Category Archives: FOAMed

FOAMed Resources Part IX: Residency Program-Sponsored FOAMed

Author: Brit Long, MD (@long_brit, EM Attending Physician at SAUSHEC) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome back to the FOAMed Resource Series with Part IX. We have discussed a wide variety of topics including critical care, ultrasound, pediatrics, and toxicology. Today we focus on FOAMed coming to you from residency programs. These sites provide some of the best education out there, so hold on tight for more great educational content!

  1. https://coreem.net/

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CORE EM comes straight from FOAMed heavyweight Anand Swaminathan and the NYU EM program. This site focuses on yep, you guessed it, core content. The site provides regular blogposts (including cases, journal club, and core topics), videos, as well as a podcast. It provides free, bread and butter education that is second to none.

 

  1. http://www.tamingthesru.com/

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Taming the SRU (Shock Resuscitation Unit) from Cincinnati is another major contributor to core content. The site contains a blog focusing on several aspects of emergency medicine including procedures, ultrasound, cases, core content, and education. The site is associated with a podcast, and the “Annals of B-Pod” are downloadable journal-type articles on interesting cases and conditions.

 

  1. http://brownemblog.com/

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Brown Emergency Medicine publishes great content on cases, core topics, journal reviews, procedural videos, images, and controversial topics in EM. Asynchrony EM is a FOAMed-guided tour of EM topics. The site also has an overview of 52 classic articles in EM.

 

  1. https://em.umaryland.edu/educational_pearls/

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UMEM education pearls provide almost daily updates on classic EM topics and cutting edge research. The site is easy to use and follow, and all posts are referenced so you can gather more information if needed. The UMEM educational hub contains video lectures from some of the best in EM and critical care – https://umem.org/educational/

 

  1. http://blog.clinicalmonster.com/

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The residents of Kings County Hospital ED bring you an up-to-date, evidence-based blog on board review topics, ECGs, clinical cases, critical care, toxicology, pediatrics, radiology, and many others. Content is almost released daily, and oh yeah, they have lectures from grand rounds for those visual learners.

 

  1. http://www.everydayebm.org/; http://emed.wustl.edu/journalclub/Home.aspx

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Washington University in St. Louis has put together a great combination of FOAMed content. This sites contains case-based learning, FOAM supplement (a combination of great FOAMed topics), EMS cases (brought in by ambulance), consultant teachings, challenging cases, and classic and challenging ECGs. The residency’s journal club is also available, with discussions on key topics vital to everyday practice.

 

  1. http://www.nuemblog.com/

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NUEM comes from Northwestern University EM. This blog contains content on new literature, dogma in EM, and interesting cases, broken down by organ system. Each post is well written and referenced, as well as peer reviewed by a staff expert in the subject.

 

  1. http://sinaiem.org/

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Sinai EM is a great blog that provides several posts per week focusing on imaging, cases, controversy, and literature updates. The vast majority of EM content is well represented. They also cover the core literature, focusing on one article in one week.

 

  1. http://www.cmcedmasters.com/blogs.html

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Carolinas Core Concepts comes from the CMC EM residency program. The blog contains several categories, each providing valuable content. Core Concepts provides you with the basics for success in EM through bullet point reviews. The site also contains resident driven blogs including ortho, cardiology, tox, and peds, as well as attending blogs on coding/billing, ultrasound, and health policy.

 

  1. http://emdaily.cooperhealth.org/

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EM DAILY from Cooper University Health Care gives you great educational pearls. Every day of the week focuses on a specific topic, with basics on Monday, advanced techniques on Tuesday, radiology on Wednesday, conference on Thursday, critical care on Friday, Wellness on Saturday, along with several others. A weekly summary is provided on Sunday for those who desire an all-in-one stop.

 

  1. http://emblog.mayo.edu/

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The EMBlog from the Mayo Clinic EM Program provides a platform for FOAMed focusing on new and controversial studies, resident education, social medicine, shared decision making, and disposition. This blog’s strength is in its coverage of topics not covered elsewhere in FOAMed, specifically the social aspects of our care in the ED. You don’t want to miss this resource.

 

  1. http://www.lasvegasemr.com/foam-blog

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Las Vegas EMR contains posts including bread and butter topics in EM, while also evaluating myths and dogma in daily EM practice. Conference videos on lectures are provided on the site, giving learners of all levels access to more content. All posts are well referenced as well.

 

  1. http://hqmeded.com

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HQMedED comes from Hennepin County Medical Center. This site is a collection of online videos and lectures on EM topics ranging from procedures, ECG, pediatrics, critical care, and toxicology, as well as core content. This is a great resource for visual learners.

 

  1. http://www.templeem.com/blog

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The Temple EM Residency blog provides regular updates in common EM topics through an evaluation of the most current literature. Posts are provided at least once per week, though more commonly this occurs several times per week. If you want to stay up to date on relevant literature, this is the blog for you.

This is not an all-encompassing list, and if you like other resident-run blogs, please comment below! Stay tuned for more in the series.

#EMConf: Live Tweeting?

Author: Vidya Eswaran, MD (EM Resident Physician, Northwestern University Feinberg School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

It’s no secret that the #FOAMed movement is strong on Twitter. Blogs, articles, and opinions are shared on a nearly 24/7 basis. Within minutes, clinical questions can be answered, connections can be made, and knowledge can be shared among physicians from around the world. Increasingly, Twitter use at conferences has also grown. An analysis of tweets sent from an Australian Emergency Medicine Conference from 2011 to 2014 showed a 920% increase in the number of tweets from 460 to 4694, and an increase in number of tweet generators from 54 to 572.[1] This phenomenon is not limited to Emergency Medicine, and specialties such as Family Medicine,[2] Urology, Oncology,[3] and Surgery[4] have all participated in this trend. It has even been posited that “Global twitter conferences could be a cost-effective and low-carbon complement to traditional conferences”.[5]  Beyond tweets from large-scale meetings, residency programs are increasingly tweeting ‘pearls’ from their weekly educational conferences using the hashtag #EMConf.[6] From Dec 28, 2016 to Jan 6, 2017, 277 tweets were sent with the hashtag #EMConf by 145 users, reaching an audience of 135,835. I myself have sent numerous tweets from national conferences as well as from my own residency program’s weekly conference and have found myself asking the questions: Are my tweets serving any purpose, or am I merely adding to the background noise on the Twitter-sphere? Could my tweets serve more harm than good?

The Case for Live-Tweeting

Attending conferences is expensive – the flight, hotel, and food expenses can add up, especially for residents on a limited income. The core behind the entire FOAMed movement is to break down barriers to accessing medical education, and tweeting conferences is another means to this end. By attending conferences-by-proxy via Twitter, physicians can learn what is on the forefront of clinical innovation as well as review the fundamentals. This makes us better physicians, and thereby can improve the care we give our patients – our ultimate goal.

One thing I’ve learned in my, albeit short, time as an EM physician, is that practice variation abounds – regionally, hospital-wide, and even amongst providers in the same department. By sharing information from conferences we encourage engagement and discourse from physicians around the world. From this there is the possibility to learn how different physicians practice, and with careful consideration, physicians could apply a new practice pattern to their patient care through further education on the topic.

One might question the percentage of conference tweets which actually hold educational value. One study, at least, seems to show the majority does. The authors analyzed data from 2014 European Public Health Conference held in Glasgow. 1066 tweets were retrieved, of which 60% had session-related content while social/logistic-related tweets were only 16%.[7]

While providing free access to educational content to emergency physicians is a very benevolent task, I would be remiss to say that live-tweeting a conference is without any personal benefit. The conference attendee who sends out tweets has the potential to expand his or her personal network on social media. For some an increase in the number of followers is in itself an achievement, and as the case with networking of any kind, can lead to increased opportunities in the future. Benefits also exist for the speaker whose lecture is being tweeted. Live-tweets of your presentation can serve as free publicity of your research or of your presentation skills and could lead to opportunities to speak at other institutions or conferences. Finally, conferences themselves benefit from live-tweeting of their events. By raising awareness of their conference, Twitter serves as a free source of advertising and branding, and might encourage those not in attendance to register in the future. Additionally residency programs which tweet their conferences may find their tweets to be a source of advertising to residency applicants.

The Case against Live-Tweeting

A common criticism of FOAMed in general is that the content published is not as rigorously assessed for accuracy as more traditional sources of education. FOAMed proponents have responded by emphasizing that peer-review does in fact occur both prior-to and after publication of FOAMed pieces. Live-tweeting magnifies this issue. Tweets are often sent rapidly, as the tweet writer sits in the conference – opening potential for mistakes not only from the conference speaker but from the transcriber as well. One study analyzed tweets sent from an emergency medicine conference where speakers were asked to assess the level to which tweets from their talk accurately represented what they intended to convey. The investigators found that speakers believed that 43.2% tweets represented, 43.2% partly represented, and 8.1% misrepresented what they intended to convey.[8] While likely a genuine mistake on the part of the tweet generator, the implications could be grave if wrong information were applied in a clinical situation. Along these lines, it is possible that comments made by the speaker may be taken out of context leading to sensationalization and misrepresentation, which can be harmful not only in terms of the veracity of the tweet but may have negative repercussions for the speaker him/herself.

