The following Sackler911 poll is now closed.  Here are the
final results:


POLL QUESTION: A 51-year-old man is brought to the ED by EMS with a BP 90/60
mmHg, HR 110 beats per minute, RR 18 breaths per minute, and oxygen saturation
of 97% on room air. The patient tells you that he has a history of bleeding
ulcers. On exam, his abdomen is tender in the epigastric area. He is guaiac
positive (pressence of fecal occult blood) with black stool. He has a bout of
hematemesis (vomiting blood) and you notice that his blood pressure is now 80/50
mm Hg, HR is 114 beats per minute, and the patient is starting to drift off.
Which of the following is the most appropriate next step in therapy?

CHOICES AND RESULTS
- Assess airway, establish two large-bore IVs, cross-match for two units of
blood, administer 1-2 liters of normal saline, and schedule an emergent
endoscopy, 6 votes, 100.00%
- Assess airway, establish two large-bore IVs, crossmatch for two units of
blood, and administer a proton pump inhibitor, 0 votes, 0.00%
- Place two large-bore IVs, crossmatch for two units of blood, administer a 1-2
liters of normal saline, and schedule an emergent endoscopy, 0 votes, 0.00%
- Intubate the patient, establish two large-bore IVs, cross-match for two units
of blood, administer a 1-2 liters of normal saline, and schedule an emergent
endoscopy, 0 votes, 0.00%
- Intubate the patient, establish two large-bore IVs, crossmatch for two units
of blood, and administer a proton pump inhibitor, 0 votes, 0.00%



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Enter your vote today!  A new poll has been created for the
Sackler911 group:

A 51-year-old man is brought to the ED by EMS with a BP 90/60 mmHg, HR 110 beats
per minute, RR 18 breaths per minute, and oxygen saturation of 97% on room air.
The patient tells you that he has a history of bleeding ulcers. On exam, his
abdomen is tender in the epigastric area. He is guaiac positive (pressence of
fecal occult blood) with black stool. He has a bout of hematemesis (vomiting
blood) and you notice that his blood pressure is now 80/50 mm Hg, HR is 114
beats per minute, and the patient is starting to drift off. Which of the
following is the most appropriate next step in therapy?

   o Assess airway, establish two large-bore IVs, cross-match for two units of
blood, administer 1-2 liters of normal saline, and schedule an emergent
endoscopy
   o Assess airway, establish two large-bore IVs, crossmatch for two units of
blood, and administer a proton pump inhibitor
   o Place two large-bore IVs, crossmatch for two units of blood, administer a
1-2 liters of normal saline, and schedule an emergent endoscopy
   o Intubate the patient, establish two large-bore IVs, cross-match for two
units of blood, administer a 1-2 liters of normal saline, and schedule an
emergent endoscopy
   o Intubate the patient, establish two large-bore IVs, crossmatch for two units
of blood, and administer a proton pump inhibitor


To vote, please visit the following web page:
http://groups.yahoo.com/group/Sackler911/surveys?id=12734284

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!

The following Sackler911 poll is now closed.  Here are the
final results:


POLL QUESTION: A 19-year-old man is brought to the ED by EMS after he was found
lying on the floor at a dance club. EMS states that the patient seemed
unconscious at the dance club but as soon as they transferred him onto the
gurney he became combative. Upon arrival in the ED, his blood pressure is 120/65
mm Hg, heart rate is 75 beats per minute, temperature is 98.9°F, respiratory
rate is 12 breaths per minute, and oxygen saturation is 98% on room air. On
physical exam, his pupils are mid-sized, equal and reactive to light. His skin
is warm and dry. Lung, cardiac, and abdominal exam are unremarkable. As you walk
away from the bedside, you here the monitor alarm signaling zero respirations
and the oxygen saturation starts to drop. You perform a sternal rub and the
patient sits up in bed and starts yelling at you. As you leave him for the
second time, you hear the monitor alarm again signal zero respirations. You
administer naloxone, but there is no change in his condition. Which of the
following is most likely the substance ingested by this patient?


