alleviate some of the associated cognitive load (8).  

Overall, cognitive load is an exciting and evolving area in research and has many diverse applications in emergency medicine and medical education as a whole. 

References and Further Reading

  1. Sweller, J. (1988). Cognitive Load During Problem Solving: Effects on Learning. Cognitive Science, 12, 257-285.
  2. Mancinetti, M., Guttormsen, S., Berendonk, C. (2019). Cognitive load in internal medicine: What every clinical teacher should know about cognitive load theory. European Journal of Internal Medicine, 60, 4-8. 
  3. Paas, Fred, et al. (2003). Cognitive Load Measurement as a Means to Advance Cognitive Load Theory. Educational Psychologist, 38(1), 63–71.
  4. Shively, J, NASA-Ames Research Center. (2016). Workload Measurement in Human Autonomy Teaming: How and Why? National Aeronautics and Space Administration. Accessed May 2020 at https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20160008388.pdf
  5. Paas, F., Ayres, P., Pachman, M. (2008). Assessment of cognitive load in multimedia learning therory, methods and applications. Recent Innovations in Educational Technology that Facilitate Student Learning, Chapter 2, pg.11-35. 
  6. Croskerry, P. (2014). ED cognition: any decision by anyone at any time. CJEM, 16(1), 13-9.
  7. Johannessen, E., Szulewski, A., Radulovic, N., Gilic, F., Braund, H., Wu, K., White, M., Rodenburg, D., Howes, D., Davies, C. (2019). Measuring cognitive load in a clinical setting: Medical learning and practice. (M.A.Sc thesis), Queen’s University, Kingston, Canada. 
  8. Fraser, K.L. et al. (2018). Cognitive Load Theory for debriefing simulations: implications for faculty development. Advances in Simulation, 3, 1-8.
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Infectious mononucleosis

Infectious mononucleosis
~ Nadine Schottler, Great Britain ~ Leave a comment

Case Presentation

A 16-year-old boy presents to A&E with a fever, an extremely sore throat, and a recent blotchy rash on his back that has been concerning him. He complains of feeling extremely tired and lethargic for the past two weeks. He denies having recently been in contact with anyone ill and confirms that he is up-to-date with his vaccinations. He mentions a visit with his local GP last week, where his doctor prescribed a dose of amoxicillin for a suspected throat infection. He has no other significant medical history. Upon further examination, his pharynx and tonsils appear inflamed with whitewash exudate and he has swollen neck lymph nodes in both the anterior and posterior triangles of the neck.

What is/are the most appropriate next step(s) in the patient’s management?

  • A) Reassure the patient and discharge
  • B) Perform a throat swab
  • C) Arrange a full blood count and a monospot test
  • D) Arrange a rapid antigen test for group A streptococcus

The answer is c) Arrange a full blood count and a monospot test

What is Glandular Fever?

Infectious mononucleosis, also known as glandular fever, is an infection resulting most commonly (80-90%) from an Epstein-Barr virus (EBV). About 95% of adults in the world have been infected with EBV; however, it is rare for it to progress into glandular fever. Glandular fever is most commonly seen in individuals aged 15-24, but can present in all age groups. The prevalence of glandular fever is estimated to be between 5-48 cases per 1000 persons. Glandular fever is rather rate in those under 10 or older than 30 (1/1000 persons), so it may not need to be in your top differentials in those age groups! In young adults, the likelihood of developing glandular fever from a primary EBV infection is about 50%; in older adults the chances of EBV infection progressing to glandular fever is slim.

For the most part, glandular fever is not contagious. It’s mostly spread through contact with saliva; such as by kissing, sharing food, or children putting things in their mouths. It can also be spread through sexual contact. Luckily, in most occurrences, glandular fever is self-limiting and lasts two to four weeks. The most common lasting effect is fatigue, which can continue from weeks to months.

When Should You Suspect Glandular Fever?

The classic ‘triad’ of symptoms for glandular fever are: 

  • Fever
  • Lymphadenopathy
  • Pharyngitis (‘sore throat’)

Bilateral posterior cervical lymphadenopathy is typical for glandular fever. Tonsils may also be enlarged, and exudate on the tonsils is described as ‘whitewash’. 