FOAMed is often criticized because its content is not broad. One study found that topics such as airway techniques, ECG interpretation, resuscitation, ultrasonography, and analysis of literature were overrepresented while cutaneous, hematologic, obstetric and gynecologic, and non-traumatic musculoskeletal disorders were rarely covered.[9] A similar case could be made for tweets from conferences. Just as we will never know if an unattended tree in the forest makes a noise as it hits the ground, we cannot glean information from a talk at which nobody tweets. A larger number of tweet generators may attend talks at conferences about popular or exciting topics, and other, perhaps more mundane, but equally important topics may not be broadcasted.

We can all remember a lecture in which we have found our minds wandering, or had the experience of being in a thoroughly engaging presentation, only to forget what was taught the next day. Those who tweet during conferences have two tasks: they must both pay attention to the content being delivered as well as expend mental energy to summarize important points into 140 character ‘pearls’. It seems inevitable that some content will be missed in the process. Not only is the tweet generator missing out on educational content, but their Twitter followers are also not gleaning the entirety of the presentation. Of all the critiques regarding live-tweeting, I think this to the most dangerous and in need of the most investigation. The primary goal for any learner, whether it be in a residency program setting or at a national conference, is to fill his or her own personal educational needs. Only then can one focus on spreading that knowledge to others. If live-tweeting prevents active engagement in the course, then it can be argued that the ‘risks’ of tweeting outweigh the benefits. On the other hand, others may find tweeting to be in line with their personal learning style by encouraging them to listen, synthesize, and summarize the main points of a lecture in real-time. Additionally, the act of typing may in itself serve as further ‘active learning’ to cement key topics.

To Tweet or Not to Tweet?

There are many questions yet to be answered – can learning from tweets be quantified, is there a way to ensure the greatest degree of accuracy in live-tweets, can we ensure that learners aren’t distracted from lecture content while tweeting? At this point in time I think I will continue to live-tweet. I enjoy being a part of the FOAMed community both as a generator of tweets as well as an enthusiastic reader of others’. As I ride the bus into shifts on Thursday mornings I find myself skimming through tweets from residency programs around the country, saving the ones I find interesting for further investigation. As with most things on the internet, however, I approach everything I read with a healthy dose of skepticism. It is on me to trust, but verify, what others tweet before implementing it into my clinical practice.

To those of you considering live-tweeting your next conference, I encourage you to pay close attention to how tweeting affects your learning. If you feel it is a distraction, perhaps take notes during the lecture and then tweet afterwards, when you have more time summarize and synthesize the material. If you wonder about the veracity of a statement or if you are unclear about whether you are representing the speaker’s point, perhaps wait to send the tweet until you can confirm your doubts with the speaker him/herself.

Will Twitter completely obviate the need to attend conferences? I doubt it. There are many benefits, both tangible and intangible to being physically present: from engaging in discourse, to asking the speaker questions directly, networking with other conference participants and having fun with friends, new and old, in different locales.  But for those who cannot attend, with a bit of caution, Twitter can offer an invaluable avenue to be a part of the clinical dialogue.

For more on Twitter use at conferences, see these great sites:

https://socialmediaforlearning.com/2015/06/23/tips-for-tweeting-at-conferences-shult15/

http://www.chronicle.com/blogs/profhacker/ten-tips-for-tweeting-at-conferences/54281

References/Further Reading:

[1] Udovicich C, Barberi A, Perera K. Tweeting the meeting: A comparative analysis of an Australian emergency medicine conference over four years. J Emerg Trauma Shock 2016;9:28-31.

[2] Mishori R, Levy B, Donvan B. Twitter use at a family medicine conference: analyzing #STFM13. Fam Med. 2014 Sep;46(8):608-14.

[3] Wilkinson S, Bastro M, Perovic G, Lawrentschuk N, Murphy D. The social media revolution is changing the conference experience: analytics and trends from eight international meetings. BJU International 2015: 115(5):839-846.

[4] Logghe H, Maa J, Schwartz J. Twitter usage at Clinical Congress rises markedly over two years. Bull Am Coll Surg. 2013 Feb;98(2):22-4.

[5] S Avery Gromm, S Hammer, G Humphries. The age of the Twitter conference. Science 2016: 352(6292): 1404.

[6] MR Haas et al. #EMConf: utilizing Twitter to increase dissemination of conference content. Medical Education 2016; 50: 564-591.

[7]  Bert F, Paget DZ, Scaioli G. A social way to experience a scientific event: Twitter use at the 7th European Public Health Conference. Scandinavian Journal of Public Health, 2016; 44: 130–133

[8] Roland D, May N, Body R, et al. Emerg Med J 2015;32:412–413.

[9] Stuntz R, Clontz R. An Evaluation of Emergency Medicine Core Content Covered by Free Open Access Medical Education Resources. Ann Emerg Med. 2016 May;67(5):649-653.e2. doi: 10.1016/j.annemergmed.2015.12.020. Epub 2016 Feb 11.

GI Bleeds: Who Needs ICU Level Care?

Authors: Christina Thorngren, MD, MPH and Janna Welch, MD (University of Texas Dell School of Medicine Emergency Medicine Residency Program) // Edited by: Erica Simon, DO, MHA (@E_M_Simon), Brit Long, MD (@long_brit ), and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

It’s a busy Saturday night in the ED. Scanning the patient tracking board, you come across an ESI 2: A 55 year-old woman with a chief complaint of generalized weakness. The nursing note details a review of systems positive for epigastric abdominal pain and black stools of one week duration. VS: HR 110, BP 105/64. As the patient rolls by in a wheelchair, you note her impressive pallor. After offering a quick greeting, placing her on the monitor, and dropping orders, you make your way to the clerk’s desk to notify him of an anticipated admission. As the clerk makes inquires regarding the required bed, your focus shifts to the patient: is she stable enough for the ward or does she require ICU level care?

If you’ve had a similar inner monologue while treating a GI bleed, the discussion below offers a number of tools to aid in your clinical decision-making.

Introduction

Developing a clinical gestalt regarding a patient with a gastrointestinal bleed (GIB) can be challenging even for the seasoned emergency medicine physician. Anecdotally, we’ve all heard of the hemodynamically stable patient with one bloody bowel movement prior to arrival that acutely decompensates in the ED. While the decision to admit these patients to the ward versus the ICU may be clear in the setting of unstable VS or post endotracheal intubation, there are often times when we encounter shades of gray. The following discussion will hopefully shed some light on topic, and offer a quick discussion of risk stratification methods for EM physicians to utilize when addressing upper and lower GI bleeds.

Upper GIB

An upper GIB is defined as bleeding from a source proximal to the ligament of Treitz.1 Etiologies of upper GIBs include esophageal varices, peptic ulcers, gastritis, Mallory-Weiss tears, arteriovenous malformations, and rarely, Dieulafoy lesions (large diameter, tortuous vessels, protruding through the submucosa of the GI tract).2 Collectively, the annual incidence of upper GI bleeds is 48-180 cases per 100,000 adults, with a mortality ranging from 10-14%.1   Nearly 80% of upper GIBs resolve spontaneously, while 20% require acute intervention.1 Several studies have identified severe gastrointestinal bleeding (GI bleeding resulting in shock, or a decrease in hematocrit of ≥ 6% from baseline) as possessing a mortality rate of nearly 39%.1

While it is clear that patients with severe GI bleeds require inpatient admission, are there methods to determine when it is appropriate to discharge hemodynamically stable patients for outpatient follow-up?

Current literature cites the following scores for use in the mortality risk stratification of upper GIBs: the Clinical Rockall Risk Score,3 the Modified Glasgow-Blatchford Score,4,5 the AIMS65 Score,6 and the PNED Score.7,8 While these scores were initially developed to assess inpatient mortality in the setting of upper GIBs, secondary outcomes included risk for re-bleeds and 30 day mortality, making them useful tools for the emergency physician.3

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Is one of these methods superior to the others? Let’s quickly discuss the statistical method of comparison:

The utility of a scoring systems is determined by calculating the area under the receiver operating curve (AUROC). An AUROC of 1 is a perfect test that when employed, will accurately and precisely predict an outcome 100% of the time. In contrast, an AUROC of 0.5 is of little utility as it precisely and accurately predicts an outcome 50% of the time (i.e. – no better than flipping a coin).

Ideally, to assess the risk stratification methods detailed above, all scores would be applied to one cohort of patients, and the AUROC calculated and compared. To date, there have been no studies performed which directly compare the Clinical Rockall Risk Score, the Modified Glasgow-Blatchford Score, the AIMS65 Score, and the PNED Score. Of the research published:

  • In 2012, Cheng, et al.5 compared the Modified Glasgow-Blatchford Score and the Clinical Rockall Score as applied to 167 patients presenting with GIBs (study endpoint: in-hospital mortality or re-bleeding). An AUROCs of 0.85 (CI 0.72-0.98) for the Modified Glasgow-Blatchford Score, and 0.59 (CI 0.32-0.87) for the Clinical Rockall Risk Score (p <0.0022) was identified.
  • Marmo, et al.8performed a head-to-head comparison of the PNED score and Clinical Rockall Score in 1360 patients (end point: in-hospital mortality) and found respective AUROCs of 0.81 (CI 0.70-0.90) for PNED, and 0.66 (CI 0.6-0.72) for the Clinical Rockall Score (p-value of <0.000).
  • In 2016, Aubougergi et al.6 performed a comparison of the AIMS65 and the Modified Glasgow-Blatchford Score in 298 patients (endpoint: inpatient mortality), identifying an AUROC of 0.85 (CI 0.81-0.89) for AIMS65 and 0.66 (CI 0.61-0.72) for Modified Glasgow-Blatchford Score (p of <0.01).