CHOICES AND RESULTS
- gamma-hydroxybutyrate (GHB), 2 votes, 20.00%
- Diazepam, 1 votes, 10.00%
- Cocaine, 0 votes, 0.00%
- Phencyclidine (PCP), 6 votes, 60.00%
- Heroin, 1 votes, 10.00%



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Hello all,

As a confused medical student attempting to make some of the most
stressful decisions of his life, I found the 400 shekel Emergency
Medicine conference well worth it. I would encourage anyone to
attend any conference in whatever specialty where american
physicians are present and just chat it up and introduce yourself;
particulary if it is a field you are possibly considering. Doctors
love to talk about themselves and their fields and it is this wealth
of information about life as an american doctor that is most
particularly lacking as a student here at Sackler.
The advisement I received is invaluable and hopefully you too will
find something useful from the next conference you attend.

Sincerely, Darren Lucas

-I typed up what I discussed and hope that it helps you.

March 11, 2008
Emergency Medicine conference

Advisement from Professor Holliman: American EM physician and
student advisor for 20 years at Penn. State Univ. Previously on York-
Hershey EM admissions. Currently building healthcare system in
Aghanistan.

In general:
The profession is looking for physicians with excellent clinical and
people skills. Need to work with all different kinds of people and
all different kinds of colleagues within the hospital. See many
kinds of people who walk in that door and each patient is a
challenge. Will diagnose many patients. Patients are in more
critical need of care. Need to know the entire breadth of medicine.
The need is increasing and more positions are being offered. As in
any specialty, you need to be comfortable with dealing with the
downsides of the profession as they will occur on a daily basis.

The upsides:
Great hours and flexibility of schedule with great reimbursement and
the ability to leave your work at the hospital following your shift.
Lifestyle is great and happy physicians.

The downsides:
Ability to deal with a non-existent schedule and not being able to
know what patient will be seen next. In addition, an ability to deal
with the drug addicts and lowlifes of society that will walk through
the door on a daily basis. The non-continuity of care that is
usually noted of EM but is not particularly specific to EM anymore.
Other specialties also rarely follow their patients and pass them
around with more often with the group setup and you will see certain
CHF and asthma patients more than once for example.

Application:
Very competitive. Everything is assigned a point value and then
added up to grant interviews. Most important are third year rotation
grades, EM elective letters, letters, but step1 score is about
seventh on the list and step2 is held in a higher regard as it is
more clinically based.
Other things to consider to gain points are volunteer service,
research, knowledge of another language even if basic, membership in
the respective professional organization such as SAEM (saem.org) or
EMRA (emra.org) in order to show commitment to the profession.
Complete the application early, by early October. You should have
everything in except the letters from the first elective you do and
you should follow up on these letters and get them in asap as most
programs will only look at completed files.
Apply to 20-25 places. Many programs simply throw away every fifth
application without even looking at it due to the sheer volume they
receive (800 for 10 spots). They know they are throwing away great
applicants.

Recommendations:
You need 3 letters from EM specifically, most preferably all 3 from
a faculty physician that can say, "I worked with him/her and they
did a good job". So someone you work with. You will get 2 letters
from your first elective, and the other from the second elective.
Try to get your letters from the guys at the top who will be
naturally recognized in the field due to their research (most
likely). EM in general feels that other fields do not understand
them, so even a great letter from another specialty is not quite as
good as a letter from EM in general, perhaps an outstanding letter.

The personal statement:
It needs to demonstrate 3 things specific to EM. First, a
demonstration that you understand what EM is all about. Second, find
a way to describe yourself as an empathetic / people person. Third,
write about the things that make you stand out from other
applicants, perhaps the international schooling experience.

Electives: the order.
First-EM (2 letters)
Second-an intensive field such as surgery, medicine ICU, any ICU, or
anaesthesia. Something to build your clinical skills.
Third-EM (1 letter)
Fourth-The fourth in any of these helpful areas, EM applicants are
usually most weak in peds. Outpatient peds, outpatient ortho,
dermatology, sports med, any surgical subspecialty.
Do an elective at places where you think you have a shot at being
accepted. They give you an interview if you do an elective there, so
try not to waste this chance.

Programs: 3 types
-three year programs are the large majority
-1-2-3-4 years continuous program
-2-3-4 years program with a required previous transitional year that
is usually at the same institution.
The four year programs are generally geared towards more
administrative experience. It has repercussions following residency
regarding academics and is more favorable to gain a faculty position
( I was not totally clear on this).