Additional signs and symptoms that could include:

  • Prodromal symptoms: 
    • Fatigue, chills, myalgia, headache
  • Palatal petechiae
    • 1-2mm in diameter and lasting 3-4 days
  • Abdominal pains 
  • Nausea and vomiting 
  • Non-specific rash
    • In this case, the patient had a maculopapular rash which is associated with EBV infection. It can be caused by the infection directly but more commonly presents after being treat with amoxicillin; patients should not take penicillin antibiotics when they have infectious mononucleosis. 
  • Splenomegaly 

If you see, or the patient tells you, of any of the following symptoms during their visit to the emergency department, it requires hospitalization! 

  • Difficulty swallowing 
  • Difficulty breathing 
  • Severe stomach/abdominal pain

These may suggest malignancy. Difficulty swallowing and breathing are most often due to inflamed tonsils and may require steroids. Severe stomach/abdominal pain might suggest a ruptured spleen. Refer to your local guidelines for investigation and treatment if these symptoms present. 

Differential Diagnoses

Viral pharyngitis

  • This is the most common alternative diagnoses
  • Viral pharyngitis tends to be more erythematous 
  • Exudate is not common with viral pharyngitis

Bacterial tonsillitis

  • Bacterial tonsillitis is more commonly described as having ‘speckled’ exudate on tonsils, compared to the ‘whitewash’ exudate on tonsils in glandular fever
  • Lymphadenopathy is usually limited to the upper anterior cervical chain, where in glandular fever, lymphadenopathy can be commonly seen in both anterior and posterior triangles

Other differentials could include other causes of lymphadenopathy, such as inflammation/infection, lymphoma, or leukemia. Alternative viral infections should also be considered (e.g. cytomegalovirus, acute toxoplasmosis, acute viral hepatitis, inter alia). 

Investigations If Glandular Fever Is Suspected

In children younger than 12, or a person who is immunocompromised, a blood test for EBV viral serology should be arranged (if the patient has been ill for seven days). 

In individuals older than 12, a full blood count with differential white cell count and a monospot test should be arranged in their second week of illness. Glandular fever is likely if:

  • The monospot test is positive
  • The full blood count has more than 20% atypical lymphocytes 

OR

More than 10% atypical lymphocytes and the lymphocyte count is more than 50% of the total white cell count.

Treatment

The patient only needs to be hospitalized if they have stridor, difficulty swallowing, are dehydrated, or there is a chance of potentially serious complications (such as a splenic rupture). Steroids should only be used if the patient shows to have difficulty breathing, otherwise, management should be conservative. If the patient doesn’t have any of these concerning signs, it is appropriate to advise the patient of their illness and discharge them for follow-up with their GP.

Some Recommendations To Patients

Some things you can advise the patient on for self-management of glandular fever include:

  • Symptoms usually only last 2-4 weeks 
  • Fatigue may be the last symptom to resolve
  • Relieve symptoms of pain and fever with paracetamol or ibuprofen
  • Encouraging normal daily routines and that exclusion from work or school is not necessary
  • Spreading of disease can be limited by avoiding kissing and not sharing eating utensils
  • They should return to the hospital if they suspect any serious complications (such increased difficulty to breath/swallow, or severe abdominal pain)

References and Further Reading

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Defibrillator: Clear!

Defibrillator clear
~ Jule Santos, Brasil ~ Leave a comment

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

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

What would your answer be?

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

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

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

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

Defibrillation versus cardioversion

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

Defibrillation

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

Electrical Cardioversion

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

Special Situations

Digital Intoxication

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

Pacemaker / Implantable cardioverter-defibrillator (ICD)

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

Pregnancy

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

Things To Consider

Keep your devices tested!

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

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

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

No conductive gel, what can we do?

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

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

Location recommended by Advanced Cardiac Life Support (ACLS)

Antero-lateral

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

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

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

Complications

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

References and Further Reading

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

Cerebral Venous Sinus Thrombosis

~ Sumaiya Hafiz, UAE ~ Leave a comment

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

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

What is Cerebral Venous Thrombosis (CVT)?

