Education

Mobile Applications for the ED Provider

We conducted an online survey of the approximately 200 EM providers (attendings, fellows, residents, nurse practitioners, and physician assistants) affiliated with BrownEM. The survey asked providers which medical apps they had downloaded on their mobile devices and which apps they actually used on a regular basis. Ninety-nine providers answered the survey (response rate 49.5%); the distribution of respondents was 51% attendings, 33% residents/fellows, and 16% NPs/PAsThe results of the survey are presented below, categorized by type of mobile app. Most of the apps and resources described below are widely used and highly circulated throughout the emergency medicine community. Just as in consumer mobile health, we found that although many apps are downloaded, few are used on a regular basis; on average, BrownEM providers reported that they had six medical apps downloaded on their phone, but only regularly used two. Highlighted below are the apps that providers most frequently find themselves using in day to day practice. BrownEM has no financial ties to any of these applications or their developers.

 

Just in time resources (percent of respondents using the app)

Epic.png

1. Epic Haiku

(77%)

The essential companion application for the Epic EMR. The most useful feature is the ability to capture clinical images and upload them to the patient’s chart. Because sometimes a picture really is worth a thousand words.

iOS | Android

UptoDate.png

2. UpToDate

(38%)

One of the most widely used, peer reviewed online reference sources for physicians. A great resource for a quick refresher on a topic, however much information is not necessarily important for ED management.

iOS | Android

MDcalc.png

3. MD Calc

(26%)

An app that aggregates clinical decision rules, medical formulas, and other hard to remember checklists/criteria. Simple to use, free to download. Also available online.

iOS | Android

Epocrates.png

4. Epocrates

(24%)

All-in-one application with guidelines, pill identification, drug interaction tool, drug monographs, and more. Free app with limited features, or a premium version is available.

iOS | Android

Abx Guide.png

5. EMRA Antibiotics Guide

(20%)

The official antibiotics guide published by EMRA. The app requires a $20 investment but is updated yearly with new recommendations for drug choices. An incredibly helpful resource for when you can’t quite remember what drug to reach for or its dosing.

iOS | Android

 

Runner Ups

WikiEM.png

WikiEM

Mobile version of the opensource, wikipedia-like encylopedia of emergency medicine. A good quick reference with the caveat of it being publicly editabe.

iOS | Android

Medscape.png

MedScape

Similar to Epocrates but is free and has an offline version. Good resource for pill identification, drug info, and drug interactions.

iOS | Android

Eye Chart

A simple, straightforward app for checking visual acuity at 4ft.

iOS

 

When looking at the educational resources used in our department, there is one clear winner. EM:RAP is the go-to resource used by almost every single survey respondent. A few apps are featured below that may be worth investigating as they are fun, educational, and easy to use.

Educational resources (percent of respondents using the app)

EMRap.png

EM:RAP

(97%)

The well-known and almost ubiquitous EM:RAP is an excellent way to keep current. With new podcasts and content published on a monthly basis it can be considered an EM staple. Paid subscription is required for the content, but the app is free.

iOS | Android

QxRead.png

QxRead

(17%)

A literature aggregator. Fill in your specialty, favorite journals, and areas of interest and it will pull together recent articles geared towards your interests. An amazing way to keep up with the literature. It integrates with Brown’s library system to access articles.

iOS | Android

ECG Guide.png

ECG Guide

 

(7%)

Great for refreshing yourself on ECGs findings. Has over 200 ECGs that you can be quizzed on with teaching pearls. $0.99

iOS | Android

 

Suggested Apps

OneMinuteUS.png

1 Minute Ultrasound

60 second video clips of the bread and butter EM ultrasound scans. Perfect for showing students or a quick refresher before going into a room.

iOS | Android

Resuscitation!

