Welcome to the official blog of the St. John's Riverside EM residency!
Below you'll find resident and faculty education posts and discussions, residency news, FOAMed highlights, and more! For Ultrasound-focused content, see our Probetrotters page!
Chief Resident Selection
Congratulations to Dr. Adrian Cotarelo and Dr. Nishad Rahman, who were selected to be the rising Chief Residents for the upcoming academic year!
Welcome to the Class of 2024!
A warm welcome to our rising intern class of 2024! We can't wait to meet you in June, and here's to a great three years!
Ultrasound Blog - Facelift!
Hospital Video Tour and Program Overview Videos
Approaches to the Diagnosis of Peritonsillar Abscess with Point-of-Care-Ultrasound
Happy new year! For the first content review of 2021, Dr. Rosner discusses Ultrasound guided methodologies for identifying peritonsillar abscesses. Peritonsillar abscesses are the most common deep neck infections, and 80% of cases are found in patients aged 10 to 40. Ultrasound is an important modality in differentiating, diagnosing and treating peritonsillar abscesses in the Emergency Department, with both intraoral ultrasound and transcutaneous ultrasound as viable options.
Click HERE for the full review!
Happy Holidays from SJRH EM!
Take a look at a few of the top creations that beat out the competition during the gingerbread house making contest, as well as our Holiday Goodies Zoom baking social!
St. John's Riverside - at the Forefront of the COVID-19 Vaccine Distribution
Today marks the beginning of the St. John's Riverside Hospital COVID-19 vaccine distribution. Our residents, attendings, and front-line staff at all levels are among the first in the nation making history in this victory of science. Here's to a better year to come!
SimWars Semifinals Victory
Congratulations to the St. John's Riverside team for winning the Bronx bracket for the 2020 (first ever virtual) AllNYCEM SimWars semifinals competition! SimWars is a simulated case competition involving multiple residency programs throughout New York State. Teams go head-to-head in challenging clinical scenarios with state of the art simulation technology while being evaluated on their medical management, communication, and teamwork.
On to the finals!
Click HERE to read more about AllNYCEM, and SimWars!
Journal Club: Comparison of the Accuracy of Emergency Department-Performed Point-of-Care-Ultrasound in the Diagnosis of Lower-Extremity Deep Vein Thrombosis.
García, J. P., et al. (The Journal of Emergency Medicine, 2018)
With sufficient training, emergency physicians can effectively use three-point compression ultrasound to diagnose proximal lower extremity DVTs. This prospective cross-sectional study assessed the accuracy of emergency physician-performed three-point compression ultrasound to diagnose DVT in comparison to the standard radiology-performed Doppler ultrasound. POCUS DVT is less time consuming than comprehensive ultrasound, and was performed in an average of five minutes in this study.
Click HERE for the full review!
Transesophageal Echocardiography (TEE) for Cardiopulmonary Resuscitation
Transesophageal Echocardiography (TEE) is increasingly used in emergency departments to guide cardiopulmonary resuscitation, as an alternative to the more common Trans Thoracic Echo (TTE). TEE provides a visual stimulus during pulse checks, allowing the resuscitation team to check the effectiveness of ongoing chest compressions, and can provide additional diagnostic information (see below). It has been shown by Andersen et al, found that TEE used to visualize chest compressions directly over the left ventricle (LV)versus traditional placement and compression of the aortic root improve hemodynamics and increased Return of Spontaneous Circulation (ROSC) rates.
Click HERE for the full review!
Pumpkin Carving Competition: Surviving 2020
Happy Halloween from SJRH EM! Please enjoy our departmental submission for the annual St. John's Riverside Hospital pumpkin carving competition, run by our very own Dr. Liz So!
Journal Club: Utility of Point-of-Care Lung Ultrasonography for Evaluating Acute Chest Syndrome in Young Patients With Sickle Cell Disease
Cohen, S. G., et al. (Annals of Emergency Medicine, 2020)
Acute chest syndrome is the leading cause of mortality in patients with sickle cell disease. As a result, these patients experience multiple radiological exposures starting at very young ages. If ultrasound is comparable to the current gold standard of chest radiography, patients with sickle cell disease may experience significantly less radiation exposure over their lifetimes.
Click HERE for the full journal article review!
Resident research conference 2020
This week was our annual Resident Research Day, where both the Emergency Medicine and Internal Medicine residents submitted their research presentations. The top 2 abstracts, and top case report were selected among the submissions for award.
Click HERE to view the submissions!
EMRA/ACEP Resident Fellow health policy program
A huge congratulations to our very own Dr. Nishad Rahman who was selected for one of only two spots nationwide for the EMRA/ACEP Resident Fellow Health Policy Elective in Washington DC! Resident fellows undertake a four week health policy program on Capitol Hill designed to train the next generation of health policy advocates on both the state and national levels. Read more about the program here. Congratulations Dr. Rahman!
Follow Dr. Rahman on Twitter @Nishad_A_Rahman
More than beets the eye:
A Simple Case of Suprapubic Catheter Displacement
History of Presenting Illness:
A 64 year old woman with history notable of severe multiple sclerosis, neurogenic bladder, recurrent urinary tract infections, and indwelling suprapubic catheter (placed two months ago) presents to the ED after her catheter became partially dislodged. Her daughter is her caretaker and maintains the catheter, and she is unsure how the catheter became dislodged, but it was first noticed today. The daughter reports a change in her mother’s urine color two days ago (previously yellow), as well as a foul odor to the urine. She denies any fevers, chills, weakness, or pain around the catheter site. She is typically asymptomatic when she has a UTI. She has never experienced urine discoloration like this before and has not received any new medications or dyes over the past month. And no, she has not been eating copious amounts of beets, berries, or rhubarb.