-If you do NOT get accepted: simultaneously apply for a transitional
year. Transitional year programs usually have 1 month of EM
included, request an extra month and do them both early in the year.
When you reapply, focus on the 2-3-4 programs so you can just enter
as second year resident, but also apply to the others or where you
want to go as well. It will strengthen your application regardless.
Some programs require international grads to do 1 year in the usa
before considering the application. It will place you on the same
level as an American graduate.

Websites:
www.saem.org
www.emra.org
www.acep.org

Enter your vote today!  A new poll has been created for the
Sackler911 group:

A 19-year-old man is brought to the ED by EMS after he was found lying on the
floor at a dance club. EMS states that the patient seemed unconscious at the
dance club but as soon as they transferred him onto the gurney he became
combative. Upon arrival in the ED, his blood pressure is 120/65 mm Hg, heart
rate is 75 beats per minute, temperature is 98.9°F, respiratory rate is 12
breaths per minute, and oxygen saturation is 98% on room air. On physical exam,
his pupils are mid-sized, equal and reactive to light. His skin is warm and dry.
Lung, cardiac, and abdominal exam are unremarkable. As you walk away from the
bedside, you here the monitor alarm signaling zero respirations and the oxygen
saturation starts to drop. You perform a sternal rub and the patient sits up in
bed and starts yelling at you. As you leave him for the second time, you hear
the monitor alarm again signal zero respirations. You administer naloxone, but
there is no change in his condition. Which of the following is most likely the
substance ingested by this patient?


   o ã-hydroxybutyrate (GHB)
   o Diazepam
   o Cocaine
   o Phencyclidine (PCP)
   o Heroin


To vote, please visit the following web page:
http://groups.yahoo.com/group/Sackler911/surveys?id=12731238

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!

The following Sackler911 poll is now closed.  Here are the
final results:


POLL QUESTION: A 42-year old man who was in a motor vehicle crash comes to the
ED where you clear his airway.  He has intact, normal breath sounds bilaterarlly
and appears to be ventilating and oxygenating well.  Initial assessment of the
cardiovascular system reveals hypotension with a BP of 80/60, a heart rate of
110 bpm, distended neck veins, and muffled heart sounds on auscultation.  You
perform a procedure that quickly corrects his blood pressure as well as confirms
your suspected diagnosis.  You performed..

CHOICES AND RESULTS
- A lumbar puncture, 0 votes, 0.00%
- A needle decompression of the pleural space, 0 votes, 0.00%
- A pericardiocentesis, 12 votes, 100.00%
- An infusion of fluids (normal saline), 0 votes, 0.00%



For more information about this group, please visit
http://groups.yahoo.com/group/Sackler911

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Enter your vote today!  A new poll has been created for the
Sackler911 group:

A 42-year old man who was in a motor vehicle crash comes to the ED where you
clear his airway.  He has intact, normal breath sounds bilaterarlly and appears
to be ventilating and oxygenating well.  Initial assessment of the
cardiovascular system reveals hypotension with a BP of 80/60, a heart rate of
110 bpm, distended neck veins, and muffled heart sounds on auscultation.  You
perform a procedure that quickly corrects his blood pressure as well as confirms
your suspected diagnosis.  You performed..

   o A lumbar puncture
   o A needle decompression of the pleural space
   o A pericardiocentesis
   o An infusion of fluids (normal saline)


To vote, please visit the following web page:
http://groups.yahoo.com/group/Sackler911/surveys?id=12727667

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!

I just wanted to thank you Glenn for a great presentation of the case and the answer choices.

I recognize that the given data about the patient might be enough to warrant a chest tube insertion, but I'm curious if other information might have been neglected.  Specifically, it's my understanding that this injury being a trauma injury, you would see evidence to confirm that the pleural cavity has been punctured, whether it was from a foreign object, or something internal, like a broken rib.  I guess my question is whether or not you will always be able to confirm this diagnosis by just looking at the patient, and if this is necessary before your perform the procedure?

