AEM Education and Training 15: Science Policy Training for a New Physician Leader

Welcome to the fifteenth episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON TITLE TO ACCESS):

Science Policy Training for a New Physician Leader: Description and Framework of a Novel Climate and Health Science Policy Fellowship. Jay Lemery, MD, Cecilia Sorensen, MD, John Balbus, MD, MPH, Lee Newman, MD, MA, Christopher Davis, MD, Elaine Reno, MD, Renee Salas, MD, MPH, MS, Emilie Calvello Hynes, MD, MPH

LISTEN NOW: INTERVIEW WITH FIRST AUTHOR Jay Lemery, MD, FACEP, FAWM

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Jay Lemery, MD, FACEP, FAWM

Professor of Emergency Medicine

University of Colorado School of Medicine

Abstract

The accelerating health impacts of climate change are undermining global health, and the roles of the health sector in addressing the many challenges of climate change are being articulated by governments, multilateral institutions, and professional societies. Given the paucity of physician engagement on this issue to date, there now exists a clear need for health professionals to meet this new challenge with the development and cultivation of new knowledge and skill sets in public health, environmental science, policy, and communication. We describe a novel GME fellowship in climate and health science policy, designed to train a new generation of clinicians to provide the necessary perspective and skills for effective leadership in this field. This fellowship identifies available university resources and leverages external collaborations (government, medical consortiums, affiliate institutions in public health, and environmental science), which we describe as being replicatable to similar training programs of any number of medical specialties and likewise bring meaningful opportunities to their respective training programs and academic departments. The creation of this novel fellowship in climate and health policy provides a roadmap and potential path for similar programs to join us in addressing the defining health issue of this generation and many to follow.

Give 'Em the Old One-Two: Boxer's Fracture

Case

A healthy 22-year-old right-handed man presents to the ED with right hand pain. He reluctantly endorses punching a concrete wall with an ungloved fist. On exam, the patient is holding his hand with fingers in partial flexion. There is mild swelling over the third through fifth MCPs with mild erythema and intact skin. Neurovascular exam is normal. Plain films were obtained.

Courtesy of Radiopedia.com

Courtesy of Radiopedia.com


What is the Diagnosis?

Fractured neck of fifth metatarsal. AKA, Boxer’s fracture

Overview

Boxer’s Fractures are a very common injury seen in the ED. Highest incidence are in men 10-19 years followed by men 20-29 years. The two most common mechanisms of injury are falls or direct blows with high axial loads (i.e. punching a fixed, inelastic object). Interestingly, despite the name, these fractures are not typically seen in experienced boxers, as boxing training aims to teach one to lead with the first and second knuckles, aligning the forces of impact into an axial load that transmits and distributes force through the larger bones and joints of the forearm and upper arm. Studies have suggested roughly 30% of hand fractures are metacarpal fractures and they account for nearly 19% of ER fracture visits. The metacarpal neck is the most commonly fractured site. The fifth metacarpal is the most commonly fractured metacarpal. Fractures to the first metacarpal are less common and are often managed operatively. First metacarpal fractures include Bennett’s fractures (fracture-dislocation of the base of the first metacarpal), and Rolandos fractures (comminuted version of Bennett’s fracture) and can also occur as a result of an axial load mechanism such as punching.

Evaluation 

Typical symptoms include tenderness or pain focally over the distal metacarpal. Physical examination should include careful inspection for possible “fight bites” given the common potential mechanism of injury. Comparing to the uninjured hand can help highlight distorted anatomy. Evaluate for possible rotational misalignment of the metacarpals by observing convergence of the finger tips with flexed MCPs and PIPs. Note that in this position, phalanxes should point to the scaphoid. Evaluate for extensor mechanism injuries. Due to the intrinsic pull of the interosseus muscles, metacarpal neck fractures typically result in dorsal angulation of the apex of the fracture, resulting in a clinical appearance of a depressed MCP joint. 

Radiology

Obtain AP, oblique, and lateral hand films

Special views: 

Brewerton View

Brewerton View

Roberts View

Roberts View

Indications for CT:

  • Inconclusive plain films with high clinical suspicion for injury

  • Complex fractures of metacarpal head

  • Multiple CMC dislocations

Associated injurieS:

Given the mechanism, skin break or lacerations over the knuckle may not only represent a potential open fracture, but should also lend themselves to a high degree of suspicion for a “fight bite,” with associated microbiological concern, and managed accordingly. Other fight-related injuries should also be considered and evaluated for as well.

