Letters of Recommendation.

Letters of recommendation (LORs) are a central element of an applicant's portfolio for the National Resident Matching Program (known as the "Match"). This is especially true when applying to competitive specialties like emergency medicine (EM). LORs convey an applicant's potential for success, and also highlight an applicant's qualities that cannot always be recognized from a curriculum vitae, test scores, or grades. Traditional LORs, also called narrative LORs, are written in prose and are therefore highly subjective. This led to the establishment of a task force by the Council of Emergency Medicine Residency Directors in 1995 to develop a standardized LOR. Revisions of this form are now referred to as a standardized letter of evaluation. These evaluations in this format have proven to increase inter-rater reliability, decrease interpretation time, and standardize the process used by EM faculty to prepare evaluations for EM applicants. In this article, we will discuss LORs; address applicants' concerns, including from whom to request LORs (EM faculty vs. non-EM faculty vs. non-clinical faculty), number of LORs an applicant should include in his or her application materials, the preferred manner of requesting and the timing in which to ask for an LOR, as well as the philosophy behind waiving the right to see the letter.

Transcutaneous Electrical Nerve Stimulation (TENS) in the Emergency Department for Pain Relief: A Preliminary Study of Feasibility and Efficacy.

INTRODUCTION: Given the high rates of opioid addiction and overdose in the United States, non-opioid means of treating pain are increasingly needed. Transcutaneous electrical nerve stimulation (TENS) therapy is an effective non-opioid modality for treating pain, but has not yet been routinely used in emergency department (ED) settings. In this study we asked the following questions: Are TENS units a feasible treatment for pain in the ED? How effective are TENS units for the management of pain in a general ED population? METHODS: At our institution, we performed a pilot study using TENS units for pain. Patients in the ED were given, at the discretion of the ED provider, TENS units for the treatment of pain. Patients could be included for acute or chronic pain on whatever part of the body that was safe to use with TENS. RESULTS: A chart review of patients receiving TENS units in the ED (n=110) revealed that TENS was useful in relieving pain, along with other treatments, in 99% of cases. When surveyed, 83% of patients reported a functional improvement while using the TENS, and 100% of patients would recommend a TENS unit to a family or friend. When surveyed, 100% of ED staff observed that TENS units were effective in treating pain for patients, and 97% would want to use them if they themselves were patients. CONCLUSION: Overall, in this small pilot study, TENS units appeared to be effective in our ED for reducing pain, when added to standard treatment. Additional studies are needed to determine which conditions are most responsive to TENS therapy, and the magnitude of pain reduction when used alone.

Case Management Reduces Length of Stay, Charges, and Testing in Emergency Department Frequent Users.

INTRODUCTION: Case management is an effective, short-term means to reduce emergency department (ED) visits in frequent users of the ED. This study sought to determine the effectiveness of case management on frequent ED users, in terms of reducing ED and hospital length of stay (LOS), accrued costs, and utilization of diagnostic tests. METHODS: The study consisted of a retrospective chart review of ED and inpatient visits in our hospital's ED case management program, comparing patient visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program. We examined the LOS, use of diagnostic testing, and monetary charges incurred by these patients one year prior and one year after enrollment into case management. RESULTS: The study consisted of 158 patients in case management. Comparing the one year prior to enrollment to the one year after enrollment, ED visits decreased by 49%, inpatient admissions decreased by 39%, the use of computed tomography imaging decreased 41%, the use of ultrasound imaging decreased 52%, and the use of radiographs decreased 38%. LOS in the ED and for inpatient admissions decreased by 39%, reducing total LOS for these patients by 178 days. ED and hospital charges incurred by these patients decreased by 5.8 million dollars, a 41% reduction. All differences were statistically significant. CONCLUSION: Case management for frequent users of the ED is an effective method to reduce patient visits, the use of diagnostic testing, length of stay, and cost within our institution.

The Efficacy of Case Management on Emergency Department Frequent Users: An Eight-Year Observational Study.

