Category: Medical Education

Question Of The Day #5

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod 5 trauma

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

  • A) Order CT scan of abdomen and pelvis
  • B) Perform Diagnostic Peritoneal Lavage (DPL)
  • C) Call surgery team for exploratory laparotomy
  • D) Perform emergent thoracotomy

This patient has sustained blunt abdominal trauma from his seat belt. This is indicated by the linear area of ecchymoses, known as a “seat belt sign”. This is a worrisome physical exam finding that should raise a concern about a severe intra-abdominal injury. All trauma patients presenting to the emergency department should be assessed using an organized approach, including a primary survey (“ABCs”) followed by a secondary survey (more detailed physical examination). The FAST (Focused Assessment with Sonography in Trauma) examination is part of the primary survey in a trauma patient. Some sources abbreviate the primary survey in trauma as “ABCDEF”, which stands for Airway, Breathing, Circulation, Disability, Exposure, FAST exam. The primary survey attempts to identify any life-threatening diagnoses that need to be addressed in a time-sensitive manner. Examples include cardiac tamponade, tension pneumothorax, and intra-abdominal bleeding. The FAST exam includes 4 basic views: the right upper quadrant view (liver and right kidney), pelvis view (bladder), left upper quadrant view (spleen and left kidney), and cardiac/subxiphoid view (heart). An E-FAST, or extended FAST, includes the four standard FAST views plus bilateral views of the lungs to evaluate for pneumothorax. An abnormal FAST exam demonstrates the presence of free fluid on ultrasound. In the setting of trauma, free fluid is assumed to be blood. Free fluid on ultrasound appears black, or anechoic (indicated by yellow arrows in below image).

question of the day 5 trauma

The space between the liver and right kidney (“Morrison’s Pouch”) is often the first location or blood to accumulate in a patient with intra-abdominal bleeding. Trauma patients who are hemodynamically unstable with a positive FAST exam (this patient) should go to the operating room for emergent exploratory laparotomy (Choice C) to determine the source of their bleeding. Performing a CT scan of the abdomen and pelvis (Choice A) would be the correct answer if the patient was hemodynamically stable and had a positive FAST exam. Allowing this patient to leave the emergency department for a CT scan would be dangerous as this patient could rapidly decompensate. Performing a Diagnostic Peritoneal Lavage (Choice B) would be the correct answer if the patient was hemodynamically stable but had a normal FAST exam. An emergent thoracotomy (Choice D) is more typically performed in patients with penetrating trauma who have cardiac arrest shortly before presenting to the emergency department. This intervention attempts to identify and treat any reversible causes of cardiac arrest. Correct Answer: C

References

Butler, M. (2015). “Boring question: What is the role of the FAST exam for blunt abdominal trauma?” Canadiem. https://canadiem.org/boring-question-what-is-the-role-of-the-fast-exam-for-blunt-abdominal-trauma/

Franzen, D. (2016). “FAST examination”. SAEM. https://www.saem.org/cdem/education/online-education/m3-curriculum/bedside-ultrasonagraphy/fast-exam

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Question Of The Day #4

question of the day
~ Joseph Ciano, USA ~ Leave a comment
question of the day 4

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

  • A) Lumbar Puncture
  • B) IV 1000mL 0.9% NaCl
  • C) IV Ceftriaxone
  • D) Non-contrast CT head

This patient describes her headache as severe, sudden-onset, and different than her prior headaches. These clues on history should raise concern for a subarachnoid hemorrhage (SAH) as the cause of her headache. Choice A (Lumbar Puncture) helps evaluate headaches caused by meningitis, pseudotumor cerebri (idiopathic intracranial hypertension), and SAH. Choice B (IV 1000mL 0.9% NaCl) is sometimes used to treat headaches, like migraines, but this patient should first receive another testing as there is a concern for SAH. Choice C (IV Ceftriaxone) is the correct initial treatment for bacterial meningitis, but this patient has a higher pretest probability for SAH. Choice D (Non-contrast CT head) is the right answer. Non-contrast CT scan of the brain performed within 6 hours of headache onset have high sensitivity to rule out aneurysmal SAH. The sensitivity of the non-contrast CT scan diminishes to 91-93% at 24hours after headache onset and continues to decrease after this to 50% sensitivity at seven days after pain onset. Lumbar puncture is recommended for a patient with a negative CT scan, high pretest probability for SAH, and presentation after 6 hours of headache onset. Findings on Lumbar Puncture that support the diagnosis of SAH include Xanthochromia (yellow appearance of the CSF due to blood breakdown) and inadequate clearing of red blood cells in the CSF between tubes 1 and 4. Treatment for SAH includes blood pressure control, seizure prophylaxis, and neurosurgical consultation, and nimodipine to prevent vasospasm and rebleeding. The Hunt and Hess scoring system can be used to predict clinical outcomes for patients with SAH. Correct Answer: D