A series of interactive clinical vignettes where you must chose the correct workup, management, and disposition for an evolving patient presentation.

iOS | Android

Figure1.png

Figure 1

Think of this app as “Instagram for doctors” but with an educational twist. Users submit images of interesting cases for discussion. Check out our account @BrownEM

iOS | Android

 

Finally, multiple providers made suggestions for resources they find incredibly helpful but are not app based. Below is a compilation of some of the top websites, programs, resources, and organizational tools that help some of us keep it together.

Evernote – A could based platform for organizing notes, documents, and files across multiple devices.

Dropbox and Google Drive – Online cloud storage platforms that allow for the sharing of documents, images, files across computers and with other users. Essential tools for the modern EM provider.

Lexicomp – A comprehensive drug reference with information regarding dosing, efficacy, and adverse effects. Access is provided for free through Lifespan intranet. A mobile app is also available to download.

Podcasts – By now most folks have gotten a taste of the podcast life. Everybody has their favorites depending on their interests. A couple of podcasts that this author has found to be particularly high yield are:

  • Pediatric Emergency Playbook – bread and butter PediEM cases and core content
  • EMCRIT – Scott Weingart’s pride and joy, cutting edge stuff but lots of opinions
  • UltrasoundPodcast – From scanning basics to literature reviews, they have it all
  • FOAMCast – brings together the best of FOAM, new literature, and core content
  • GEL Podcast – a new ultrasound podcast discussing the evidence behind scanning
  • EM Basic – as the name implies, bread and butter EM basics
  • ED ECMO – high tech critical care brought into the world of EM

BrownEM has recently taken the plunge into the podcasting world under the guidance of Dr. Gita Pensa. Check out the BrownEM podcast here.

Twitter – with thousands of EM docs tweeting daily, there is a niche interest for everybody in the FOAMed (Free Open Access Medical Education) Twitter-verse. Critical care, airway management, wellness, education, sex and gender, ophtho, anesthesia – you name it, and somebody is tweeting about it. **Buyer beware, the veracity of some tweets cannot be guaranteed**

Blogs – the online companions to many podcasts, twitter accounts, and residency programs. Great sources of information that usually have posts on relevant and interesting topics, with useful images, original content, and amazing references.  The two most highly recommended by our providers are Life in the Fast Lane and Academic Life in Emergency Medicine

Faculty Reviewer: Megan Ranney, MD

Humpty Dumpty had a Great Fall

Case:

A 54-year-old male presented to the ED after falling from a 10-foot ladder while painting his home. He complains of left foot pain, especially in the heel. Examination reveals edema of the left posterior foot, and he is unable to bear weight. 

 Figure 1: Left foot physical examination findings. https://www.aofas.org/PRC/conditions/Documents/Calcaneal-fracture.pdf

Figure 1: Left foot physical examination findings. https://www.aofas.org/PRC/conditions/Documents/Calcaneal-fracture.pdf

 Figure 2: Plain films of the left foot. http://radiopaedia.org/cases/calcaneal-fracture-and-associated-spinal-injury

Figure 2: Plain films of the left foot. http://radiopaedia.org/cases/calcaneal-fracture-and-associated-spinal-injury

A fracture of the calcaneus can be a painful and devastating injury. Although uncommon, calcaneal fractures can lead to long-term disability. Physical examination of the ankle can be misleading and radiographic evidence can be difficult to interpret making a high index of suspicion in the right clinical setting important. The most common mechanism for a calcaneal fracture is high-energy trauma to the foot. Seventy-two percent of these fractures result from falls,[i] but other high-energy mechanisms, such as motor vehicle crashes, can also cause calcaneal injury.  

Types of Calcaneal Fractures:

There are two broad categories of calcaneal fractures: extra-articular and intra-articular:

25-30% of fractures are extra-articular. All fractures that do not involve the posterior facet are included in this category. These include calcaneal tuberosity avulsion fractures and extra-articular Lover’s fracture. The name is derived from the fact that a suitor may jump from the bedroom window while trying to escape from the lover's spouse.    

Calcaneal fractures are more frequently intra-articular, involving the subtalar joint (the calcaneus and the talus form the subtalar joint). A lover fracture may be intra- or extra-articular.

