When Educational Images Don't Reflect the Population: Phlegmasia Cerulea Dolens, a Case Report.

Introduction: Phlegmasia cerulea dolens (PCD) is an uncommon, potentially life-threatening complication of acute deep venous thromboses that requires a timely diagnosis. The name of the condition, the visual diagnostic criteria, and the preponderance of cases in the literature referencing findings exclusively in patients with lighter skin complexions means that PCD may not be on the differential diagnosis for the patient with more melanated skin who is experiencing this time-sensitive vascular emergency. Case Report: We describe one case of PCD in a patient with darker skin complexion and the importance of identifying clinical findings, regardless of skin color, given the paucity of reference images for PCD in darker complected patients. Our literature review yielded 60 case reports for PCD. Only two papers included images referencing patients of color. Conclusion: Accurate diagnosis requires recognition of diagnostic findings, which may vary significantly between phenotypically distinct populations. Many pathognomonic physical exam findings rely on descriptors based on presentation in phenotypically white patients.

Arterial insufficiencies: Central retinal artery occlusion.

Central retinal artery occlusion (CRAO) is a relatively rare emergent condition of the eye resulting in sudden painless vision loss. This vision loss is usually dramatic and permanent, and the prognosis for visual recovery is poor. A wide variety of treatment modalities have been tried over the last 100 years with little to no success, with the exception of hyperbaric oxygen therapy. The optimum number of treatments will vary depending on the severity and duration of the patient's symptoms and the degree of response to treatment. The majority of patients will stabilize within a few days after symptom onset. Utilization review is recommended for patients treated for more than three days after clinical plateau.

HBO2 for sudden sensorineural hearing loss.

Sudden sensorineural hearing loss (SSNHL) presents as an abrupt onset of hearing loss; 88% of these presentations are idiopathic (ISSHL). Many mechanisms of injury and etiopathologies have been postulated, but they share a common result - hypoxia of the organ of Corti leading to hair cell-cilia fusion, synaptic, dendritic swelling and sustained depolarization. Of all of the various treatments tried, only corticosteroids and hyperbaric oxygen (HBO2) therapy have shown benefit in randomized controlled trials (RCTs). This paper reviews the pathophysiology of SSNHL, the variety of treatments studied, and the best evidence (both retrospective case controlled and prospective randomized controlled studies) for the use of HBO2 and corticosteroids. The best results are obtained when these two treatments are combined and initiated within 14 days of symptom onset. HBO2 is given at 2-2.5 ATA for 90 minutes for 10-20 sessions. Steroids should be dosed at 1mg/kg/day and slowly tapered over two to three weeks. If a patient is not a good candidate for or refuses systemic steroids, good results have also been obtained using intratympanic (IT) steroids in combination with HBO2. Patients should be followed by and otolaryngologist before, during and following HBO2. For severe hearing loss treatment with HBO2 improves by 37.7 dB, 19.3dB for those with moderate loss and 15.6 dB improvement overall. These recoveries, on average, improve a patient's hearing from ranges requiring hearing aids and sign language, to levels at which normal or near-normal hearing is restored.

Management of central retinal artery occlusion following successful hyperbaric oxygen therapy: case report.

OBJECTIVE: This case report presents a patient with central retinal artery occlusion (CRAO) who was successfully treated with hyperbaric oxygen (HBO2) but subsequently suffered a recurrence of his visual loss. METHODS: CRAO may be treated successfully with HBO2 if treatment is undertaken promptly after the onset of vision loss. The goal of HBO2 therapy is to oxygenate the ischemic inner retinal layers via diffusion from the hyperoxygenated choroidal circulation until recanalization of the central retinal artery occurs. RESULTS: A 71-year-old man presented with hand motion vision and fundus findings of CRAO in his left eye. Treatment with HBO2 was initiated approximately 9.5 hours after loss of vision. The patient experienced return of vision to a near-normal level during HBO2. His vision loss recurred, however, 15 minutes after the HBO2 session. There was a delay to follow-up HBO2 treatments, and the improvement of vision that resulted from these subsequent HBO2 sessions was much less than that experienced during his initial HBO2 treatment. CONCLUSION: Recovery of vision during initial HBO2 treatment indicated that this patient's retina had not yet suffered irreversible ischemic damage at that point in time. CRAO patients with a good result from initial HBO2 treatment should be admitted to a stroke center and should have their visual status monitored hourly. Should vision loss recur, aggressive use of intermittent 100% normobaric and hyperbaric oxygen is indicated to preserve retinal function until central retinal artery recanalization occurs. An evidence-based management plan for such patients is presented.

Medical students' perceptions of an emergency medicine clerkship: an analysis of self-assessment surveys.