Reference

Nelson AM, Mase CA, Ma O. Spontaneous Subarachnoid and Intracerebral Hemorrhage. “Chapter 166: Spontaneous Subarachnoid and Intracerebral Hemorrhage”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

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Question Of The Day #3

question of the day
~ Joseph Ciano, USA ~ Leave a comment
question of the day 3

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

  • A) IV 1,000mL of 0.9% NaCl
  • B) IV 50mL of 25g dextrose solution
  • C) IV 250mL of 3% NaCl
  • D) IV 40mg Furosemide

Choice A (IV 1,000mL of 0.9% NaCl) is an isotonic crystalloid fluid helpful in a patient with depleted intravascular volume (i.e., dehydration). This patient is clinically dehydrated (dry oral mucosa and mild tachycardia); however, hypertonic 3% NaCl is a more appropriate initial treatment. Choice B (IV 50mL of 25g dextrose solution, or commonly known as “D50”) is an appropriate treatment for a patient with hypoglycemia. Checking a glucose level is a crucial part of the initial assessment of all patients with altered mental status, but this patient has a reported normal glucose level. Choice D (IV 40mg Furosemide) is a diuretic that would worsen this patient’s dehydration and acute kidney injury. This patient has severe hyponatremia along with neurological symptoms (coma and seizure). Hyponatremia plus neurologic symptoms, like vomiting, seizures, reduced consciousness, cardiorespiratory arrest, necessitate rapid correction of sodium with hypertonic (3%) NaCl solution. 3% NaCl solution can be infused 100-150mL over 15-20min and repeated up to 3 doses total. A serum sodium level should be measured after each administration of 3% NaCl in order to limit the increase in the sodium level to no more than 8-12 mEq/L over the first 24hours. This is done to reduce the risk of osmotic demyelination syndrome. Correct Answer: C

Reference

Petrino R, Marino R. Fluids and Electrolytes. “Chapter 17: Fluids and Electrolytes”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

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NEXUS Criteria

nexus criteria
~ Keerthi Gondy, USA ~ Leave a comment
Clearing cervical spine injury without imaging via the NEXUS Criteria
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The First Nexus Criteria Reference

Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32(4):461-469. doi:10.1016/s0196-0644(98)70176-3

Question Of The Day #2

question of the day
~ Joseph Ciano, USA ~ Leave a comment
question of the day 2

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

  • A) Synchronized Cardioversion
  • B) Asynchronized Cardioversion
  • C) Transcutaneous Pacing
  • D) Intravenous 1 mg Adrenaline

The patient in this scenario has decompensated into cardiac arrest from Ventricular Tachycardia (Vtach). The patient’s history of heart failure puts him at risk for cardiac arrhythmias. It is important to be suspicious of transient cardiac dysrhythmias for any patients who present to the Emergency Department with syncope and no prodromal symptoms. A lack of prodromal symptoms (i.e., diaphoresis, dizziness, nausea) prior to syncope should raise concern for a possible cardiac etiology of the syncope. Choice A (Synchronized Cardioversion) would be the correct management for patients with Vtach with a pulse or patients with tachyarrhythmias and hemodynamic instability (i.e., hypotension). Choice C (Transcutaneous Pacing) would be the correct management for patients with bradyarrhythmia and hemodynamic instability. If Transcutaneous Pacing is ineffective at increasing the heart rate, and the patient remains hemodynamically unstable, the next step would be Transvenous Pacing. But, our case is pulseless ventricular tachycardia, so there is no indication for transcutaneous pacing. Choice D (Intravenous adrenaline 1 mg) may be helpful in a patient with cardiac arrest with Pulseless Electrical Activity or Asystole, VTach, or VFib, but this is not the best initial action. The ACLS algorithm indicates that all patients with cardiac arrest due to Pulseless Ventricular Tachycardia or Ventricular Fibrillation should receive Asynchronized Cardioversion (Choice B). Asynchronized Cardioversion is also called defibrillation. CPR may be initiated prior to cardioversion if defibrillation pads are not attached to the patient.

