Medical Education

Interview with Dr. Jessica Mason

Welcome to a special episode of the Brown Emergency Medicine Podcast. In this episode, we have the pleasure of hearing from Dr. Jessica Mason in an interview conducted by Brown EM resident Dr. Jessie Werner.

Dr. Mason speaks with us regarding her career as an Emergency Medicine physician and renowned educator. She describes how she got her start with podcasting with her series ‘Med Forum’ and how she expanded her reach to not only physicians with ‘EM:RAP’ and ‘Resident Call Room,’ but also to non-physicians with her series ‘This Won’t Hurt a Bit.’

Listen Now:

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Jessica Mason, MD

Assistant Clinical Professor, Department of Emergency Medicine, UCSF Fresno

Dr. Mason is an Assistant Clinical Professor at UCSF Fresno and is the fellowship director of the Emergency Medicine Medical Education fellowship. She is the Deputy Editor of EM:RAP and the Managing Editor of EM:RAP C3, EM:RAP HD, EM:RAP Live, and EM:RAP C3. She is also a co-host and writer for the podcast series ‘This Won’t Hurt a Bit.’

Special thanks to Dr. Jessica Mason for her mentorship in creating this podcast and for her ongoing dedication to medical education.


Catch our other interviews and other new series on our new Brown EM Podcast iTunes stream. Subscribe here!

AEM Education and Training 09: Looking Through the Prism - Caring for LGBTQI Patients in the ED

Welcome to the ninth 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):

Looking Through the Prism: Comprehensive Care of Sexual Minority and Gender‐nonconforming Patients in the Acute Care Setting. Angela F. Jarman MD, MPH; Alyson J. McGregor MD, MA; Joel L. Moll MD ; Tracy E. Madsen MD, ScM; Elizabeth A. Samuels MD, MPH; Mollie Chesis; Bruce M. Becker MD.

LISTEN NOW: AUTHOR INTERVIEW WITH angela jarman, MD, Mph

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Angela Jarman, MD, MPH

Assistant Professor, Department of Emergency Medicine

University of California, Davis

This interview discusses a commentary in AEM E&T which synthesizes a didactic session co‐led by the SAEM Sex and Gender in Emergency Medicine Interest Group and the Academy for Diversity and Inclusion, which was presented by the authors at the SAEM 2018 annual meeting in Indianapolis, Indiana.

The National Institutes of Health have recently recognized LGBTQ (lesbian, gay, bisexual, transgender, queer) as an official health disparity and designated the Sexual and Gender Minority Research Office in an effort to support evidence‐based medical care for this underserved patient population. As the front line of medical care for the underserved, emergency medicine (EM) physicians need to be equipped with the tools to care for these patients in a culturally competent and clinically appropriate manner. EM providers must develop an understanding of their patients’ social and medical context to provide both sensitive and effective care and to teach residents and other learners. A significant number of patients who seek treatment in the emergency department define themselves as LGBTQI—lesbian, gay, bisexual, transgender, queer, or intersex. This commentary combines both affective and objective information on the importance of semantics and language, appropriate communication, and confronting our own implicit biases in caring for this vulnerable population, creating a unique perspective and paradigm for the practice of EM and a blueprint for education. 

The authors have provided this handout for further information:

https://drive.google.com/file/d/1WDyk0HcCCP3DKmgGRdom53s8LKZB5Znz/view?usp=sharing

Excerpt:

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ADDITIONAL REFERENCES:

“Don’t be a jerk” EM Pulse Podcast, Episode 9. https://ucdavisem.com/2018/07/17/dont-be-a-jerk/

http://www.transstudent.org/gender/

NIH ORWH sex/gender. Available at https://orwh.od.nih.gov/research/sex-gender.

Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people. National Academies Press (US), Washington, DC; 2011

Clayton JA, Tannenbaum C. Reporting Sex, Gender, or Both in Clinical Research? JAMA 2016; 316(18):1863-1864

Madsen TE, Bourjeily G, Hasnain M, Jenkins MJ, Morrison MF, Sandberg K, Tong IL, Trott J. Sex- and Gender-Based Medicine: The Need for Precise Terminology. Gender and the Genome;1(3):122-28.