BACKGROUND: Case management is an effective short-term means to reduce Emergency Department (ED) visits in frequent users of the ED. OBJECTIVES: Our study aimed to assess the long-term efficacy of intensive case management in frequent users of the ED. METHODS: This was an observational study of ED usage conducted at a community hospital that has an ED case management program in which frequent users of the ED are enrolled and provided with intensive care management to reduce ED use. RESULTS: We identified 199 patients that were enrolled for 6 or more years. Patients averaged 16 visits per person per year in the year prior to enrollment. Patients averaged the following number of visits per person per year after enrollment: year 1 (7.1), year 2 (4.1), year 3 (3.1), year 4 (3.3), year 5 (3.1), year 6 (2.0), year 7 (2.1), and year 8 (1.9), all statistically significant compared to the year prior to enrollment. Twenty-nine patients, despite case management, continued their frequent use, and required a revision to their plan of care. Five patients required a second revision to their plan of care secondary to recurrent ED usage. Persistent use despite case management was primarily due to prescription medication misuse and chronic pain. CONCLUSION: Case management of ED frequent users seems to be an effective means to reduce ED usage in both the short and long term. Patients with prescription drug misuse or chronic pain may continue to demonstrate frequent use despite case management, and may require revisions to their plan of care.

Albert Behnke: nitrogen narcosis.

As early as 1826, divers diving to great depths noted that descent often resulted in a phenomenon of intoxication and euphoria. In 1935, Albert Behnke discovered nitrogen as the cause of this clinical syndrome, a condition now known as nitrogen narcosis. Nitrogen narcosis consists of the development of euphoria, a false sense of security, and impaired judgment upon underwater descent using compressed air below 3-4 atmospheres (99 to 132 feet). At greater depths, symptoms can progress to loss of consciousness. The syndrome remains relatively unchanged in modern diving when compressed air is used. Behnke's use of non-nitrogen-containing gas mixtures subsequent to his discovery during the 1939 rescue of the wrecked submarine USS Squalus pioneered the use of non-nitrogen-containing gas mixtures, which are used by modern divers when working at great depth to avoid the effects of nitrogen narcosis.

Wound debridement: lessons learned of when and how to remove "wild" maggots.

BACKGROUND: Wounds, particularly chronic wounds, are a common presentation to the Emergency Department (ED), and in severe cases can contain maggots. Maggot debridement therapy is a popular technique for wound debridement, but is limited to the use of sterilized larvae due to concerns of contamination and invasion of "wild" maggots into healthy tissue. Wild maggots in chronic wounds, therefore, should be removed, yet there is no reported literature that describes a technique for their removal. OBJECTIVE: This article presents a step-by-step approach for the safe removal of "wild" larvae in a wound using Yankauer suction. CASE REPORT: We present a case of a homeless man presenting to the ED with a foot wound found to have "wild" maggots that required removal. CONCLUSION: The technique described in this article is a simple, safe, and efficient way for the Emergency Physician to remove "wild" larvae from wounds.

How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain?

CONTEXT: Narcotics are frequently prescribed in the Emergency Department (ED) and are increasingly abused. Prescription monitoring programs affect prescribing by Emergency Physicians (EPs), yet little is known on how EPs interpret prescription records. OBJECTIVE: To assess how EPs interpret prescription narcotic history for patients in the ED with painful conditions. DESIGN/MAIN Outcome Measures: We created an anonymous survey of EPs consisting of fictitious cases of patients presenting to the ED with back pain. For each case, we provided a prescription history that varied in the number of narcotic prescriptions, prescribing physicians, and narcotic potency. Respondents rated how likely they thought each patient was drug seeking, and how likely they thought that the prescription history would change their prescribing behavior. We calculated κ values to evaluate interobserver reliability of physician assessment of drug-seeking behavior. RESULTS: We collected 59 responses (response rate = 70%). Respondents most suspected drug seeking in patients with greater than 6 prescriptions per month or greater than 6 prescribing physicians in 2 months. Medication potency did not affect physician interpretation of drug seeking. Respondents reported that access to a prescription history would change their prescribing practice in all cases. κ values for assessment of drug seeking demonstrated moderate agreement. CONCLUSION: A greater number of prescriptions and a greater number of prescribing physicians in the prescription record increased suspicion for drug seeking. EPs believed that access to prescription history would change their prescribing behavior, yet interobserver reliability in the assessment of drug seeking was moderate.