Reference

Long B, Koyfman A, Anantharaman V, Lim S, Ong MH, Kenneth T, Manning JE. “Chapter 24: Cardiac Resuscitation”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9thed. McGraw-Hill.

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Question Of The Day #1

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

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

  • A) Begin an Unfractionated Heparin drip
  • B) Administer 20mg of IV Labetalol
  • C) Administer 324mg of Aspirin
  • D) Call a Cardiology consultation

The patient in this scenario has an aortic dissection until proven otherwise. Administering anticoagulation (Choice A: Unfractionated Heparin Drip) would be the correct treatment for a pulmonary embolism. Although the patient has mild tachycardia and tachypnea on the exam, characteristics of the history and exam point closer to a diagnosis of aortic dissection. Features of the history that support a diagnosis of aortic dissection include pain described as “tearing”, “ripping”, or sharp pain radiating to the back. Other characteristics include unequal blood pressures in the extremities or neurological symptoms. Aortic dissections that migrate proximally may cause cardiac tamponade or a STEMI if they involve the coronary arteries. Choice C (Aspirin) would be the treatment for Acute Coronary Syndrome. Choice D (Call a Cardiology consultation) would not be appropriate for a patient with aortic dissection. A cardiothoracic surgical consultation would be appropriate in a patient with an aortic dissection involving the ascending aorta (Type A aortic dissection). Aortic dissections distal to the left subclavian artery that involve the descending aorta (Type B aortic dissection) are typically managed medically with blood pressure control. Choice B (IV Labetalol) is the correct answer as Aortic Dissections require aggressive blood pressure control with a goal of less than 120/80 mmHg. Beta-blockers, like Labetalol, are considered first-line therapy as they provide both alpha and beta-adrenergic receptor blockade. This allows the reduction of blood pressure without a reflex tachycardia response. Esmolol is an alternative therapy. Beta-blockers decrease vessel shearing forces that could worsen intimal vessel tearing. If beta-blockers alone cannot control blood pressure sufficiently, other medications can be included in the treatment regimen, like nicardipine, nitroglycerin, nitroprusside.

Reference

Johnson GA, Prince LA. “Chapter 59: Aortic Dissection and Related Aortic Syndromes”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

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Triads in Medicine – Rapid Review for Medical Students

triads in medicine
~ Sumaiya Hafiz, UAE ~ Leave a comment

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

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

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Free Open Online Emergency Medicine Course for Medical Students

~ Arif Alper Cevik ~ 2 Comments

Dear colleagues,

I hope this message finds you well in the busy and risky days of COVID-19. 

As known by most of you, the International Emergency Medicine Education Project has been providing free emergency medicine educational resources for medical students since June 2018. Currently, content produced by 175 contributors from 27 countries reached thousands of students from 197 countries around the globe. 

COVID-19 pandemic made many differences in our lives. Education is no exception to this. Because of the pandemic precautions, medical students miss their normal course of education. This may be a bigger issue in countries lacking e-learning options. Therefore, we have been thinking of ways to help students and educators who might be needing such a resource. 

As some of you might know, we were already planning to start a MOOC for medical students in upcoming years. However, COVID-19 forced us to fasten our plans. We have been working for a solution to help students and educators, who lack the means to continue their education activities. Finally, we managed to create a platform: iem-course.org. This platform is designed to provide free online emergency medicine courses for medical students. 

In this platform, we activated the first course, “Emergency Medicine Core Content Course.” It is a 4-week course, covering 11 core topics of emergency medicine. The course includes video and reading assignments, multiple formative quizzes. In addition, if students prefer to receive a course completion certificate, they can take the summative assessment at the end. The reading assignments are curated from freely available online resources (e.g., iEM Education Project 2018 eBook and Society for Academic Emergency Medicine’s CDEM Curriculum chapters). Videos are provided by Lecturio, and all emergency medicine videos (200 items) are freely available for students who join the “iEM/Lecturio Emergency Medicine Core Content Course.” All students around the world are free to register and use the resources provided in this course. 

We hope that this course may help students and educators to overcome educational challenges related to pandemic. We consider this initiative as our responsibility to our international community in these difficult days. We thank all emergency medicine societies, organizations and institutions that endorsed and supported us since the beginning. We are grateful to our contributors, who made creating a project like this possible by writing chapters, providing images and videos. If you are interested in contributing, please let us know by e-mail. 

iEM Course is a social responsibility initiative of iEM Education Project

Also, we would like to remind you of other iEM project resources below: 

iem-student.org is the main hub of the iEM Education project. Students can reach 2018 eBook chapters, blog posts, video, image, audio archives through this website. 

