Welcome to the Mount Sinai Emergency Medicine Residency Website.

Here you will find information regarding rotation schedules, academic resources, wellness and facts about our program and residents. Check out our bios and photos. Please also visit the Emergency Department's official residency website. This site is intended for Mount Sinai EM residency purposes only, and no information on these pages is intended or should be construed as medical advice. Read more.

Small Bowel Obstruction Likelihood Ratios.

A 78-year old man presents with abdominal pain and decreased oral intake. His vitals are normal but he looks uncomfortable. After you introduce yourself, you palpate his abdomen which is diffusely tender. Your immediate gestalt is “Small Bowel Obstruction” but you’re not sure why. Frankly, you think, “I can do better than gestalt.”

Can you?

1. What are the various positive and negative likelihood ratios for clinical and radiographic features of a small bowel obstruction? (recall +LR>10 is considered useful for genuinely increasing suspicion of disease, -LR <0.1 is considered useful for genuinely decreasing suspicion of disease).

1a. Previous surgery?

1b. Abdominal distension?

 

2. What is the sensitivity and specificity of imaging modalities for small bowel obstruction?

2a. A normal abdominal X-ray?

2b. Air fluid levels seen on abdominal X-ray

2c. CT findings.

 

3. In a trained EM provider, what are the likelihood ratios for small bowel obstruction using bedside ultrasound?

 

Continue reading “Small Bowel Obstruction Likelihood Ratios.” »

Ignoring Hiccups Lasting >48 Hours is a Bad Idea. Here’s Why and What to Do…

Chief complaint: Hiccups (i.e. “singultus”).

Timing: 3 days.

Diagnosis: Persistent hiccups.

Etiology: Unknown.

Who cares? You care. Why? Because persistent hiccups (>48 hours) and intractable hiccups (>1 month!) is likely indicative of an underlying illness that needs work-up/diagnosis.

1. What is the difference between a “bout,” “persistent,” and “intractable” hiccups?

2. What’s an ED-ready trick to treat the symptom?

Continue reading “Ignoring Hiccups Lasting >48 Hours is a Bad Idea. Here’s Why and What to Do…” »

6 Month Old Wheezer. Trial of Saline and Albuterol Nebs, Right?!

PEM fellow Dr. Michelle Vazquez presents a case of: A 6 month old boy comes to the ED with an elevated respiratory rate and lots of wheezing on exam. He had a tactile fever at home and in the ED his temperature is measured at 100.4F. His oxygen saturation is 90% on room air.

There is no family history of asthma. The mother had a recent cold. Vaccines are up to date.

You briskly take a history and physical. The baby is tachypneic (breathing in the 60s) and is mildly tachycardic and has some diffuse wheezing. The exam is otherwise non-contributory.
You are getting ready to put the child on a trial of supplemental oxygen, some hypertonic saline nebs, albuterol, and some corticosteroids and maybe even get an X-ray because that’s what people seem to do for cases of suspected bronchiolitis. You also consider racemic epinephrine if things go badly.
But what do the guidelines say? Which of these is supported for use in the EMERGENCY DEPARTMENT according to the most recent clinical guideline from the combined “Bronchiolitis board group” (General Pediatrician, Family Physician, Pediatric Hospitalists, Emergency Physicians, Neonatologists, Pediatric Infectious Disease)?

How Many Chest X-rays Would It Take….

A young woman presents to the Emergency Department with chest pain of sudden onset while blowing up a balloon at her kid’s birthday party.

Vitals are normal but due to slightly decreased breath sounds on the left, you are concerned for pneumothorax. ECG is normal. No other complaints.

You order a chest x-ray but the radiologist calls to inform you that you can’t get the study until the patient is proven to be without child (beta-HCG negative is a requirement in most institutions for a chest X-ray).

She just urinated and does not need labs and wants to just get her chest x-ray already. She wants to know if she can skip the bHCG test.

1. Can we skip the bHCG test and get that Chest Xray?

2. How many chest X-rays would it take to confer teratogenicity in a pregnant woman? (i.e. how many mRads does a CXR confer, and what is the maximum tolerated dose during pregnancy?

3. Are there any guidelines that discourage the requirement of requiring a pregnancy test before CXR?

Continue reading “How Many Chest X-rays Would It Take….” »

Predicting and Dealing with Difficult Peripheral Iv Access.

Nurse: Doctor, this patient is a tough stick. I tried 3 times and I got nothing. Can you help?

Doctor: Sure! I’ll grab the linear ultrasound vessel finder and get that line in for you, thereby potentially saving this non-critically ill patient from an unnecessary central venous catheter (free pearl #1).

Nurse: Ok! Do you need the special longer IV angiocatheters?

Doctor: Why yes, I do. Because I always use the special longer IV angiocaths, as they have a much better chance of not coming out later (free pearl #2).

 

Then you realize: It has been a little while since you last did an ultrasound guided IV.  So, you check out ultrasoundpodcast.com and watch these brief FOAM videos.

http://www.ultrasoundpodcast.com/2013/02/microcastiv/

http://www.ultrasoundpodcast.com/2013/10/ultrasound-guided-peripheral-iv-podcast-give-nurses-teach-providers-foamed/

 

Now that you’re up to speed,

1. Name a few predictors of difficult peripheral IV access.

 

2. When deciding on a vein to use, which features are preferable?

a) Proximal

b) Distal

c) Shallow

d) Deep

e) combo of option a + option c

f) combo of option b + option c

g) combo of option a + option d

h) combo of option b + option d

 

3. What is the likelihood that an ultrasound-guided IV will survive even a few hours if the vein is >1.2cm deep?

a) 29%

b) 50%

c) 74%

d) 88%

Continue reading “Predicting and Dealing with Difficult Peripheral Iv Access.” »

Carl “Scooter” Mickman


Archives

Categories