FOAMed is pleased to release another collection of clinical pearls from your favorite attendings. The subject for this edition is Nephrolithiasis. Many thanks to all the attendings who took time out of their busy schedules to provide responses.





Continue reading is pleased to release another collection of clinical pearls from your favorite group of attendings. The topic this time around is Cardiac Arrest and Medical Codes. Many thanks to all the attendings who took time out of their busy schedules to provide responses.





Continue reading is pleased to introduce a new reoccurring post called Clinical Pearls: Ask a Yale EM Attending. This post will feature a collection of tips from our attendings on subjects where there is variability in practice and room for “the art of medicine”. This month’s topic is migraines, a frequent ED complaint with plenty of space for “style” when it comes to management. Thank you to all the attendings who took time out of their busy schedules to provide responses.




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What would you do in this case?

58yo m h/o HTN presents with 3 days of high fevers and productive cough. He’s a reasonable but not outstanding protoplasm, but he looks sick. Temp 102.4, HR 110, BP 115/82, satting 92%. He doesn’t drink or smoke. He has decreased LLL sounds, his CXR has a REAL consolidation. You give abx, you decide to admit, you fluid resuscitate and treat that fever, BUT…. do you give roids???


What do you think after reading this week’s article?


This is an interesting question also being discussed in the FOAMed world.


Dr. Melissa Hazlitt is leading an awesome journal club this week! Comments for discussion welcome.



The language of medicine is one that can both illuminate and obscure: “I have a patient with a Lisfranc fracture,” is often all one needs to say to get the full attention of the consulting orthopedist. Yet, “I have a septic patient who I think warrants ICU-level care,” universally prompts the intensivist to ask for more information prior to accepting the admission. This is for good reason as sepsis-like physiology is present in many disease processes and even many non-disease states, such as normal labor, intense physical activity, and competing in the national debate finals, which do not need ICU-level care.

Simply meeting the criteria for sepsis as previously defined (SIRS + probable infection) does not fully describe how ill a patient may be, because sepsis is heterogeneous syndrome with an intentionally overly inclusive definition. The previously broad criteria reflect both a need to avoid missing patients who might be suffering from this life-threatening condition and an acknowledgement that the underlying pathophysiology is complex and not yet completely understood. Yet in spite of this sensitive but not very specific terminology, modern medicine still misses some of these patients—those with occult sepsis. As such, the hope is that a better understanding of the pathophysiology of sepsis, with additions and revisions made to its very definition and the states along its continuum, would yield the needed advances in detention and management, and mortality reduction. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), would seemingly seek to address these at-risk and under-identified patients, but it seems to have gone completely the other way in an effort to redefine sepsis more precisely as far as outcomes are concerned. Of note, this summary is actually of the manuscript describing the derivation of these new definitions, not of the consensus statement itself.
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Emergency Medicine Lectures will take place at Yale on Wednesday, January 13th in Harkness Auditorium beginning at 9:00am. Breakfast will be served.

    10am – Gyn Emergencies – Dr. Newton
    11am – R.E.S.U.S. Discussion Session on Delayed Sequence Intubation – Drs. Goldflam & Roh

The R.E.S.U.S. session is a new flipped classroom discussion model based on the highly successful discussion session recently organized by our very own PGY-4 Steve Van Ooteghem.
R.E.S.U.S. stands for:
R real, relevant, roundtable
E evidence based
S social media integrated
U up-to-date
S smart and scientific
This session will be focused on delayed sequence intubation, and to prepare for it, please check out the following resources.
The Paper: Weingart, S. D., Trueger, N. S., Wong, N., Scofi, J., Singh, N., & Rudolph, S. S. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015; 65: (4), 349-355.
EMCrit’s Everything About DSI
Charts with DSI Algorithims and Podcast Links
EMRAP June 2014’s highlight on DSI
Feel free to bring up any additional sources about DSI during discussion this Wed (from social media, websites, FOAM, or other formal journal articles, etc.).

Rettungskorsett by Florian Thillmann, via Wikimedia Commons.

When a trauma patient is altered or obtunded, even with vitals signs that do not indicate the need for immediate operative intervention, one’s suspicion for significant injury is higher than if the same patient had a GCS of 15. This concern often persists even after an exhaustive diagnostic work-up that frequently includes advanced imaging of the head and cervical spine, and has raised the question of how good is CT at identifying significant cervical spine pathology in the absence of an accompanying clinical exam.
Dr. Jennifer Roh lead our most recent Journal Club looking at the Patel et al.’s systematic review of just this topic.
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Check out this great video on nasopharyngoscopy by Dr. Glenn Paetow that has received awards from EMCrit and HippoEM. Dr. Paetow, currently one of Heppepin‘s Chief Residents, made this as a second-year. It’s a great overview of ED-based nasopharyngoscopy with tons of tips of the trade.

Well, yes, many of the events that bring pediatric patients to the Emergency Department could be due to child abuse or neglect. In fact, the American Academy of Pediatrics just recently published a new Clinical Report, The Evaluation of Suspected Child Physical Abuse. The main focus of this publication is that physical abuse is terrifyingly common across all socio-economic groups, under-diagnosed, and associated with significant long-term medical, psychological, and social harm.
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34 year-old male self-presents to the Emergency Department after being hit in the abdomen with a baseball bat 3 hours before while walking too close to the on-deck circle at his son’s high school baseball game.

Figure 1: Parietal swelling with bruising after motor vehicle accident. courtesy of Agarwal N, Kumar S, Joshi MK, Sharma MS, via OPENi.

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