Flickr image archive is where we share images and short videos provided by our contributors. All photos and short videos are free to download. You can use these items in your presentations and exams. 

Youtube video archive is where we share clinical videos and interviews with world-renowned experts. 

SoundCloud audio archive is where we share iEM 2018 ebook chapters recorded in audio so students can download and listen anytime and anywhere.

All iEM resources are cost- and copyright-free for all medical students and educators. Please share these resources with your students and colleagues in need. If you are interested in sharing your available resources through our platforms, please contact us. We are stronger together.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

On behalf of iEM Education Project Team

For more information, please visit iem-course.org

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5 Ways Technology Drives Medicine to New Horizons

5 ways technology drives medicine
~ Ibrahim Sarbay, Turkey ~ Leave a comment

Recently, I published a Turkish article about my predictions on how emergency medicine will be in 2040 in the well-known Turkish FOAMed blog Acilci.net. In this article, we had the opportunity to brainstorm through a futuristic story about a typical Emergency Department in 2040. We have also conducted an online survey to collect the future projections of more than 40 scientists working on medicine, genetics and engineering fields; and included these predictions in the said article.

As this article was praised, I want to write about 5 ways technology will change Emergency Medicine in the coming years.

Let’s start.

Virtual Reality

VR

Virtual reality is an immersive, three-dimensional, computer-generated environment. While it may seem like technology for gaming and entertainment, it is exceptionally suitable to be used in medicine. One of the most prominent applications of it is in teaching Anatomy, allowing manipulations and dissections on the human body, more precisely than classical cadaveric dissections. Any medical student can access these materials from anywhere in the world. It is also cost-effective and requires less expertise, making it a dream come true for medical faculties(1). Surgical teams started to use 3D printing to build amazingly lifelike reproductions of real patients, and VR will only make it easier and better.

Artificial Intelligence

artificial intelligence

Artificial Intelligence (AI) is a popular term these days. It means “a system’s ability to correctly interpret external data, to learn from such data, and to use those learnings to achieve specific goals and tasks through flexible adaptation.”(2) Scientists all over the world are working determinedly to gain maximum benefit from this technology. AI outperforms a conventional algorithm for emergency department electrocardiogram interpretation. Apparently, it can even diagnose heart arrhythmias with cardiologist-level accuracy. An AI-enabled ECG can detect if a patient has atrial fibrillation even if the patient has a normal sinus rhythm during the test(3). Can we determine the ejection fraction using ECG? For sure. Is it possible to determine age and gender? Of course. If you are tired about ECG, let’s try another one: Can atrial fibrillation be detected just by looking at a patient’s face? Well it turns out deep-learning and a smartphone camera are all you need to do so. AI is capable of surpassing human experts in breast cancer prediction, and it can read X-Rays better than humans. It can diagnose pneumonia better than radiologists. An Israeli company announced that its algorithms were successful in helping to detect the presence of coronary artery disease. Another initiative, Sonde Health Inc., develops a voice-based technology platform for monitoring and diagnosing mental and physical medical conditions. AI will also help to solve doctor shortages: According to MIT Technology Review, Chinese doctors and tech companies are developing tools to automate routine medical tasks and alleviate China’s doctor shortage.

And these are just the baby steps of AI!

Health Wearables

health wearables

When we say «Health wearables,» the first thing that comes into mind might be a smartwatch capable of health features, but it covers an area much broader than that (Can we count pocket-sized ultrasound devices as Health Wearables? Probably.) A tech company Kymira works on a heart monitoring t-shirt that uses a single-lead ECG and movement reducing hardware to offer an accurate reading of heart rate during exercise. Just like Apple Watch, AliveCor’s Kardia measures ECGs and can detect atrial fibrillation with high sensitivity. With the slogan of «Personal ECG for the whole family», Wiwe can detect arrhythmias, help making risk assessment for stroke and sudden cardiac arrest, and also determine blood oxygen levels. The Clinicloud, the EKO Core, the eKuore Pro measure heart and lung sounds as digital stethoscopes. Omron Blood Pressure Smartwatch and the MOCAcare pocket sensor, can monitor blood pressure.