Schuster MA, Reisner SL, Onorato SE. Beyond bathrooms — meeting the health needs of transgender people. NEJM 2016;375:101–103.

Soc Sci Med. 2014 Feb;103:33-41. doi: 10.1016/j.socscimed.2013.06.005. Epub 2013 Jun 18.

Structural stigma and all-cause mortality in sexual minority populations. Soc Sci Med. 2014 Feb;103:33-41. doi: 10.1016/j.socscimed.2013.06.005. Epub 2013 Jun 18.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding Editors: Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities.

Bauer GR, Scheim AI, Deutsch MB, et al. Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey. Annals of Emergency Medicine. 2014;63(6):713-720.

Brown JF, Fu J. Emergency department avoidance by transgender persons: another broken thread in the "safety net" of emergency medicine care. Annals of Emergency Medicine. 2014;63(6):721-722.

Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at www.transhealth.ucsf.edu/guidelines .

Chisolm-Straker M, Jardine L, Bennouna C, Morency-Brassard N, Coy L, Egemba MO, Shearer PL (2017) Transgender and gender nonconforming in emergency departments: a qualitative report of patient experiences, Transgender Health 2:1, 8-16, DOI: 10.1089/trgh.2016.0026.

Deutsch MB, Jamison Green, Keatley J, Mayer G, Hastings J, Hall AM. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health. J Am Med Inform Assoc. 2013;20:700-703

IOM. Collecting sexual orientation and gender identity data in electronic health records: Workshop summary. Washington, DC: Institute of Medicine;2013.

James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality;2016.

Jalali S, Sauer LM. Improving Care for Lesbian, Gay, Bisexual, and Transgender Patients in the Emergency Department. Annals of Emergency Medicine. 2015;66(4):417-423.

Lambda legal. Creating equal access to quality health care for transgender patients: transgender-affirming hospital policies. May 2016. Http://assets.Hrc.Org//files/assets/resources/transaffirming-hospitalpolicies-2016.Pdf?_Ga=2.179968679.225917522.1494296888-1373396650.1480810731

Samuels EA, Tape C, Garber N, Bowman S, Choo EK. “Sometimes you feel like the freak show”: A Qualitative Assessment of Emergency Care Experiences Among Trans and Gender Non-Conforming Patients. Ann Emerg Med 2017: doi:10.1016/j.annemergmed.2017.05.002.

World Professional Association for Transgender Health, Standards of Care for the Health of Transexual, Transgender, and Gender Nonconforming People 5 (7th ed.), http://www.wpath.org/uploaded_ les/140/ les/Stan- dards%20of%20Care,%20V7%20Full%20Book.pdf

Meeting Uncle Rhabdo

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THE PATIENT:

A 28 year old previously healthy male presents to the emergency department with concerns for worsening back pain that is predominantly left sided and along the lumbar spine. Two days prior to the visit he recalls a work out that consisted of many dead lifts. He also played basketball the following day and rode his bike into work, which is more activity than usual for him. He tried NSAIDs for pain control, but his pain is more intense and he noticed his urine looked brown today. He denies any fevers, history of IVDU, weight gain or loss, urinary tract infections or STDs, immunosuppression, recent spinal fracture or procedure, incontinence or retention.

PHYSICAL EXAMINATION:

144/83, 82, 37.1, 18, 98%

Gen: well appearing, no acute distress

HENT: normocephalic, MMM

CV: RRR

Pulm: CTAB

Abd: soft, nontender, nondistended

MSK: muscle spasms along the left lumbar paraspinal muscle, no midline tenderness to palpation, muscle compartments in the upper and lower extremities are soft

Neuro: L1-S5 strength 5/5 and sensation to light touch is intact

Skin: pink, warm, dry

THE COURSE:

As an experienced clinician you are able to quickly arrive at a diagnosis of rhabdomyolysis from the brief history and physical exam, but what else needs to be done? In the emergency department we need to initiate diagnostic studies to evaluate the severity of illness and help plan for an appropriate disposition. Thankfully, your history and exam reveal no red flag findings for more concerning etiologies of back pain, so your evaluation can be quite focused. The patient had lab work sent off and was provided with IVF boluses and given analgesia with marked improvement in his symptoms. He was admitted to the medical floor for continued care for the next couple days.