Thanks,
Sam

----- Original Message ----
From: Glenn Skow <glennskow@aol.com>
To: Sackler911@yahoogroups.com
Sent: Thursday, February 28, 2008 5:53:29 PM
Subject: [Sackler911] Answer to our first case

I want to thank everyone who participated in our first case presentation.  I hope you will find these useful.  The case that was presented was as follows:

 

A 24 year-old man comes to the E.R. after being involved in an automobile collision. You clear his airway, but find absent breath sounds in the right chest. Distended neck veins are present and a blood pressure of 80/60 mm Hg (normal: 120/80) is measured. Which of the following would be your next course of action?

1)      Send the patient for a chest x-ray

2)      Continue with the patient examination before determining treatment

3)      Immediately insert a needle/chest tube into the right chest

4)      Prepare the patient for surgery

The answer to this question was choice number 3.  The patient in this case has suffered a traumatic injury to the right lung allowing air to escape into the pleural space causing a progressive increase in positive pressure.  This is known as a Pneumothorax.  As air builds up in the pleural space and the pressure continues to rise, a pneumothorax can develop into what is known as a Tension Pneumothorax, which is life-threatening.  A Tension Pneumothorax exists when the pressure has increased to the point (when it equals or exceeds venous pressure) where it can compress the structures in the chest (such as the heart and trachea) and shift them to the opposite side.  With the pressure now exceeding venous pressure, venous return, cardiac output and blood pressure will all decrease.  There is also a physical compression of these structures, such as the heart that now has to work harder to pump blood.   As a result, we see jugular venous distension in the neck. 

 

In Short, the signs of a tension pneumothorax as was described in this case are absent breath sounds over the affected lung, distended jugular veins, and hypotension.  One sign that was not listed was that of tracheal deviation.  As I said before, the structures of the chest will be shifted to the opposite side in a tension pneumothorax so you would expect that the trachea might shift to the left side in this case where the injury was on the right.

 

As this is a life-threatening, clinical suspicion is enough to treat this patient, which is accomplished by inserting a needle/chest tube to decrompress the chest.  You are basically providing a means for the trapped air in the pleural space to escape.  If your diagnosis is correct, you will see an instantaneous improvement in the patient.

 

The reason why you would not send this person for a chest x-ray (Choice A) is that this is a true emergency and your patient can die while you wait for an x-ray.  This point holds true for a lot of cases, if your patient is unstable, as was this patient being hypotensive, you stabilize before anything else.  This same reasoning can be used to justify why you would not continue with the physical exam (Choice B) before providing treatment.    As you find life-threatening ailments on a physical exam, treat them before continuing on.

 

I have posted a photo to our yahoo group.  The link is below, but am not sure it will work.  The photo is an example of a pneumothorax seen on chest x-ray. 

 

http://health. ph.groups. yahoo.com/ group/Sackler911 /photos/view/ 4aa7?b=1

 

I hope this explanation made sense.  As it was my first attempt at answering a case, a welcome any feedback.  If there are any questions do not hesitate to email me or call me (054.497.7317) .  Hopefully more people will participate in our next case.  Thank you again for participating.

 

Glenn

---

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The following Sackler911 poll is now closed.  Here are the
final results:


POLL QUESTION: A 24 year-old man comes to the E.R. after being involved in an
automobile collision.  You clear his airway, but find absent breath sounds in
the right chest.  Distended neck veins are present and a blood pressure of 80/60
mm Hg (normal: 120/80) is measured.  Which of the following would be your next
course of action?

CHOICES AND RESULTS
- Send the patient for a chest x-ray, 4 votes, 30.77%
- Continue with the patient examination before determining treatment, 2 votes,
15.38%
- Immediately insert a needle/chest tube into the right chest , 7 votes, 53.85%
- Prepare the patient for surgery, 0 votes, 0.00%



For more information about this group, please visit
http://groups.yahoo.com/group/Sackler911

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/web/index.html

Enter your vote today!  A new poll has been created for the
Sackler911 group:

A 24 year-old man comes to the E.R. after being involved in an automobile
collision.  You clear his airway, but find absent breath sounds in the right
chest.  Distended neck veins are present and a blood pressure of 80/60 mm Hg
(normal: 120/80) is measured.  Which of the following would be your next course
of action?

   o Send the patient for a chest x-ray
   o Continue with the patient examination before determining treatment
   o Immediately insert a needle/chest tube into the right chest
   o Prepare the patient for surgery


To vote, please visit the following web page:
http://groups.yahoo.com/group/Sackler911/surveys?id=12723226

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!