History and Physicals:
Journal Article Summary:
During the third week of my Emergency Medicine rotation, a patient with a PMHx of metastatic breast cancer presented with a pericardial effusion requiring drainage. Cardiothoracic surgery was consulted with discussion of the best window technique. Based on this discussion, I set out to find an article that provided evidence for which technique is best in various scenarios.
The article compares the outcomes associated with subxiphoid vs thoracotomy pericardial window techniques by evaluating perioperative pain scales along with recurrence rates. The article is based on a retrospective single-center observational study of all window procedures. The data includes time to extubation, narcotic requirements, and the development of a recurrent pericardial effusion.
Results found that out of 179 patients, 127 subxiphoid procedures were performed and 52 left anterior mini-thoracotomy procedures were performed. There was no difference in the two for the amount of fluid drained or in the perioperative mortality rate. Postop patients had less time before extubation with the subxiphoid approach and required less narcotics within 48 hours after surgery. However, patients with thoracotomy had less rates of effusion recurrence. Based on these findings, I would recommend subxiphoid for patients with low risk factors for recurrence of pericardial effusions and thoracotomy approach for patients at higher risk of recurrent pericardial effusions.
Site Visit Summary:
The first case I presented was chosen because it was a chief complaint with a diagnosis I had not anticipated. A young male in his 20s with no significant PMHx had presented with one month of a cough. The physical exam had clear lungs bilaterally with no adventitious sounds and was otherwise unremarkable. My differential was narrowed was allergic rhinitis or post-viral cough. It was the physician assistant I was working with that day who had ordered a chest x-ray due to the longevity of the cough with no prior history of allergic rhinitis or known recent viral illness. The chest x-ray had come back positive for a large mass in one lung lobe and the patient was subsequently sent to the other side of the Emergency Department that deals with higher levels of acuity for full workup including a CT scan and cardiothoracic/oncology consult. I felt that this case demonstrates the importance of always keeping the differential wide and including more serious pathologies.
The second case presented was on a patient with a right anterior shoulder dislocation treated with a closed reduction. I chose this case because it was a good opportunity to practice writing a history and physical with a procedure included within the plan. My site evaluator and I discussed various other procedural sedation choices and techniques for anterior shoulder reduction which has broadened my knowledge on the subject. This procedure took multiple attempts before the reduction was successful and the key take away was learning how to be persistent and also know when to stop and re-evaluate when initial attempts are unsuccessful.
My third and last case presented was on a woman with metastatic breast cancer presenting for SOB and subsequently diagnosed with a pericardial effusion. This case allowed me to perform a POCUS to diagnose the effusion and subsequently brought about discussion on different window techniques used to drain the fluid. The case also brought up discussion on when to treat disease vs when to treat symptoms palliatively, especially in this grey-area.
Typhon Case Logs:
This rotation was full of “firsts”. I performed my first IV start, first stapling & removal, first suturing & removal, first pelvic exam, and first POCUS. I was the most worried about suturing and was surprised to find that it was my strongest suit. However, I struggled initially with starting IVs but after practice, practice, and more practice I was competent in performing them towards the end of my rotation. Talking patients through the procedures both before they began and during was something I improved upon throughout the rotation as well. I initially struggled to explain procedures without using fancy medical terminology but became better with my explanations with the more comfortable I became with performing them.
At the end of this rotation my perspective of what an emergency department is and is not changed. I noticed a lot of patients coming into the ED with chronic problems that needed to be addressed and managed by primary care but often patients were unable to receive this care from lack of insurance tied to financial difficulties. In this sense, the ED is a safe haven allowing patients to get basic refills on medications like asthma inhalers but there were also pitfalls in what could be managed. For instance, there were patients with high blood pressure requesting initiation of hypertension treatment, but this could not feasibly be provided with no structured follow up. There were also a lot of cases that would have been better served with social rehabilitation and support rather than true ED management such as undomiciled residents looking for shelter or non-life threatening withdrawals from substance abuse. In these cases, the medical management focused on comfort care such as providing beds, meals, and showers. In sum, I was able to better learn the role and scope an ED department plays in medicine.
I have learned from this rotation that I really enjoy performing procedures as I enjoy doing tactile tasks. I found that doing things such as suturing, and POCUS stimulated me both mentally and physically. I did not go into this rotation thinking that working in the Emergency Department would be something that I wanted to do after graduation because I have always found joy in creating longer term relationships with patients where I can see their health outcomes improve over time. I surprised myself by noticing how gratified I felt every time I was able to help with an acute intervention or pick up a medical diagnosis that prevented the patient from having a bad outcome. My new love of procedures has me excited to see what my surgery rotation will have in store for me. I am now seriously considering a job in the emergency department as a new PA graduate.
Last, I want to reflect upon a very memorable patient for me. There was a male in his late 20s around my age who came in for a persistent cough x1 month. The history was not pointing towards any particular hints in a diagnosis. The patient was up to date on all his recent vaccinations, had no recent travel, was not immunocompromised, no recent illnesses, and no history of asthma, although he had a smoking history that was less than 10 years. I had narrowed down the diagnosis to a benign cause and ready to provide the patient with reassurance and treatment for either allergic rhinitis or post-viral cough. However, the PA I worked with that day suggested that because we are in the ED and this patient seemed worried enough to come here that we should get a chest x-ray to rule out more sinister causes of the cough. The chest x-ray came back with the impression of a large lung mass which was subsequently diagnosed as lung cancer with an endocrine origin. The case taught me to keep my differentials wide and always consider more serious pathologies even when it does not seem apparent. This pick up by the PA will potentially save or prolong this patients life and is a lesion I will carry with me into future rotations.