Happy EM Residents Day!   The RLT and Faculty  just want to give another Huge SHOUT OUT to our Residents,  THE  Greatest Residents On the Planet!  THANK YOU!!!   

It was another very educational Conference Day, Hope you enjoy the notes.

Frazer/Paquette     Oral Boards

 Case 1  33 yo pregnant female (27 weeks) presented with abdominal pain.   Labs showed a leukocytosis, anemia,  low platelets and dohle bodies.   LFT’s were jacked up.   D-dimer was 23.   Diagnosis was HELLP syndrome.    Fetal Heart tones were 80.   Patient placed in left lateral decubitus position and OB called to take patient to OR for delivery.  Platelets were given.    HELLP  more common in multigravidas.  Pregnant patients with RUQ pain/tenderness and  nausea, vomiting, and malaise being diagnosed with a  viral illness, hepatitis, or GB disease is a common pitfall that has resulted in maternal death or severe morbidity

Case 2  25 yo male presented with left forearm pain following a fight.  Pt was struck in the forearm with a pipe.  X-rays are negative for fracture.  Pt has marked pain and muscle compartment of mobile wad is hard to palpation. Compartment pressure was markedly elevated. Diagnosis was compartment syndrome.    3 compartments in the forearm: dorsal, volar, mobile wad.  Treatment was emergent fasciotomy. 

•  Acute Compartment Syndrome  delta pressure = diastolic blood pressure ‒ measured compartment pressure
• Acute Compartment Syndrome delta pressure < 30 mmHg indicates need for fasciotomy.   
• (Up to Date   Compartment Syndrome)

 Case 3  60 yo female presented with acute psychosis.  Only lab abnormalities were elevated BUN and hypercalcemia (level=15).   CT head was negative.    IV fluids, calcitonin, and a bisphosphonate were given. 

Severe hypercalcemia — Patients with calcium >14 mg/dL require  aggressive therapy. The acute therapy of such patients consists of a three-pronged approach

• Volume expansion with isotonic saline at an initial rate of 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150 mL/hr
  Loop diuretic therapy is not recommended because of potential complications and the availability of drugs that inhibit bone resorption, which is primarily responsible for the hypercalcemia.
• Administration of salmon calcitonin (4 international units/kg)
• Administration of a bisphosphonate (zoledronic acid)
• Saline and calcitonin take effect in 12-48 hours.  Zoledronic acid takes effect in 2-4 days
• (Up to Date   Management of hypercalcemia)

Steele     ABEM Visiting Lecturer

 30, 000 Active ABEM Diplomats

Emergency Medicine  is the 23^rd Recognized specialty

ACEP started in 1976

ABEM became a primary board in 1989

Mission of ABEM: To ensure the highest standards in the specialty of EM.   2^nd mission is to enhance the value of board certification for emergency physicians

All questions on Board Tests have to come from the Model of EM Practice (on ABEM website)

Qualifying test is on a single day and lasts 6.5 hours.  You have to score 75 to pass.

Oral exam is also a single day test that takes 4 hours

There is a video on the ABEM website of how the Oral Board Exam is administered.

2013 Application fee =420.     Qualifying exam =$960     Oral Exam=$1,225

Time limit from end of training until you pass the qualifying exam is 5 years.  After you pass the qualifying exam you have 5 years to pass the Oral Exam.

Kelly Williamson comment:  Hospitals you work for will not be this lenient.  If you are not board certified in the first year or two, they will fire you. 

 

Steele     ABEM Visiting Lecturer   Career Satisfaction in EM

87% of EP’s are satisfied.   65% are highly satisfied.   1/3 felt burnout was a significant problem.   Diversity of activities that are part of an EP’s job (clinical, academic, administrative) correlated highly with career satisfaction.

 Variables correlated with Career satisfaction:  Leadership roles,  job feels personally rewarding, job security and fair compensation, involvement with teaching/consulting/political activity,  supportive environment. 

 Variables correlated with low Career Satisfaction: not enough personal time, high census ED,  longer length of shifts, night shifts, problematic colleagues.

 Factors important to women in EM:  Recognition at work, career advancement opportunities, schedule flexibility, fair compensation, academic practice.

 Sources of stress: erratic schedule, unreasonable patient requests, fear of making mistakes, threat of malpractice, problems with nursing staff.

 REM sleep usualy occurs toward the end of sleep cycle.    So if you are awoken early, you loose REM sleep.   

 Night owls tend to tolerate night shifts better than Larks (morning people).    Flexible sleepers tend to tolerate shift work better than people who need optimal conditions to sleep.

 Shift work tends to take a toll on psychiatric health,  relationships, and can increase the risk of substance abuse.

 Working a series of 5 night shifts in a row results in a substantial decrease in cognitive performance.

