News
Entertainment
Science & Technology
Life
Culture & Art
Hobbies
News
Entertainment
Science & Technology
Culture & Art
Hobbies
PECARN STELAR Podcast - Episode 5: Addressing Substance Use Disorder in children and adolescents – The impactful role of the ED - emDocs
Adolescent substance use is significantly more prevalent than is recognized. The emergency department (ED) can be a great resource to acutely manage complications and help set up long term management goals and provide resources.
Medical Malpractice Insights: SCFE - Who called whom and when? - emDocs
Author: Chuck Pilcher, MD FACEP (Editor, Med Mal Insights) // Reviewers: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit) Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFLis to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here. Chuck Pilcher, MD, FACEP Editor, Med Mal Insights SCFE: Who called whom and when? “Who?” “What?” and “I don’t know.” Another version of Abbott & Costello’s classic skit “Who’s on first” Facts: An 11-year-old female feels a sudden pain in her L hip while doing a flip turn during swimming practice. She sees her PCP a week later and is diagnosed with a “groin strain.” The pain persists and she is re-examined by different PCP a few days later. The dx is changed to “adductor strain.” A month later she falls and feels a “pop” in her hip and is taken to the ED. An x-ray of her hip reveals a slipped capital femoral epiphysis (SCFE). The EP claims that Orthopedist A is contacted and advised that the patient can be seen in the office. The name of Orthopedist A is not recorded. The patient is seen by Orthopedist B and undergoes fixation stabilization 4 days later. Avascular necrosis (AVN) develops and the pt requires a total hip replacement. An attorney is contacted and a lawsuit is filed claiming delay in dx caused the avascular necrosis. The lawsuit named the first 2 PCP’s for delay in diagnosis. The EP and orthopedist A and/or B were all named for an inappropriate delay in surgery. Plaintiff: The first two PCP’s missed my diagnosis. They didn’t even do an x-ray. The EP made the correct diagnosis, claimed he spoke with Orthopedist A but didn’t document it and allowed Orthopedist A to convince him that immediate surgery was unnecessary. Phone records show that it was actually Orthopedist B with whom the EP spoke, so we’re suing both of them. Defense: Orthopedist A testifies that he was “on vacation” on the day of the ED phone call. Orthopedist B testifies that he wasn’t called because “If I was called, I would have operated immediately.” The surgery was successful. Avascular necrosis is a potential complication no matter when the fixation stabilization is done. Result: Because of all the unknowns in this case, the various parties agreed to settle for undisclosed amounts pre-trial. Takeaways: If you speak with a consultant, identify him/her/them, what advice you were given and why you did or did not follow it. Share the agreed upon plan with the patient, e.g., “Dr. X recommends Y. He and I have discussed this and you should follow up according to our plan.” One cannot prove when the slipped epiphysis would have manifested itself on an x-ray. It could have been at the time of the swimming incident or only after the fall a month. Once SCFE is identified, surgical stabilization should be done ASAP. That said, the role of timing as a cause of complications like AVN remains a debatable issue. SCFE classically presents in an overweight adolescent with non-radiating, dull, aching pain in the hip, groin, thigh, or knee, and no history of trauma. Reference: Slipped Capital Femoral Epiphysis Treatment & Management. Walter KD. Medscape eMedicine. Updated Sep 29, 2023.
EM@3AM: Ehrlichiosis - emDocs
A 70-year-old male with presents with 5 days of fever and 3 days of anuria and malaise. He also notes worsening abdominal distention and shortness of breath. He found and removed a tick 3 weeks ago and another one 1 week ago. Labs reveal WBC 2,200 cells/microL, HGB 11.2 g/dL, Plt 21 × 109/L, BUN 86 mg/dL, Creatinine 6.8 mg/dL, AST 350 U/L, ALT 119 U/L.