Traditionally EEGs are tests that require hospital settings, but a new device lets you record EEGs in your home. With a noninvasive neural interface that sits on the back of the head, it is possible to control compatible software. Do you want to send a text message with a thought? Say no more!

Great new apps and devices let visually impaired people engage with their environments in ways that were a dream once.

3D Printers

The 3D printing process builds a three-dimensional object from a computer-aided design model. Due to the increasing technological developments, there have been significant improvements in the field of 3D printing in recent years. For example, US-based CELLINK develops bioprinters and bioprinting materials for providing models to enable 3D cell culture, personalized medicine, and enhanced therapeutics. United Therapeutics, managed to bioprint lung tissues. Scientists from Spain have presented a prototype for a 3D bioprinter that can make functional human skin. 3D printed orthopedic casts became an alternative to conventional casting to treating bone fractures.

CRISPR and genomics

genomics

CRISPR is the abbreviation of «clustered regularly interspaced short palindromic repeats,» and it is a family of DNA sequences found within the genomes of prokaryotic organisms. Since the description of it in 1987 by Yoshizumi Ishino and his colleagues’, CRISPR have attracted researchers’ attention due to its great potential. By the end of 2014 more than 1000 research papers had been published that mentioned CRISPR (4). CRISPR associated nucleases have shown to be useful as a tool for molecular testing. Scientists used CRISPR to successfully delete one of the defective genes responsible for hypertrophic cardiomyopathy in human embryos. In 2017, a team of Chinese researchers successfully increased resistance to HIV in mice by replicating a mutation. Researchers managed to treat mice infected with antibiotic-resistant infections using CRISPR-engineered bacteriophages. CRISPR may help grow new and healthier food. It also helps fighting with the disease in Ways we couldn’t even imagine in the past: By targeting female reproduction in the malaria mosquito vector Anopheles gambiae, scientists try to eradicate malaria.

Conclusion

We still have a long way to go. It is not difficult to predict that some of the «magnificent» innovations promoted today will turn up to be phony. Although technology advances; problems such as anti-vaccination, global warming, poverty will open up new fronts. Still, the future will absolutely bring great potentials. We are eagerly looking forward to see.

References and Further Reading

  1. Al-Jibury O. Use of Virtual Reality in Medical Education – Reality or Deception? Med Case Rep. 2017, 3:1. doi: 10.21767/2471-8041.1000039
  2. Kaplan, Andreas; Haenlein, Michael (1 January 2019). “Siri, Siri, in my hand: Who’s the fairest in the land? On the interpretations, illustrations, and implications of artificial intelligence”. Business Horizons. 62 (1): 15–25. doi:10.1016/j.bushor.2018.08.004
  3. Attia ZI, Noseworthy PA, Lopez-Jiminez F, et al. An Artificial Intelligence-Enabled ECG Algorithm for the Identification of Patients With Atrial Fibrillation During Sinus Rhythm: A Retrospective Analysis of Outcome Prediction. Lancet 2019;394:861-867.
  4. Doudna JA, Charpentier E. Genome editing. The new frontier of genome engineering with CRISPR-Cas9. Science 2014. 346 (6213): 1258096. doi:10.1126/science.1258096
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iEM Education Project in 12 Questions

iem edu project interview
~ iEM Education Project Team ~ Leave a comment

Many simultaneous activities are going on inside the iEM Education project. This is one of the reachest platforms for medical students and educators in order to help improving undergraduate emergency medicine. We listed 12 questions and asked the iEM Education Project founder and director. Here are all answers in 8 minutes video. At the end of the video, please do not hesitate to click here to be a contributor.

ACEM2019 and Incredible India

ACEM 2019 and increadible India
~ Arif Alper Cevik ~ Leave a comment

The 10th Asian Conference on Emergency Medicine was successfully completed in New Delhi, India, during the last couple of days. The conference hosted around 1700 attendees around the globe, mainly Asia. There were approximately 300 speakers from all continents. Dr. Tamorish Kole and Dr. Sirinath Kumar were the two Emergency Medicine professionals who behind the success of this conference. Both experts are also a member of the board of directors of the Asian Society for Emergency Medicine (ASEM). At the end of the conference, Dr. Kole took over the presidency from Prof.Dr. Yildiray Cete (Turkey) who served to ASEM for two years.

ASEM board
Asian Society for Emergency Medicine, Board of Directors

Vice-President of India, Venkaiah Naidu, opened the conference with promising support to the improvement of Emergency Medicine care in India as well as highlighting the implementation of Emergency Medicine into the undergraduate curriculum. As many countries in Asia, Indian medical graduates are working in acute care settings after graduation. Therefore, focusing on undergraduate education can help many countries in the same context. 

