The Medical School Years.

Medical school can be very challenging, especially when students are considering applying to competitive specialties, like emergency medicine. Once medical students know that emergency medicine is the field they want to specialize in, a multitude of other questions arise, including how many EM rotations should they do? How can they shine during their EM rotations? When should they schedule their rotations, electives, and sub-internships? How can they get the strongest letters of recommendation? What are residency program directors looking for? Therefore, we are going to present in the Medical Student Forum section of the Journal of Emergency Medicine a series of six articles covering this and more.

Uniformed Medical Students and Residents in Emergency Medicine.

"Uniformed medical students and residents" refers to medical school enrollees and physicians in training who are obligated to serve in the military after graduation or training completion. This is in exchange for 2 forms of financial support that are provided by the military for individuals interested in pursuing a career in medicine. These programs are offered namely through the Uniformed Services University of Health Sciences (USUHS) and the Health Professions Scholarship Program (HPSP). Uniformed medical school graduates can choose to serve with the military upon graduation or to pursue residency training. Residency can be completed at in-service programs at military treatment facilities, at out-service programs, at civilian residency training programs, or via deferment programs for residency training at civilian programs. Once their residency training is completed, military physicians should then complete their service obligation. As such, both USUHS and HPSP students should attend a basic officer training to ensure their preparedness for military service. In this article, we elaborate more on the mission, requirements, application, and benefits of both USUHS and HPSP. Moreover, we expand on the officer preparedness training, postgraduate education in the military, unique opportunities of military medicine, and life after completion of military obligation.

Hospital-wide survey of bacterial contamination of point-of-care ultrasound probes and coupling gel.

OBJECTIVES: The purpose of this study was to determine the hospital-wide incidence of bacterial contamination of point-of-care (bedside) ultrasound probes and coupling gel at a single academic medical center to predict the risk of nosocomial spread of infection. METHODS: Bacterial cultures were performed on all point-of-care ultrasound probe surfaces and associated gel bottles in our institution (82 total probes in 9 separate departments). This process was repeated every 2 weeks for a total of 8 weeks; therefore, each probe was cultured 4 times during the study period. RESULTS: Of the 320 probe cultures, 18 (5.6%), resulted in positive growth, all of which identified nonpathogenic organisms common to human skin flora and the environment. No methicillin-resistant Staphylococcus aureus or other notable pathogens were identified. No gel cultures resulted in bacterial growth. CONCLUSIONS: Bacterial contamination of point-of-care ultrasound probes and coupling gel is low at this single academic medical center and involves nonpathogenic organisms only.

The double-line sign: a false positive finding on the Focused Assessment with Sonography for Trauma (FAST) examination.

BACKGROUND: Emergency physicians commonly perform Focused Assessment with Sonography for Trauma (FAST) examinations to evaluate for free intraperitoneal fluid. Many ultrasound findings can be misinterpreted as free fluid, resulting in false-positive FAST examinations. OBJECTIVES: To describe a previously unreported ultrasound finding that can be misinterpreted as free intraperitoneal fluid. CASE REPORT: A 32-year-old man was stabbed in the left upper abdomen. A FAST examination was performed and a right perinephric fat pad was interpreted as showing free fluid in Morison's pouch. After transfer to a trauma center, a repeat FAST examination revealed no signs of intraperitoneal free fluid. Wound exploration showed no signs of penetration into the peritoneal cavity. CONCLUSIONS: When performing a FAST examination, a wedge-shaped hypoechoic area in Morison's pouch that is bounded on both sides by echogenic lines (the "FAST Double-Line Sign") is likely to represent perinephric fat and may result in a false-positive FAST examination.

Biliary causes of postcholecystectomy syndrome.

BACKGROUND: The postcholecystectomy syndrome refers to the persistence of gastrointestinal symptoms after cholecystectomy; patients with this syndrome commonly seek treatment in the Emergency Department (ED). There are a multitude of biliary and non-biliary causes of postcholecystectomy syndrome. OBJECTIVES: To review the biliary causes of postcholecystectomy syndrome and present a suggested diagnostic workup. DISCUSSION: A number of biliary causes are discussed, including choledocholithiasis, bile duct injury and biliary leaks, cystic duct and gallbladder remnants, sphincter of Oddi dysfunction, and biliary ascariasis. The ED workup should focus on differentiating biliary from non-biliary causes of the patient's symptoms. CONCLUSION: A right upper quadrant abdominal ultrasound, liver transaminases, alkaline phosphatase, and serum bilirubin are the tests most useful in the ED for making this distinction and determining the most appropriate treatment and disposition of the patient. Computed tomography may be of use in the initial post-operative period.