 Naps can improve cognitive function and reduce performance lapses.

 Institute of medicine recommends against 12 hour shifts.

 Gore    Case  Follow Up

 36 yo female, 1 week post partum,  presents with headache and neck stiffness.   Pt also has chest pain and SOB.   Vital signs are normal   Physical exam is normal except for heart murmur. Initial thinking was to focus on the headache as possible post-LP headache, meningitis or SAH.   However being diligent emergency docs other tests were performed to evaluate a broad DDX.  Troponin was neg.   D-dimer markedly elevated.   CXR and CT head were normal.   

 CT chest for PE was done based on the elevated D-Dimer  and it demonstrated an intimal flap in the ascending aorta.  TEE showed aortic regurgitation and dissection.

 Pregnancy is a vascular stress test.      This pregnant patient had a broad differential diagnosis.  Clues to dissection: Chest pain and….. headache,  heart murmur,  elevated d-dimer.   Anytime a patient has chest pain and some other complaint, especially neuro or vascular symptoms, think dissection.   

D-dimer in dissection may (or may not) help risk stratify patients with Chest pain for aortic dissection.   Low levels lower risk.  High levels increase risk.  This is still a controversial test in this setting.  There are no prospective RCT’s evaluating it’s effectiveness.  Most of the studies are retrospective case series.   It worked here though!

Manage blood pressure and aortic pulse pressure with nicardipine and esmolol.  Ascending dissections require surgery.   Pain management is also critical. 

Harwood comment:  In the post-partum period management of aortic dissection is the same as in the non-pregnant patient .     You should make note that the ED physician had to be perseverant  with diagnostic testing and consultations until the diagnosis was rock solid and the patient went to the OR.    Elise comment: A take home point is that courage of conviction is critical for the emergency physician.  It was important in this case to keep pressing on for the correct diagnosis.

Harwood comment:  There have been a number or cases recently in the press of vascular catatrophies during the peri-partum period.

 

DenOuden    Case Follow Up

 53 yo male with SOB, 25 lb weight gain, leg swelling,  polydipsia/polyuria.  BP at clinic was 235/135.

No PMH

Exam shows: 3+ edema bilat, acne and darker skin.   Labs show low K and elevated bicarb.  VBG shows metabolic acidosis.  BNP is minimally elevated.   Pt has leukocytosis.   ECHO shows nl contractility and no pericardial fluid.  EKG demonstrates sinus rhythm with LVH.  Right sided perihilar mass noted on CXR.

 Cushing’s Syndrome is the diagnosis.   Mnemonic for  symptoms/signs of Cushings:

CUSHINGOID      C=cataracts  U= Urine potassium is high and serum potassium is low     S= skin changes with hyperpigmentation, easy bruising and striae  H=hypertension     I=Increase risk of infections    N=Neuropsychiatric  symptoms (anxiety, paranoia)   G=Glucose intolerance    O=Osteonecrosis of the femoral head/Osteoporosis      I=Increased androgens in women, Increased fat in the supra clavicular fossa.       D=DVT risk.  

 Adipose in the supraclavicular fossae that obscures the clavicles is a relatively specific sign of Cushing's syndrome

 

Supraclavicular Adipose

 

 

5% of Cushing’s Cases are due to paraneoplastic syndromes.

The diagnosis in this case was a small cell lung cancer with a paraneoplastic syndrome causing Cushing’s syndrome.

 

Carlson   Oral Boards  Primer

 Practice your opening statement.  “ When I walk into the room what do I see, smell, and hear?”  

Talk to the patient initially for a brief time then decide whether to start evaluating the ABC’s.  If they can’t adequately respond to your initial question, get moving on the ABC’s

Give your nurse some initial orders to start off, “undress patient, IV/O2/monitor/pulse ox

 Consider all sources for history including EMS, family, friends, and patient’s primary doc.  Always ask for medications and allergies.

Do  a systematic physical exam on all patients.    The examiner should move you along through normal exam areas.   Be sure to ask for skin exam.  If the examiner asks you “what are you looking for?”  That is commonly a clue that the exam area being asked about has a significant finding. 

 Re-assess the patient regularly.  Treat pain right away.

 Thinking  out loud can be very helpful if you know what is going on.   If you don’t know what is going on be careful about thinking out loud so that you are not wasting time or letting the examiner know you don’t know what is going on. 

 You should know ACLS med doses.   You usually can use references/consultants for non-ACLS doses.     Don’t give a specific dose if you don’t know it.

If you get lost, review the positives you have noted on H&P and diagnostic testing and work from there.

 For Boards,  Know ACLS algorithms,  indications/contraindications for thrombolytics, antidotes, and procedural techniques.