Tactical Medicine News Blog

The Case of the Unexpected Outcome presented an attending trying to deal with a poor outcome in one of their patients despite competent medical management. No matter how good of a clinician we are, odds are that at some point this will happen to all of us. In addition to being potentially emotionally devastating, a serious miss can make us question our competence and shift our practice patterns from evidence- to anecdote-based. Check out the ALiEM community’s discussion of the case.

In this constantly evolving world of learner competencies, assessments, and milestones often is forgotten the important role of clinical teachers. We can all remember clinical instructors that stand out despite the grueling years of medical school and residency training. We admired them for various reasons and remember the insights and teaching pearls they bestowed upon us. But what exactly were the qualities that they possessed that other instructors did not have? What exactly did they have that made them a good clinical teacher in medicine?

Frequently, patients with acute alcohol intoxication are brought to the emergency department (ED) for evaluation and treatment.  Although practice patterns vary, it is not an uncommon practice to give normal saline to these patients in the hopes that the saline will cause a dilution effect on the level of alcohol helping patients sober faster and therefore having a shorter length of stay in the ED.  At the end of 2013 a study was published evaluating intravenous fluids and alcohol intoxication.

We are all familiar with the concept of pediatric EDs. We see them as medical students, we train in them as residents, and we work alongside pediatric EM fellows. It is generally clear what pediatric EDs have to offer: smaller sized beds and equipment, nurses trained in pediatric triage and assessment who know how to put IVs in babies and calm crying kids, and physicians with training in pediatric Emergency Medicine. But what about the other end of the age spectrum? Over the last 10 years geriatric EDs, also called Senior EDs, have been popping up around the country. You may have been wondering why that is, and what they have to offer. Here are a few thoughts.

D-dimer testing is sensitive for thrombus formation, and in patients who are not high risk, this test is used to rule-out venous thromboembolism. D-dimer has been shown to increase with age, which can cause a lower specificity (i.e. more false positive tests) in older patients.  Specificity can range from 49 – 67% in patients ≤ 50 years of age, but in older patients (i.e. ≥ 80 years of age) the specificity is quoted as 0 – 18%. The result of this is, older patients often have more diagnostic imaging, but a higher cut-off may lead to increased false negative cases (i.e. missed VTE) and make this strategy less safe. So could age adjusted d-dimer testing increase specificity without affecting sensitivity?