The Importance of Wellness in Medicine – My Story and Introduction to a Series of Blog Posts

wellness in medicine

Either be the light in the room or the mirror that reflects it

I always believe that going to work means putting personal issues aside. As physicians, we have a role to make every patient feel welcome, cared for, and heard. However, being in the ER can be stressful. Not only can stress impact our job performance, but it can increase the burnout rate. So begs the questions; how you handle stress, why is it important and what happens when you lose your main source of stress reduction, is there a back-up plan. For my wellness series, I hope to discuss my own experience of losing my main outlet for stress so you know who I am and why I am writing about this topic, the importance of physical fitness, effective quick workouts for a busy ED lifestyle, and a favorite topic of mine, imposter syndrome. As medical students, aspiring ED physicians or an ED physician, I believe we have a role to protect our own health, so that we may best support our patients. 

As medical students, aspiring ED physicians or an ED physician, I believe we have a role to protect our own health, so that we may best support our patients.

brenda - who I am

My name is Brenda-Maricela and I have just finished my first year of medical school at Central Michigan University as an international student, having done all prior education in Canada. While, academically, I had performed well in medical school, mentally, I was burnt out. It is not that I was not used to difficult schoolwork, I had graduated from the University of Toronto, where I was quite accustomed to immense workloads, working part-time jobs and juggling extra-curriculars. It was the fact that I had no outlet for my stress.

You see, prior to medical school, my outlet would be running. I was a modern-day Forest Gump. I craved the long runs that would allow me to shake off any stress I was holding onto. The longer the run the better. I was addicted. During my MSc, I was training with the University of Toronto Triathlon club, running road races and trying to win my age group and felt I could face any challenge that crossed my path. However, I would never have anticipated that I would not be able to run for 2 years. 

In the summer of 2018, I recall the moment where I was getting off of a chair at a conference. I felt a twinge in my right knee but thought nothing of it. I had a minor limp, but nothing too severe. A week later the pain grew, and before I knew it, I was in the ER. “I believe you have Patellar Femoral Pain Syndrome,” the doctor told me while reviewing my X-Rays. Patellar Femoral Pain Syndrome (PFPS) is a clinical term to define anterior knee pain, which often shows no structural damage in imaging.

brenda ER

It is most common in female athletes, and given the multifactorial nature, there is no single treatment. However, it often resolves with physical therapy and reducing activity. Reading about PFPS is one thing, experiencing it is a nightmare.

What would I do without running? The most common advice that I had received was to switch to biking and swimming, something which was a lower impact. These strategies worked, but as time had waned on, my knees became worse and soon, even the pool became a source of pain. I was in a rut. I would do anything to get the endorphins, but nothing would suffice. I would do anything to run again, let alone kneel in a yoga class. I saw multiple doctors, physical therapists, chiropractors and each time, I got the same diagnosis and was told it would resolve on its own.

Spring 2019, I got the phone call informing me of my acceptance to medical school. It was something I had dreamed of since I was a little girl. On one hand, I was ecstatic, but on the other hand, I was drained, depressed and couldn’t look at a jogger on the roads without feeling a sinking feeling in my stomach. How on earth was I going to get through medical school? During my undergraduate degree, I had exercising to sharpen my mind and combat stress. I knew medical school would be intense. How would I deal with the stress? What if my knee got worse? I would be in a new country, without friends and family. Would I draw too much attention if I limped, sat all the time, didn’t participate with social outings? I almost wanted to defer a year. However, my father and biggest mentor reminded me that I had managed to get through the application process without my exercises, perhaps studying would be a good distraction.

My father was right about studying being a distractor. At times, I would be so focused on learning the content, that I forgot about the pain. Other times, my brain would be so fried that I needed a distraction. But what could I do? Sitting for so long, my body craved movement, but my knees would be hesitant. During this time, I did educate myself on other exercise styles such as High-Intensity Interval Training (HIIT), or As Many Reps as Possible Workouts (AMRAP), both with weights, and both focusing on the upper body and core. I will discuss the concept of AMRAP and HIIT in my second article, where I talk about quick and effective workouts. I believe that a sound body and mind are critical to perform well and avoid burn out in, school, the ED and beyond. However, the busy lifestyle as a medical student or a physician may make the time a limiting factor. Therefore, short effective workouts may be of use, and I hope to share my research and experiences.

