J Emerg Med
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The American Board of Emergency Medicine joined nine other American Board of Medical Specialties member boards to sponsor the subspecialty of Hospice and Palliative Medicine; the first subspecialty examination was administered in 2008. Since then an increasing number of emergency physicians has sought this certification and entered the workforce. There has been limited discussion regarding the experiences and challenges facing this new workforce. ⋯ The Emergency and Hospice and Palliative Medicine integrated workforce is facing novel challenges, opportunities, and growth. The first few years have seen a growing interest in the field among emergency medicine resident trainees. As the dual certified workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care.
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Renal colic results in > 1 million ED visits per year, yet there exists a gap in understanding how the majority of these visits, namely uncomplicated cases, are managed. ⋯ For patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance. No consensus guidelines exist yet to address when to admit or utilize inpatient urologic procedures.
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Case Reports
Point-of-Care Ultrasound Diagnosis of Intravascular Air After Lower Extremity Intraosseous Access.
Vascular air embolism is a rare but potentially deadly phenomenon. Early diagnosis allows providers to initiate measures aimed at preventing further air entry, preventing the migration of air to the lungs, and mitigating the hemodynamic effects of pulmonary air embolism. ⋯ An emergency physician used point-of-care ultrasound to identify intravascular air before embolization to the pulmonary vasculature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Bedside ultrasound can be used as a tool for early diagnosis of intravascular air. Emergency physicians should be aware of the typical sonographic manifestations of intravascular air and the initial steps in treating vascular air embolism.
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The ghost pepper, or "bhut jolokia," is one of the hottest chili peppers in the world. Ghost peppers have a measured "heat" of > 1,000,000 Scoville heat units (SHU), more than twice the strength of a habanero pepper. To our knowledge, no significant adverse effects of ghost pepper ingestion have been reported. ⋯ A 47-year-old man presented to the Emergency Department (ED) with severe abdominal and chest pain subsequent to violent retching and vomiting after eating ghost peppers as part of a contest. A subsequent chest x-ray study showed evidence of a left-sided pleural effusion and patchy infiltrates. A computed tomography scan of the abdomen and pelvis showed pneumomediastinum with air around the distal esophagus, suggestive of a spontaneous esophageal perforation and a left-sided pneumothorax. The patient was intubated and taken immediately to the operating room, where he was noted to have a 2.5-cm tear in the distal esophagus, with a mediastinal fluid collection including food debris, as well as a left-sided pneumothorax. The patient was extubated on hospital day 14, and was discharged home with a gastric tube in place on hospital day 23. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous esophageal rupture, Boerhaave syndrome, is a rare condition encountered by emergency physicians, with a high mortality rate. This case serves as an important reminder of a potentially life- threatening surgical emergency initially interpreted as discomfort after a large spicy meal.
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Case Reports
Delayed Antitoxin Treatment of Two Adult Patients with Botulism after Cosmetic Injection of Botulinum Type A Toxin.
Injection of botulinum toxin type A for cosmetic purposes is common. It is believed to be safe, but adverse reactions have been reported, including dysphagia, generalized paralysis, respiratory depression, and death caused by focal injection of the toxin. Early administration of antitoxin in patients with adverse reactions is the mainstay of management, but the time window for its clinical efficacy is not well defined. ⋯ Two female adult patients with clinical botulism after botulinum toxin type A injection are described. Both patients had received intramuscular injection of botulinum toxin type A in their calves at beauty shops for cosmetic reasons. They developed clinical botulism about 3 days postinjection. They presented late to the emergency department. Monovalent type A botulinum antitoxin was administered 7 and 9 days from symptom onset, respectively. Both patients showed clinical improvement after the antitoxin treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients may present to the emergency department with systemic effects of botulinum toxin type A after cosmetic injection. Clinical efficacy of botulinum antitoxin treatment was observed in two patients who were given the drug 7 and 9 days after the occurrence of symptoms of botulism after cosmetic injection of botulinum toxin type A. It may be worthwhile to commence antitoxin treatment even if patients present late.