While it is unclear which mortality stratification method is most appropriate for use by the emergency physician, it is safe to say that the higher the mortality risk as characterized by these scores, the greater the necessity for advanced levels of patient care.

Have any of these scores been directly assessed for utility in predicting the need for ICU admission?

Of the mortality risk stratification scores above, only the Clinical Rockall Score has been evaluated for its utility in determining the requirement for ICU-level care. In a study of 565 consecutive patients treated for acute upper GIBs at Wellington Hospital, New Zealand (1988-1991), Phang et al.7 identified an overall mortality rate of 22% in patients presenting with a Clinical Rockall score of 4-7, leading the authors to identify this as a high-risk population requiring ICU level care.7

Publications to watch:

Of note, an abstract by Raemakers et al. was recently published online (prior to the full article in Academic Emergency Medicine), discussing the value of pre-endoscopic risk scores for upper GIBs in the ED. For more information as it becomes available:

Ramaekers R, Mukarram M, Smith C, Thiruganasambandamoorthy V. The predictive value of pre-endoscopic risk scores to predict adverse outcomes in emergency department patients with upper gastrointestinal bleeding — A systematic review. Acad Emerg Med 2016 Sep 19; [e-pub]. (http://dx.doi.org/10.1111/acem.13101)

 Lower GI Bleeding

The majority of life-threatening bleeds originate from the upper GI tract, however profuse bleeding from the lower GI tract often causes hemodynamic instability. Approximately 20-25% of GIBs are distal to the ligament of Treitz, and result in a mortality rate of 2%- 4% (mortality has been demonstrated to increase with advancing age).9 Potential sources of lower GIBs include diverticular disease, malignancy, angiodysplasia, and colitis.9

Unlike upper GIBs, there is far less consensus regarding risk stratification parameters for lower GIBs. Several studies have demonstrated low systolic blood pressure, tachycardia, the use of aspirin, and the presence of medical comorbidities as increasing the risk of mortality in the setting of a lower GIB.9-11

In their study of 688 patients presenting with lower GIBs, Chong, et al.10 demonstrated a lack of reported abdominal tenderness as an independent risk factor for mortality (possibly as pain is often associated with more benign etiologies of bleeding, and could lead to earlier patient evaluation and treatment).10 The authors also identified prolonged bleeding (> 4 hours) as a risk factor for mortality in the setting of lower GIB.10,11

In conducting their study, Chong et al. also utilized a cohort of 410 patients to develop a clinical prediction score (HAKA score) to identify patients most likely presenting with a severe lower GIB. The authors identified severe bleeding as: bleeding requiring transfusion of ≥ 2 units of packed red blood cells, manifesting as a decrease in hematocrit of > 20% from baseline, recurrent bleeding within 24 hours, or readmission for lower GI bleeding within one week of initial presentation. The HAKA score, detailed below, demonstrated a PPV (for scores ≥ 2) of 44% for severe lower GI bleed, and a NPV of 88%.10

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Recognizing the need to investigate risk factors for severe lower GIBs, in 2003 Strate and colleagues published data characterizing presenting symptoms of lower GIBs and their odds of association with severe bleeding (as defined above by Chong, et al.).11 In 252 consecutive patients presenting to Brigham and Womens’ hospitals in Boston, MA from 1996-1999, the following characteristics were associated with severe lower GI bleeding:

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Conclusion

Extensive research has been performed in an attempt to develop clinical decision-making tools for the risk stratification of patients with GI bleeds. Ultimately, patients who are hemodynamically unstable, risk stratify as having a high mortality secondary to GI bleeding, or are at risk for having a severe lower GI bleed, should be admitted to an ICU setting.

Back to the Case

Review of the patient’s electronic health record reveals a history of chronic back pain (prescribed naproxen), hypertension, and hyperlipidemia. Initial screening labs identify a Hgb of 8.1 and BUN of 45. The patient is likely experiencing an upper GIB secondary to NSAID therapy. Utilizing the Modified Glasgow-Blatchford Scale, you quickly identify the patient as having a high risk of mortality. After consulting for ICU admission, you contact gastroenterology. The next morning you open the patient’s record and note the identification of a NSAID gastropathy on endoscopy. The patient ultimately required a blood transfusion, but is hemodynamically stable.

References / Further Reading

  1. Barkun A, Bardou M, Kuipers E, Sung J, Hunt R et al. International concensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010; 152:101-113.
  2. Baxter M and Aly E. Dieulafoy’s lesion: Current trends in diagnosis and management. Ann R Coll Surg Engl. 2010; 92(7): 548-554.
  3. Monteiro S, Goncalves T, Magalhaes J, Cotter J. Upper gastrointestinal bleeding risk scores: Who, when and why? World J Gastrointest Pathophysiol. 2016; 7(1):86-96.
  4. Blatchford O, Murray W, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000; 356(9238):1318-1321.
  5. Cheng D, Lu Y, Sekhon H, Wu B. A modified glasgow blatchford score improves risk stratification in upper gastrointestinal bleed: a prospective comparison of scoring systems. Alimen Phamacol Ther. 2012; 36(8): 782-789.
  6. Abougergi M, Charpentier J, Berthea E, Rupawala A, Dheder J, et al. A prospective, multicenter study of the aims65 score compared with the Glasgow-blatchford score in predicting upper gastrointestinal hemorrhage outcomes. J Clin Gastroenterol. 2016; 50(6): 464-469.
  7. Phang T, Vornik V, Stubbs R. Risk assessment in upper gastrointestinal haemorrhage: implications for resource utilization. N Z Med J. 2000; 113(1115):331-333.
  8. Marmo R, Koch M, Cipolletta L, Capurso L, Grossi E, et al. Predicting moratlity in non-variceal upper gastrointestinal bleeders: validation of the Italian pned score and prospective comparison with the rockall score. Am J Gastroenterol. 2010;105(6):1284-1291.
  9. Qayed E, Dagar G, Nanchal R. Lower gastrointestinal hemorrhage. Crit Care Clin. 2016: 32(2):241-254.
  10. Chong V, Hill A, MacCormick A. Accurate triage of lower gastrointestinal bleed (LGIB) – a cohort study. Int J Surg. 2016; 25:19-23.
  11. Strate L, Orave E, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med. 2003;163(7):838-843.

Managing Sexual Assault in the Emergency Department

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident at SAUSHEC, USAF) and Daniel Sessions, MD (Medical Toxicologist, South Texas Poison Center / Assistant Program Director at SAUSHEC, USA) // Edited by: Courtney Cassella, MD (@Corablacas, EM Resident Physician, Icahn SoM at Mount Sinai) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

http://www.nsvrc.org/saam/about/graphics

It’s seven o’clock on a Saturday morning; as you sip your coffee in a feeble attempt to awaken neurons, you glance up as a nurse passes, leading a young female to a room. The woman appears distraught and disheveled: dress wrinkled, eyes bloodshot, cheeks tear-stained and blackened by the previous night’s makeup. As you glance at the patient tracking board, you note her chief complaint: Alleged Sexual Assault. Engrossed by a sickening, sinking feeling, you attempt to locate your department’s sexual assault protocol binder. As you walk toward the room you prepare yourself mentally for what will likely be an emotionally taxing encounter for all involved.

If you’ve found yourself in a situation similar to that depicted above, and could use a refresher on this important topic: read on as we discuss must knows for the ED management of sexual assault.

Epidemiology of Sexual Assault

Between 300,000-700,000 American women are sexually assaulted annually.1 While 94% of assault patients who present to emergency departments are females, current studies indicate a lifetime prevalence of sexual assault as occurring among 1 in 33 males.2 Adolescents disproportionately represent the majority of sexual assault victims (incidence peaking between the ages of 16 –19 years), with approximately 40% of this population reporting assault during their first sexual encounter.3-5

Contrary to popular belief, nearly 80% of persons having experienced sexual assault report knowing their offender; 18% identifying their assailants as former spouses or love interests.6  Hailed as one of the most widespread and under-reported violent crimes in the U.S.7, rape is associated with non-genital trauma in 40-81% of cases, with 5% requiring hospitalization for serious injury.5,8,9

The Role of the Emergency Physician

This review will address patient stabilization, provide recommendations for obtaining a medical and assault history, and detail pregnancy and sexually transmitted infection prophylaxis. An in-depth discussion of the forensic examination will be omitted, as requirements regarding healthcare provider training, tools contained within forensic collection kits, time allotted between alleged assault and court admissible evidence collection, and chain of custody legislation vary according to individual state law.

