Malford T. Pillow

Social Media Guidelines and Best Practices: Recommendations from the Council of Residency Directors Social Media Task Force

Social media has become a staple of everyday life among over one billion people worldwide. A social networking presence has become a hallmark of vibrant and transparent communications. It has quickly become the preferred method of communication and information sharing. It offers the ability for various entities, especially residency programs, to create an attractive internet presence and “brand” the program. Social media, while having significant potential for communication and knowledge transfer, carries with it legal, ethical, personal, and professional risks. Implementation of a social networking presence must be deliberate, transparent, and optimize potential benefits while minimizing risks. This is especially true with residency programs. The power of social media as a communication, education, and recruiting tool is undeniable. Yet the pitfalls of misuse can be disastrous, including violations in patient confidentiality, violations of privacy, and recruiting misconduct. These guidelines were developed to provide emergency medicine residency programs leadership with guidance and best practices in the appropriate use and regulation of social media, but are applicable to all residency programs that wish to establish a social media presence.

An Emergency Department-initiated, Web-based, Multidisciplinary Approach to Decreasing Emergency Department Visits by the Top Frequent Visitors Using Patient Care Plans

BACKGROUND Many patients present to the Emergency Department (ED) for multiple visits. Whatever the cause, assuring the highest quality of care is difficult in the ED. OBJECTIVES We sought to implement a web-based, ED-initiated, multidisciplinary program to improve patient care and reduce frequent visits to the ED. METHODS The top 50 ED frequent visitors were identified and care plans were constructed. Care plans consist primarily of a summary of the patients pertinent history and any psychosocial issues that can contribute to frequent use of the ED, and recommend treatment plans for these patients. RESULTS During the study period, ED visits by the top 50 chronic frequent visitors ranged from 88 to 98 visits/month and 28 to 31 admissions/month. As of January 2007, the top 50 frequent visitors had 94 ED visits/month (1,129 visits/year) for 2.2% of the total census, and 31 admissions/month (372 admissions per year) for approximately 3.3% of the total admissions. Each frequent visitor has approximately 22.6 visits/year (range from 11 to 41) and 7.3 admissions/year (range from 0 to 20). By May 2008, the top 50 frequent visitors had a decrease to 88 visits/month (1,059 visits/year) and 28 admissions/month (340 admissions/year), with each frequent visitor having 21.2 visits/year and 6.8 admissions/year. Social determinants included psychiatric disease (36%), substance abuse (22%), malingering (20%), medication noncompliance (16%), and unstable housing (10%). CONCLUSIONS There was a trend toward a decrease of monthly ED visits by the top 50 ED frequent visitors, but no effect on the rate of admissions. Based on these preliminary data and the relative ease of integration into the system, this project shows the potential to begin to address the problem of chronic ED use with patient care plans.

Acute Pancreatitis: What's the Score?

BACKGROUND Acute pancreatitis (AP) is a common presentation in the emergency department (ED). Severity of pancreatitis is an important consideration for ED clinicians making admission judgments. Validated scoring systems can be a helpful tool in this process. OBJECTIVE The aim of this review is to give a general outline on the subject of AP and compare different criteria used to predict severity of disease for use in the ED. DISCUSSION This review updates the classifications and scoring systems for AP and the relevant parameters of each. This article assesses past and current scoring systems for AP, including Ranson criteria, Glasgow criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II), computed tomography imaging scoring systems, Bedside Index of Severity in Acute Pancreatitis (BISAP) score, Panc 3, Harmless Acute Pancreatitis Score (HAPS), and the Japanese Severity Score. This article also describes the potential use of single variable predictors. Finally, this article discusses risk factors for early readmission, an outcome pertinent to emergency physicians. These parameters may be used to risk-stratify patients presenting to the ED into mild, moderate, and severe pancreatitis for determination of appropriate disposition. CONCLUSION Rapid, reliable, and validated means of predicting patient outcome from rapid clinical assessment are of value to the emergency physician. Scoring systems such as BISAP, HAPS, and single-variable predictors may assist in decision-making due to their simplicity of use and applicability within the first 24 h.

Levamisole-adulterated Cocaine Induced Vasculitis with Skin Ulcerations

A 40-year-old man with Hepatitis C and a history of cocaine abuse presented with multiple stages of painful rashes on his extremities and ears. On examination, the patient had several areas of purpuric macules and retiform purpura to his legs and ears (Figures 1 and 2), as well as large ulcerations with erythematous borders on bilateral lower extremities (Figure 3). Laboratory studies revealed mild leukopenia (white blood cell 3.8 K/uL), positive anti-nuclear antibody (ANA), and negative cryoglobulins. Anti-myeloperoxidase antibodies (MPO-ANCA) and anti-proteinase-3 (PR3-ANCA) were also positive. Skin biopsy revealed dermal purpura and thrombi.

Perceptions of Basic, Advanced, and Pediatric Life Support Training In a United States Medical School

BACKGROUND Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS) are integral parts of emergency resuscitative care. Although this training is usually reserved for residents, introducing the training in the medical student curriculum may enhance acquisition and retention of these skills. OBJECTIVES We developed a survey to characterize the perceptions and needs of graduating medical students regarding BLS, ACLS, and PALS training. METHODS This was a study of graduating 4th-year medical students at a U.S. medical school. The students were surveyed prior to participating in an ACLS course in March of their final year. RESULTS Of 152 students, 109 (71.7%) completed the survey; 48.6% of students entered medical school without any prior training and 47.7% started clinics without training; 83.4% of students reported witnessing an average of 3.0 in-hospital cardiac arrests during training (range of 0-20). Overall, students rated their preparedness 2.0 (SD 1.0) for adult resuscitations and 1.7 (SD 0.9) for pediatric resuscitations on a 1-5 Likert scale, with 1 being unprepared. A total of 36.8% of students avoided participating in resuscitations due to lack of training; 98.2%, 91.7%, and 64.2% of students believe that BLS, ACLS, and PALS, respectively, should be included in the medical student curriculum. CONCLUSIONS As per previous studies that have examined this topic, students feel unprepared to respond to cardiac arrests and resuscitations. They feel that training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations.

Oral lesions secondary to cocaine use.

A 47-year-old female with a history of hepatitis C and drug abuse presented to the emergency department (ED) with a 3-week history of oral and chin ulcers, productive cough, and dyspnea. Her initial vital signs were BP 80/51, HR 111, RR 20, Temp 97.9°F. Physical exam was notable for oral and chin lesions to the tongue and anterior gums (Figure 1 and ​and2).2). Otherwise no other bullous or embolic lesions were noted on the patient. Initial labs were remarkable for white blood cell count 1.2 K/L, sodium 128 mEq/L, bicarbonate 23 mEq/L, blood urea nitrogen 20 mg/dL, creatinine 0.4 mg/ dL. Urine drug screen was positive for cocaine and opioids. Human immunodeficiency virus (HIV) test was negative. Dermatology, which was consulted during her inpatient stay to evaluate the cause of the oral lesions, noted only non-specific spongiform pattern of inflammation on biopsy. The lesions began to fall off and heal during her hospital stay, and the team noted that all the lesions were to the anterior mouth. Upon further questioning, she admitted to burning her lips and mouth on a crack pipe. Figure 1. Lesion to mucosa of inner lip. Figure 2. Multiple lesions on tongue. Cocaine-associated oral lesions can present in a variety of ways, including poor dentition, mouth ulcerations found to the anterior mouth (as in our patient), and lesions in various stages of healing.1 In this septic patient, the lesions were initially thought to be indicators of severe systemic disease, but were merely a distractor. Interestingly, a study did find a small increased incidence of HIV in patients presenting with crack pipe burns.2

A rare cause of widened mediastinum.

Figure 1. Chest X-ray study showing a significantly widened mediastinum (arrows). A 53-year-old man with history of hypertension, coronary artery disease, and chronic left leg deep vein thrombosis on Coumadin (Bristol-Myers Squibb Company, Princeton, NJ) presented complaining of chest pain. The pain was dull, midsternal, gradual in onset, and rated 5/10. There was no radiation of the pain, and the patient initially said that this pain was similar to his previous cardiac pain. Review of systems was positive for mild exertional chest pain and occasional shortness of breath. Vital signs were stable and the examination was remarkable for a 2/6 systolic ejection murmur. Electrocardiogram showed right bundle branch block without ischemia. Cardiac enzymes were normal. Chest X-ray study (Figure 1) showed widened mediastinum. A computed tomography scan with angiography of the chest (Figure 2) revealed a pulmonary aneurysm with the main pulmonary artery dilatated to 71 mm and enlargement of both pulmonary arteries. An echocardiogram showed a severely dilatated right ventricle, moderate tricuspid regurgitation, and a pulmonary artery pressure of approximately 66 mm Hg, consistent with pulmonary hypertension. The patient’s pulmonary aneurysm was thought to most likely be secondary to chronic undiagnosed pulmonary embolisms causing pulmonary hypertension. His symptoms resolved, so he was medically optimized and discharged. The aneurysm has remained stable since his first visit. Pulmonary artery aneurysms are found in approximately 1 in 14,000 postmortem examinations (1). Congenital heart disease is thought to cause the majority of

Cardiac arrest from postpartum spontaneous coronary artery dissection.

We present the case of a 32-year-old woman who presented to the emergency department with a witnessed cardiac arrest. She was otherwise healthy with no cardiac risk factors and had undergone an uneventful repeated cesarean section 3 days priorly. The patient underwent defibrillation, out of ventricular fibrillation to a perfusing sinus rhythm, and was taken to the catheterization laboratory where coronary angiography findings showed spontaneous dissection of the left anterior descending artery. The patient received a total of 6 stents during her hospital stay and was eventually discharged in good condition. Spontaneous coronary artery dissection is a rare entity with a predilection for pregnant or postpartum women. Early diagnosis and treatment are key for survival, and when identified early, mortality rate is reduced.