Tactical Medicine News Blog

Submassive pulmonary embolism (PE) is responsible for approximately 20% of all PEs.  Although the in-hospital mortality has been reported as about 5%, there is significant morbidity associated with this diagnosis such as chronic pulmonary hypertension, impaired quality of life, persistent right ventricular disfunction, and recurrent venous thromboembolism.  The literature suggests that systemic thrombolytics can improve morbidity and maybe mortality, but this comes at the risk of increased major bleeding and intracranial hemorrhage (2 – 3%) when compared to anticoagulation alone.

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.” This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

In anticipation of the upcoming holidays, we have a stock of brand new ALiEM turquoise socks for sale. We gave them out to our core team members at the recent American College of Emergency Physicians (ACEP) Scientific Assembly in 2016. Needless to say, they were a big hit. These are now available for online purchase (along with the remaining few blue ones that we will retire after this last stock runs out). Currently they are only available for purchase and shipment in the United States. Come join our extended ALiEM family!

Background: The most recent surviving sepsis campaign recommends the use of hydrocortisone in patients with refractory septic shock (i.e. vasopressor dependent).  However, the use of hydrocortisone in severe sepsis without shock still remains a very controversial topic. Recommendations for hydrocortisone are mostly based on 2 randomized clinical trials (i.e. Annane et al [2] and CORTICUS [3]), but subsequent meta-analyses had more mixed results.  Shock reversal was consistently improved irrespective of disease severity; however, mortality outcomes were not as consistent.  Therefore, it has been hypothesized that early hydrocortisone administration could prevent shock by attenuating patient’s inflammatory response.

Welcome to season 4, episode 2 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine! In this month’s case, a junior resident feels violated and shamed after a sexually aggressive encounter with an orthopedic attending physician.