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

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

Epidemiology and Risk Factors

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

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

Anatomy

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

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

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

Pathophysiology

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

History and Physical Examination

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

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

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

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

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

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

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

Lesions in deep venous sinuses may present with altered mental status

Differentials

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

Investigations and Imaging

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

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

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

1) Empty delta sign

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

2) Dense clot sign

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

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

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

Treatment and Management

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

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

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

Prognosis

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

Things To Consider

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

References and Further Reading

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Recent Blog Posts By Sumaiya Hafiz

Imposter Syndrome In The Medical Field

~ Brenda Varriano, Canada ~ Leave a comment

Authors

Brenda Varriano and Matthew Welch

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

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

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

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

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

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

Part 2: Solutions and Pitfalls (Matthew Welch)

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

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

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

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

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

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

Miller, 2020

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

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

Acknowledgments

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

References and Further Reading

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

Student Engagement is a Priority on the Development Agenda

~ Mohamed Hussein, Egypt ~ Leave a comment

Introduction

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

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

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

Potential causes of human resource limitation in emergency medicine

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

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

The building blocks of student engagement

The Clerkship

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

 

The Interest Group

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

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

 

The ‘Student Council’

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

Conclusion

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

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

Further Reading(or watching):

Countries Recognize Emergency Medicine as a Specialty

The Importance of The Emergency Medicine Clerkship

Special Considerations for Homeless Patients in the Emergency Department

~ Helena Halasz, Hungary ~ Leave a comment

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

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

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

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

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

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

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

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

Areas of improvement:

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

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

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

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

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

References and Further Reading

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

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Sepsis – An Overview and Update

An Overview and Update
~ Kohylah Piper, Antigua & Barbuda ~ Leave a comment

What is Sepsis?

Sepsis is a composite of symptoms and clinical signs that correspond to infection within a patient. This clinically heterogeneous syndrome may be fatal due to the extensive inflammatory processes and organ dysfunction it can provoke.

The New Definition of Sepsis

In 2016, after a revision by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, sepsis was redefined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection.”

This new definition of sepsis means that the patient’s body, in response to infection, reacts by causing damage to its own organ structures, and this process can progress to the point where death can be an unfortunate end result.

Along with this up-to-date definition of sepsis, up-to-date criteria for evaluating sepsis were also provided; however, let’s first consider the causes of sepsis.

What is the Aetiology of Sepsis?

Sepsis can be caused by various organisms ranging from viruses to fungi to protozoans; however, bacterial infections are the main offenders. Vincent et al. (2009) concluded in the international EPIC II study that gram-negative bacteria were the principal perpetrators, accounting for 62%, while the gram-positives followed with a frequency of 47%. Of these groups, the principle organisms include:

  • Staphylococcus aureus and Pseudomonas at 20%
  • Escherichia coli at 16%

Different risk factors may predispose persons to become infected by these organisms.

Risk Factors

  • Non-Communicable diseases (Diabetes Mellitus, Chronic Kidney Disease)
  • Hemodialysis
  • Liver disease
  • Immunodeficient conditions
  • Trauma
  • The elderly, children, infants
  • Burns
  • Corticosteroid Use
  • Cancer
  • Prolonged Hospital Stay
  • Indwelling catheters

What is the Clinical Presentation of Sepsis?

The presentation of sepsis ranges from acute to insidious. There are cases where the patient may indicate a site of infection to cases where there is none apparent. Symptoms and signs of this syndrome generally include the following:

Another early sign of sepsis includes the presence of leukopenia or leukocytosis.
Along with these parameters, there are also specific signs within each organ system that must also be taken into account when investigating the source of primary infection or exploring the secondary effects of the same.

For example, when examining the respiratory system, listen for adventitious sounds or decreased breath sounds that may point to pneumonia and other chest infections. Respiratory causes of sepsis account for 42% of cases, according to the EPIC II study.

Patients who present with abdominal pain should be evaluated to rule out infection sources in abdominal structures such as the appendix, colon, pancreas, gallbladder. Other sources of infection may include the urinary tract and the prostate gland.

Patients with a history of trauma, wounds, and recent surgeries should be evaluated for any signs of wound infection (e.g., pain, erythema, purulent discharge, weeping wound, abscess formation)

In patients who are already admitted to the hospital and have been given invasive adjuncts, such as a central line, urinary catheters, and hemodialysis access sites, evaluate for inflammatory signs around the insertion site.

Warning Signs of Severe Sepsis

Sepsis progresses through a continuum that begins with a systemic inflammatory response syndrome (SIRS) and ends with multi-organ dysfunction syndrome (MODS), where mortality is almost inevitable. Its severest form is known as Septic Shock, a subcategory of sepsis where there is a great probability of mortality due to severe metabolic and circulatory irregularities.

The New Criteria for Evaluating Sepsis

The Sequential Organ Failure Assessment score, otherwise known as the SOFA score, is the new criteria used to evaluate sepsis. It replaces the SIRS Criteria.

