UCONN Emergency Medicine Interest Group

Archive for September, 2011|Monthly archive page

Ultrasound Case #4

In RADIOLOGY on September 25, 2011 at 11:19 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: shortness of breath

HPI: 62 yo female with no significant pmh presents with shortness of breath worsening over the last 3 days with associated lest sided chest pain, low grade fever and non productive cough.

SH: 40 pack year smoking history, occasional alcohol.  Denies drug use.

FH: Lung cancer

PE: T 100.8 BP 110/90 HR 99 RR 24 SAT 90% ra. GEN: Uncomfortable, speaking in fragmented sentences.  CV: Regular rate and rhythm, no MRG.  PULM: Moderate respiratory distress.  Absent breath sounds in the base and midway up the back on the left.  Dullness to percussion on the left compared to the right.

EKG: Normal sinus rhythm with occasional PVCs.

Labs: WBC 12.5 with left shift, remainder of CBC, Chem7, PT/INR and cardiac enzymes grossly within normal limits.

Bedside U/S: see beginning of post for 1st still image; click for video.

What is the cause of the patient’s dyspnea? (click below to see the answer below the fold)

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Upcoming meeting

In ANNOUNCEMENTS on September 21, 2011 at 7:01 PM

The next EMIG meeting has been scheduled for Monday, September 26th from 6-8 PM at Dr. Fuller’s. Further details available by contacting lburns@up.uchc.edu. Presenters will be Colin Huguenel, MSIV and Max Falkoff, MSIV.

EM Images #7

In IMAGES on September 12, 2011 at 3:46 PM

Syndicated from the UCONN EM Residency website; credit to Dr. London for images and text.

Scenario: a 47-year-old gentleman came for a follow-up visit for positive blood cultures. He had been seen 2 days earlier with a past medical history of asthma and the history that approximately two weeks earlier he had been at a campfire where apparently someone nearby was burning poison ivy. Immediately he had broken out in a rash on his hands and neck and face and all areas that were exposed and not covered by clothes. He also noticed that his symptoms of cough and shortness of breath increased after that incident. He then came to HHED where he had had blood cultures, an x-ray that showed pneumonia and had been discharged on azithromycin. His blood cultures were positive for Staph and he had been requested to return to the ED. His physical exam showed some inspiratory râles in the LLL where the infiltrate had been and some expiratory wheezes throughout. After treatment had been initiated in the ED, prior to admission, he developed another skin eruption, seen in accompanying photograph.

What was the treatment and what is this reaction? (click below to see answers below the fold)

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Wilderness Medicine Symposium

In ANNOUNCEMENTS on September 8, 2011 at 8:22 PM

Just a reminder that UConn’s 11th Annual Wilderness Medicine Symposium is fast approaching!

Does the scent of formaldehyde still hang in your nose? Has HDH not given you enough free time already? Have clinical rotations made you long for the great outdoors? Have residency applications made you in need of some R&R? Well if so then come join us on Friday evening (9/30) for a night full of camping, fire making, marshmallow roasting, singing, dancing, and story telling in the good old Connecticut wilderness at Winding Trails here in Farmington. Then stay Saturday morning and afternoon for didactic and practical sessions covering various topics in wilderness medicine. Please note that if you cannot make it on Friday evening for camping you can still attend the morning and afternoon teaching sessions on Saturday. Lunch will be provided on Saturday, and participants will be given our annual Wilderness Medicine Symposium t-shirt. Best of all, this fantastic event is free of charge!

Please RSVP by this Saturday Sept 10th to kfarmer@student.uchc.edu or chuguenel@student.uchc.edu if you would like to attend. Any questions regarding the event are welcome!

We’ve moved!

In ANNOUNCEMENTS on September 7, 2011 at 5:44 PM

Just a quick announcement: we’ve moved domains so that the web address for this site is now simply uconnemig.com (as opposed to uconnemig.wordpress.com). Don’t worry- if you put in the old address, you will get automatically redirected to the current address, so you don’t need to edit your bookmarks or anything. The change is purely an aesthetic one.

While I’m at it with the announcement, as the site is now almost exactly 5 months old, I’d greatly appreciate it if you visitors would take the time to leave a comment with some feedback. What features do you like? What don’t you like? What would you like to see more of? Any new cool ideas on how the site can be expanded? All feedback would be greatly appreciated.

Thank you,
Max Falkoff

Journal Article Synopsis: Triage and High-Acuity Patients

In JOURNAL CLUB on September 2, 2011 at 7:00 AM

Summary of “Mandatory Triage Does Not Identify High-Acuity Patients Within Recommended Time Frames. ” Weber, Ellen J.; McAlpine, Ian; Grimes, Barbara. Annals of Emergency Medicine. Vol 58, Issue 2. Aug 2011. pp. 137-142

What is already known on this topic:
Structured triage is commonly thought to identify the most acutely ill walk-in patients. While there is mandatory triage at most US emergency rooms, there is currently no published data showing that is effective in recognizing the most high-acuity patients within timeframe targets. In England, triage (in the traditional sense) was abandoned, as it was thought to be more of a hindrance than a help.

What question this study addressed:
This study looked to see if the process of triaging identified the most acutely ill patients within the “appropriate” timeframe, as determined by the Emergency Severity Index (ESI). By ESI standards, level-1 walk-in patients should be treated by a physician upon arrival, and level-2 walk-in patients should be treated within 10 minutes.

What was the study design:
This was a retrospective cross-sectional study which took place over the course of one year. It examined time from arrival to treatment all ESI 1 or 2 walk-in patients in the ED of a US, urban, tertiary-care hospital with an annual census of 39,000 patients (15% of whom arrive via ambulance.) The majority of walk-in patients were subject to ESI 5-tier triage, unless they were in “emergency condition,” in which case they were taken immediately to a treatment room where triage was completed.

What this study adds to our knowledge:
The study examined data from one ED over the course of one year, and found that triaging resulted in prolonged triage times (greater than those proposed by the ESI). Less than half of high-acuity patients were seen within ten minutes of arrival to the ED. Overall, median interval time from triage to treatment was 12.3 minutes, with a range of 128 minutes, and a 95th percentile of 38.6 minutes. Three quarters of these high-acuity patients arrived during peak hours, during which time median interval time was 13.5 minutes.

How this is relevant to clinical practice:
ED clinicians count on triage to identify the most acutely ill patients within a reasonable timeframe. The effectiveness of triage should therefore be examined in light of its value to both patients and physicians. A large amount of resources, time, and staffing are necessary for triage practice. As hospitals are considering cost and benefit carefully, triage should be evaluated for its utility in meeting the goal of triaging patients within the recommended time-frame. If it is not working to the advantage of physician and patient, alternative approaches for providing care without unnecessary delays should be considered.

Other considerations:
Several innovations for patient intake are being considered for implementation in the US. Some ED’s fill patient rooms as patients arrive, however, this is not useful once rooms are full. Some ED’s have a physician or mid-level provider staffed specifically to help triage. In England, ambulance arrivals and high-acuity walk-ins are brought immediately to patient rooms. Others remain in the waiting area where they are treated in order of arrival. There is no formal triaging or taking of vitals, although nurses continually asses patients for possible accelerated need for treatment, including need for pain medication. With this system in place, more nurses are available to work within the treatment area.

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