Stabilizing the Patient

The evaluation of an emergency department patient begins with an assessment of the ABCs. In extreme cases, patients with non-genital trauma may present with internal injuries, blunt head injury, and knife or gunshot wounds (2%)10 requiring intervention to address altered mental status or hemodynamic instability. After life- or limb-threatening injuries have been addressed, the patient should be moved to a quiet setting to begin discussion of consent and history taking.5,7

Providing Information & Obtaining Consents

Aside from immediate stabilization, information is the most valuable tool in caring for your patient.

Understand the limitations of the evaluation and treatment which your organization is capable of providing (to include the forensic examination), be familiar with state laws regarding timelines for reporting, and arm yourself with resources for referral (forensic exam specialists, counselors, chaplains, etc.) as appropriate.

If needed, state attorney’s offices may be contacted regarding the provision of a patient advocate. In addressing the patient, it is important to inform him/her that he/she may undergo forensic examination without the requirement for reporting.10 The typical time frame for evidence collection is within 72 hours to 5 days. Providers should check within their state what is the maximum time frame post assault for court admissible evidence collection. It is highly recommended that an advocate be provided to assist the patient during the examination, and facilitate the sharing of information regarding legal options.10,11 

Consents must be obtained for information gathering and performance of a forensic examination.5,11 If the patient would like to report the assault, local law enforcement personnel must be contacted. The patient should be advised of state legislations/circumstances, which require mandatory reporting. Examples include12:

  • Sexual assault of an elderly person or vulnerable adult
  • Sexual assault of a minor (categorization as a “minor” varies from state to state)
  • Non-accidental trauma
  • Injuries sustained secondary to criminal conduct (definitions of “criminal conduct” vary by state)
  • Assault with a deadly weapon

Obtaining an Appropriate Medical & Sexual History

In an effort to avoid repeated psychological trauma, portions of the medical and sexual history may be deferred until a later time at which an interview and forensic examination is to be conducted by the state certified/trained personnel. Medical history taking should include a query of the following:

Medical History5,11
Last Menstrual Period
Recent (60 days) anal-genital injuries, surgeries, diagnostic procedures or medical treatments that may affect the interpretation of current physical findings
Pertinent medical condition(s) that may affect the interpretation of physical findings (blood dyscrasias, etc.)
Pre-existing physical injuries prior to the alleged assault

 

Pre/Post Assault History5,11
Other intercourse within the previous 5 days (anal, vaginal, or oral); intercourse with or without ejaculation; condom use
Voluntary alcohol or drug use prior to the assault
Voluntary alcohol or drug use between the time of the assault and presentation for examination

 

Post Assault Hygiene History (Presenting ≤ 72 hours Post Assault)5,11
Bodily functions: urination, defecation
Utilization of genital or body wipes or douches
Removal or insertion of tampons or diaphragms
General hygiene activities: bathed/showered/washed; changed clothing; ate or drank; brushed teeth or gargled

 

Assault Related History5,11
Loss of memory/consciousness
Presence of non-genital or anal-genital injury
Date/Time/Location of assault
Alleged assailant(s)/Age/Gender/Ethnicity/Relationship to patient
Methods utilized for assault: Weapons, physical blows, restraints, burns, strangulation, threat(s) of harm, involuntary ingestion of drugs

 

Assault Related Acts as Described by the Patient5,11
Vaginal Penetration
Anal Penetration
Oral copulation of genitals/anus
Non-genital acts (licking, kissing, suction injury, biting)
Ejaculation
Use of foreign bodies
Contraception or lubricant use


Performing the Physical Exam

Elements of the physical exam include an assessment of5,11,13:

  • The patient’s general appearance/emotional status
  • A complete physical examination of the head, body, and extremities with documentation of all visible injuries
  • A genital examination with colposcopy for females if available

Elements of evidence collection include5,11,13:

  • Swabs/smears of involved orifices
  • Patient saliva samples
  • Fingernail scrapings
  • Packaging of patient clothing
  • Head hair and pubic hair combing and collection
  • External genitalia and peri-anal swabbing
  • Swabbing of bodily areas soiled with blood, semen, or saliva
  • Blood typing of specimens obtained

For an example of the forensic examination document sheet, see the Rosens’ text: Reference 5.

A Word on Sexual Assault Nurse Examiners (SANE)

In 2002, the International Association of Forensic Nurses (IAFN) created a certification program to: develop nurses who were experts in history-taking, treatment of trauma response and injury, documentation and collection of evidence, and the delivery of testimony required to bring sexual assault cases through the legal system.14 Today the IAFN maintains SANE education guidelines and has extended the scope of forensic nursing to include certification programs in pediatric sexual assault nursing (SANE-P vs. adult/adolescent SANE-A).15

There are currently greater than 400 SANE programs across the nation, the majority associated with major medical centers.16 (To find a program, the following search engine may be employed: http://www.forensicnurses.org/search/custom.asp?id=2100).

Why is this pertinent for emergency physicians? Although further research is required (secondary to small sample sizes, and differing definitions regarding the provision of care), studies have identified improved patient outcomes through the employment of dedicated sexual assault nurse examiners:

Sievers et al., 2003: Criminal laboratory analysts completed 515 audits of sexual assault evidence kits submitted to the Colorado Bureau of Investigation from October 1999-April 2002 (279 kits completed by SANEs, 236 completed by physicians and local nurses). As compared to physicians and local nurses, SANEs were:

  • More likely to have a completed chain of custody requirements (92%) as compared to 81% of physicians/local nurses.
  • More likely to have properly sealed individual specimen envelopes (91% vs. 75%).
  • More likely to have labeled the individual specimen envelopes (95% vs. 88%), and to have collected the appropriate amount of pubic hair (88% vs. 74%), and head hair (95% vs. 80%).
  • More frequently included the appropriate number of blood tubes (95% vs. 80%), collected the appropriate amount of swabs (88% vs. 71%), and included a vaginal fluid slide for sperm motility (87% vs. 72%).17

Campbell et al., 2005: Empirical literature review of the psychological recovery of survivors, the provision of comprehensive medical care, the documentation of forensic evidence, and the reliability of testimony during prosecution, demonstrated SANE nurses as effective in all domains. (As recognized by the authors: numerous studies reviewed lacked methodological controls).18

Interestingly, this has become a topic of debate, as some would argue that SANE nursing programs decrease resident exposure to sexual assault patients, thus limiting resident education regarding proper procedures and protocols.

In 2007, McLaughlin et al. demonstrated a knowledge deficit amongst emergency medicine residents, trained in an institution equipped with a SANE program, with respect to written knowledge regarding the sexual assault exam, collection of evidence (simulation utilizing mannequins), performance during standardized patient interviews, and documentation:

Twenty-three (85%) residents completed the study. Pre-intervention, residents scored 56% on the written knowledge test, 63% on evidence collection, 71% on standardized patient interviews, and 66% on the written note.18

After an educational intervention, McLaughlin and his colleagues noted: Residents demonstrated significant post-intervention improvements in written knowledge (improvement 24%; 95% confidence interval [CI] 20% to 27%) and evidence collection (improvement 18%; 95% CI 12% to 24%). Resident post-test scores were similar to those of SANE providers.18

Sexually Transmitted Infection (STI) and Pregnancy Prophylaxis

The likelihood of acquiring an STI after rape is difficult to predict, and varies according to the type of assault, the assailant, and geographic location. Current studies estimate the relative risk of contracting trichomonas as 12%, gonorrhea as 4-12%, and chlamydia as 2-14%.5,13,19

The Centers for Disease Control and Prevention (CDC) recommend the following prophylactic regimen in the treatment of the sexual assault patient:

Figure 1. Prophylactic STI Regimens for the Sexual Assault Patient (Ref 20)

Although prophylaxis for syphilis is not recommended by the CDC, previous studies report the risk of contraction post sexual assault as approaching 5%.5,13,19 Prophylaxis should be considered in areas or populations where the syphilis is prevalent. Alternatives to prophylactic treatment include the documentation of a recommendation for VDRL/antibody specific testing at a later date.13

The risk of HIV transmission from a single sexual assault is less than 0.1%.5,13 Experts recommend discussing victim and assailant risk factors (Figure 2 – Detailed in Rosen’s text), and utilizing shared decision making to determine the appropriateness of post-exposure prophylaxis (PEP).5,20

Figure 2. Sexual Assault Victim (SAV) and Assailant Risk Factors for HIV Susceptibility and Infectiousness (Ref 5)
Figure 2. Sexual Assault Victim (SAV) and Assailant Risk Factors for HIV Susceptibility and Infectiousness (Ref 5)

Current regimens for non-occupational post-exposure prophylaxis in adults and adolescents include21:

  • Tenofovir disoproxil fumarate (300mg QD) and emtricitabine (200mg QD) +
    • Raltegravir (400mg BID) or Dolutegravir (50mg QD)

OR

  • Tenofovir disoproxil fumarate (300mg QD) and emtricitabine (200mg QD) +
    • Darunavir (800mg QD) + Ritonavir (100mg QD)

Note: Studies demonstrate PEP as most effective when initiated within 72 hours of exposure.20 The CDC recommends providing the patient with a one-week supply of PEP medications, and scheduling follow-up at the one-week point to discuss medication tolerance and side-effects.20 Patients electing to take PEP require interval follow-up for serial laboratory studies (antiviral therapy commonly associated with renal, hepatic, and hematologic side effects).5,20 HIV testing should be performed for all sexual assault victims at 6 weeks, 3 months, and 6 months post assault.20

The CDC recommends post-exposure hepatitis B vaccination (without HBIG) for all sexual assault patients if previously un-immunized. The hepatitis B vaccination series should be completed with subsequent doses at 1-2 months, and 4-6 months after the first injection.20

The risk of pregnancy after a sexual assault is estimated as 2-4%.11,13 Females of reproductive age should be offered pregnancy prophylaxis.20 Ovral, Lo/Ovral, and Nordette may be administered up to 72 hours post assault.11 The most common side-effect associated with these medications is nausea, therefore patients should be discharged with an anti-emetic.11 Female assault victims should be instructed to perform a pregnancy test if menstruation does not occur 3-4 weeks post treatment.11 See Figure 3 for information regarding pregnancy prophylaxis regimens.