Rupture of the pectoralis major: a case report and review.

BACKGROUND: Rupture of the pectoralis major muscle is a rare clinical entity that is becoming more common due to the increasing popularity of weightlifting and recreational sports. Due to the rarity of this condition, it may be missed at initial presentation and inappropriately treated, potentially leading to increased disability. OBJECTIVES: This case highlights the mechanism of injury, clinical features, diagnosis, and treatment of rupture of the pectoralis major. CASE REPORT: The patient was a 31-year-old male bodybuilder who presented to the Emergency Department with acute pain and swelling in the left axilla after performing a bench press with a 400-pound barbell. The diagnosis of pectoralis major rupture was suspected and confirmed by magnetic resonance imaging, and early surgical repair was performed. CONCLUSION: The most common mechanism of injury is excessive tension on a maximally contracted pectoralis major muscle. Weightlifting, specifically bench pressing, is a common cause. The diagnosis can usually be made based on a patient's history and physical examination, but shortly after injury, the diagnosis may be obscured by severe pain and swelling. Magnetic resonance imaging is the imaging modality of choice when the diagnosis remains unclear, and can avoid surgical delays. Early diagnosis and treatment within 3 to 8 weeks after the injury has the advantage of avoiding adhesions and muscle atrophy, and can prevent a delayed return to normal activities. Given the trend toward improved results with early surgical repair of complete rupture, it is important to raise awareness about pectoralis major muscle injury among Emergency Physicians to prevent missed or delayed diagnosis and repair.

Exercise-induced bilateral rectus sheath hematomas presenting as acute abdominal pain with scrotal swelling and pressure: case report and review.

Rectus sheath hematoma (RSH) is an uncommon but significant cause of acute abdominal pain in patients presenting to the Emergency Department. RSHs are often misdiagnosed as other more common causes of abdominal pain. This case describes a 23-year-old male presenting with acute abdominal pain, scrotal swelling, and associated scrotal pressure. The case highlights the uniqueness of this particular presentation and the clinical features, risk factors, diagnosis, and treatment of RSH.

Kikuchi's disease: a rare cause of cervical lymphadenitis and fever.

Cervical lymphadenitis and fever are common in patients presenting to the Emergency Department (ED). Kikuchi's disease is a rare, self-limited cause of fever and cervical lymphadenitis often misdiagnosed as lymphoma or lupus and inappropriately treated, potentially causing numerous ED visits for unrelieved symptoms. The case described is that of a 29-year-old with persistent fever and cervical lymphadenitis who presented to the ED with a suspected allergic reaction to an antibiotic. The diagnosis of Kikuchi's disease was made in association with nasopharyngeal carcinoma and partial hydatidiform mole. The case highlights the clinical features, diagnosis, and treatment of Kikuchi's disease.

Prospective durability testing of a vascular access phantom.

INTRODUCTION: We assessed the acoustic transmission, image quality, and vessel integrity of the Blue Phantom™ 2 Vessel Original Ultrasound Training Model with repeated use. METHODS: The study consisted of two phases. During the first phase, a portion of the Blue Phantom™ rubber matrix (without a simulated vessel) was placed over a two-tiered echogenic structure and was repeatedly punctured with a hollow bore 18-gauge needle in a 1 cm(2) area. During the second phase, a portion of the matrix with a simulated vessel was repeatedly punctured with another hollow bore 18-gauge needle. During both phases we obtained an ultrasound image using a high-frequency linear probe after every 100 needle punctures to assess the effect of repeated needle punctures on image quality, acoustic transmission, and simulated vessel integrity. RESULTS: Testing on the rubber matrix alone (first phase) without a vessel demonstrated a gradual decrease in image quality and visualization of the proximal and distal portions of the target structure, but they remained visible after 1,000 needle punctures. The second phase demonstrated excellent acoustic transmission and image quality on both transverse and longitudinal images of the rubber matrix and simulated vessel after 1,000 needle punctures. The anterior and posterior vessel walls and needle tip were well visualized without any signs of vessel leakage on still images or with compression and power Doppler. CONCLUSION: The Blue Phantom™ 2 Vessel Original Ultrasound Training Model demonstrated excellent durability after 1,000 needle punctures in a 1- cm(2) area. Based on the length of simulated vessel in each model, it should support over 25,000 simulated attempts at vascular access.