So, while AMRAP and HIIT didn’t replace running, it would provide some mental soundness on days when I felt particularly on edge. Over time my knees improved, and I owe thanks to some wonderful healthcare providers in Michigan. Unfortunately, while volunteering with Special Olympics in November 2019, I got a hockey-related injury to my knees, setting my progress back a few weeks. I was devastated. Mentally, I was fried, emotionally I was drained. However, the schoolwork was still there, and I had to study. So, what did I learn from November 2019 to present? I learned how important mental health and physical wellness is. This has been a topic among peers who lost their gyms due to COVID-19, thus experiencing a loss of an outlet for stress. Personally, I saw the difference that stress made in my productivity, wellbeing and ability to retain information. So, I started exploring different outlets, many of which will be discussed in upcoming articles.

Exercise is still my favorite outlet, and I think it should be a part of a daily regimen. So, for my next two articles, I will discuss different styles of exercises and free resources I discovered on the web, such as timers, YouTube Channels and websites. Following my articles on exercise and fitness, I would like to dive into the science of yoga. I remember being told about traditional meditation, however, I found that my mind was too busy, and ironically, meditation caused me stress. Many of my ED-oriented friends similarly need to keep mentally busy, and one had recommended yoga as an active meditation. This being said, traditional mediation is effective, and my ED mentor loves it. Therefore, meditation will be discussed, most likely through research and interviews with those who have benefited from it. Finally, I intend to write about imposter syndrome. A lack of self-love can be a mental stressor. If we can learn to love and appreciate all that we have accomplished, I believe that the stress will go down. To show some self-love sounds simple but is often something that so many medical students struggle with. I know I question my own acceptance into medical school, being my own worst critic.

To conclude this article, I want to say I am passionate about medicine, and in seeing my colleagues succeed. Given my enthusiasm for exercise, and having done some personal training in the past, I am eager to share all I know. Maybe I’ll be running when I write my next article. If not, I know there are alternatives, and I hope what I share can be of use to my colleagues around the world. As I tell my friends, even if life clips your wings, just know you have all it takes to fly.

References and Further Reading

LaDonna KA, Ginsburg S, Watling C. “Rising to the Level of Your Incompetence”: What Physicians’ Self-Assessment of Their Performance Reveals About the Imposter Syndrome in Medicine. Acad Med. 2018;93(5):763-768. doi:10.1097/ACM.0000000000002046

Moukarzel A, Michelet P, Durand AC, et al. Burnout Syndrome among Emergency Department Staff: Prevalence and Associated Factors. Biomed Res Int. 2019;2019:6462472. Published 2019 Jan 21. doi:10.1155/2019/6462472

Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264-2274. doi:10.1007/s00167-013-2759-6

 

Cite this article as: Brenda Varriano, Canada, "The Importance of Wellness in Medicine – My Story and Introduction to a Series of Blog Posts," in International Emergency Medicine Education Project, August 17, 2020, https://iem-student.org/2020/08/17/the-importance-of-wellness-in-medicine/, date accessed: September 27, 2020

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

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

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: September 27, 2020

Sickle Cell, Pain and the Emergency Department

Sickle Cell Disease

It’s 2 AM, and the Pediatric Emergency Department (ED) at a community  hospital in New York is overflowing with children and caregivers. A young Nigerian boy is being transported down the center of a hallway, past a long line of doors to patient rooms. The porter is calm and walks briskly, determined to bring this boy to get immediate care. The boy winces, his hands outstretched next to him, rigid, and frozen in space, and while he is seated in the wheelchair, his legs bent at the knees are thin frames, held in place with his feet planted on the wheelchair pedestals. He is afraid to move any of his extremities; tears are rolling down his face; he is fighting the urge to grimace and furrow his brow. He cries how much it hurts to move. He knows he needs help.  Behind him, his mother follows close holding a one-year-old baby in her arms, and behind her, five other young children aged 3 through to thirteen stream in. There is quiet concern on all of their faces. The older siblings have seen this before. We learn that he has Sickle Cell Disease (SCD). He has been in excruciating pain for the past 4 hours and is now presenting with dactylitis. This case has not been the first in this ED, and like other EDs across the United States and in the world, the number of cases presenting with SCD will increase.