THE WORK UP:

CK >20,000 IU/L (labs upper limit for reporting without further analysis and quantitative estimates, normal range 20-210, remained >20,000 for 5 consecutive days) finally on day 6 CK 10, 933 IU/L

BMP: Glu 113, BUN 19, Cr 1.0 (on discharge was 0.84), Na 139, K 3.8, Cl 104, CO2 29, Ca 8.9

Urinalysis: Brown, cloudy, trace ketones, specific gravity >1.03, blood 3+, protein >300

Urine microscopic analysis: RBC none seen, WBC 3, amorphous crystals present

Urine myoglobin: >8,750 mcg/ml (normal range < 28mcg/ml)

DISCUSSION:

The key clinical manifestations of rhabdomyolysis include a triad of muscle tenderness and weakness as well as dark urine, so the triage note already had it set up on a silver platter for you. Remember, however, as with any triad in medicine this classic presentation is rare. Some studies revealed that over half of patients do not report muscle pain or weakness. Rhabdomyolysis occurs due to muscle necrosis and the release of intracellular contents into the circulation. Patients may present with a wide range of symptoms and the most concerning complications include hyperkalemia, renal failure and rarely disseminated intravascular coagulation. Patients who present with concomitant acute kidney injury tend to have worse outcomes and the mechanism of injury is primarily related to the nephrotoxic effects of myoglobin. In an acidic environment myoglobin may precipitate and subsequently damage the kidneys by obstruction of the renal tubules, cause oxidative damage and vasoconstriction.

The etiologies of rhabdomyolysis can be broken up into four broad categories: impaired production or use of ATP, dysfunctional oxygen or nutrient delivery, increased metabolic demand exceeding capacity, and direct myocyte damage. Recently, on EM: RAP Dr. DeLaney argued that this can be further simplified into two broad categories, exertional and non-exertional. Classic cases include trauma patients who have crush injuries but can also occur with heat related illnesses such as heat exhaustion or stroke, or in cases of hyper-kinetic states. Medications implicated in this disease process include antipsychotics and statins as well as others such as illegal drugs like cocaine.

CK levels classically rise within two to twelve hours after the onset of injury and peak within three days. The level should return to baseline within ten days. The diagnosis is often considered if the CK level is above five times the upper limit of normal at presentation, roughly 1,000 IU/L. More discrete categories can also be used to differentiate mild to severe cases based on CK levels, however, it is the degree of renal impairment that likely has the greatest role on patient outcome. Emergency department management includes aggressive IVF hydration with a target urine output of approximately 250 ml/hr and attempts to identify and correct the underlying pathology. Some argue for urinary alkalinization; however, the literature is limited with regards to strong recommendations on this topic. Common electrolyte abnormalities include: hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. Disseminated intravascular coagulation can rarely be seen as a result of thromboplastin and prothrombotic agents released from damaged myocytes. Acute kidney injury is more common if the presentation includes a CK >5,000 IU/L and in cases with sepsis, acidosis, or dehydration. Ultimately, most patients do well during their hospital courses and rarely require significant interventions, but mortality may be upwards of 20% in those that present with significant kidney injury noted at the time of presentation, therefore, careful evaluation of the patient’s lab studies and admission for close observation remains the mainstay of treatment.

Faculty Reviewer: Dr. Gita Pensa

SOURCES:

  1. DeLaney, M. “Rhabdomyolysis: Part 1 Diagnosis and Treatment.” www.emrap.org March 2018, 18 (3)

  2. DeLaney, M. “Rhabdomyolysis: Part 2 Disposition.” www.emrap.org March 2018, 18 (3)

  3. Majoewsky, M. “Rhabdomyolysis: C3 Project.” www.emrap.org June 2012, 2 (6)

  4. Sauncy, H. (2017). Don’t Get Broken Up About Muscle Breakdown. In Mattu, A. Marcucci, L. et al (Eds.), Avoiding Common Errors in the Emergency Department: Second Edition (pp. 414-16). Philadelphia: Wolters Kluwer.