EM@3AM: Corneal Transplant Complications - emDocs
A 61-year-old male with a history of bilateral corneal transplants due to Fuchs' endothelial dystrophy presents with progressive visual decline in his right eye over the past three days. He describes associated redness, photophobia, and mild foreign body sensation. He denies trauma but acknowledges inconsistent use of his prescribed steroid eye drops. He has decreased visual acuity in the right eye, mild conjunctival redness, and absence of purulent discharge. Slit-Lamp reveals corneal swelling with scattered keratic precipitates and mild anterior chamber inflammation.
EM@3AM: Thyrotoxic Periodic Paralysis - emDocs
A 28-year-old otherwise healthy male presents for an acute episode of bilateral lower extremity weakness causing him to fall in the bathroom. The episode started approximately 30 minutes prior to arrival. He had a similar episode three months prior which resolved quickly during his ED visit. Neuro exam includes intact sensation in all distributions to light touch. Hip flexion ⅖ bilaterally, knee extension ⅗ bilaterally, plantar and dorsiflexion ⅘. Bilateral upper extremities shoulder flexion, elbow flexion, and extension 5/5. Labs reveal low potassium, phosphate, magnesium, TSH.
EM@3AM: Bradypnea - emDocs
A 53-year-old male with hyperlipidemia and cervical stenosis presents with dyspnea, which has been worsening since his cervical spinal fusion 6 days ago. He states he is very fatigued and feels as though he cannot get a deep breath. Vital signs revealed a BP of 136/76, HR of 88, RR of 9, SpO2 of 94% on room air, and a temperature of 97.6 F. On physical exam, the patient is lethargic, has nasal flaring, and is using accessory muscles to breathe. Lung sounds are clear. On cardiac exam, there is normal rate and rhythm without murmur, rubs, or gallops. His capillary refill is 2 seconds. His surgical incision looks clean and without any signs of infection. An ABG is drawn and reveals pH of 7.53, pCO2 of 58, and PO2 of 83. Chest X-ray shows some mild atelectasis but no acute infiltrates. What is the diagnosis?
PECARN STELAR Podcast - Episode 4: How Researchers Conduct Implementation Science Research - emDocs
Implementation science is the scientific study of how people adopt practices. In healthcare this typically refers to translating evidence based practices into clinical care. Dr. Fishe focused on implementation science in EMS care particularly with regards to asthma.
EM@3AM: Systemic Lupus Erythematosus - emDocs
A 23-year-old female presents to the ED with slurred speech, left lower leg weakness, and confusion. A friend is with her and states that the patient does not take any medications, has no past medical history, but has been complaining of various symptoms over the past year. On exam, the patient has 0/5 strength in her left lower extremity, has slurred speech, and is unable to answer most of your questions. You code stroke the patient. CT head/CTA head and neck are unremarkable, but MRI brain reveals stroke.
EM@3AM: Inflammatory Bowel Disease - emDocs
A 24-year-old male with no past medical history presents with several days of oral ulcers and throat pain. He also notes multiple months of diarrhea and hematochezia. He has lost roughly 30 lbs over the preceding 6 months. He has normal vital signs but appears malnourished, with a weight of 48 kg. He has dry oral mucous membranes, abdomen is diffusely tender, and he has ulcers on the uvula and soft palate. Labs reveal anemia, leukocytosis, electrolyte abnormalities, and elevated inflammatory markers. What is the diagnosis?
EM@3AM: Systematic Approach to Massive Hemorrhage and Nuances in Special Patient Populations - emDocs
A 32-year-old female presents with chief complaint of “abdominal pain”. Her pain started 8 hours ago and became severe within the last 30 minutes. Initial vitals demonstrate a blood pressure of 88/48 mm Hg, HR 122 bpm, Temp 36.4 C, and 20 respirations/min. On your physical exam she has tenderness to palpation in the left lower pelvic region with rebound tenderness. You note her hypotension and perform RUSH exam. During your exam you note free fluid in the rectouterine pouch. As you finish your exam, she is now pale, clammy, and minimally responsive to pain with repeat blood pressure 64/33 mm Hg. What is the systematic approach to a patient with signs of massive hemorrhage?