No Sun in Sight Well, here it is - Memorial Day Weekend - and there is no sun in sight. How depressing. I was hoping for a fun weekend out in the park riding my bike and maybe getting in some photography. Now it is raining, and there is rain forecast for all weekend.

On a brighter note, I don't have to go in to clinic on Monday, because it is a holiday. I think this is the first holiday (besides Christmas) I've had off all year. I'm so excited. I'm probably going to sleep all day!!

So, now I'm on my Osteopathic Manipulative Medicine (OMM) rotation. It hasn't been nearly as bad as I thought it would be. The patients are mostly healthy, and only have a few musculoskeletal complaints. It's nice to see someone come in complaining of pain and leave feeling considerably better and to think, "I did that." It's a very empowering feeling.

In other news, I've been asked to work on an article for the EMRA web site about Osteopathic medical students and the choices we have to make in going into Emergency Medicine. Many of these are common to all Osteopathic medical students, but there are some differences. Right now, I'm in the data-collection phase and will hopefully open the paper soon. Of course, I also have to write a case report for the OMM rotation - I'd like to find some way to tie OMM to EM: Maybe, "The Use of Osteopathic Manipulative Treatment in Non-cardiac chest pain," or other such topic.

I've also been looking at internships/residencies recently (as always). I'm still looking to go up to the northeast - where I would like to end up eventually. I still have a favorite 1 or 2 programs I'd like to enter, but I've widened my search a bit. I now have a half-dozen or more other programs I could thrive in. Most of my criteria are met in each of these, and they have only one or two flaws (in my eyes), so I am willing to train there, if need be. So, now I have roughly 8 programs to apply to.
The internship search is stalled at 3 programs, however. Each of these are larger institutions with a few ACGME programs that also have AOA internships offered each year. So, the plan is to apply to one of these internships during the 2006 match and then apply to my EM programs during the 2007 match season.

Sure, that will extend my training to 4 years, but I think it will be worth it to insure that I can practice in any state in the United States in the end. I, like Matt M., am unwilling to completely sever my ties with the AOA at this time (although I think about just saying "F*** them" almost every day). I hope that in years to come, the AOA hierarchy comes more to the middle and is willing to discuss issues important to ALL members, not only those so ingrained in the osteopathic philosophy that they cannot see past their own nose. I'm hoping and praying for that day to come. Maybe we can all say a little prayer.  ¶ 7:14 AM 0 comments

  Great News!! I received word the other day that I was appointed to the Medical Student Council of the Emergency Medicine Residents Association (EMRA) as a regional coordinator for Texas, Arizona, Nevada, and New Mexico! I was so excited! I applied for this position a couple of months ago and have been waiting for news ever since.

Hooray for me!!

What does this mean? Well, basically I am now part of an organization dedicated to spreading the word about Emergency Medicine and coordinating the medical school interest groups in the above-mentioned states and providing them information about EM and EMRA. We also coordinate and organize the residency fair at the American College of Emergency Physicians Scientific Assembly in Washington, D.C. this September. Basically, we try to get as many residency programs to come and show their wares at the Scientific Assembly so the students can get a glimpse of what they are all about: what the program offers, the format of the program, patient population and volume, etc. We also encourage student research and increased education about EM topics in medical school curricula.

Check out the EMRA website for more information about what we do and what we are all about.

Ok, I'm done advertising for now. I just wanted to share the good news.  ¶ 8:22 AM 0 comments

  Patient Files: Volume 2 Patient: G.C.
Age: 57
Race: Caucasian
Date of Visit: 5/10/2005

History of Present Illness:

Mrs. G.C. is a 57 year old caucasian female presenting to the Urgent Care Clinic with complaint of a "roly poly" underneath the skin of her right forearm. She noted this has been present for the past 1-2 years, is not tender unless it is traumatized, and has slowly been growing in size since she first noticed it. It has not caused her any problems, but she would like it evaluated because of fears of malignancy.

She also complains of right neck, shoulder and arm pain on and off for the past year after lifting heavy boxes at school, where she is a teacher. She has taken ibuprofen for pain relief, which has been effective, for the most part, and brings this up only because it has begun to bother her again in the past 2 days. She denies any weakness, paresthesias, change in temperature, or numbness of the affected extremity - only pain.

PMH/PSH:

Mrs. G.C. has hypertension, which is currently treated with a beta blocker and a thiazide diuretic, and hyperlipidemia, which is treated with a "statin."

Family History:

Noncontributory

Allergies:

NKDA

Medications:

As noted above, she takes a beta blocker and thiazide diuretic for hypertension, a "statin" for hyperlipidemia, and occasionally takes ibuprofen for pain relief.

Social History:

She is married with grown children. She lives in the surrounding area in a house with her husband. She is a teacher at a local junior high school. She denies tobacco/EtOH/drug use, but admits to smoking when she was younger.

Physical Exam:

Mrs. G.C. is a well developed and well nourished middle aged female. She is in no acute distress.

Her HEENT, CV/Pulmonary, and Abdominal exam are negative. Breast and GU exams are deferred.

Upon exam of her right upper extremity, a 3x2cm soft, mobile mass is appreciated on the dorsal radial surface of her wrist. It is nontender to palpation, is not hot to the touch, is not erythematous, and does not demonstrate fluctuance or a cystic character. There are no apparent overlying skin structure abnormalities and functional testing of her right wrist and elbow are normal. Muscle strength is 5/5 in the right upper extremity and there is no abnormality in the neurovascular exam.