Clinical Presentation:

Patients often present after a fall from a height with complaints of heel pain and swelling. Examination of the patient with a foot or ankle injury follows the standard approach; inspection, palpation, range of motion testing, etc.  The heel may appear short and wide when compared to the non-injured foot. A hematoma extending to the sole of the foot is called "Mondor Sign" and is highly suspicious for calcaneal fracture. Remember to closely examine the skin for lacerations, blisters, and tenting.

Imaging:

Fractures of the calcaneus can be very subtle, and these fractures often are missed on radiographs. When the mechanism of injury or exam is highly suggestive of calcaneus fracture, lateral radiographs should be evaluated by measuring Bohler's angle or the critical angle of Gissane. The axial (Harris) view of the foot may demonstrate widening of the heel or lateral wall displacement. This view should be obtained if the standard films are negative but strong clinical suspicion exists. Comparison views are helpful if the diagnosis remains in question.

It is also important to differentiate calcaneal fractures based on whether they are intra-articular or extra-articular, and displaced or nondisplaced, as these findings will dictate treatment. CT imaging is often necessary to better define the extent of the fracture. Multiple classification schemes have been used for calcaneus fractures, the most popular of which is the Sanders classification system used to describe intra-articular calcaneal fractures. This classification is based on the number of intra-articular fracture lines and their locations on CT imaging. Type I fractures are non-displaced. Type II have two articular fragments. Type III has three articular fragments. Type IV fractures have more than three articular fragments and are highly comminuted.[ii]  

MRI has a limited but potentially important role in select cases. If an occult non-displaced calcaneus fracture is suspected (e.g., persistent symptoms plus suggestive but indeterminate findings on CT), MRI may be used to confirm or rule-out a fracture. MRI is also sensitive for detecting stress fractures of the calcaneus.

Bohler's Angle:

On lateral radiograph, Bohler's angle is the angle between two tangent lines drawn across the anterior and posterior aspects of the superior calcaneus on the lateral view. A Bohler angle of less than 20° suggests calcaneal fracture[iii], though a normal Bohler angle does not exclude fracture.

 Figure 3: Bohler's angle. http://www.wikiradiography.net/page/Calcaneal+Fractures

Figure 3: Bohler's angle. http://www.wikiradiography.net/page/Calcaneal+Fractures

Critical Angle of Gissane:

Measured on lateral radiograph, this “critical angle” is formed by the downward and upward slopes of the calcaneal superior surface. A normal angle of Gissane measures between 100 and 130 degrees, with a greater angle indicating fracture of the posterior subtalar articular surface.

 Figure 4: Gissane's Angle. https://dailyem.files.wordpress.com/2013/12/gissane.jpg

Figure 4: Gissane's Angle. https://dailyem.files.wordpress.com/2013/12/gissane.jpg

In 2006, Knight et al. published a randomized case-control trial evaluating the use and aid of Bohler’s angle and critical angle of Gissane. Of emergency department physicians studied, 97.9% were able to make an accurate diagnosis of calcaneus fracture without the benefit of measuring either angle on lateral radiograph.[iv]

Case Continued:

Our patient is also complaining of low back pain in addition to his heel pain. Examination of the lower back reveals axial lumbar tenderness without neurologic deficits.

Consider Associated Injuries:

Patients with calcaneus fractures often have concurrent injuries, and it is important to consider this possibility in their evaluation. Following major trauma, an obvious deformity of the hindfoot or ankle injury may distract us from these other injuries.  In addition to bony injuries, the amount of force required to fracture the calcaneus can cause damage to the surrounding soft tissues. Patients can develop compartment syndrome in the “calcaneal compartment” which, if left untreated, can lead to claw toe deformity. Up to 10% of calcaneal fractures will develop compartment syndrome and half of these can develop foot deformities, including clawing of the toes.[v]

High-energy impact to the feet can be accompanied by other lower extremity fractures in 25% of patients, vertebral injuries in 10% of cases, and contralateral calcaneus injuries in 7%.[vi] The mechanism of injury often involves a substantial load to the axial skeleton, such as jumping from a second story window. Therefore, a careful and focused spine evaluation is warranted. A thorough and focused tertiary survey should aim to rule out other injuries in common areas, in particular the thoracolumbar spine.

