Barry C. Simon

Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-blind Placebo-controlled Study

BACKGROUND Acute alcohol withdrawal syndrome (AAWS) is encountered in patients presenting acutely to the Emergency Department (ED) and often requires pharmacologic management. OBJECTIVE We investigated whether a single dose of intravenous (i.v.) phenobarbital combined with a standardized lorazepam-based alcohol withdrawal protocol decreases intensive care unit (ICU) admission in ED patients with acute alcohol withdrawal. METHODS This was a prospective, randomized, double-blind, placebo-controlled study. Patients were randomized to receive either a single dose of i.v. phenobarbital (10 mg/kg in 100 mL normal saline) or placebo (100 mL normal saline). All patients were placed on the institutional symptom-guided lorazepam-based alcohol withdrawal protocol. The primary outcome was initial level of hospital admission (ICU vs. telemetry vs. floor ward). RESULTS There were 198 patients enrolled in the study, and 102 met inclusion criteria for analysis. Fifty-one patients received phenobarbital and 51 received placebo. Baseline characteristics and severity were similar in both groups. Patients that received phenobarbital had fewer ICU admissions (8% vs. 25%, 95% confidence interval 4-32). There were no differences in adverse events. CONCLUSIONS A single dose of i.v. phenobarbital combined with a symptom-guided lorazepam-based alcohol withdrawal protocol resulted in decreased ICU admission and did not cause increased adverse outcomes.

Pseudomyocardial infarction and hyperkalemia: A case report and subject review

A case of diabetic ketoacidosis with hyperkalemia and ECG evidence of pseudomyocardial infarction is presented. Electrocardiogram abnormalities resolved shortly after treatment of the elevated potassium. The electrophysiology of hyperkalemia and theories to explain observed ECG changes are discussed. Pseudoinfarction changes that may be peculiar to patients with diabetic ketoacidosis and hyperkalemia are examined.

How Prevalent Are Potentially Illegal Questions During Residency Interviews

Purpose To study the prevalence of potentially illegal questions in residency interviews and to identify the impact of such questions on applicants’ decisions to rank programs. Method Using an Electronic Residency Application Service–supported survey, the authors surveyed all applicants from U.S. medical schools to residency programs in five specialties (internal medicine, general surgery, orthopedic surgery, obstetrics–gynecology [OB/GYN], and emergency medicine) in 2006–2007. The survey included questions about the frequency with which respondents were asked about gender, age, marital status, couples matching, current children, intent to have children, ethnicity, religion, or sexual orientation, and the effect that such questions had on their decision to rank programs. Results Of 11,983 eligible applicants, 7,028 (58.6%) completed a survey. Of respondents, 4,557 (64.8%) reported that they were asked at least one potentially illegal question. Questions related to marital status (3,816; 54.3%) and whether the applicant currently had children (1,923; 27.4%) were most common. Regardless of specialty, women were more likely than men to receive questions about their gender, marital status, and family planning (P < .001). Among those respondents who indicated their specialty, those in OB/GYN (162/756; 21.4%) and general surgery (214/876; 24.4%) reported the highest prevalence of potentially illegal questions about gender. Being asked a potentially illegal question negatively affected how respondents ranked that program. Conclusions Many residency applicants were asked potentially illegal questions. Developing a formal interview code of conduct targeting both applicants and programs may be necessary to address the potential flaws in the resident selection process.

Superior Cluneal Nerve Block for Treatment of Buttock Abscesses in the Emergency Department

BACKGROUND The buttock is a common location for cutaneous abscesses among patients presenting for emergency department care. Procedural pain management sufficient to permit adequate incision and drainage often requires moderate sedation or general anesthesia. DISCUSSION We describe a patient with a buttock abscess who successfully underwent incision and drainage with a regional superior cluneal nerve blockade instead of moderate sedation. CONCLUSIONS Our experience suggests that superior cluneal nerve blockade may reduce the need for procedural sedation, expedite care, and reduce costs for some patients presenting with buttock abscesses.

Asking for a commitment: violations during the 2007 match and the effect on applicant rank lists.