BACKGROUND: No studies have been performed that evaluate the perceptions of medical students completing an emergency medicine (EM) clerkship. Given the variability of exposure to EM in medical schools nationwide, assessment of the student rotation may inform the structure and content of new and existing clerkships, particularly in relation to student's acquisition of the core competencies. OBJECTIVES: To investigate whether undergraduate medical students rotating through an EM clerkship improved their understanding and abilities in core content areas and common procedural skills; to evaluate whether improvement was affected by rotation length. METHODS: All students participating in an EM clerkship over a 12-month period were asked to complete an anonymous voluntary pre- and post-rotation survey. Confidence with patient assessment, diagnosis, and management plans; trauma and medical resuscitations; formal and informal presentations; basic procedure skills and understanding of the modern practice of EM were self assessed using a Likert scale. Group mean scores on each question on the pre- and post-clerkship surveys were calculated and compared. The mean scores on each survey item, both pre- and post-clerkship, were compared between 2- and 4-week clerkship rotation groups. RESULTS: Two hundred thirty-nine students participated in the rotation during the 12 months of the study. One hundred sixty-one (161), or 67.4%, completed the pre-rotation survey, and 96 (40.2%) completed the post-rotation survey. Overall, students showed significant mean gains in confidence with initial patient assessment, diagnosis, and management plans (p < 0.01, 0.02, <0.01) and with basic procedure skills (p < 0.01 for all). Students completing a 2-week rotation did not differ significantly from f4week rotators in confidence levels, except in the area of formal presentation skills (p = 0.01), where the 4-week students demonstrated a statistically significant advantage. The 2-week clerkship participants were significantly less confident in all procedures except EKG interpretation, splinting, and venipuncture (p = 0.28, 0.22, 0.05). Regardless of rotation length, students generally felt they had sufficient exposure to patients and opportunities for hands-on learning and practice, and overwhelmingly would recommend the EM clerkship to a fellow student, regardless of their chosen specialty. CONCLUSIONS: Medical students show significant gains in confidence with acute care knowledge, disease management, and procedure skills after completion of an EM clerkship. Although a 4-week clerkship may be preferable to expose students to the widest variety of patients and procedures, all students can benefit and improve in core competencies after an EM undergraduate experience.

Acute, painless vision loss.

This article provides a review of various conditions causing sudden, painless vision loss. The conditions of amaurosis fugax, central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), vitreous hemorrhage, ischemic optic neuropathies (ION), posterior cerebrovascular accidents, and retinal detachment (RD) are discussed. The history, physical, pathophysiology, and treatment of each disease state are discussed along with possible preventative measures for each. An emphasis is made on early ophthalmologic involvement for potential vision restoration and the importance of a thorough history and physical for all patients with ocular complaints.

Hyperbaric oxygen improves rate of return of spontaneous circulation after prolonged normothermic porcine cardiopulmonary arrest.

AIM: This controlled, prospective, randomized porcine study tests the hypothesis that high-dose hyperbaric oxygen (HDHBO2) compared with normobaric oxygen (NBO2) or standard-dose hyperbaric oxygen (SDHBO2), improves return of sustained spontaneous circulation (ROSC) after a normothermic, normobaric, 25-min, non-intervened-upon cardiopulmonary arrest. The study incorporated a direct mechanical ventricular assist device (DMVAD) for open chest continuous cardiac compressions (OCCC) to assist advanced cardiac life support (ACLS). The experiment demonstrates a dose response to oxygen concentration in the breathing mix used in resuscitative ventilation. MATERIALS AND METHODS: Male pigs (average 30kg weight) underwent a 25-min, normothermic, non-intervened-upon cardiopulmonary arrest. Following arrest all animals were ventilated with 100% oxygen and were subjected to OCCC, incorporating DMVAD-aided ACLS. The animals so treated were randomized to be in one of three groups, with six animals in each group. The NBO2 group remained at 1.0 atmosphere absolute (ATA), while the SDHBO2 and HDHBO2 groups were initially placed at 1.9 and 4.0ATA, respectively. Uniform, but not American Heart Association (AHA) protocol, ACLS was maintained as needed over the ensuing 2h for all animals in all groups. At the end of 2h, the animals were euthanized. RESULTS: Continuously sustained ROSC (mean arterial pressure > or =50mmHg at all times), without the need of the pump assist over the 2-h resuscitation attempt that followed the 25-min arrest, occurred in four out of six animals in the HDHBO2 group, and in none of the animals in the NBO2 or SBHBO2 groups (p< or =0.001). CONCLUSIONS: Our results show significantly sustained ROSC using HDHBO2 to resuscitate swine after a 25-min, non-intervened-upon, normothermic cardiopulmonary arrest. These results could not be achieved using NBO2 or SDHBO2.