SOFA takes into consideration six parameters that relate to specific organ systems. These systems are aligned with clinical signs and laboratory values, which fit into a numerical score ranging from 0 to 4, where 0 corresponds to normal values, and 4 corresponds to a high level of organ failure. See the image below, adapted from Vincent et al. (1996).

Since this criteria at its base enable physicians to assess the level of dysfunction occurring in the patient’s organ systems, the higher the score given, the more probable there will be an increase in mortality.

Using the SOFA criteria,  a score equal to and greater than 2 in the presence of confirmed or suspected infection corresponds to organ dysfunction. It indicates a mortality risk of around 10%.

The abbreviated version of the SOFA score, known as quick SOFA or qSOFA, is helpful for screening patients suspected to have sepsis by quickly evaluating three parameters, mental status, systolic blood pressure, and the respiratory rate.

REBELEM Blog (2016) qSOFA Score

Laboratory and Imaging

The general laboratory, imaging, and special studies for sepsis can include various tests depending on the suspected source of the infection, for example:

  • A Chest X-ray may show signs of pneumonia or any other lung infection.
  • CT imaging may reveal abdominal abscesses, perforation of the bowels.
  • An ultrasound can rule out pelvic sources of infection, as well as in organs such as the gall bladder.
  • Cardiac tests (electrocardiogram and troponins) may reveal suspected causes such as Myocardial Infarction.
  • Routine tests such as Complete Blood Count and Chemistry studies provide a baseline analysis for infection screening and organ dysfunction (kidney and liver).
  • Procalcitonin is a sepsis biomarker and increases in the presence of systemic bacterial infection.
  • Blood, urine, and source cultures should be taken for organism identification and antibiotic sensitivities.
  • Certain clinical presentations may necessitate abscess aspiration, lumbar puncture, or paracentesis.
  • Arterial blood gas is also a beneficial test for analyzing how septic a patient may be.

It is also important to note that serum lactate has become an important test in diagnosing sepsis, especially in relation to septic shock. (Lee and An, 2016)

The image below provides a summary of test results related to sepsis, as adapted from Mahapatra and Heffner (2020):

Treatment of Sepsis

The foundational aspects of treating sepsis rest upon rapid recognition and rapid remedy.

Schmidt and Mandel (2021) explain that resuscitation must be aggressively instituted in order to reperfuse the organs; just like antibiotic therapy, fluid resuscitation should be implemented within the first hour. It is given at 30 mL/kg and should be finalized by the third hour.

Initial antibiotic therapy should aim to cover both gram-positive and gram-negative organisms, any other considerations must be fully in line with the information found in the patient’s history, and physical examination. Where the source of infection necessitates surgical intervention, this must be pursued additionally.

The patient’s response to the treatments should be continuously monitored for improvements or worsening condition, and appropriate transfers should be pre-empted, for example, if the patient needs to be transferred to the Intensive Care Unit.

Key Points

  1. Sepsis is a clinically heterogeneous syndrome, which has a progression that can lead to severe cellular, metabolic, and overall hemodynamic dysfunction.
  2. If left un-recognized or, if it is not treated aggressively, the patient outcomes may be dim.
  3. The SOFA score is a criteria that is used in-depth and in a quick overview to assess the level of organ dysfunction in suspected or confirmed sepsis.
  4. Patients should be consistently monitored while exploring for the possible primary source.
  5. Sepsis is treated with rapid infusion of intravenous fluids and by using broad-spectrum antibiotics.
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References and Further Reading

Healthcare: A back up industry

Healthcare: A back up industry
~ Sajan Acharya, Nepal ~ Leave a comment

Examples of system failure are littered around the medical field and often disguised as professionalism or better yet heroism. “One resource seems infinite and free: the professionalism of caregivers”, says an opinion piece published in The New York Times. The article goes on to say that an overwhelming majority of health care professionals do the right thing for their patients, even at a high personal cost. Noteworthy is the availability heuristic that comes into play. “Of course they should work in favor of their patients, no matter what, isn’t that why they chose the medical profession!?”, you ask. They sure did. A lot of why you believe that medical professionals must go out of their way to help patients can be explained by what news you are being exposed to these days. The availability heuristic! That kept aside the gist of the article can roughly be summed up in the following excerpt

“Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just a bad strategy. It’s bad medicine. This status quo is not sustainable — not for medical professionals and not for our patients.”

