May 31, 2021

Earlier this year, my home shop began administering the Johnson & Johnson COVID-19 vaccine to patients in the emergency department (ED). Thirteen years of experience in emergency medicine has afforded me many opportunities to counsel patients on lifestyle modifications, death and dying, tPA administration, and many other complex medical issues. However, I’ve never experienced a more polarizing topic than the COVID-19 vaccination. My initial attempts were met with a few quick wins. While in fast-track, a middle-aged Hispanic man presented with an injury to his left knee. I suspected a patellar tendon rupture, and while we waited for the orthopedist to evaluate his knee, I offered him the COVID-19 vaccine. He smiled acceptingly and slapped his left shoulder with his right hand, signaling the location he wished to receive his vaccine and said: “Yeah! I’ll take it.” “I want it too!” His wife exclaimed. Though not yet a patient, she sat patiently at her husband’s bedside, awaiting the orthopedists. She was quickly registered and vaccinated. 

May 17, 2021

Background: A patient presents to the emergency department (ED) for medical treatment. After comprehensive evaluation and management, the patients condition improves and you prepare to discharge the patient home. The nurse notifies you the blood pressure (BP) is 185/105 and asks if you are comfortable discharging the patient in light of the abnormal vital signs. 

This clinical scenario happens regularly in the ED. Our training in emergency medicine has always been: We do not treat asymptomatic hypertension in the ED.” In fact, ACEPs 2013 Clinical Policy statement recommends referring patients with asymptomatic hypertension for outpatient follow-up and NOT starting antihypertensive therapy in the ED. However, this tends to be a controversial topic with various clinical opinions and practices. Ask ten emergency medicine physicians: What BP value would make you uncomfortable when discharging a patient? You may get ten different answers.

Patient safety is paramount. Furthermore, individual physicians have varying levels of risk tolerance and aversion which contribute to treatment decisions. This paper attempts to address concerns in patients with elevated blood pressure readings in the ED.

May 3, 2021

Background: In 2019 the World Health Organization listed “Antimicrobial Resistance” as a top 10 threat to global health. This was echoed in a 2021 document. [WHO 2019, WHO 2021] The classic medical teaching regarding antimicrobial therapy pushed for longer treatment courses. There was a commonly held myth that premature cessation or prescription of a short course of antibiotics could select for more virulent pathogens thereby re-exacerbating and intensifying illness as well as hastening the development of antibiotic resistance. However, microbial stewardship is of paramount importance and we should embrace shorter courses of antibiotics when clinically appropriate.

April 22, 2021

In the fall of 2014, while working overnight in the emergency department at a community hospital in NJ, a patient (let's call him John) presented with ACE inhibitor angioedema. At first glance, his lips were swollen, but his tongue and oropharynx were unremarkable, and there were no signs of respiratory distress. I ordered an "anaphylaxis cocktail" and checked on him a few moments later.  John's condition deteriorated. His tongue, now swollen, protruded and forced his mouth open. He spoke in a muffled voice and drooled his oral secretions. I quickly phoned anesthesia for fiberoptic intubation. My heart sank when I was notified they were unavailable.
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