Figure 3. Emergency Contraception
Figure 3. Emergency Contraception (Ref 11)

Psychological Care & Follow-Up

Long-term sequelae of sexual assault include depression, drug and alcohol abuse, and sexual dysfunction.13 Studies indicate that up to one-third of sexual assault victims experience PTSD.13 As compared to the general population, rape victims are thirteen times more likely to attempt suicide.13,22 Experts recommend that all sexual assault victims be referred to a rape crisis center within 48 hours of evaluation.13

Medical follow-up visits should be scheduled for the sexual assault patient at 1-2 weeks, and 2-4 months for repeat STD testing, VDRL/FTA-ABS testing, and PEP monitoring as appropriate.5,13,20

Special Topic: Date Rape Drugs

The incidence of drug-facilitated sexual assault (DFSA) is increasing worldwide.5,23 Flunitrazepam (Rohypnol), gama-hydroxybutyrate (GHB), and ketamine have been heralded as the new “date rape drugs,” so let’s do a quick review:

Flunitrazepam (Rohypnol) – a benzodiazepine ten times as potent as valium, is currently available in Europe and Latin America, and is distributed as 1 or 2 mg tablets. In 1996, the U.S. FDA enacted legislation to inhibit the importation of Rohypnol secondary to concerns for abuse. Street names for flunitrazepam include: “Mexican Valium,” “circles,” “roofies,” “la rocha,” “roche,” “R2,” and “rope.” At high doses Rohypnol may cause sedation and significant respiratory depression, however, the drug is distributed in such small concentrations that supportive care is generally all that is required.26

Gama-hydroxybutyrate (GHB) – a naturally occurring fatty-acid derivative of the neurotransmitter, GABA, was originally marketed in the 1990s as a dietary supplement. Today, the over-the-counter sale of GHB has been banned due to its association with seizure-like activity and reflex autonomic activation. GHB is commonly available in oral solutions, and its delivery as such has earned it the street names of “liquid ecstasy,” “soap,” and “salty water.” Individuals ingesting GHB commonly experience symptoms of CNS depression and anterograde amnesia. Bradycardia and tonic-clonic seizures are also well-documented side-effects. Patients exposed to large concentrations often require airway support, including intubation.26

 Ketamine – a derivative of phencyclidine hydrochloride (PCP), was developed in the 1960s for use as a dissociative anesthetic. Ketamine primarily interacts with NMDA receptors to inhibit the release of glutamate, but is also known to stimulate muscarinic, nicotinic, cholinergic, and opiod receptors. Ketamine is currently employed in the medical setting for procedural sedation, pain control, and for the treatment of depression, and is available under the street names of “K,” “kit-kat,” “super K,” and “jet.” Ketamine is sold as a solid or powder for users to inject, ingest, smoke, or snort. Ketamine may cause significant sympathetic activation resulting in tachycardia and hypertension, and users often experience apnea shortly after drug administration. Drug effects are much more prevalent in users who inject ketamine as opposed to ingest it (significant first pass metabolism after oral intake).26 Patients commonly require supportive care. In extreme cases, airway management may be indicated.

The Utility of Serum/Urine Screening in the Emergency Department

Forensic examination requires sampling of blood and urine if the patient endorses substance use/abuse or if he/she reports concern for drug-facilitated sexual assault.5,11 In the setting of DFSA, samples are rarely useful to the emergency medicine physician as the majority of drugs utilized are rapidly absorbed and metabolized5,25:

  • The half-life of Rohypnol is reported as 10-15 hours => frequently undetectable by UDS and requiring high performance liquid chromatography or gas chromatography-mass spectrometry (GC-MS) for identification. (Flunitrazepam and its metabolites, 7-amino-flunitrazepam and norflunitrazepam, are identifiable for up to 3 days post administration by GC-MS).26
  • The half-life of GHB is 20 minutes. GHB is not detectable by standard serum and urine toxicology screens due to its short half-life and its elimination through exhalation (metabolized to CO2). GC-MS will detect GHB up to 6-8 hours post administration.26
  • Serum and urine tests for ketamine (and norketamine, it’s metabolite) are not available as standard laboratory sets.26

As an aside, it is important to note that ethanol remains the number one substance of choice for perpetrators of sexual assault.24,25 While published data from the U.S. is lacking, large studies from Sweden and Norway demonstrate elevated blood alcohol concentration as the number one toxicologic finding in victims of sexual assault27,28:

Hagemann et al., 2013: Retrospective, descriptive study of female patients ≥ 12 years of age presenting for evaluation post sexual assault from 2003-2010 (n=120). In total 102 patient serum samples, drawn within 12 hours of the alleged assault, tested positive for ethanol. The median blood alcohol concentration (BAC) at the time of the assault was 1.87 g/L. Patients testing positive for ethanol more often reported a public place of assault and stranger assailant.27

Jones, et al., 2012: Retrospective review of a Swedish national forensic database (TOXBASE) for female victims of sexual assault having contributed blood and urine samples, 2008-2010 (n=1406) and 2003-2007 (n=1806). In the 2008-2010 group, ethanol was detected as the only drug in 41% (603) of victims, and in the 2003-2007 group as 43% (772) of victims – significantly more prevalent than the previously mentioned date rape drugs representing 2.5% (36) and 3.2% (58) of victims.28

Key Pearls

  • Stabilize the patient as appropriate – 5% of victims require hospitalization secondary to severe injury5,8,9
  • Understand your options and do what’s in the best interest of the patient:
    • Call the patient advocate (state attorney’s offices will provide a list of resources if needed)
    • Refer as appropriate:
      • If the patient may be better served by an institution with a SANE program, then transfer
    • Provide pregnancy prophylaxis as appropriate
    • Provide STI prophylaxis
    • Provide Hepatitis B vaccination if un-immunized
    • Discuss risk factors for HIV transmission and the risks/benefits of prophylaxis
    • Involve a rape crisis counselor EARLY
      • Many patients experience PTSD, depression, and suicidal ideation post assault13
    • Stress the importance of follow-up for STI monitoring, PEP evaluation as indicated, and continued emotional support