Management:

Not all metacarpal fractures are managed the same. Important factors in management include degrees of shaft angulation and length of metacarpal shaft shortening, dependent on which metacarpal is injured, neurovascular status, and whether the injury is open or closed.

METACARPAL ACCEPTABLE DEGREE OF SHAFT
ANGULATION (degrees)
2nd 10
3rd 20
4th 30
5th 40

Operative indications:

  • Unacceptable degree of angulation (per table above)

  • Unacceptable shaft shortening >5 mm regardless of metacarpal

  • Rotational deformity of any digit >10 degrees

  • Multiple fractures

  • Intraarticular fracture or involvement of metacarpal head

  • Most first metacarpal fractures (Bennett’s and Rolando)

Non-Operative Treatment:

  • Analgesia

    • Consider an ulnar nerve block!

  • Reduction 

    • Using a c-arm for real-time X-ray feedback may be helpful. 

    • Jahss technique: 90 degrees flexion of MCP and the PIP (AKA 90-90 approach). Apply dorsal pressure to the proximal phalanx while stabilizing metacarpal shaft.

Jahss Technique

Jahss Technique

  • Splint 

    • Ulnar gutter for immobilization of the fourth and fifth metacarpals

    • Volar splint for immobilization of the second and third metacarpals.

  • Ice

  • Elevation

  • Tylenol/NSAIDs

  • Referral to hand surgeon for follow-up

Take home points:

  • Boxer’s Fractures are a common injury, most often seen in young men.

  • Consider wounds associated with these fractures as potential fight bites given the mechanism

  • The more radial the metacarpal involved, the less degree of angulation is acceptable without surgical intervention, while there is no degree of acceptable malrotation

Faculty Reviewer: Dr. Nicholas Asselin

References: 

  1. Nakashian et al. Incidence of metacarpal fractures in the US population. Hand. 2012. 7(4):426. 

  2. Ashkenaze and Ruby. Metacarpal fractures and dislocations. Orthopedic Clin North Am. 1992 23:19. 

  3. Haughton et al. Principles of hand fracture management. Open Orthop Journal. 2012. 6;43-55. 

AEM Education and Training 14: Emergency Medicine Resident Efficiency and Emergency Department Crowding

Welcome to the fourteenth episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

AEM E and T Podcasts logo[1].png

DISCUSSING (CLICK ON TITLE TO ACCESS):

Emergency Medicine Resident Efficiency and Emergency Department Crowding. Ryan Kirby, MD, Richard D. Robinson, MD, Sasha Dib, MD, Daisha Mclarty, MD, Sajid Shaikh, MS, Radhika Cheeti, Amy F. Ho, MD, Chet D. Schrader, MD, Nestor R. Zenarosa, MD, Hao Wang MD, PhD

LISTEN NOW: INTERVIEW WITH AUTHORS Ryan Kirby, MD and Hao Wang MD, PhD

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Ryan Kirby, MD, FACEP

Residency Program Director, Department of Emergency Medicine, John Peter Smith Health Network

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Hao Wang MD, PhD, FACEP

Research Director, Department of Emergency Medicine, John Peter Smith Health Network

Abstract

Objectives

Provider efficiency has been reported in the literature but there is a lack of efficiency analysis among emergency medicine (EM) residents. We aim to compare efficiency of EM residents of different training levels and determine if EM resident efficiency is affected by emergency department (ED) crowding.

Methods

We conducted a single‐center retrospective observation study from July 1, 2014, to June 30, 2017. The number of new patients per resident per hour and provider‐to‐disposition (PTD) time of each patient were used as resident efficiency markers. A crowding score was assigned to each patient upon the patient's arrival to the ED. We compared efficiency among EM residents of different training levels under different ED crowding statuses. Dynamic efficiency changes were compared monthly through the entire academic year (July to next June).

Results

The study enrolled a total of 150,920 patients. A mean of 1.9 patients/hour was seen by PGY‐1 EM residents in comparison to 2.6 patients/hour by PGY‐2 and ‐3 EM residents. Median PTD was 2.8 hours in PGY‐1 EM residents versus 2.6 hours in PGY‐2 and ‐3 EM residents. There were no significant differences in acuity across all patients seen by EM residents. When crowded conditions existed, residency efficiency increased, but such changes were minimized when the ED became overcrowded. A linear increase of resident efficiency was observed only in PGY‐1 EM residents throughout the entire academic year.

Conclusion

Resident efficiency improved significantly only during their first year of EM training. This efficiency can be affected by ED crowding.