Significant toxicity in a young female after low-dose tricyclic antidepressant ingestion.

BACKGROUND: Tricyclic antidepressant (TCA) ingestions are a relatively common pediatric ingestion, with significant potential for both cardiac and neurological toxicity. Previous studies on pediatric TCA ingestions have found the threshold of toxicity to be 5 mg/kg. CASE: We report a case of an 8-year-old girl who presented to the emergency department with depressed mental status and seizure-like movements. An extensive workup was pursued to evaluate the cause of her mental status, which only revealed a positive urine toxicology screen for TCA. Quantified serum levels of amitriptyline were 121 ng/mL (therapeutic range, 50-300 ng/mL) and nortriptyline were 79 ng/mL (therapeutic range 70-170 ng/mL), 18 hours after onset of symptoms. Subsequent history obtained after her mental status returned to normal revealed that she had ingested amitriptyline at a dose of 0.8 mg/kg. CONCLUSIONS: Tricyclic antidepressant ingestion has a high potential for toxicity in pediatric patients. This case suggests, contrary to previous literature, that toxicity may occur even with small doses.

Anorexia nervosa: a case report of a teenager presenting with bradycardia, general fatigue, and weakness.

BACKGROUND: Anorexia nervosa is a disease with high prevalence in adolescents and carries the highest mortality of any psychiatric disorder. CASE: We present a case of a 17-year-old female presenting to the emergency department with bradycardia that was subsequently diagnosed with anorexia nervosa. We also review the clinical features, diagnosis, complications, and emergency department management of this disease. CONCLUSIONS: Patients with anorexia may present with multiple medical complaints, and it is imperative that the emergency physician be familiar with the syndrome so as to correctly identify and treat patients with this disease.

Charles McBurney: McBurney's point.

Charles McBurney published a treatise on appendicitis in 1891, in which he described the exact point on the abdomen at which tenderness was maximal in cases of acute appendicitis--the point now known as "McBurney's point." He also described his approach to both the diagnosis and management of appendicitis, which at the time consisted of careful observation, total disuse of the stomach, and early laparotomy. Since 1891, many advances in the diagnosis of acute appendicitis have been made. Emergency physicians evaluating patients with abdominal pain may rely on laboratory studies, particularly the white blood cell count, and abdominal imaging with either ultrasound or computed tomography in addition to the history and physical examination. Despite these advances, tenderness to palpation over McBurney's point remains a key finding on abdominal examination in the assessment of patients with abdominal pain.

Quantifying drug-seeking behavior: a case control study.

BACKGROUND: Drug-seeking behavior (DSB) is common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of anecdotal evidence. STUDY OBJECTIVES: To perform a case-control study examining the relative frequency of DSB in suspected drug-seeking patients as compared to all ED patients. METHODS: We performed a retrospective chart review of 152 drug-seeking patients and of age- and gender-matched controls, noting which of the following behaviors were exhibited during a 1-year period: reporting a non-narcotic allergy, requesting addictive medications by name, requesting a medication refill, reporting lost or stolen medication, three or more ED visits complaining of pain in different body parts, reporting 10 out of 10 pain, reporting > 10 out of 10 pain, three or more ED visits within 7 days, reporting being out of medication, requesting medications parenterally, and presenting with a chief complaint of headache, back pain, or dental pain. RESULTS: The odds ratios for each studied behavior being used by drug seeking patients as compared to controls were: non-narcotic allergy: 3.4, medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits in 7 days: 30.8, out of medication: 26.9, headache: 10.9, back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated odds ratio of infinity for these two behaviors. CONCLUSIONS: Requesting parenteral medication and reporting greater than ten out of ten pain were most predictive of drug-seeking, while reporting a non-narcotic allergy was less predictive of drug-seeking than other behaviors.