References / Further Reading

  1. Sampsel K, Szobota L, Joyce D, Graham K, Pickett W. The impact of a sexual assault/domestic violence program on ED care. J Emerg Nurs. 2009;35(4):282-289.
  2. Tjaden P, Thhoennes N: Extent, nature, and consequences of rape victimization: findings from the national violence against women survey. National Institute of Justice Special Report. Washington, DC: U.S. Department of Justice; 2006. Available from www.ncjrs.gov/pdffiles1/ nij/210346.pdf.
  3. Poirier, M. Care of the female adolescent rape victim. Pediatr Emerg Care, 2002;18:53.
  4. Adams J, Giradin B, Faugno D. Adolescent sexual assault: Documentation of acute injuries using photo-colposcopy. J Pediatr Adolesc Gynecol. 2001;14:174-180.
  5. Slaughter L. Sexual Assault. Rosen’s Emergency Medicine – Concepts and Clinical Practice. 8th ed. Chapter 67. 855-871. Elsevier Saunders. Philadelphia, PA.
  6. Bureau of Justice Statistics: National crime victimization survey: criminal victimization. 1998. Washington, D.C.: U.S. Dept of Justice Programs; 1999.
  7. Dunn S, Gilchrist V. Sexual assault: Family violence and abusive relationships. J Prim Care. 1993; 20(2):359-373.
  8. Kobernick M, Seifert S, Sanders A. Emergency department management of the sexual assault victim. Emerg Med Clin N Am. 1985; 2:205-214.
  9. Saltzman L, et al: National estimates of sexual violence treated in the emergency departments. Ann Emerg Med. 2007; 49:210-217.
  10. Marchbanks P, Lui K, Mercy J. The risk of injury from resisting rape. Am J Epidemiol. 1990; 132:540-549.
  11. McConkey T, Sole M, Holocomb L. Assessing the female assault provider. JNP. 2001; 26(7):28-41.
  12. Scalzo T. Rape and sexual assault reporting laws. National Center for Prosecution of Violence Against Women. Available from: https://www.evawintl.org/Library/DocumentLibraryHandler.ashx?id=571
  1. Linden J. Sexual assault. Emerg Med Clin N Am. 1999; 17(3):685-697.
  2. Speck P, Peters S. Forensics in np practice. Adv Nurse Pract. 1999;7(11):18.
  3. International Association of Forensic Nurses. Forensic nursing scope and standards 2015. Available from: http://c.ymcdn.com/sites/www.forensicnurses.org/resource/resmgr/Docs/SS_Public_Comment_Draft_1505.pdf?hhSearchTerms=%222015protect%20$elax%20pm%20$andprotect%20$elax%20pm%20$draft%22
  1. Sexual Assault Resource Service. SANE programs in the United States. Available from: http://www.sane-sart.com/
  2. Sievers V, Murphy S, Miller J. Sexual assault evidence collection more accurate when completed by sexual assault nurse examiners: Colorado’s experience. J Emerg Nurs. 2003; 29(6):511-514.
  3. Campbell R, Patterson D, Lichty L. The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes. Trauma Vioence Abuse. 2005;6(4):313-329.
  4. McLaughlin S, Monahan C, Doezema D, Crandall C. Implementation and evaluation of a training program for the management of sexual assault in the emergency department. Ann Emerg Med. 2007:49(4):489-494.
  5. Jenny C, Hooton T, Bowers A, et al. Sexually transmitted disease in victims of rape. 
N Engl J Med 322:713-716,1990
  6. Centers for Disease Control and Prevention. Sexual assault and STDs. 2010. Available from: http://www.cdc.gov/std/treatment/2010/sexual-assault.htm
  7. Centers for Disease Control and Prevention. Updates for antiretroviral postexposure prophylaxis after sexual, injection drug use, or nonoccupational exposure to HIV. 2016. Available from: https://stacks.cdc.gov/view/cdc/38856
  8. Kilpatrick D, Edmunds C, Seymour A. Rape in America-a report to the nation. Crime Victim Research and Treatment Center. Charleston, SC, Medical University of South Carolina, 1992.
  9. Du Mont J, Macdonald S, Rotbard N, Asllani E, Bainbridge D: Factors 
associated with suspected drug facilitated sexual assault. CMAJ 2009; 
180:513-519.
  10. Dinis-Oliveira R, Magalhaes T. Forensic toxicology in drug-facilitated sexual assault. Toxicol Mech Methods. 2013:23(7):471-478.
  11. Jones A, Kugelberg F, Holmgren A, Ahlner J. Occurrence of ethanol and other drugs in blood and urine specimens from female victims of alleged sexual assault. Forensic Sci Int. 2008;181:40-46.
  12. Smith K, Larive L, Romanelli F. Club drugs: methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride and gama-hydroxybutyrate. Am J Health-Syst Pharm. 2002;50(1):1067-1076.
  13. Hagemann C, Helland A, Spigset O, Espnes K, Ormstad K, et al. Ethanol and drug findings in women consulting a sexual assault center-associations with clinical characteristics and suspicions of drug-facilitated sexual assault. J Forensic Leg Med. 2013;20:777-784.
  14. Jones A, Holmgren A, Ahlner J. Toxicological analysis of blood and urine samples of victims of alleged sexual assault. J Clin Toxicol. 2012;50:555-561.

FOAMed Resources Part VIII: EMS/Prehospital

Authors: Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW Medical Center / Parkland Memorial Hospital)

The Prehospital environment is where emergency medicine begins. These providers are paramount in the initial stages of evaluation and management of critically ill patients. While most providers in the ED have medical or trauma rooms with adequate equipment and space, this is not the case for EMS. The stress, situation, and patient all present significant challenges to care providers.

The following list is comprised of blogs/podcasts with great education pearls, valid content, and major impact on EM, with clear reference citation. If you have found other great resources, please mention them in the comments below!

 

  1. https://prehospitalmed.com/tag/minh-le-cong/

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Prehospital and Retrieval Medicine (PHARM) from Minh Le Cong is a fantastic prehospital resource with podcast and blog. Posts center on transport/retrieval medicine, airway, sedation, and prehospital critical care. This resource is a must for those with interest in airway, sedation, and EMS. Each podcast and blog post is well researched, providing succinct keys to success.

 

  1. http://emcrit.org/?s=prehospital

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Scott Weingart’s blog and podcast contain several posts on cutting edge prehospital topics and procedures. REBOA, amputation care, hemostatic resuscitation, airway, sedation, hypothermia, and many more controversial topics are covered. These posts are well researched, with citations to the primary studies. Many of the prehospital podcasts contain interviews with experts in the field of prehospital medicine.

 

  1. http://www.fireemsblogs.com

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Fire EMS Blogs is a network of sites covering EMS, rescue, hazmat, command, and training from San Diego. A wide variety of blogs are available including discussion of interesting cases, ECG interpretation, life as an EMS provider, and evidence-based medicine.

 

  1. http://hemscriticalcare.com

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HEMS Critical Care from Philip Neuwirth brings together posts from blogs around the FOAMed universe pertaining to EMS/prehospital medicine into one place. If you’re interested in prehospital medicine and don’t have the time to regularly look through multiple online blogs, this resource does it for you.

 

  1. http://www.tamingthesru.com/hems-and-ems/

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Taming the SRU is an all-around great resource concerning emergency medicine. The podcast and blog’s prehospital page covers topics including out-of-hospital cardiac arrest, stroke care, trauma, and STEMI. Posts and podcasts are thorough, and each podcast has a summary in bullet format.

 

  1. http://emfirstblog.com

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EMFirst is dedicated to first responders and prehospital providers. Benjamin Ayd and Pratik Das cover classic and cutting edge EMS topics including TXA, REBOA, trauma, and ketamine. Not many posts are up now, but this site has a ton of potential.

 

  1. http://www.medicnerd.com

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Medic Nerd from founder Mike Stewart seeks to provide enjoyable and effective EMS education through videos and blog posts. Videos explain physical exam findings, IV drip rates, prehospital procedures, interesting cases, and controversial studies. For those studying for a qualifying exam, flashcards are also provided (http://www.medicnerd.com/critical-care-paramedic-review-flashcards/).

 

  1. http://prehospitalwisdom.blogspot.com

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Prehospital wisdom from Denver Paramedics is a blog with posts on EMS runs, interesting cases, and ECGs. Controversies in prehospital medicine are investigated, including C-spine protection, adenosine, distracting injury definition, and many others.

 

  1. http://resus.me/category/prehospital/

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RESUS.ME has a complete prehospital section with EMS procedures, literature, and conferences. Posts provide key prehospital literature updates in a format that illuminates the key takeaways.

 

  1. http://www.ems12lead.com/

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EMS 12-Lead is a leading resource for and by paramedics who are interested in all things EKG. Check out their posts to see EKG and cardiac rhythm analysis for patients in the field, and you can also submit your own case.

 

  1. http://www.scancrit.com

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SCANCRIT is a blog covering anesthesia, critical care, and emergency medicine, with a focus on the critically ill patient. Posts are written by two Scandinavian anesthesiologists, who evaluate in-hospital and out-of-hospital medicine. Recent posts have investigated GCS, VF, hemorrhage evaluation and management, brain bleeds, and ATLS updates.

Thanks for reading our look at EMS resources. Comment below with other helpful sites!

FOAMed Resources Part VII: Medical Education and Simulation

Authors: Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC) and Manpreet Singh, MD (@MPrizzleER – emDOCs.net Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)// Edited by: Alex Koyfman, MD (@EMHighAK)

Not all emergency physicians work in an academic center. However, all physicians teach, whether this includes nurses, technicians, residents, consultants, or medical students. Education is part of who we are. Whether by text, video, audio, experience, simulation, or a combination, we are constantly learning. Education is a core component of everyone who works in the medical field. A provider can have tremendous impact on the department through education of techs, nurses, students, residents, and other physicians.

Part VII of the FOAMed series will evaluate education and simulation resources. The following list is comprised of blogs/podcasts with great education pearls, valid contact, and major impact on EM, with clear reference citation. If you have found other great resources, please mention them in the comments below!

 

  1. http://lifeinthefastlane.com/ed-registrars-guide-to-clinical-teaching/

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When it comes to clinical teaching, LIFTL offers a tremendous guide with references, an approach to teaching, and overview of different types of learners and teaching methods. This is a great place to start.

 

  1. https://flippedemclassroom.wordpress.com

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FlippedEM Classroom provides educators with a virtual platform for core knowledge. The site also contains a link (https://flippedemclassroom.wordpress.com/12-tips/) with tips to teaching and using educational resources, along with links to the CDEM curriculum. The tips page covers multimedia use, forming objectives, segment lessons, quizzes, classroom discussion, providing feedback, using scripts, and more.

 

  1. http://emblog.mayo.edu/?s=how+to+succeed+as+a+teacher

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The Mayo Clinic EMBlog offers a fantastic video series on teaching in emergency medicine. Dustin Leigh and Daniel Cabrera cover preparing to teach, asking questions, goal setting, learning, feedback, and skills. Overall this series is a tremendous resource.

 

  1. https://cdemcurriculum.com

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The CDEM Curriculum site serves as a resource for medical students and clerkship directors. This is great for EM clerkship directors, as content focuses on third year, fourth year, and peds EM students. Videos, diagrams, and curriculum notes are provided. This resource is extremely helpful for those forming a curriculum. The EM Stud Podcast offers medical students an understanding of the application process and how to excel in EM.

