EM Evaluation Reflection: For my Emergency Medicine rotation evaluation, I presented a 68-year-old male patient who presented to the ER for stroke-like symptoms. I felt comfortable presenting this patient as a stroke workup is familiar having had some experience with the stroke team on my first rotation in Internal Medicine. This patient had a significant past medical history upon presentation, I was careful to include all of the significant diseases in my HPI as well as following up in my projected plan for this patient. This patient’s presentation was a fairly common one for stroke history. He presented with right-sided hemiparesis, slurred speech, and right-sided facial droop. Because he came in within 3 hours of his symptom onset, he was a good candidate for tPA infusion. I had never before seen tPA given to a patient. I was also able to accompany the patient to CT scan upon his arrival to the ER, and so I was able to see the patient’s scan in real-time as well as participate in helping to monitor the patient while they were in radiology. The patient was admitted to the medical ICU post tPA infusion for observation and for an MRI of the brain, which could not be done emergently. I felt that this patient was an important one to write about as stroke patients commonly present to the ER and their medical plan should be something I know well. Writing this particular H&P will help me to better formulate a plan quickly for a patient where time is of the essence.
EM Article Summary: This article discusses the higher incidence of infective endocarditis among IV drug abusers and the prevalence of infection by less common pathogens and the prevalence of red side heart effects, specifically in the southern US and how the data collected will compare to published literature. In this study, a retrospective cohort study of 299 cases of infective endocarditis cases from 2013-2017 was analyzed. The location of the study parameters was a large tertiary referral hospital in Eastern Tennessee. Demographic, IV substance use status, radiographic, and echocardiographic data were collected. The blood culture results utilized were from the sets obtained at the beginning of each patient’s hospitalization. Interestingly, when compared with other national studies and published literature, this study found that they had 24 cases of pseudomonas infective endocarditis while the other notional studies only had 1. Also, according to this study, IV drug users were more likely to have MSRA and MSSA infective endocarditis rather that enterococcus or streptococcus (non-IV drug users). Also, this study alludes to why as much as 15% (similar to the national average according to prior studies) of patients had no growth in their blood culture samples. I found this to be an interesting take on the lives of the IV drug abusers in this study. Researchers speculate that the sterile blood cultures without growth were probably from patients who had left other institutions AMA after receiving antibiotic treatment. This is only a speculation, but still a thought-provoking take. Also, there was speculation regarding the high prevalence of pseudomonas infective endocarditis cases in this study. Researchers discussed the possibility of a contaminated batch of heroin circulating in this specific area of the study but were unable to prove such. Overall, I found this article to be lacking in high-quality evidence, but was still interesting none the less as the questions brought up by the data collected can be further researched for more concise resolutions.
EM Self Reflection: For this rotation in Emergency Medicine, I thoroughly enjoyed the hectic atmosphere of the ER itself. I was very thankful to have had my rotation in a level-one trauma center and to gain that invaluable experience. I was exposed to emergent situations involving coding patients and was able to participate in performing chest compressions for the first time in my life. I hadn’t realized before how exhausting it would be to perform chest compressions, but I was told by the supervising staff that I was at least performing them correctly. I was also given the opportunity to “bag” an intubated patient, which required more attention to detail than I had originally thought. While working with the team, I was given more responsibility than I was used to in prior rotations. I was given a list of patients to follow and would interview patients prior to them being seen by the PA, give a report on each patient seen, and give an assessment with working diagnosis and plan for each patient. I was critiqued on my technique in real-time, which I found to be extremely beneficial to my clinical education. I was also taught to use ultrasound for point-of-care exams, including US-guided peripheral IV placements and echocardiograms bedside. This rotation has been my favorite so far, and the experience and clinical knowledge I have gained will definitely help me to improve my clinical skills.
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