Sickle Cell Disease in the Emergency Dept: a global public health issue iEM Dhir

Sickle Cell Disease (SCD)

SCD is a condition that causes red blood cells to morph from a biconcave dumbbell-shaped disc, into a rigid semi-circular shape. This disease is inherited genetically by receiving two sickle genes, one from each parent and risk for complications are attributed to a variety of factors, including deoxygenation, dehydration. It is most common in African Americans as well as Latinos and people of Middle Eastern, Indian, Asian and Mediterranean backgrounds.  In the United States, SCD is the most common genetic blood disorder and affects approximately 100,000 Americans(1) and although babies are screened at birth, management plans vary with the degree of disease progression and exacerbation severity, as well as with the availability of resources and education.

RBCs in Sickle Cell Disease
Image: Sickle cells and normal red blood cells from Sickle Cell Disease, Genome. Gov

Why Emergency Physicians need to be Familiar with SCD

SCD affects both pediatric and adult patients, and it has been reported that patients between the ages of 18 to 30 years old have increased emergency department utilization. A major reason for this is due to the transition by young adults from pediatric to adult care in the management of SCD, and this population is simultaneously also learning to navigate the health care system and community resources (pediatric to adult care, insurance, independent decision making, housing, education, workforce) as discussed further below(2). In addition, the use of community health workers is important as they can act as liaisons between the health care systems and patients to disseminate information and resources. However, despite the awareness of the disproportionate use of the ED among patients with SCD, the social factors that impact care remain unknown(3) and more research and investigation is needed to understand this patient population.

Often when a complication or crisis occurs in patients with SCD, patients seek immediate care in the Emergency Department. Included in the potential list of complications include infections, such as those with encapsulated bacteria; sepsis; stroke; splenic sequestration, and early treatment is essential in managing patients. Of these complaints, the emergent cases to be aware of in the ED include vaso-occlusive crisis and pain, sickle cell anemia (SCA)(4) central nervous system such as stroke, and acute chest syndrome (ACS), where ACS due to blocked capillaries in the lungs, may be caused by infections, asthma exacerbations and/or pulmonary embolisms, and is the leading cause of morbidity in patients with SCD. Further, the Emergency Severity Index (ESI) Version 4 triage system, commonly used in the majority of EDs in the United States, suggest that patients with SCD be triaged as ESI level 2, indicating a very high priority, and that rapid placement be facilitated(5).

Although the discussion of complications of SCD including the presentation and management is a complex topic, and will be covered in detail in future posts, information and algorithms for clinicians are available online for reference. One such resource is a treatment algorithm that acts as a how-to guide for SCD and is available online in the Annals of Emergency Medicine(6). This approach is based on the point-of-care hemoglobin level, and discusses issues such as myonecrosis, aplastic crisis, ACS.

Sickle Cell Disease in the Emergency Dept: 1 in 4 patients in the USA with SCD receive standard care iEM Dhir

Pain in SCD

When tissues and organs are not adequately perfused with oxygen, in part due to the sickled shape of RBCs, tissue damage and death can occur. Patient management of vaso-occulusive crisis and pain varies by practices and the medications available for use around the world, however it is important to note that pain in patients with SCD is often extreme and may require treatment with opioids. In a response to the American Society of Hematology (ASH) draft recommendations to Sickle Cell Disease-Related Pain in May 2019(7),  emDOCs.net published a response to the drafted recommendations and offered insight to pain management and includes an algorithm(8). The insight provided is essential in decreasing the suffering experienced by patients during an SCD crisis, and notes the use of Dilaudid, Ketamine, Dexmedetomidine, and Lidocaine. Further, the understanding of limiting the use of NSAIDS due to impaired renal function caused by the disease is also outlined in the response.