Figure 5: L1 Burst Fracture. http://radiopaedia.org/cases/calcaneal-fracture-and-associated-spinal-injury

Treatment:

Nondisplaced fractures (Sanders Type I) can be treated nonoperatively. In general, patients should be placed in a bulky compression dressing (Jones dressing) until the initial swelling subsides. The dressing can then be replaced by a removable splint or boot to begin range-of-motion exercises of the ankle and the subtalar joint. Non-weight-bearing for at least 6 weeks after injury is recommended.

Displaced intra-articular fractures require surgical intervention, and it is important to arrange for prompt orthopedic follow-up. Emergent orthopedic consultation is required for open fractures, fractures associated with neurovascular injury, fractures associated with dislocation (which must be reduced immediately), and suspicion or diagnosis of acute compartment syndrome.

Figure 6: Surgically repaired calcaneal fracture. http://orthoinfo.aaos.org/topic.cfm?topic=A00524

The Take Home:

  • Physical examination of the ankle can be misleading and radiographic evidence can be difficult to interpret. It is important to have a high index of suspicion for calcaneal fracture in the appropriate clinical setting.
  • Bohler’s angle can be used to identify subtle fractures. Less than 20 degrees is consistent with a calcaneus fracture.
  • CT is the imaging modality of choice in evaluating calcaneal fractures.
  • ED physicians should always consider the possibility that calcaneus fractures can be bilateral and associated with other lower extremity fractures and/or thoracolumbar spine fractures. 
  • An important early complication is acute compartment syndrome.
  • Emergent orthopedic surgery consultation is necessary for intra-articular, open, or displaced calcaneal fractures.
  •  

Reviewed by Dr Jeffrey Feden, Attending and Assistant Professor and Dr Neha Raukar, Attending, Assistant Professor and Director, Division of Sports Medicine, Department of Emergency Medicine, Alpert Medical School of Brown University.

References:

[i] Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Foot (Edinb). 2009 Dec;19(4):197-200. doi: 10.1016/j.foot.2009.05.001. PubMed PMID: 20307476.

[ii] Daftary A, Haims AH, Baumgaertner MR. Fractures of the calcaneus: a review with emphasis on CT. Radiographics. 2005 Sep-Oct;25(5):1215-26. Review. PubMed PMID: 16160107.

[iii] Isaacs JD, Baba M, Huang P, Symes M, et al. The diagnostic accuracy of Böhler's angle in fractures of the calcaneus. J Emerg Med. 2013 Dec;45(6):879-84. doi: 10.1016/j.jemermed.2013.04.055. Epub 2013 Sep 17. PubMed PMID: 24054885.

[iv] Knight JR et al. Boehler’s angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. 2006. Am J Emerg Med, Jul; 24 (4): 423-427.

[v] Germann CA, Perron AD, Miller MD, Powell SM, Brady WJ. Orthopedic pitfalls in the ED: calcaneal fractures. Am J Emerg Med. 2004 Nov;22(7):607-11. Review. PubMed PMID: 15666272.

[vi] Weedier IS, Charted J: Emergency Department Evaluation and Treatment of Ankle and Foot Injuries. Emergency Medicine Clinics of North America 2000;18:85-113.

 


 

Keep Your Eye on the Target: POCUS for Intussusception

Case:

HPI: An 18 month old previously healthy female with a history of mild intermittent constipation, but no prior abdominal surgeries presented to the ED with 3 days of non-bilious, non-bloody emesis and abdominal pain not responsive to laxatives and Zofran. On the day of presentation she developed multiple episodes of screaming associated with grabbing her stomach and pulling up her legs. Episodes lasted for 30 seconds to 1 minute and self-resolved. She was afebrile. Oral intake and urine output were decreased, and she had no stools on the day of presentation. Her last bowl movement was 1 day prior to presentation and was loose without blood. The patient had nasal congestion and rhinorrhea the prior week.