Venkaiah Naidu
Venkaiah Naidu, Vice-President of India

This topic one of the items discussed in the ASEM Board of Directors meeting. Creating a widely acceptable undergraduate curriculum is a necessity for Asian countries, especially those in the development stage of Emergency Medicine. ASEM board formed a sub-committee to work on this highly significant problem. Dr. Mohan Tiru (Singapore) and I will be leading board members to continue and finalize the process. Because the International Federation for Emergency Medicine (IFEM) currently working on a comprehensive update process for its’ undergraduate curriculum, there is no need to reinvent the wheel for ASEM. Taking the updated version of the IFEM undergraduate curriculum as the main framework and working on it to create a precise Asian undergraduate curriculum will be enough and probably the fastest way. However, there is a need to understand the current situation and needs in Asian countries. Therefore, the sub-committee of ASEM will work on learning needs assessment and current situation analysis until the IFEM undergraduate curriculum finalized. The expected time for the new updated version of the IFEM undergraduate curriculum is April-May 2020. Completing learning needs assessment and current situation analysis of Asia by March-April 2020 will give the Asian board a chance to move forward with updated IFEM undergraduate curriculum. Probably, developing the Asian curriculum will be possible in a short period of time until the end of 2020.

ASEM board meeting
Asian Society for Emergency Medicine, Board of Directors Meeting

While ACEM2019 continues, I was able to meet a couple of contributors to the International Emergency Medicine Education Project. I visited Rob Rogers’ well-known course, Medutopia, which aims to increase the quality of the teaching skills of educators. According to Dr. Rogers, this is the most enthusiastic and knowledgable group since the Medutopia journey has begun. Dr. Andy Little and Dr. Mike Giosondi were other two experts who gave the course with Dr. Rogers. You can read and listen to Dr. Rogers’ contributions to the International Emergency Medicine Education Project here.

I also came across to Dr. Simon Carley from Manchester, who is well-known for ST.EMLYN’s blog. He gave a couple of amazing talks during the conference, including one plenary presentation.

Simon Carley, plenary session
Simon Carley, plenary session
Arif Alper Cevik and Simon Carley
Arif Alper Cevik and Simon Carley

One of the surprising things was meeting with one of our blog authors Dr. Kaushila Thilakasiri (Sri Lanka) and her team. This energetic group was not only coming for ASEM to attend meetings, but they also came to compete in SimWars. And of course, they won the first prize.

Kaushila Thilakasiri and Sri Lanka team

Two days of workshops and three days of the busy scientific program passed like lightning. In addition to scientific activities, ACEM 2019 team prepared many social events for participants. I think, socially and scientifically, ACEM 2019 was a very busy conference. This created many networking opportunities.

One of the final event was graduation ceremony of 2018-2019 class of Emergency Medicine residents. Around 120 new graduated were appreciated with a nicely setted up ceremony with attendence of leaders of Emergency Medicine such as Prof. Lee Wallis (Past President of IFEM), Dr. Taj Hassan (Pas President of Royal College of Emergency Medicine) and Prof. James Ducharme (President of IFEM) as well as local leaders of Emergency Medicine of India.

2018-2019 Indian Emergency Medicine Graduates
2018-2019 Indian Emergency Medicine Graduates

As a summary, ACEM2019 was a successful gathering for international Emergency Medicine experts and Asian emergency physicians, residents and medical students.

ACEM 2021 will be in Hong Kong. ASEM board of directors decided to give ACEM2023 to Manila, Phillipines and ACEM2025 to Dubai, United Arab Emirates. We hope to see you all in these upcoming events.

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How to make the most of your EM Clerkship

How to make the most of your EM Clerkship
~ Sumaiya Hafiz, UAE ~ Leave a comment

Emergency Medicine has something for everyone!

Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.

Prepare a list of common conditions

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

core em clerkship topics

There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.

As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.

Brush up on your history taking and examination skills

Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.

Read about common ED procedures

ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”

list of selected procedures

Watch videos on examination, interpreting X-rays, & procedural skills

Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.

Interpretation of ECG & X-rays

Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.

How to read c-spine x-rays

How to read chest x-rays

How to read pelvic x-ray

Books

Before the rotation

Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.

iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)

If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.

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During the rotation

During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.

These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.

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