 

  1. https://www.aliem.com/category/non-clinical/med-education/ and https://www.aliem.com/category/non-clinical/simulation/

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Academic Life in Emergency Medicine is designed for educators of all levels. The blog contains material not only on clinical content (learning capsules, AIR series, Tricks of the Trade, Diagnosis on Sight), but many non-clinical topics including simulation and educational techniques. The IDEA series provides material on cases, simulation, and procedural education, while the MEdIC series addresses challenging educational/learner scenarios.

 

  1. https://soundcloud.com/teachingcoursepodcast

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The Teaching Course Podcast comes from the originators of the Teaching Course. It is dedicated to providing educators with techniques and inspiration to teach those of all levels. Episodes including developing a network, asking great questions, designing a lecture or talk, the flipped classroom, and feedback.

 

  1. https://cordemblog.wordpress.com

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This blog from the Council of Residency Directors in Emergency Medicine provides posts on bedside teaching, publishing research, developing curriculum, remediation, asynchronous teaching, interviews, and procedural teaching. Each post is well-written and researched, providing succinct educational tips.

 

  1. https://emsimcases.com

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EM Sim Cases provides tremendous simulation cases, each with educational objectives and goals. Cases are broken down into subject matter (cardiology, toxicology, OB, GI, trauma, etc.), with each containing downloadable content covering a case vignette, objectives, required equipment, study results (ECG, Xray, labs), timing, key actions, teaching points, and references. Authors also provide tips on mannequin use. This is a premier simulation resource for emergency medicine.

 

  1. http://thesimtech.com/av-stimuli/

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The Sim Tech site provides downloadable simulation cases, all with objectives, key actions, and learning points. Videos on moulage, or applying mock injuries to add realism, are an important feature of this website. The blog also contains examples images, ECGs, ultrasound videos, Xrays, and injury photos.

 

  1. http://thesgem.com

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The Skeptics’ Guide to EM (SGEM) uses social media to disseminate the most current literature. This evidence-based medicine resources provides succinct literature reviews of studies that will affect your daily practice of medicine. The goal of SGEM is to shorten knowledge translation from 10 years to less than one year. Several sections include “Hot of the Press”, “Paper in a Pic”, “Xtra”, and “Journal Club.” This is a great blog for those interested in constructing an EBM curriculum or journal clubs.

 

  1. http://stemlynsblog.org

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St. Emlyn’s EM contains content ranging from core topics to educational techniques and theories, and the site aims at improving EM through free and open access education. The topic page links to educational posts, and the journal club category contains gold nuggets on how to conduct a journal club, posts on literature search/question design, and appraisal checklists. Sample Journal Clubs are provided, with links to the separate studies. A great place to start includes the educational theories page (http://stemlynsblog.org/educational-theories-you-must-know-st-emlyns/), which offers a foundation for educators.

 

  1. http://canadiem.org

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CanadiEM aims to improve emergency care in Canada and around the world by building an online community of practice for healthcare practitioners and providing them with high quality, freely available educational resources. Content ranges from clinical topics and flashcards to educational skills and simulation (http://canadiem.org/category/all/education-quality-improvement/fei/). Mentorship tips, student resources (CaRMS), and even department flow hacks make for an amazing resource.

 

  1. https://first10em.com

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First 10 EM makes the list again. This blog from Justin Morgenstern provides monthly literature updates, great blog posts on managing sick patients, and videos. The simulation page contains simulation resources, guidelines, and debriefing information.

 

  1. http://scanfoam.org

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scanFOAM contains a blog that asks experts in simulation “How I Sim.” This is a great series investigating how people in medical education look at teaching, simulation, debriefing, and simulation in the future. Several other lectures provide theories and tips on simulation and education.

 

  1. https://icenetblog.royalcollege.ca and https://icenetblog.royalcollege.ca/category/keylime/

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This blog and podcast (KeyLIME) provide great educational and simulation resources. The blog has posts on educational literature, educational design, simulation, technology, educational leadership, and scholarship. The podcast addresses common educational issues such as resident evaluation, duty hours, feedback, competency, running a clerkship, and much more.

 

That’s it for education and simulation resources. Please comment if you have found other blogs/podcasts providing great educational content.

FOAMed Resources Part VI: The Fundamentals

Author: Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC) // Edited by: Alex Koyfman, MD (@EMHighAK)

Now on to Part VI: The Fundamentals. This post evaluates EM core knowledge. Just like in sports, medicine is all about a strong foundation. Our prior posts have evaluated resources including ECG, pediatrics, toxicology, US, and critical care.

From day 1 of medical school, we work to develop a strong core and foundation for future learning. No matter how long you have been practicing, every provider can learn something new. A strong foundation allows for further expansion and growth.

The following list is comprised of blogs/podcasts chosen based on educational value, applicability to EM, content validity, and appropriate citation; however, the numbers do not indicate a rating. As before, if you have like other resources and have found them useful, comment below. Thanks for reading!

 

  1. https://flippedemclassroom.wordpress.com

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Flipped EM Classroom is a great place to start for learners and residents. This online curriculum from Clerkship Directors in EM contains videos and links on the approach to common complaints in EM, as well as specific diseases. Each page you select provides several videos and show notes. This resource is indispensable for those starting their career in EM.

 

  1. http://coreem.net

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CORE EM is a great resource from NYU and Anand Swaminathan, “dedicated to bringing Emergency Providers all things core content Emergency Medicine. In the spirit of Emergency Medicine our content is available to anyone, anywhere, anytime.” CORE EM fulfills this promise and much more. This resource has a podcast with over 60 episodes, blog posts covering key topics, procedural videos, and journal review with breakdown of EM literature.

 

  1. http://embasic.org

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EM BASIC from Steve Carroll is for predominantly medical students and interns learning the foundational skills of EM. This podcasts begins with a chief complaint, from which the host covers vital components of the history, physical examination, workup, and treatment. Shownotes in pdf format are also provided.

 

  1. https://emergencymedicinecases.com

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Emergency Medicine Cases from Anton Helman is a free medical education podcast, blog, and website which targets physicians, residents, students, nurses, and paramedics. Starting in 2010, this podcast now has over 1.5 million downloads. This resource covers a topic with at least 2 experts, often in a case-based discussion. Each podcast is accompanied by in-depth notes for further learning. The site also has a best evidence section, Best Case Ever, CritCases, Journal Jam, and EM Cases Digest.

 

  1. http://canadiem.org/crackcast/ and http://canadiem.org

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Crack Cast on CanadiEM is built on Core Rosen’s Medical Knowledge with a podcast covering the basic content of each chapter of Rosen’s tremendous textbook. Shownotes with key points are provided for each podcast. CanadiEM is also a great resource, especially their “Boring Cards,” which are quick review points on common board and clinical topics.

 

  1. https://emin5.com

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EM in 5 is a great resource for those of you with 5 minutes or less to learn about a key topic in EM. Topics include airway, cardiac, neurology, OB, ophthalmology, derm, orthopedics, ECG, education, EMS, endocrine, pediatric, respiratory, ENT, urology, trauma, US, ID, toxicology, and others.

 

  1. http://foamcast.org

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FOAMcast from Jeremy Faust and Lauren Westafer is a great resource that brings together FOAMed and Core Content into monthly, 15-20 minute podcasts with shownotes. Each post contains some of the most up to date FOAMed from around the world. Rosh Review questions on the topic at the end of each podcast/post provide further education.

 

  1. http://blog.clinicalmonster.com

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This blog from the residents of Kings County Hospital ED provides evidence-based medicine reviews, interesting cases, ECGs, images, toxicology, pediatric, and board review topics. They also have lectures from Grand Rounds. For those with only a couple of minutes at a time to learn, this site contains succinct educational pearls on core topics.

 

  1. http://www.rcemfoamed.co.uk

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RCEM FOAMed Network is a virtual learning network that produces a monthly literature review podcast on new literature, guideline review podcast, podcast summaries, interviews with topic experts, and a blog with educational points. The content is easily searchable and categorized by subject matter.

 

  1. https://first10em.com

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First 10 EM is a resource from Justin Morgenstern devoted to understanding key actions in the first 10 minutes of management and resuscitation of critically ill patients. Posts take the form of scenarios, allowing readers and learners to visualize the case and necessary steps. This site contains procedural and examination videos, handouts, simulation resources, and articles of the month (a look at key literature in EM).

 

  1. http://emupdates.com

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Emergency Medicine Updates from Reuben Strayer originated from flashcards. These functioned as summaries of Rosen’s Emergency Medicine. Over 1410 cards were posted, which has grown over time. These searchable flashcards are great to have while on shift or if studying a short period of time. The blog also contains tremendous posts on common ED issues.

 

  1. http://stemlynsblog.org/about/

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St. Emlyn’s is a collection of FOAMed aimed at improving the practice of EM. The site contains a virtual hospital with cases, Best Bets for evidence-based reviews, and great blog posts. The podcast covers key FOAMed and foundational topics in EM.

 

  1. http://www.heftemcast.co.uk

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HEFT EMCAST is from the Heart of England’s Foundation Trust’s ED. The site produces evidence-based updates and posts with a podcast. The ED Knowledge Nuggets are a great way to obtain a succinct review of EM topics.