Pertinent Physical Exam:
Vitals: Temp 97.6F; HR 85; RR 16; BP 176/90; O2 sat 99% on RA
General: Awake, alert, and fully oriented, in no acute distress. Contracted upper extremities.
Abdomen: No overlying erythema, cellulitis, discharge, or tenderness noted around suprapubic catheter insertion point. Catheter tubing and Foley bag as pictured. Catheter noted to be displaced but not fully removed. Foul smelling, cloudy, deep purple colored urine. Abdomen is soft and nontender, with normoactive bowel sounds.
Pertinent Lab Data:
CBC - WBC 5.1; Hg 9.5 (Baseline)
CMP - Creatinine 0.3; BUN 9.3
Troponin I - negative
UA - unavailable; machine is broken
What is the cause of the apparent urine discoloration in this patient?
What are risk factors for developing this condition?
Purple Urine Bag Syndrome
Purple Urine Bag Syndrome (PUBS) is a condition in which the urinary catheter bag and tubing become stained purple due to bacterial activity within the bag. This process is attributed to the bacterial metabolic breakdown of tryptophan into indole, which is further processed by the liver into indoxyl sulfate. Once indoxyl sulfate is excreted into the urine, bacteria which have colonized the urine bag process it further into indirubin (red) and indigo (blue) which stain the urine bag, giving the characteristic purple appearance. Klebsiella, Proteus, and Providencia species, among others, have been implicated in PUBS. Multi-bacterial colonization is likely in a long-term catheter bag. While the change in urine appearance is dramatic, PUBS is not associated with severe infection.
Take home points:
Purple Urine Bag Syndrome is an uncommon condition that may affect patients with chronic indwelling catheters due to bacterial breakdown products forming both red and blue pigments simultaneously.
PUBS is thought to be relatively benign aside from indicating a possible UTI, but the striking color can be alarming to family and providers unfamiliar with the presentation.
Risk factors for developing PUBS include chronic catheterization, female sex, sedentary lifestyle or immobility, high tryptophan diets, and constipation
UltraSound for the Diagnosis of Distal Forearm Fracture
Have you ever wondered if ultrasound could help you diagnose a distal forearm fracture? Well I’m here to answer that for you today! The short answer is “yes, it absolutely can”!
Now, I can hear your voices right now: where is the evidence? Well, come on down!
Evidence - Study #1
In pediatric forearm fractures, Douma-den Hamer performed a meta analysis demonstrating a sensitivity of 97% , specificity 95% , positive likelihood ratio (LR) 20.0 and negative LR 0.03. With the 6-view method showing higher specificity and positive LR compared to the 4-view method.
A 6-view method which you can perform with copious gel or in a water bath in the attached image.
Although ultrasonographers were blinded for the x-ray results, they were obviously aware of clinical exams and history.
There is a need for universal definition of a threshold value for fracture as obtained by ultrasound. Up till now some studies used only cortical disruption (e.g. steps, brakes, gap, interruptions), while others also included (subperiostal) hematomas and soft tissue changes. These different definitions in threshold likely affects the results for fracture detection in Salter Harris 1 fractures in children and other subtle fractures.
In general there should be an uniform technique for visualization and fracture definition in ultrasound for distal forearm fractures.
The measured difference in sensitivity and specificity in this study between ulna and radius is partly explained by the fact that accompanying ulna fractures (especially near the joint) were missed, and the prevalence of ulna fractures, accompanied or isolated are lower than radial fractures.
Conventional x-ray was used as reference standard comparator, which is not the golden standard to detect fractures. Occult fractures occur in convention x-ray in about 2–36% due to overlapping structures, under-mineralized ossification centres and non-perpendicular x-ray beam to the fracture line. Because the included studies compared ultrasound to conventional x-ray, true fractures seen on ultrasound, but missed by conventional x-ray were labelled as false positive. Actual sensitivity could even increase further if these fractures were labelled rightly or a more sensitive imaging modality was used.
Finally the majority of the studies were in the pediatric population but this may be a strength as an open physis could be a false positive
Evidence - Study #2
Most recently, a systematic review of blinded studies investigating its effectiveness in the identification of upper and lower limb fractures has been performed. In this study, Champagne et al demonstrated highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 93% and 92% for upper limb fractures , and 83% and 93% for lower limb fractures.
Trials which used ultrasonography to image multiple anatomical sites or which recruited smaller participant populations reported lower diagnostic accuracies. The former is a finding that has been previously reported in the literature and suggests that focussed sonographer training on specific anatomical regions may result in greater accuracy due to the learning curve associated with imaging different bones.
Several of the included studies had small sample sizes. The influence of sample size on diagnostic accuracy highlights the imprecision of small studies and supports the authors’ recommendations that future research be conducted in larger groups with a more focussed anatomical region of interest.
Ultrasonography is a user-dependent imaging modality, and few studies measured the effect of sonographer experience and training on the reliability of their imaging. Intra- and interrater reliability were infrequently reported, with only three of the 26 included studies noting values for these
Where can I learn more?
 Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. Douma-den Hamer D, Blanker MH, Edens MA, Buijteweg LN, Boomsma MF, van Helden SH, et al. PLoS ONE 2016
 The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis. Natalie Champagne, Leila Eadie, Luke Regan & Philip Wilson. BMC Emergency Medicine volume 19, Article number: 17 (2019)