Vitals: Pulse 124 | Temp 98.7 °F (37.1 °C) | Resp 26 | Wt 15.7 kg | SpO2 98%

Exam: Unremarkable with the exception of diffuse abdominal tenderness and voluntary guarding, but no rebound. No hepatosplenomegaly was appreciated. Bowel sounds were diminished.

Given the story and exam, the clinical suspicion for intussusception was high, and an initial two view abdominal x-ray was obtained: 

  Figure 1:  Abdominal Xrays

Figure 1: Abdominal Xrays

2 View Abdominal x-ray revealed a soft tissue mass in the right upper quadrant concerning for intussusception (arrows). A comprehensive ultrasound confirmed ileocolic intussusception.

A bedside point-of-care ultrasound was performed while patient was awaiting comprehensive radiographic evaluation. A donut-shaped mass was visualized in the right lower quadrant, consistent with ileo-colic intussusception.

  Figure 2a:  Cross-sectional view of a donut-shaped mass, consistent with intussusception

Figure 2a: Cross-sectional view of a donut-shaped mass, consistent with intussusception

  Figure 2b:  Longitudinal view of the intussusception

Figure 2b: Longitudinal view of the intussusception

The patient underwent a successful air-enema reduction. Post air reduction, the left lateral decubitus film shows resolution of the paucity of gas previously seen in the RUQ.

  Figure 3:  Post reduction xray

Figure 3: Post reduction xray

Epidemiology of Intussusception:

Intussusception is the most common abdominal emergency in early childhood, particularly among children younger than 2 years of age. Approximately 60% of children with intussusception are less than 1 year old and 80-90% are less than 2 years old. Additionally, it is the most common cause of intestinal obstruction in infants between 6 and 36 months and there is a slight male predominance, with a male:female ratio of approximately 3:2.

Intussusception in this age group most often occurs at the ileocecal junction, leading to ileocolic intussusception. The intussusceptum, a proximal segment of bowel, telescopes into the intussuscipiens, a distal segment.

Approximately 75 percent of cases of intussusception in children are considered to be idiopathic because there is no clear disease trigger or pathological lead point. Mesenteric lymph nodes may act as a lead point and may occur in the setting of gastroenteritis (both viral and bacterial), viral upper respiratory illnesses, flu-like illnesses, and adenovirus. Henoch-Schönlein purpura, HSP, is also associated with intussusception, but more commonly ileo-ileal. Non-infectious causes of lead points include Meckels, polyps, tumors (lymphoma), hematomas, vascular malformations, duplication cysts, and post-operative scarring.

Clinical Features:

The classic presentation of intussusception includes sudden onset intermittent, severe, crampy, and progressive abdominal pain, accompanied by inconsolable crying and drawing up the legs towards the abdomen, with return to baseline between episodes. As lethargy may follow episodes of abdominal pain, intussusception should be on the differential diagnosis for any young child presenting with unexplained lethargy or altered mental status. Non-bloody, non-bilious emesis is often present. The classically described triad of pain, palpable abdominal mass, and currant jelly stool occurs in <15% of children.

Imaging Techniques:

Abdominal plain films: A two view abdominal x-ray can be used to evaluate the bowel gas pattern and to exclude perforation in patients with suspected intussusception. It is not the imaging method of choice, as a negative plain film cannot rule out intussusception. A plain film is less sensitive and specific than ultrasonography for intussusception, but may include the following suggestive findings:

  • Signs of intestinal obstruction (distended loops of bowel with absence of colonic gas)
  • Target sign (two concentric circles superimposed on the right kidney)
  • Crescent sign (soft tissue density projecting into the gas of the large bowel)
  • Obscured liver margin (as seen in the patient in this vignette)
  • Lack of air in the cecum
  • Pneumoperitoneum (RARE, secondary to perforation)

Ultrasonography:  Abdominal ultrasound is the modality of choice, with sensitivity and specificity approaching 100% when performed by experienced ultrasonographers. The classic imaging findings include a “target sign” or “bull’s eye” that occurs due to the layers of intestines within one another. This target is usually ≥3 cm in diameter.