 

  1. https://www.aliem.com/aliem-approved-instructional-resources-air-series/

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ALiEM AIR Certified Series provides high quality blog posts and podcasts from the FOAMed universe on key content. The ALiEM selection board evaluates and selects the content based on a scoring tool. Thus far, modules include Cardiology, Respiratory, GU/Renal, OBGYN, environmental, Neurology, Cutaneous, and orthopedics. This is a great resource, as each module takes anywhere from 1 to 6 hours to complete and contains some of the best content in one place.

 

  1. http://rebelem.com

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R.E.B.E.L. EM covers a range of topics, mainly focusing on EBM, ECGs, and inservice/board review topics. Originally from Salim Rezaie, this resource is packed full of learning with a podcast (REBEL Cast) and review topics (REBEL Reviews). The blog content is succinct and easy to follow in bullet format, always providing a “Clinical Bottom Line” with important points. Each post also links to other resources on the same topic.

 

  1. http://www.emdocs.net

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Yes, I am a little biased, but emDocs.net brings you great content based on literature updates and core knowledge in the form of three to five weekly posts. This resource covers practice updates, interesting cases, junior knowledge (1-2 page write ups on common ED entities), and other great FOAMed resources (Peds EM Morsels, R.E.B.E.L. EM, and CORE EM). The searchable blog provides succinct reviews on many ED conditions.

Just like last week’s critical care resources, we sought to bring you the top educational resources for foundational development.  Thanks for reading, and stay tuned for next week’s resource list on educational and simulation resources.

FOAMed Resource Series Part V: Critical Care

Author: Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC) // Editor: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW Medical Center / Parkland Memorial Hospital)

Critical care is an essential part of emergency medicine. Many of us in EM love the initial resuscitation and management of patients who require immediate, life-saving care.  Every patient deserves our best, and emergency providers often need to make decisions within seconds that can drastically change management.

FOAMed has demonstrated the ability to improve knowledge translation, allowing us access to the most up to date literature. Today’s FOAMed resource post will evaluate critical care. Prior parts of the series have evaluated ECG, ultrasound, pediatrics, and toxicology. For more information, please see these prior posts:

ECG: http://www.emdocs.net/foamed-resource-series-part-ecg/

US: http://www.emdocs.net/foamed-resource-series-part-ii-ultrasound/

Pediatrics: http://www.emdocs.net/foamed-resource-series-part-iii-pediatrics/

Toxicology: http://www.emdocs.net/foamed-resource-series-part-iv-toxicology/

This list of critical care resources by no means covers all of the available FOAMed critical care blogs or podcasts. The following list is comprised of blogs/podcasts with the best educational pearls, valid content, and EM clinical impact, with appropriate references. Only currently-active sites are listed. If you have found other helpful resources, please mention them in the comments below.

 

  1. http://emcrit.org and http://emcrit.org/category/pulmcrit/

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EMCrit is now a conglomeration of the original critical care blog/podcast EMCrit by Dr. Scott Weingart with PulmCrit (Dr. Josh Farkas) and EMNerd (Dr. Rory Spiegel). This resource “brings the best-evidence based information from the fields of critical care, resuscitation, and trauma and translate it for bedside use in the ED and ICU.” This is one of the best critical care resources available, with a 15-30 minute podcast every 2 weeks, along with posts and literature updates. The site has procedural videos that are second-to-none on airway management and central line insertion. PulmCrit and EMNerd provide key reviews of controversial topics and must-know studies for the EM provider. This is an essential resource for critical care and emergency providers.

 

  1. http://intensivecarenetwork.com

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The Intensive Care Network (ICN) was developed to “educate, link, and stimulate healthcare individuals involved in critical care.” Oli Flower and Roger Harris are two of the primary team leaders, and the site provides podcasts (searchable by subject, system, and specialty), videos, and a blog. Other resources include clinical cases, best evidence, radiology, ultrasound, and simulation cases.

 

  1. http://maryland.ccproject.com

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The Maryland CC Project comes from the University of Maryland Critical Care Fellows dating back to 2013. This resource provides almost weekly lectures and videos, all with an outline and show notes with each post. The site includes clinical pearls, cases, and core content lectures. Overall, this is an amazing learning resource for learners of all levels.

 

  1. http://pulmccm.org/main/

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PulmCCM first launched in 2011 to improve flow of information in pulmonary and critical care medicine. The site has several areas including “Everything Good” literature review with online journal club, “Real-World Boards” with a free place for board review questions and simulations, PulmCCM Journal which is an online peer-reviewed journal, and a library chock-full of review articles and guidelines. For those seeking a quick review of a topic, this resource is extremely helpful.

 

  1. http://lifeinthefastlane.com/ccc/

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LIFTL’s Critical Care Compendium is a collection of pages covering critical care core topics and current controversies. There are over 1650 entries, with contributors consistently updating pages. The page contains links to hundreds of topics, along with ICU Mind Maps, Critical Care Drug Manual, ECG library, questions, and fellowship overview.  A list of critical care textbooks and other FOAM resources is provided as well. This resource is an absolute must.

 

  1. http://resus.me

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RESUS.ME, or Resuscitation Medicine Education, is a blog covering acute medicine, critical care, pediatrics, trauma, ultrasound, and pharmacology. It contains key lectures from world-renown conferences as well.

 

  1. http://criticalcarereviews.com

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Critical Care Reviews is a free resource from Rob Mac Sweeney with a goal of providing a structured content in the form of open access articles. This site includes journal watch, weekly newsletter, podcast, and critical care book filled with content and the most up to date literature. You can sign up for a free, weekly email that contains critical care literature from key journals. A “Hot Articles” section contains articles chosen as most noteworthy since 2011.

 

  1. https://thinkingcriticalcare.com

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Thinking Critical Care is a blog from Philippe Rola in Canada. The site contains weekly posts aimed at common and controversial ICU topics, with a goal of “blending good evidence, physiology, common sense, and applying it at the bedside!” Guest contributors are a large component of this resource.

 

  1. http://icmwk.com

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This blog from Justin Mandeville is an amazing resource for those wanting a background on common ICU conditions. The site is broken down into categories. “Emergencies” contains algorithms for management of ICU disease, “Guidelines” has links to original guideline manuscripts, and “Key Papers” contains papers broken by subject. The “New to ICU” contains information essential for medical students and residents starting an ICU rotation, with general overview, an approach to evaluation and management, guidelines, and core papers.

 

  1. https://www.aliem.com/2016/air-pro-critical-care-part-1/ and https://www.aliem.com/2016/air-pro-critical-care-part-2-module/

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Academic Life in EM is a powerhouse for FOAMed. In particular, their ALiEM AIR-Pro Series is an awesome resource, as is their original AIR series. These are selected posts from blogs around the world based on certain topics. You’ll find posts in the ALiEM AIR-Pro Series from many of the blogs on this list. ALiEM has done the work for you, finding some of the highest quality posts from around the globe.

 

  1. http://theresusroom.co.uk/category/podcasts/september-2016

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The Resus Room by Simon Laing is a blog and podcast that provides evidence-based medicine updates and guidelines on EM and critical care content. The site contains a guidelines section with videos for equipment. Each month a summary of key literature updates is provided, along with infographic summaries.

 

  1. http://www.derangedphysiology.com/main/

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Deranged Physiology is a collection of posts evaluating ICU medicine and human physiology. The site actually started as notes from the originator detailing physiology and critical care medicine. The blog also contains cases with approach to evaluation and management, list of key chapters from textbooks, questions, and test resources for those studying for critical care boards.

 

  1. http://intensiveblog.com

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INTENSIVE is a critical care educational blog for physicians and those in training from the Alfred ICU in Australia. The site contains many great resources. “Labs and Lytes” contains case-based learning, a journal club that evaluates key studies, ECMO resources, ultrasound topics (mainly based on echocardiogram), simulation exercises, and links to many other great sites. The resource page in particular contains great self-directed learning exercises, along with examination prep.

 

  1. http://www.humanizingintensivecare.com

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The IC-HU Project is one of the only resources available aimed at improving care for patients, families, and critical care providers. Multiple posts are provided weekly on patient stories, some heart-breaking and others acting as shining beacons for humanity in medicine. This forum allows all members of the care team to share thoughts and emotions on the path to healing.

 

  1. http://edecmo.org

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EDECMO is a blog/podcast by Dr. Joe Bellezo, Dr. Zack Shinar, and Dr. Scott Weingart with a goal to increase knowledge of Extra-Corporeal Life Support (ECLS) in the ED and demonstrate how cardiopulmonary bypass can be completed. Each podcast and accompanying blog post takes the use through updates in resuscitation and ECMO uses in the ED.

 

  1. http://www.thebottomline.org.uk

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The Bottom Line is a collection of landmark critical care papers, each summarized in a standardized format with a “bottom line” at the end with key points. Each paper and review is consistently evaluated in a reliable manner. Topics are broken into specialty and system. The site also contains a blog that lists updates in conferences, editorials, and websites. For those who love to keep up to date or gain an evidence-based overview of the classic literature, this resource is of tremendous value.

 

Thanks for reading and making it to the end. As you can see, there is a great deal of critical care FOAMed. If you have found other useful sites, please let us know!