Narcotic bowel syndrome.

BACKGROUND: Narcotic bowel syndrome is characterized by chronic or recurrent abdominal pain associated with escalating doses of narcotic pain medications. It may occur in as many as 4% of all patients taking opiates, and yet few physicians are aware that the syndrome exists. OBJECTIVES: The objectives of this case report are to raise awareness of narcotic bowel syndrome among emergency physicians, as well as review the clinical features, diagnosis, pathophysiology, and emergency department (ED) management of the syndrome. CASE REPORT: We report a case of narcotic bowel syndrome diagnosed in a 24-year-old woman after > 1 year of ED visits for recurrent abdominal pain of unknown origin. CONCLUSIONS: It is particularly important for emergency physicians to be familiar with this syndrome, as many patients with narcotic bowel syndrome seek evaluation and treatment in the ED. Although the diagnosis is unlikely to be made in the ED, timely referral for evaluation of this syndrome may help patients to receive definitive treatment for their recurrent and chronic pain.

Giant hydronephrosis presenting as an acute abdomen.

BACKGROUND: Giant hydronephrosis is a relatively rare condition caused by obstruction of the renal collecting system that can present with a great number of different types of abdominal signs and symptoms. CASE REPORT: A 40-year-old man without past medical history presented to the Emergency Department with diffuse abdominal pain, nausea, and vomiting. On examination, he was found to have an acute abdomen. Computed tomography scan revealed left giant hydronephrosis secondary to an obstructing renal calculus. The patient had a left percutaneous nephrostomy tube placed, which drained over 7 L of fluid from the dilatated collecting system. CONCLUSION: Giant hydronephrosis is a rare potential cause of abdominal pain, particularly in the context of a patient with known nephrolithiasis, structural urologic abnormalities, or malignancy.

How Frequently are "Classic" Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department?

INTRODUCTION: Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior. The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication. METHODS: We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as "classic" for DSB in the existing literature. RESULTS: We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit. CONCLUSION: Drug-seeking patients appear to exhibit "classically" described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking.

Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography.

OBJECTIVE: Emergency department (ED) frequent users account for a large number of annual ED visits and often receive radiological studies as a part of their evaluation. We report a pilot study of a case management program for ED frequent users to reduce ED usage and radiation exposure. METHODS: This observational retrospective study was performed at a community hospital ED. Between May 2006 and April 2008, 96 patients were enrolled in a case management program and were followed through November 2008. The case management program consisted of a multi-disciplinary team of physicians, nurses, social services and specialists in pain management and behavioral health. Patients were enrolled if they had five or more visits to the ED in the previous month, if a concern about a patient's ED use was raised by staff, or if they were identified by the California prescription monitoring program. Case management addressed specific patient issues and assisted with receiving consistent outpatient care. The number of ED visits per patient and the number of radiological studies at each of these visits was recorded. When reviewing data for analysis, we used the number of total images in all computed tomography (CT) scans during the given time period. RESULTS: In the six months prior to enrollment, patients averaged 2.3 ED visits per patient per month. In the six months after enrollment, patients averaged 0.6 ED visits per patient per month (P<0.0001), and all visits after enrollment up to November 2008 averaged 0.4 visits per patient per month (P<0.0001). In the six months prior to enrollment, these patients averaged 25.6 CT images per patient per month. In the six months after enrollment, patients averaged 10.2 CT images per patient per month (P=0.001), and all CT images after enrollment up to November 2008 averaged 8.1 CT images per patient per month (P=0.0001). This represents a decrease in ED use by 83% and a decrease in radiation exposure by 67%. CONCLUSION: Case management can significantly reduce ED use by frequent users, and can also decrease radiation exposure from diagnostic imaging.