  Figure 4: &nbsp;Cross sectional view of intussusception

Figure 4: Cross sectional view of intussusception

  Figure 5: &nbsp;Longitudinal view of intussusception

Figure 5: Longitudinal view of intussusception

Point of Care US (POCUS) for Intussusception:

Bedside ultrasound may lead to more expeditious diagnosis, particularly when pediatric radiology is not available, and may facilitate more rapid comprehensive radiographic and/or surgical evaluation. A 2011 study showed that 6 PEM physicians could perform the exam with a sensitivity of 85%, specificity of 97%, positive predictive value of 85%, and negative predictive value of 97% for diagnosing intussusception after just a 1 hour course!

Diagnostic pitfalls with ultrasonography include enlarged lymph nodes, non-pathologic ileo-ileal intussusception, the psoas muscle, colonic stool, and the kidneys, all of which may be misinterpreted as intussusception. Scan the entire abdomen and try to localize the actual kidneys. Confirm that the depth of the image and the diameter of the findings in question are consistent with the typical intussusception parameters, and observe for surrounding peristalsis to help decrease misinterpretation of findings.

Ultrasound Technique:

Using a linear probe, start by placing the probe transversely in the RLQ and attempt to identify the psoas muscle (semicircular structure with striations and iliac vessels just medial to it). Set the depth to at least 6 cm. Slowly sweep superolaterally until the liver and gallbladder are visualized. Proceed along the course of the large bowel as the intussusception may be seen in the LLQ. If seen, an intussusception should be imaged in two planes.

  Figure 6: &nbsp;Ultrasound technique

Figure 6: Ultrasound technique

Treatment:

The preferred method of treatment for intussusception is nonoperative, with air or barium enema reduction, which is performed by radiology. Surgery should be close by in case of complication and/or need for urgent operative intervention. Operative intervention may be needed if non-operative reduction fails or if there is concern for a mass lesion as the pathological lead point, or if there is suspected or proven bowel perforation or necrosis.

Faculty Reviewer: Dr. Erika Constantine 

References:

1. KitagawS, Miqdady M. Intussusception in children. Uptodate.com. Accessed April 17, 2016. <http://www.uptodate.com/contents/intussusception-in-children source=search_result&search=intussusception&selectedTitle=1~102>.

2. Doniger SJ, Salmon M, Lewiss RE. Point-of-Care Ultrasonography for the Rapid Diagnosis of Intussusception: A case series. Pediatr Emergency Care. 2016 Feb 15. Epub ahead of print. PMID: 26890297.

3. Alletag MJ, Riera A,  Langhan ML, Chen L. Use of emergency ultrasound in the diagnostic evaluation of an infant with vomiting. Pediatr Emerg Care. 2011, Oct; 27(10):986-9.

4. Eshed I, Gorenstein A, Serour F, et al. Intussusception in children: can we rely on screening sonography performed by junior residents? Pediatr Radiol. 2004;34;134-137.

5. Ramsey KW, Halm BM. Diagnosis of intussusception using bedside ultrasound by a pediatric resident in the emergency department. Hawaii J Med Public Health. 2014 Feb;73(2):58-60.

6. Riera A, Hsiao AL, Langhan ML, Goodman TR, Chen L. Diagnosis of intussusception by physician novice sonographers in the emergency department. Ann Emerg Med. 2012 Sep;60(3):264–268. [PubMed].

7. Chang YJ, Hsia SH, Chao HC. Emergency medicine physicians performed ultrasound for pediatric intussusceptions. Biomed J. 2013 Jul-Aug;36(4):175–178. [PubMed]. 

8. Halm BM. Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound. Pediatr Emerg Care. 2013 Feb;29(2):218–221. [PubMed].