Management of pain in pediatric patients with SCA and vaso-occulsive pain also varies according to hospital and individual provider practices, and scientific investigation and patient research is needed to provide proper care to this population. An example includes a study by PECARN addressing the use of a normal saline bolus in pediatric emergency departments found an association with poorer pain control(9). Identifying and implementing results from research studies is important in understanding and managing SCD in both adult and pediatric patients.

Emergency Physicians around the world should be aware of strategies for identifying SCD, and management, specifically in areas around the world where refugees from countries with SCD prevalence is common. Countries where refugees and migrants are commonly are known to disembark, such as those in southern Europe(10) and certain areas in the United States and Canada would benefit from in-depth analysis of the issue and could allow for appropriate and accessible health care to vulnerable populations, as well as educate providers who are unexposed to managing emergencies in SCD patients while setting in place integrated and individual health plans away from emergency room dependence(11). In developing countries with SCD populations, such as Nigeria, there is a high prevalence of pediatric emergency cases, and the proper management of the disease as well as policy and hospital organization for high volume and off-hour admissions, may reduce hospital stays(12). Further, the self-efficacy of adult patients with SCD, from education, pro-active efforts, understanding of disease management, also can allow for decreased ED visits and hospitalizations for pain(13).

SCD affects approx 100,000 Americans Sickle Cell Disease in the Emergency Dept iEM Dhir

Investigations, Resources, Education

A number of investigative studies, clinical trials and research is being conducted around the world for a better understanding of SCD, including patient care in adult and pediatric patients, genetic factors, supportive services, associated co-morbidities, and search for cures. Investigations around the world include collaborations and information sharing between academic researchers, patients, clinical providers, and health care providers and officials around the world.

The National Heart, Lung, and Blood Institute hosted a series of Webinars in September 2018, during Sickle Cell awareness month from experts in blood science and sickle science research and are available to watch for free online(14). Some of the key highlights from two of the webinars: Serving the Sickle Cell Disease Community Here and Abroad; Sickle Cell Transitional Care from Childhood to Adulthood, are discussed here.

SCD occurs in 1 out of ever 365 Black or African American births, Sickle Cell Disease in the Emergency Dept, iEM Dhir

Webinar Overview Serving the Sickle Cell Disease Community Here and Abroad
Presented by Dr. Keith Hoots, Director of Division of Blood Diseases and Resources, NHLBI
  • Prevalence of the disease is so much larger in Africa than most places in the world. There are as many babies born with SCD born in Nigeria there are babies born with SCD, by estimate, as there almost are total people with SCD in the United States.
  • There is a need to share research and practices in the developed world with the developing world.
Three New Research Initiatives in Africa:
  • The Sickle Pan-African Research Consortium (SPARCO)
    Overview: The study sites for this research include East Africa (Tanzania), West Africa (Ghana, Nigeria) and central Africa (Cameroon, Democratic Republic of Congo) with the goal to later include 20 sites in 15 countries. SPARCO’s aim is to develop an SCD database, standards of care, and strengthen research investigation.
  • Realizing Effectiveness Across Continents With Hydroxyurea (REACH):
    Overview: Safety and dosing of hydroxyurea therapy for SCA in pediatric patients in sub-Saharan Africa; sponsored by the Children’s Hospital Medical Center, Cincinnati
  • Sickle Cell Disease Genomics of Africa (SickleGenAfrica)
    Overview: The purpose is to develop strategies to predict, prevent and treat organ damage in SCD and to investigate biomarkers associated with the development of organ damage, including molecules released during red blood cell damage in sub-Saharan African populations.
Webinar Overview: Sickle Cell Transitional Care from Childhood to Adulthood
Part 1 Presented by Dr. David Wong, MD, FAAP, Medical Officer, Office of Minority Health
  • SCD is no longer a childhood disease. Young adults are at a higher risk for hospitalization due to illness and pain.
  • Treatment and management examples in childhood include annual transcranial dopplers to assess for risk of stroke; vaccinations; hydroxyurea; L-glutamine; opioids for pain management; penicillin prophylaxis; RBC transfusions;  water intake to avoid exacerbations due to dehydration; splenectomy. The cure available is bone marrow transplant.
  • Prior to July 2017, Hydroxyurea was the only FDA approved therapy for 20 It is used in adults and children. It has been shown to reduces hospital admissions, pain crisis, and ACS however barriers to hydroxyurea use exist. These include difficulty with communicating the use to patients and caregivers, issues with frequent monitoring, lack of adherence, lack of provider knowledge and comfort with its use.
  • Community Health Workers (CHWs) are key players in effective patient care. CHW can provide information affected by social and health determinants from local economic and environmental (housing, employment), local communities (families, safety, support), activities (learn, work, play, move, shop), lifestyles (alcohol, drugs, smoking, sexual health, physical activity, and individual needs (age, genetics). CHW are experts in condition-specific information and navigating complex health systems, including accessing care in a medical home (the approach to providing comprehensive care). This is particularly important when care is not always contained or organized by one organization, where care should be accessible, continuous, comprehensive, family-oriented, coordinated, compassionate and culturally competent. Pediatric medical home principles include family-centered partnerships, community-based systems, transition care, value.  Interventions for education such as warning signs and treatment options and links to care are important.
  • The SCD Newborn screening program, and the Sickle Cell Disease Treatment Demonstration Program for patients who solely rely on the ED for SCD care, aid the care options for patients with SCD.

