EM Clerkship

This is the follow up to our previous episode on vaginal bleeding. This week, we will discuss an approach to vaginal bleeding when the patient is NOT pregnant.  

Common Causes * Structural* Cancer* Post-menopausal bleeding is cancer until proven otherwise* Fibroids* Adenomyosis* Polyps* Coagulopathy* Present in approximately 20% of non-pregnant vaginal bleeding* Most common = Von Willebrand Disease* Hormonal causes* Dysfunctional uterine bleeding Basic Approach to Non-Pregnant Vaginal Bleeding * Step 1: Pelvic exam* The utility of this is debated* It is best to sound thorough on your clerkship* Have a chaperone present and document this (include the chaperones name)* Step 2: Obtain Labs* CBC* Anemia?* Thrombocytopenia?* Coags* aPTT is prolonged in 50% of patients with Von Willebrand Disease!* Thyroid (TSH)* Can be obtained outpatient* Common cause of hormonal related vaginal bleeding* Step 3: Pelvic ultrasound* Evaluates for ANATOMIC causes of vaginal bleeding* Step 4: NSAIDS* This treats both abdominal pain/cramping* Also improves bleeding* Step 5: Oral contraceptive pills* Can be started on an outpatient basis* Useful in patients with hormonal/dysfunctional uterine bleeding* Stabilizes endometrial lining Additional Reading * NBME Shelf Review: OBGYN (EM Clerkship)* Non-Pregnant Vaginal Bleeding (WikiEM)

Today we are learning what to do when somebody cuts their fingertip off. Trust me, it’s not as straight-forward as you would think.

Today we are learning what to do when somebody cuts their fingertip off. Trust me, it’s not as straight-forward as you would think.

This is one of the most common chief complaints in all of Emergency Medicine. You will have one of these cases during your rotation. The most important thing to remember are your 5 tests and also how to present these cases to your attending.  

The pregnancy test is the most important test in females of reproductive age! Five Important Tests in 1st Trimester Vaginal Bleeding * CBC* Hemoglobin/Hematocrit* Mild anemia in pregnancy is physiologic and normal* Thrombocytopenia* Type and Screen* Required for blood transfusion* Determines if patient needs RhoGAM* Rho(D) immune globulin* Binds fetal Rh antigens from a fetus so that mother doesn’t develop antibodies against future Rh positive children* Prevents hemolytic disease of the newborn* Give to Rh negative mothers to protect future Rh positive children* Quantitative hCG* hCG >1500* “Cutoff” where definitive pregnancy should be seen on ultrasound* If no pregnancy is seen, highly concerning for ectopic pregnancy* hCG <1500* Ectopic pregnancy still possible* Common for healthy early pregnancies to not be visualized below this level* Urinalysis (UA)* Treat asymptomatic bacteriuria in pregnant patients* One of the only times UTI should be treated in asymptomatic patients* Theoretical increased risk of miscarriage* Pelvic ultrasound* Evaluates for ectopic pregnancy* Subchorionic hemorrhage* Miscarriage Additional Reading * Ectopic Pregnancy (EM Clerkship)

This week we are going to cover a basic approach to the constipated patient with a focus on the possible treatments for constipation.

Common Causes of Constipation * Lifestyle* Low fiber diet* Minimal water intake* Poor exercise* Medications* Especially opiates* Endocrine/electrolytes* Hypothyroidism* Hypercalcemia* Bowel obstruction* Delayed colonoscopy* Unintentional weight loss* Previous abdominal surgeries* Rectal problems* Anal fissures* Fecal impaction* Masses How to Treat Constipation * Fiber (ex. Metamucil, Citrucel)* Adds structure to the stool* Water (polyethylene glycol/miralax)* Hydrates the stool* Fat (colace)* Softens the stool* Stimulants (Senna)* Increases intestinal activity* Decreases transit time* Suppositories (Glycerine, Dulcolax, Fleet)* Stimulate rectum and cause reflexive bowel movements Additional Reading * Constipation Treatment and Management (Medscape)

One of the best events you can volunteer for as a medical student is your local marathon. You learn about musculoskeletal injuries, heat injuries, electrolyte emergencies, as well as prepare yourself for the occasional seizure, cardiac arrest, and case of anaphylaxis. You learn procedures like starting IVs, obtaining vitals, and basic wound care. It really is a great place to learn the basics of Emergency Medicine. In this episode, we will discuss marathon related emergencies.

One of the best events you can volunteer for as a medical student is your local marathon. You learn about musculoskeletal injuries, heat injuries, electrolyte emergencies, as well as prepare yourself for the occasional seizure, cardiac arrest, and case of anaphylaxis. You learn procedures like starting IVs, obtaining vitals, and basic wound care. It really is a great place to learn the basics of Emergency Medicine. In this episode, we will discuss marathon related emergencies.

You’ve heard about this story by now. Today we are going to talk about what happened at the Summa EM residency program and why it closed. Even more importantly, we are going to discuss what we can learn from this and how to be smarter when choosing residency programs in the future.

Y→ Episode Summary

DKA is one of my favorite diagnoses to treat because it follows a nice, simple, algorithmic approach. These patients are incredibly sick, but your attending will be very impressed if you have an understanding of the basic protocol. The hardest thing to remember is that the blood sugar is the LEAST important part of DKA management. Dehydration, Hypokalemia, and Ketoacids play a much more important role.

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!! Signs and Symptoms * Vomiting* Abdominal pain* Polydipsia* Polyuria Step 1: Test for DIABETIC-KETO-ACIDOSIS * Diabetes* Blood sugar* Typically notably elevated (>250 mg/dL)* Can be normal in certain circumstances* Ketones* Easiest test is a urinalysis* Serum ketones also can be obtained* Acidosis* Blood gas (arterial or venous)* pH <7.3 Step 2: Check Potassium Level * Patients frequently depleted of whole body potassium* Insulin administration will causes further drops in serum potassium level Step 3: Replace Potassium * If potassium <3.3, do not give insulin* Replace potassium prior to insulin* If potassium >3.3 but <5.5* Consider supplementing potassium at this point* May continue insulin Step 4: Give Fluids * Adult patients are frequently 3-6 LITERS depleted* 20 ml/kg NS during first hour Step 5: Start an Insulin Drip * This accomplishes 2 things…* It decreases blood sugar* It also decreases acid production Additional Reading * Peds H- Hyperglycemia and Hypoglycemia (EM Clerkship)* DKA Myths (REBEL EM)

As doctors, we treat pain. It’s good medicine, gets good patient satisfaction, and is usually why the patient came to the ED in the first place. But we are also in the middle of a prescription narcotic epidemic. So the question is, how do we appropriately and safely prescribe narcotics? Today we will cover the AAEM guidelines on the use of narcotics in the ED.