I invite you to, for some minutes, drop all the preoccupation and think about it logically. I have, time and again, submitted myself to the idea that empathy and not logic is the best way to get my point across. But today, let us first think about some pertinent analogies.

As we anticipate the dreaded tsunami of COVID-19, many governmental healthcare institutes are sending out a notice for recruiting doctors and nurses for a certain time. My sister who is a nurse said, “Why do they have to make it sound like we are disposable?”. To which, I wittingly replied, “ Well they are probably looking for paid volunteers.” But the same recurring theme covers the core of our conversation. We simply were treating healthcare as a per-need industry. When the reality is, again, a contrasting opposite. Indeed, healthcare is a backup industry. You do not wish to use it when things are going smoothly. The healthcare system of any country should stand on its mighty ability to deal with crises.

Most other industries can either do with the number of people already in the industry or have to let go of people they already had, during a disaster. That is a contrasting opposite to the healthcare industry. Every time the health of the public is threatened we start to search for volunteers and temporary hires. I argue this is because the healthcare industry is ruled by businesses in the most powerful countries. To the point that the notion of just enough or even fewer doctors working in a setting is looked upon as a heroic measure. I don’t suppose you would say. “Oh! That busy bank has only one teller, and she also works as a receptionist. How heroic of her!”, do you?

There are reserves in almost every industry. Take transportation as another example: I visited Kathmandu on a night bus during my vacation as a child. My dad introduced me to two men. Both of them were drivers. I was taken by surprise when I found out the bus only had one steering wheel. “What would the other driver do!?”, the inquisitive child in me asked. My dad was semi-asleep when he answered, “They will drive for the whole night. Don’t you think they need to rest?”. I sure do Dad, I sure do!

In aviation, the first officer (FO) is the second pilot (also referred to as the co-pilot) of an aircraft. The first officer is second-in-command of the aircraft to the captain, who is the legal commander. In the event of incapacitation of the captain, the first officer will assume command of the aircraft. A second officer is usually the third in the line of command for a flight crew on a civil aircraft. Usually, a second officer is used on international or long haul flights where more than two crews are required to allow for adequate crew rest periods.

There have been some examples of what would be analogous to a natural disaster in other industries. Let us take some economic ups and downs as examples. Remember, India demonetized Rs. 500 and Rs. 1000 notes? Bankers had to work extra hours to make sure the undertaking completed in due time. They, of course, were paid an extra allowance for that. Interestingly they did not have to open up more positions for the work to be carried out. Remember the great economic recession? It “forced” business owners to let go of their employees. Not recruit more!

I vividly remember feeling proud of one of my seniors who was portrayed as an ideal healthcare worker. “He was arranging the medicine cabinet when we visited him”, one of my professors boasted. I felt not only proud but a desire to be at his place and do as he did one day. Today I understand that 1) he could be doing something way more productive and 2) what my senior was doing when my professor reached there was a clear example of a system failure.

Let me give you an example of my intern year to demonstrate the lack of consideration of the human element in designing healthcare systems. I had to take leave for some days. It was the flu. I understand that the coronavirus situation has alchemized the glory that flu deserved all along, but those were different times. I had a severe sore throat and my body ached like some virus was gnawing on my bones. I remember feeling very guilty about being ill because while I was sniffing Vicks and popping paracetamols in the hostel. My friends (fellow interns) were working their asses off. But when the system was designed, did no one think that someone might get sick? I mean, we work around infections every day. C’mon system designers, that is blindness, not just shortsightedness. The irony is: we are in an industry where we boast about our ability to empathize with human pain, suffering, and ill-health.

Human development has been punctuated by disasters of some sort, time and again. It is almost comical that we haven’t learned our lessons and that harrowing circumstances have to keep reminding us of the need for preparedness. It almost feels like I am writing a reminder the second time. After I failed to follow through my previous reminder. For me, the first time was the Nepal earthquake 2015. I am sure you have your own first time. I can only speak of the healthcare industry because that is what I have been fortunate enough to see closely. I am sure preparedness means different things in different settings. For healthcare, it means 1) taking into account the human element and 2) realizing that healthcare is a backup industry.

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Empiric Antibiotics for Sepsis in the ED Infographics

Empiric Antibiotics for Sepsis in the ED Infographics
~ Sarah Bridge, USA ~ Leave a comment
Empiric Antibiotics for Sepsis in the ED Infographics
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Recent Blog Posts By Sarah Bridge