Follow this iEM story for part two which will include information on adult and pediatric management of SCD in the ED, as well as an overview of four NHLBI webinars: Holistic Health and Sickle Cell Disease A Focus on Mental and Behavioral Health; Genetic Therapies in Sickle Cell Disease; Bone Marrow Transplants, Other Therapies, and Sickle Cell; Improvement Initiatives and Ongoing Research.

SCD occurs 1 out of ever 16,300 Hispanic-American birthds, Sickle Cell Disease in the Emergency Dept, iEM Dhir

Further Reading

Emergency Department Sickle Cell Care Coalition: Resources
https://www.acep.org/by-medical-focus/hematology/sickle-cell/resources/

National Institute of Health’s Cure Sickle Cell Initiative:
https://www.nhlbi.nih.gov/science/cure-sickle-cell-initiative

2019 sickle cell disease guidelines by the American Society of Hematology: methodology, challenges, and innovations: https://www.ncbi.nlm.nih.gov/pubmed/31794603

Sickle Cell Disease Training And Mentoring Program (STAMP): https://www.minorityhealth.hhs.gov/sicklecell/#stamp

Episode 68 Emergency Management of Sickle Cell Disease: https://emergencymedicinecases.com/emergency-management-of-sickle-cell-disease/

Practice Variation in Emergency Department Management of Children With Sickle Cell Disease Who Present With Fever. https://www.ncbi.nlm.nih.gov/pubmed/30020250

 

References

1 Centers for Disease Control and Prevention: Sickle Cell Disease 

2 Sickle Cell Transitional Care from Childhood to Adulthood: Youtube

3 Journal of Pediatric Hematology/Oncology. 42(1):e42–e45, JANUARY 2020, DOI: 10.1097/MPH.0000000000001669 PMID: 31743315

4 Porter M. Rapid fire: sickle cell disease. Emerg Med Clin North Am. 2018;36:567–576

5 Evidence Based Management of Sickle Cell Disease: Report

6 Sickle Cell Crisis and You: A How-to Guide, Raam R., Mallemat H., Jhun P., Herbert M. (2016)  Annals of Emergency Medicine,  67  (6) , pp. 787-790

7 The American Society of Hematology Website: 

8 ED Management of Sickle Cell Vaso-occlusive Crises: Myths, Facts, and A Novel Approach to Acute Pain Management, EMdocs.net website

9 Normal saline bolus use in pediatric emergency departments is associated with poorer pain control in children with sickle cell anemia and vaso-occlusive pain, Am J Hematol. 2019 Jun;94(6):689-696

10 Lucia De Franceschi, Caterina Lux, Frédéric B. Piel, Barbara Gianesin, Federico Bonetti, Maddalena Casale, Giovanna Graziadei, Roberto Lisi, Valeria Pinto, Maria Caterina Putti, Paolo Rigano, Rossellina Rosso, Giovanna Russo, Vincenzo Spadola, Claudio Pulvirenti, Monica Rizzi, Filippo Mazzi, Giovanbattista Ruffo, Gian Luca Forni; Access to emergency departments for acute events and identification of sickle cell disease in refugees. Blood 2019; 133 (19): 2100–2103

