Appalachian Trail hikers\u27 ability to recognize Lyme disease by visual stimulus photographs.

BACKGROUND: Lyme disease is the most common vector-borne infectious disease in North America. With nearly 2,500 Appalachian Trail (AT) hikers entering the endemic area for as long as 6 months, exposure to the disease is likely. The characteristic exanthem of erythema migrans (EM) should be a trigger for seeking medical treatment, and its recognition in this relatively isolated environment is important. OBJECTIVE: The purpose of this study was to determine the ability of AT hikers to identify EM, the exanthem of Lyme disease. METHODS: Hikers were administered a photographic stimulus in this Internal Review Board-approved pilot study. Historical hiking data, basic demographics, and self-reported treatment and diagnosis were collected. RESULTS: In all, 379 responses were collected by 4 researchers at 3 geographically separate locations at or proximate to the AT from June 2011 to May 2012. Fifty-four percent of respondents (206 of 379) were able to recognize the photographs of EM/Lyme disease; 46% could not. Of those who did recognize EM, 23 (6%) had seen it either on themselves or on another hiker while on the AT. A total of 37 hikers stated that they had been diagnosed with Lyme disease while hiking, and of these, 89% were treated with antibiotics. Thirteen of these 37 hikers (35%) diagnosed with Lyme disease had visualized an embedded tick. Nine percent of all respondents reported they had been diagnosed with Lyme disease by a healthcare practitioner, whether from EM, symptomatology, or by titer. CONCLUSIONS: This study suggests that hikers are poorly able to recognize the characteristic exanthem of Lyme disease but have a high exposure risk

Endotracheal Intubation in the Pharmaceutical-Poisoned Patient: a Narrative Review of the Literature.

INTRODUCTION: Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated. DISCUSSION: A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ( toxicology OR poisons OR drug overdose OR poisoning ) AND ( intubation, intratracheal OR intubation, endotracheal OR airway management OR respiration, artificial ). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the Similar Articles feature of PubMed, along with reviewing articles\u27 reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm. CONCLUSIONS: ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations

Post-traumatic left anterior descending artery dissection.

BACKGROUND: Patients who experience trauma, particularly thoracic trauma, may be at risk for missed cardiac injury. CASE REPORT: We present a case of a 36-year-old male presenting to the Emergency Department (ED) as a trauma after a high-speed motor vehicle crash. After computed tomography (CT) scans revealed a right hemopneumothorax and multiple orthopedic injuries, the patient was admitted to the trauma neuroscience intensive care unit (TNICU), where telemetry revealed ST elevations. An electrocardiogram (EKG) was performed and he was noted to have an acute anterolateral STEMI. The patient was intubated and underwent a cardiac catheterization that revealed a dissection of his left anterior descending (LAD) coronary artery and a stent was successfully placed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In cases of trauma patients who can\u27t report the symptoms they are experiencing, or have distracting injury, there is the potential for a missed diagnosis of either significant cardiac injury and/or myocardial infarction (MI). Emergency physicians should be aware that an EKG is recommended in the ED evaluation of a trauma patient, especially those with thoracic trauma

Loperamide-Induced Torsades de Pointes: A Case Series

Background: Loperamide (Imodium™) is an antidiarrheal opioid acting at the μ receptor agonist in high concentrations. Due to the US opioid epidemic, loperamide abuse and ensuing life-threatening toxicity have surfaced. Hypothesis: The timing and duration of Torsades de Pointes (TdP) from loperamide toxicity is unpredictable and should be heeded with caution, even in asymptomatic patients and drug discontinuance. Methods: Two patients presenting with life-threatening TdP requiring lengthy hospital admissions for confirmed loperamide toxicity are discussed. Patient data were retrieved from the hospital’s EMR system

Emergency Medicine Resident Self-Assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric.

PURPOSE: The quality of clinical teaching in the emergency department from the students\u27 perspective has not been previously described in the literature. Our goals were to assess senior residents\u27 teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing. METHODS: After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician\u27s assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents\u27 teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents\u27 teaching, while residents self-assessed their performance. The participants\u27 demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants\u27 mean scores. FINDINGS: Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P \u3c 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents\u27 evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students\u27 evaluations of the residents\u27 teaching skills by residents\u27 gender did not reveal gender differences. IMPLICATIONS: MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents\u27 teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula