A Case Report of Hypoglycemia Following a Tramadol Overdose in a Non-Diabetic Patient.

INTRODUCTION: Tramadol is an opioid analgesic that binds to mu-opioid receptors and inhibits the uptake of norepinephrine and serotonin. Through its activation of these receptors, it has potential to increase the utilization of glucose and/or decrease hepatic gluconeogenesis. CASE REPORT: A 55-year-old male presents to the Emergency Department (ED) via Emergency Medical Services (EMS) following a self-reported overdose of alprazolam, lorazepam, acetaminophen with codeine, and tramadol. During EMS transport, the patient was found to be hypoglycemic with a glucose of 30 mg/dL and was administered 25 grams of intravenous (IV) dextrose 50% in water. The patient had no past medical history of diabetes mellitus, hypoglycemia, or hyperglycemia and was normoglycemic on his prior presentations to our facility 3 months and 2 years prior. Subsequent analysis found that the patient was negative for acetaminophen, ethanol, salicylates, tricyclics, and lithium. His urinalysis was positive for opiates and benzodiazepines. Upon arrival to the ED, the patient's blood glucose was 131 mg/dL but subsequently dropped to 73 mg/dL, necessitating the initiation of continuous IV fluids containing dextrose. These fluids were discontinued 3.5 hrs later and the patient was discharged 16 days later. DISCUSSION: This case illustrates that hypoglycemia can be a presenting symptom in patients with an acute overdose of tramadol with no previous history of glycemic dysregulation. Upon presentation it is important to closely monitor serum glucose concentrations to identify hypoglycemia early in order to initiate necessary hypoglycemia protocols.

Does the Medical Student Performance Evaluation Change the Decision to Invite Residency Applicants?

INTRODUCTION: Although emergency medicine (EM) residency program directors (PD) have multiple sources to evaluate each applicant, some programs await the release of the medical student performance evaluation (MSPE) to extend interview offers. While prior studies have demonstrated that MSPE content is variable and selectively positive, no prior work has evaluated the impact of the MSPE on the likelihood to invite (LTI) applicants for a residency interview. This study aimed to evaluate how information in the MSPE impacted LTI, with the hypothesis that changes in LTI would be relatively rare based on MSPE review alone. METHODS: We conducted a prospective, observational study analyzing applications to three EM residency programs during the 2019-2020 match cycle. Reviewers assessed applications and rated the LTI on a five-point Likert scale where LTI was defined as follows: 1 = definitely no; 2 = probably no; 3 = unsure; 4 = probably yes; and 5 = definitely yes. The LTI was recorded before and after MSPE review. A change in LTI was considered meaningful when it changed the overall trajectory of the applicant's likelihood to receive an invitation to interview. RESULTS: We reviewed a total of 877 applications with the LTI changing ≥1 point on the Likert scale 160 (18.2%) times. The LTI was meaningfully impacted in a minority of applications - 48 total (5.5 %, p< 0.01) - with only 1 (0.11%) application changing from 1 or 2 (definitely/probably no) to 4 or 5 (probably/definitely yes) and 34 (3.8%) changing from 3 (unsure) to 4 or 5 (probably/definitely yes). Thirteen (1.5%) applications changed from 4 or 5 (probably/definitely yes) to 3 (unsure or probably/definitely no). CONCLUSION: Review of the MSPE resulted in a meaningful change in LTI in only 5.5% of applications. Given the time required for program leadership to review all parts of the variably formatted MSPEs, this finding supports a more efficient application review, where the PD's focus is on succinct and objective aspects of the application, such as the Standardized Letter of Evaluation.

The Cost and Burden of the Residency Match in Emergency Medicine.

INTRODUCTION: To obtain a residency match, medical students entering emergency medicine (EM) must complete away rotations, submit a number of lengthy applications, and travel to multiple programs to interview. The expenses incurred acquiring this residency position are burdensome, but there is little specialty-specific data estimating it. We sought to quantify the actual cost spent by medical students applying to EM residency programs by surveying students as they attended a residency interview. METHODS: Researchers created a 16-item survey, which asked about the time and monetary costs associated with the entire EM residency application process. Applicants chosen to interview for an EM residency position at our institution were invited to complete the survey during their interview day. RESULTS: In total, 66 out of a possible 81 residency applicants (an 81% response rate) completed our survey. The "average applicant" who interviewed at our residency program for the 2015-16 cycle completed 1.6 away, or "audition," rotations, each costing an average of $1,065 to complete. This "average applicant" applied to 42.8 programs, and then attended 13.7 interviews. The cost of interviewing at our program averaged $342 and in total, an average of $8,312 would be spent in the pursuit of an EM residency. CONCLUSION: Due to multiple factors, the costs of securing an EM residency spot can be expensive. By understanding the components that are driving this trend, we hope that the academic EM community can explore avenues to help curtail these costs.

A Novel Source of Chest Pain in the Emergency Department.

This is a case report of a patient with an unusual presentation of an inferior vena cava (IVC) filter migration with a delayed presentation, and without electrical or valvular abnormalities. We discuss considerations and potential complications from IVC filter placement from the emergency physician perspective.

A Comprehensive View of Frequent Emergency Department Users Based on Data from a Regional HIE.

OBJECTIVES: A small but significant number of patients make frequent emergency department (ED) visits to multiple EDs within a region. We have a unique health information exchange (HIE) that includes every ED encounter in all hospital systems in our region. Using our HIE we were able to characterize all frequent ED users in our region, regardless of hospital visited or payer class. The objective of our study was to use data from an HIE to characterize patients in a region who are frequent ED users (FEDUs). METHODS: We constructed a database from a cohort of adult patients (18 years old or older) with information in a regional HIE for a 1-year period beginning in April 2012. Patients were defined as FEDUs (those who made four or more visits during the study period) and non-FEDUs (those who made fewer than four ED visits during the study period). Predictor variables included age, race, sex, payer class, county of residence, and International Classification of Diseases, Ninth Revision codes. Bivariate (χ(2)) and multivariate (logistic regression) analyses were performed to determine associations between predictor variables and the outcome of being a FEDU. RESULTS: The database contained 127,672 patients, 12,293 (9.6%) of whom were FEDUs. Logistic regression showed the following patient characteristics to be significantly associated with the outcome of being a FEDU: age 35 to 44 years; African American race; Medicaid, Medicare, and dual-pay payer class; and International Classification of Diseases, Ninth Revision codes 630 to 679 (complications of pregnancy, childbirth, and puerperium), 780 to 799 (ill-defined conditions), 280 to 289 (diseases of the blood), 290-319 (mental disorders), 680 to 709 (diseases of the skin and subcutaneous tissue), 710 to 739 (musculoskeletal and connective tissue disease), 460 to 519 (respiratory disease), and 520 to 579 (digestive disease). No significant differences were noted between men and women. CONCLUSIONS: Data from an HIE can be used to describe all of the patients within a region who are FEDUs, regardless of the hospital system they visited. This information can be used to focus care coordination efforts and link appropriate patients to a medical home. Future studies can be designed to learn the reasons why patients become FEDUs, and interventions can be developed to address deficiencies in health care that result in frequent ED visits.

Dermatomyositis with extensive calcification in an adult.

This report reviews a case of dermatomyositis presenting with weakness and extensive calcification in an adult. While dermatomyositis is not uncommon in adults, it is uncommon for calcifications to be present. Children develop calcifications more frequently than adults. When present in adults, small calcifications on areas of frequent trauma such as elbows and fingers are more common. However, this patient presented with large calcified deposits in his abdomen and extremities. His treatment and course are described.