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Thanks to Bing, Dr. Okuda and Dr. Strother for a wonderful day of sim cases this week. Special thanks to all who had to tolerate my acting.

A few questions came up during the discussions, and, I’ve been trying to research with limited success.

The first question concerned antibiotics for heat illness. Certainly in ambiguous cases, where there is altered mental status with moderately high temperature, antibiotic coverage is mandated. But in our case, of the athlete on a hot day? It was asserted that the heat stress leads to gut flora dissemination, and antibiotics are warranted. But I could find no reference for this, and my usual sources are silent on the issue of prophylactic antibiotics.

The second question revolved around safety factors for emergent sedation. Specifically, I wondered if the risk of aspiration in emergent procedural sedation had been quantified in adults. It turns out there’s a lot of opinion on this matter, but not a lot of data. More below:

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Please join us this week for Emergency Medicine Departmental Conference, in the 8th floor conference room at Elmhurst Hospital.

The day’s activities are planned as follows:

8am Research Lecture Series — Non-Experimental Designs — Dr. Lynne Richardson
9am Journal Club — Dr. Shen (see below for articles)
10am Critical Care Lecture — Dr. Scott Weingart
11am Trauma Series — Dr. Fasina
12pm M&M — Dr. Bentley
1pm Senior Leadership Seminar with Dr. Stuart Kessler (optional)

Lunch will be served. Please note the early start time.

Residents: The following journal  club articles are accessible by entering the login and password from my email:

Primary discussion: Ohlmann P, et al. Diagnostic and prognostic value of circulating D-Dimers in patients with acute aortic dissection. Crit Care Med. 2006 May;34(5):1358-64. PMID: 16557157.

Clinical background: Sodeck G et al. D-dimer in ruling out acute aortic dissection: a systematic review and prospective cohort study. Eur Heart J. 2007 Dec;28(24):3067-75. PMID: 17986466.

Optional additional clinical background from JAMA’s Rational Clinical Exam Series: Klompas M. Does This Patient Have an Acute Thoracic Aortic Dissection? JAMA. 2002;287(17):2262-2272. PMID: 11980527.

Please join us for Simulation Sessions this Wednesday morning, July 30, at Mount Sinai.

Half the residency will participate in Sim sessions from 9 am to noon, and the other half will be involved from noon to 3 PM. Please see my email(s) about specific group assignments. The overview is below:

• – Group A (Mostly Interns) — Peds Sim at 9 AM in the ED Conference Room, Adult Sim at 10:30 AM in Hatch
• – Group B (Mostly PGY-3) — Adult Sim at 9 AM in Hatch, Peds Sim at 10:30 AM in ED Conference Room
• – Group C (Mostly seniors) — Peds at Noon in the ED Conference Room , Adult Sim at 1:30 PM in Hatch
• – Group D (Mostly PGY-2)  — Adult Sim at Noon in Hatch, Peds Sim at 1:30 PM in the ED Conference Room

Additionally, lunch will be served outside Hatch auditorium around 11:30.

Guest blogger Marisa has written up an expert review of our recent Journal Club discussion of clevidipine, as presented by Dr. Joshua Kosowsky of Brigham & Women’s Hospital:

Just last week, Clevidipine (Cleviprex) was approved by the FDA, making it the first new IV drug approved for high blood pressure in the past 10 years. Dr Joshua Kosowsky introduced us to Clevidipine when he discussed the VELOCITY (The evaluation of the effect of ultra-short-acting clevidipine in the treatment of patients with severe hypertension) trial as published in the June 2008 Annals of Emergency Medicine (PMID: 18534716), “Clevidipine, an Intravenous Dihydropyridine Calcium Channel Blocker, Is Safe and Effective for the Treatment of Patients With Acute Severe Hypertension” (residents: the PDF of this journal is online). More below:

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A number of you have asked for a recap on Dr. Hollander’s approach to treating NSTE ACS. You can download the audio from his talk on the Conference website. I’ve gone through it again and have some citations below. His talk is indeed guideline-based (all from the ACC/AHA 2007 NSTEMI / UA guidelines — familiarize yourself with their classes of recommendations and their grading the level of evidence) but also this portion of his talk was explicitly featured in a pharmaceutical-industry sponsored event. So, as always, approach this with a skeptical mind, and please share your findings in the comments section:

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I wanted to add some pearls from Dr. Strayer on Anita’s case from today:

* The literature and expert consensus have evolved over the past decade to favor anticoagulation for below the knee (distal or calf) DVTs. The classic teaching has been that distal DVTs are benign, so ultrasonographers often do not routinely evaluate the calf veins. Because this is no longer thought to be true, consider requesting calf vein assessment if you are suspicious.

* The finding of superficial venous thrombosis warrants a search for DVT. The treatment of superficial vein thrombosis is controversial and ranges from NSAIDs to compression stockings to anticoagulation. There is no consensus on treatment–the key EM issue is to rule out DVT.

* Patients who are moderate or high risk for DVT should be anticoagulated while awaiting ultrasound. If a DVT precipitant is not clear, consider calling hematology to inquire about hypercoaguable state labs to send before administering heparin.

* Many patients with DVT are optimally managed as an outpatient with daily LMWH shots. Visiting nursing services can help.

* Our interface with outside referring physicians is complex, and navigating their requests is fraught with pitfalls. If you don’t agree with their plan, the best course of action is usually an attempt to harmonize over the phone.

Wise words.

So, lots of big things were discussed today, but I’m going to focus on Dr. Judd Hollander’s talk, as it was crammed with insight on a very common problem – achieving disposition on the 8 million patients we seen annually with chest pain (this is national, not just Sinai). Of these 8 million, 3 million are sent home and so we admit 60-65% of chest pain, of which only 15% have real disease… Cardiologists hate us for this, but is there an alternative? What’s the evidence behind what we do?

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Please join us for Emergency Medicine Department Conference this Wednesday, July 23rd. Conference will begin at 9 AM in Hatch auditorium, and will feature noted EM figures Drs. Judd Hollander and Joshua Kosowsky.

The day’s schedule is below:

9am Grand Rounds - Dr. Judd Hollander
11am Grand Rounds - Dr. Joshua Kosowsky
12pm EM / Neurology Joint Stroke Conference - Dr. Colum Avery
1pm M&M - Dr. Anita Vashi

Lunch will be served.

On Tuesday night, July 22nd, Mount Sinai will be hosting an remarkable event featuring three prominent researchers in EM, discussing study design and the impact of research on our field.

The forum will be in Hatch Auditorium in the Guggenheim Pavilion at Mount Sinai. The dinner begins at 6:30 and the ‘journal club’ starts an hour later.

The speakers and their paper topics are listed below:

Judd E. Hollander, MD, Professor, Department of Emergency Medicine at the University of Pennsylvania

• Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial. JAMA 2004;292:45-54

Lynne D. Richardson, MD,  Vice Chair, Department of Emergency Medicine at Mount Sinai School of Medicine

• Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest. N Engl J Med 2004;351:637-46.

Joshua M. Kosowsky, MD, Department of Emergency Medicine, Brigham & Women’s Hospital

• Clevidipine, an Intravenous Dihydropyridine Calcium Channel Blocker, Is Safe and Effective for the Treatment of Patients With Acute Severe Hypertension. Annals of Emergency Medicine, 2008 Jun 4 [in press].

Additionally, the speakers have agreed to be panelists for a discussion on the ethics of industry support and medical education.

Residents: To access the journal articles above, click on the links and enter the login and password in my email.

This is a great opportunity for New York City’s EM residents to come together, get to know each each other, and learn something.