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.

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.

Comparison of the multiple mini-interview with the traditional interview for U.S. emergency medicine residency applicants: a single-institution experience.

PURPOSE: The multiple mini-interview (MMI) is a validated interview technique used primarily to evaluate medical school applicants. No study has compared MMIs with traditional interviews (TIs) in the evaluation of U.S. emergency medicine residency (EMR) applicants. METHOD: During the 2011-2012 interview season, a four-station MMI was incorporated into the interview process for EMR applicants at Alameda Health System-Highland Hospital (AHS). A postinterview anonymous questionnaire was offered to all applicants after they submitted their rank lists but prior to release of National Residency Matching Program results. Respondents rated their perceptions of the MMI and TI on a five-point Likert scale. McNemar chi-square test was used to explore differences in respondents' perceptions of interview styles. RESULTS: One hundred ten interviewees completed the survey (73%). Overall, applicants found the TI more enjoyable than the MMI process (98 [89%] compared with 48 [44%], McNemar chi-square=28.66, P<.01) and preferred the TI process to the MMI (66 [60%] compared with 9 [10%], McNemar chi-square=40.81, P<.01). Sixteen applicants (14%) indicated that the use of the MMI would negatively affect their ranking of the program. CONCLUSIONS: In contrast to prior studies, U.S. EMR applicants to AHS preferred the TI to the MMI. Further investigation into the use of the MMI for selecting U.S. EMR applicants is warranted.

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.

Two cases where bedside ultrasound was able to distinguish pulmonary bleb from pneumothorax.

Distinguishing large pulmonary bullae from an acute pneumothorax can present a diagnostic challenge in the emergency setting. Plain film radiography of the chest may be inadequate to make the diagnosis. As the management of these two entities varies significantly, a clinical adjunct to aid diagnosis would prove useful. Using emergency department bedside ultrasound, we identified the typical "comet tailing" phenomenon of the movement of the lung tissue against the pleura during respiration, present in bullous disease but absent if the lung has collapsed. We present two patients, one with bullous emphysema and another with pneumothorax, in whom bedside ultrasound aided in making the diagnosis.

A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients.

OBJECTIVES: To determine if midazolam is superior to lorazepam or haloperidol in the management of violent and severely agitated patients in the emergency department. Superiority would be determined if midazolam resulted in a significantly shorter time to sedation and shorter time to arousal. METHODS: This was a randomized, prospective, double-blind study of a convenience sample of patients from an urban, county teaching emergency department. Participants included 111 violent and severely agitated patients. Patients were randomized to receive intramuscular midazolam (5 mg), lorazepam (2 mg), or haloperidol (5 mg). RESULTS: The mean (+/-SD) age was 40.7 (+/-13) years. The mean (+/-SD) time to sedation was 18.3 (+/-14) minutes for patients receiving midazolam, 28.3 (+/-25) minutes for haloperidol, and 32.2 (+/-20) minutes for lorazepam. Midazolam had a significantly shorter time to sedation than lorazepam and haloperidol (p < 0.05). The mean difference between midazolam and lorazepam was 13.0 minutes (95% confidence interval [95% CI] = 5.1 to 22.8 minutes) and that between midazolam and haloperidol was 9.9 minutes (95% CI = 0.5 to 19.3 minutes). Time to arousal was 81.9 minutes for patients receiving midazolam, 126.5 minutes for haloperidol, and 217.2 minutes for lorazepam. Time to arousal for midazolam was significantly shorter than for both haloperidol and lorazepam (p < 0.05). The mean difference in time to awakening between midazolam and lorazepam was 135.3 minutes (95% CI = 89 to 182 minutes) and that between midazolam and haloperidol was 44.6 minutes (95% CI = 9 to 80 minutes). There was no significant difference over time by repeated-measures analysis of variance between groups in regard to changes in systolic and diastolic blood pressure (p = 0.8965, p = 0.9581), heart rate (p = 0.5517), respiratory rate (p = 0.8191), and oxygen saturation (p = 0.8991). CONCLUSIONS: Midazolam has a significantly shorter time to onset of sedation and a more rapid time to arousal than lorazepam or haloperidol. The efficacies of all three drugs appear to be similar.

Ultrasound in emergency and ambulatory medicine

Our primary reason for writing this book is to help physicians interested in ultrasonography get started. While the scope and importance of ultrasonography has grown tremendously over the past several decades, the strategy for introducing ultrasonography into nontraditional settings of emergency medicine and primary care deserves special attention. The photographs, artist’s drawings, and graphics are selected to illustrate basic concepts as well as to provide a framework for more advanced use of the technology. Our aim is to make ultrasonography as accessible and clinically relevant as possible. The term “goal-directed ultrasound” means using the images as an integral part of the diagnostic and therapeutic process. Finally, this book is designed to get nonradiologists excited about the possibilities ultrasound can offer. We started out looking for the obvious right upper quadrant and pelvic pathologic conditions. Then we added the aorta and blood in the abdomen as a result of trauma and then blood around the heart. Later we began to visualize the internal jugular vein before placing our central venous lines and we looked at the heart during medical codes to definitively document pulseless electrical activity (PEA). More recently, we began looking at the kidneys to identify hydronephrosis, leg veins to assess for deep venous thrombosis, the space above the diaphragm to look for pleural effusion, and the soft tissues to identify foreign bodies or abscess formation. All these subjects and more are discussed in this book. Just before this text went to print we discovered another use for ultrasonography that has never been discussed in the literature. We had a morbidly obese patient from whom we were unable to obtain spinal fluid even with by visualizing the echos caused by her spine. The applications are exciting and can have a significant impact on the quality of patient care