Introduction Applicants to residency face a number of difficult questions during the interview process, one of which is when a program asks for a commitment to rank the program highly. The regulations governing the National Resident Matching Program (NRMP) match explicitly forbid any residency programs asking for a commitment. Methods We conducted a cross-sectional survey of applicants from U.S. medical schools to five specialties during the 2006–2007 interview season using the Electronic Residency Application Service of the Association of American Medical Colleges. Applicants were asked to recall being asked to provide any sort of commitment (verbal or otherwise) to rank a program highly. Surveys were sent after rank lists were submitted, but before match day. We analyzed data using descriptive statistics and logistic regression. Results There were 7,028 unique responses out of 11,983 surveys sent for a response rate of 58.6%. Of those who identified their specialty (emergency medicine, internal medicine, obstetrics and gynecology [OBGYN], general surgery and orthopedics), there were 6,303 unique responders. Overall 19.6% (1380/7028) of all respondents were asked to commit to a program. Orthopedics had the highest overall prevalence at 28.9% (372/474), followed by OBGYN (23.7%; 180/759), general surgery (21.7%; 190/876), internal medicine (18.3%; 601/3278), and finally, emergency medicine (15.4%; 141/916). Of those responding, 38.4% stated such questions made them less likely to rank the program. Conclusion Applicants to residencies are being asked questions expressly forbidden by the NRMP. Among the five specialties surveyed, orthopedics and OBGYN had the highest incidence of this violation. Asking for a commitment makes applicants less likely to rank a program highly.

Abdominal wall hematoma: Case report and subject review

Presented is a case of abdominal wall hematoma following a fall from a height of 20 feet. This emergency department course illustrates the diagnostic dilemma that frequently accompanies this entity. The patient was discharged from the hospital without further complication following an extensive workup and 48 hours of observation. Pathophysiology, evaluation, and treatment are then discussed in detail.

A Rare Case of Acute Right-Sided Colonic Diverticulitis Presenting as Pancreatitis

BACKGROUND This case report highlights the clinical presentation, radiologic findings, and medical management of a case of right colonic diverticulitis (RCD) with concomitant pancreatitis, a rare and easily missed entity in the emergency department (ED) of Western hemisphere countries. In our report, we present and discuss a case of RCD that led to pancreatitis in a female Asian patient. We review the epidemiology, diagnosis, and management of this disorder, and also discuss some complications associated with RCD. The importance of considering this pathologic entity within the ED differential even in those patients presumed to be at low risk for this condition is also explained, as this can prevent inappropriate surgical intervention for this presentation. CASE REPORT We describe a 40-year-old Asian woman presenting for evaluation of epigastric pain and vomiting. She was initially thought to have cholecystitis or food poisoning, but had a normal ultrasound evaluation and ultimately had co-presenting RCD and pancreatitis diagnosed after computed tomography scanning. The patient was admitted and made a full recovery after receiving medical therapy and maintaining bowel rest. This is, to our knowledge, the first reported case of RCD and concomitant pancreatitis found in the modern literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Severe epigastric pain in young Asian patients with minimal risk factors may be RCD. This condition presents much like appendicitis, cholecystitis, or food poisoning, but must be considered among early differential diagnoses and evaluated appropriately in order to prevent unnecessary interventions.

An Unusual Cause of Right Upper Quadrant Pain and Emesis

A 43-year-old otherwise healthy female presented to the ED with approximately 8 h of intermittent sharp right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. Her vital signs were unremarkable and physical examination revealed a middle-aged female in moderate distress due to pain. She had RUQ tenderness with a positive Murphy’s sign. Laboratory studies including complete blood count, complete metabolic panel, and lipase were within normal limits. The patient underwent a bedside RUQ ultrasound (US) (Figure 1) followed by computed tomography (CT) (Figures 2 and 3) of the abdomen and pelvis. The US revealed a hypoechoic structure between the diaphragm and liver without peristalsis on multiple views and cholelithiasis without evidence of cholecystitis. The CT confirmed the suspicion that this structure was the small bowel crossing between the diaphragm and the liver, also revealing a transition