11 Sickle Cell Disease Training And Mentoring Program Website 

12 Robert M Cronin, Tim Lucas Dorner, Amol Utrankar, Whitney Allen, Mark Rodeghier, Adetola A Kassim, Gretchen Purcell Jackson, Michael R DeBaun, Increased Patient Activation Is Associated with Fewer Emergency Room Visits and Hospitalizations for Pain in Adults with Sickle Cell Disease, Pain Medicine, Volume 20, Issue 8, August 2019, Pages 1464–1471

13 Enyuma, Callistus Oa et al. “Patterns of paediatric emergency admissions and predictors of prolonged hospital stay at the children emergency room, University of Calabar Teaching Hospital, Calabar, Nigeria.” African health sciences vol. 19,2 (2019): 1910-1923. doi:10.4314/ahs.v19i2.14

14 National Heart, Lung, and Blood Institute Webinars

* Images from The Sickle Cell Disease Tool Kit.

Cite this article as: Bryn Dhir, USA, "Sickle Cell, Pain and the Emergency Department," in International Emergency Medicine Education Project, January 27, 2020, https://iem-student.org/2020/01/27/sickle-cell-pain-and-the-emergency-department/, date accessed: September 27, 2020

Stabbing LLQ Pain

A 19-year-old female presents to the emergency department (ED) complaining of 48 hours of worsening, stabbing left lower quadrant abdominal pain. The patient notes an intermittent, foul-smelling vaginal discharge for the past week. She also endorses fever, nausea, vomiting, dyspareunia, dysuria, and generalized fatigue. The patient is sexually active with one male partner and uses combination OCPs in conjunction with inconsistent utilization of condoms. She denies vaginal bleeding, fevers, jaundice, vomiting, constipation, or diarrhea. Her last menstrual period (LMP) ended 16 days ago and was typical of her usual menses. The patient has a history of menarche at 14 and coitarche at 17. She denies any use of tobacco but admits intermittent alcohol and marijuana use. She has no past medical or relevant family history. There are no known drug allergies.

Physical exam reveals a well-developed female in mild discomfort but no acute distress. Her vitals are unremarkable except for a temperature of 38.5 and a heart rate of 102. Her abdominal exam reveals moderate tenderness to palpation, worse in the left lower quadrant, with no rebound tenderness. There is no costovertebral angle tenderness, Rovsing sign or McBurney point tenderness. External genitalia is unremarkable. A pelvic exam demonstrates foul purulent discharge in the vaginal vault emanating from the cervical os with no visible blood products. Cervical motion tenderness and pain on palpation of bilateral adnexa are present. Left adnexa is more tender and has a palpable mass on it.

Want to learn more?

Cite this article as: iEM Education Project Team, "Stabbing LLQ Pain," in International Emergency Medicine Education Project, March 15, 2019, https://iem-student.org/2019/03/15/stabbing-llq-pain/, date accessed: September 27, 2020

Pain Relief

Healthcare providers should have a sound understanding of the anatomy, physiology, and psychology of addictive behaviors. A focused history and examination should concentrate on items that can indicate inconsistencies or falsifications associated with inappropriate drug-seeking behavior. It was always difficult as a decision has to be made between “losing” to drug seekers and denying analgesia to patients who are genuinely in need. It is best to give patients the benefit of the doubt with due diligence.

from iEM's Drugs for Pain Relief chapter Tweet

"Drugs for pain relief' chapter written by Nik Ahmad Shaiffudin Nik Him and Azizul Fadzi was added into the content list.

Neck pain after a bar fight

674.1 - C1 fx - 6-7 sublux

In case you didn’t encounter a young trauma patient today!

You are working in a rural hospital. A 34-year-old male trauma patient was brought to the ED by his friends! You applied primary and secondary survey. The patient describes only neck pain. He has a central tenderness at the c-spine area. The facility does not have a CT scan, and you order c-spine X-ray. 

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!