Examination of her neck and right shoulder reveal decreased PROM and AROM of the cervical spine and right shoulder joint. There are multiple tenderpoints identified in the shoulder and cervical musculature. Again, strength and neurovascular examinations are WNL.

Differential Diagnosis:

"Roly Poly:" lipoma, ganglion cyst, epidermoid cyst, tenosynovitis, traumatic injury, arthritic changes, soft tissue sarcoma

Neck/Shoulder pain: arthritis, traumatic injury, cervical disc herniation with nerve impingement, somatic dysfunction NOS, tenosynovitis

Diagnosis and Treatment:

After consultation with the patient, a diagnosis of lipoma is considered most likely. The decision is made to observe this for now, since it is not causing a problem at this time. The patient has an appointment with her PCP in 1 month and is instructed to discuss this finding with her PCP at that time and have the PCP monitor for growth or change in character. We discussed the possible future need for biopsy or excision of this mass - the patient understood and agreed with the above plan.

Regarding the neck and shoulder pain, the patient was offered the following: stretching exercises, continued use of NSAIDS, physical therapy referral and NSAID therapy, trigger point injection and NSAIDS, or observation. The patient decided upon a trigger point injection, noting she had one previously and received relief afterwards. The patient was counselled regarding the risks and benefits of trigger point injection, to which she agreed and still desired treatment.

After the trigger point site was identified, it was cleansed with betadine and alcohol. The site was topically anesthetized with ethyl chloride and 1% lidocaine was infiltrated into the area to provide deeper anesthesia. Afterwards, a 25g 1.5 inch needle was introduced into the trigger area. The plunger was withdrawn and a few bubbles were noted in the syringe. The needle was withdrawn approximately 1 cm and 2cc of a marcaine/kenalog solution were injected into the trigger point and the surrounding area. The needle was withdrawn and the injection site was covered with a bandaid.

The patient was observed for 15 minutes as per clinic policy after an injection and the patient was released home with samples of an NSAID for pain. She was told to return if symptoms did not improve or worsened.

Approximately 30 minutes later, the patient returned to the clinic complaining of shortness of breath and chest pain. She stated this had been progressing over the past 20 minutes until she felt she could not breathe. Her SaO2 was 97% on room air, her respiratory rate was 28-30, pulse 110, and she was in mild respiratory distress. Lung examination revealed slightly diminshed breath sounds on the right. Cardiac exam was normal aside from tachycardia. A stat chest xray was ordered to rule out pneumothorax and the patient was placed on O2 at 2L/min via nasal cannula.

The xray showed a 10-15% pneumothorax in the right apex. The patient was sent to the Emergency Department for treatment.

In the ED, she was observed and a repeat CXR in 6 hours showed no increase in pneumothorax size. The patient was admitted overnight for observation and a repeat CXR in the morning. The next morning, she was released to home, feeling better.

Discussion:

This case illustrates that any procedure has attendant risks, for which we must always be watchful. A seemingly benign procedure performed a thousand times without problems by this particular physician produced a harmful (and potentially deadly) complication. Fortunately, she recovered well and had only a little morbidity.

Pneumothorax (PTX) is air in the potential space between the parietal and visceral pleura. This space is usually occupied only by a few milliliters of serous fluid to lubricate the layers as they move against each other during respiration. PTX has many causes: penetrating wounds, ruptured emphysematous bullae, fractured ribs, etc. Many times the cause is unknown, as PTX occurs in seemingly healthy young people (usually males) in a familial pattern, frequently causing a tension PTX. This is a condition in which air is extruded into the pleural space through a one-way valve and cannot escape. As a result, the intrapleural pressure increases and the lung tissue and mediastinal contents are forced into the contralateral hemithorax, reducing blood return to the right heart and thereby reducing overall cardiac output.

The signs and symptoms of PTX include dyspnea, hypoxia, tachypnea, anxiety, decreased breath sounds, decreased SaO2, and pleuritic chest pain. These symptoms may vary depending on the size of the PTX. Tension PTX may present with decreased breath sounds, tracheal shift away from the midline, and hypotension or shock. The patient may or may not be conscious.

PTX is diagnosed by chest xray. If the PTX is small, an expiratory film may be required to see the air in the pleural space. Diagnosis can also be made by chest CT, but this is much more expensive. Tension PTX is a clinical diagnosis, since the patient will most likely be dead before a chest xray can be performed.

Treatment of PTX depends on the type and size. Tension PTX is a medical emergency requiring immediate action. An 16 or 18ga angiocath is inserted into the pleural cavity in the second intercostal space in the midclavicular line to immediately relieve the pressure and convert the closed PTX into an open one. A tube thoracostomy is then inserted and set to water seal and wall suction. Non-tension PTX are treated much the same way if they are significant, with the exception of the angiocath insertion. If the PTX is small and non-progressing, the patient may be observed to insure resolution and discharged home.

In patients with hereditary bullous disease of the lungs, surgery to remove the bullous areas of lung must sometimes be performed (lobectomy or segmental resection) to prevent recurrent PTX.

Follow-Up:

Upon talking with Mrs. G.C. after her discharge, she said she was feeling much better - her dyspnea had resolved and she no longer had any chest pain. Best of all, she said her shoulder no longer hurt as well!  ¶ 9:28 PM 0 comments