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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.

Legion-umbrella-ella-ella

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Yesterday, the 7th mortality from legionella in NYC occurred. There have been 71 cases since July 10, all of them in the South Bronx after Legionella was found in cooling towers. This bacteria typically live in reservoirs of water or humidified spaces. It is a common cause (2 to 9 percent) of community-acquired and hospital-acquired pneumonia known as Legionnaire’s disease. The NYC Department of Health has issued suggestions on diagnosis and management of these patients; new cases should be reported to 866-NYC-DOH1 (1-866-692-3641).

Presentation
Clinical symptoms include typical symptoms of pneumonia (cough, fever, SOB), but have a high suspicion for this organism if your patient also endorses GI symptoms (nausea/vomiting, diarrhea, abdominal pain) and/or neurologic symptoms (confusion, headache).

Diagnosis
The initial diagnostic test that should be ordered in the ED is a urinary antigen test although sensitivity is highly variable. At Mount Sinai Hospital, this test is performed in house and will result in 1 hour. Sputum cultures should also be sent and this is the most important test for definitive diagnosis; be sure to indicate that the culture is for legionella as special medium is used. Laboratory abnormalities include hyponatremia, thrombocytopenia, and LFT changes. There is no specific finding on chest XR that would narrow your diagnosis to legionella.

Treatment
The most susceptible patients are those who are elderly, diabetic, smokers, and immunosuppressed–antibiotics should be initiated immediately. Although there are no RCTs comparing the two, flouroquinolones (levofloxacin) and macrolides (azithromycin) are equally effective. For recently hospitalized patients and those from nursing homes, levofloxacin is the antibiotic of choice.

“doc, I Have 10/10 Pain!”

Ketamine

Pain control is one of the primary responsibilities of an emergency physician. At our disposable are a variety of medications and procedures (nerve blocks, etc) we use at our discretion based on the severity of pain, effectiveness of analgesia, time to administer, and side effects of the treatment.

As an alternative to traditional analegesia (acetaminophen, NSAIDs, opioids), a systematic review of the literature on low-dose ketamine, otherwise known as subdissociative dose ketamine (<1mg/kg), for analgesia was recently published on Academic Emergency Medicine. Most of us have used ketamine for procedural sedation and as an induction agent for its dissociative effects, but it is not often utilized for analgesia.

In the review, four studies (all RCTs) were reviewed with the primary outcome being change in pain score and the secondary outcome being occurrence of adverse events such as vomiting or dissociation. 2 of the 4 studies reported significant reductions in pain while 1 study other study reported lower pain scores without absolute numbers. 2 studies demonstrated a reduction in opiate use by patients. A pediatric study reported increased vomiting with ketamine although this was not reported in adult studies.

Since this review, there have been new studies published and others are in the works. For now, subdissociative ketamine may be an alternative to or for pain refractory to traditional analgesia, possibly even for an unstable, hypotensive patient you want to give analgesia to prior to cardioversion. One recent study (3) recommends 0.3mg/kg for optimal analgesia. However, future RCTs are needed to describe its efficacy and safety.

Academic EM systematic review:

1. http://onlinelibrary.wiley.com/doi/10.1111/acem.12705/full

New studies:

2. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial.
http://www.ncbi.nlm.nih.gov/pubmed/25624076

3. Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in the emergency department: results of a randomized, double-blind, clinical trial.
http://www.ncbi.nlm.nih.gov/pubmed/25377395

My Head Hurts

35 y F presents to ED with sudden onset worst headache of life starting 3 hours ago.  Refractory to treatment with excedrin.  No history of Migraines.  Concern for SAH. What is your management algorithm to rule out SAH?  Do you CT/LP?

Continue reading “My Head Hurts” »

Orthopedic Injuries

34 y M with right midfoot swelling and pain after injuring while playing football.  The patient describes a hyper-plantarflexion mechanism.  Physical exam notable for bruising to medial plantar foot and diffuse swelling to dorsal midfoot with tenderness to palpation.  XR is seen below:

Lisfranc No Arrows

What is the diagnosis?

Continue reading “Orthopedic Injuries” »

Exertional Syncope

23 y M presenting to ED with episode of syncope while playing soccer this afternoon.  Endorses preceding palpitations, but denies any associated CP/diaphoresis/n/v/sob.  EKG is as follows:

Arvd

What is the diagnosis?

Continue reading “Exertional Syncope” »

Leslie Pendery, MD


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