J Emerg Med
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Haff disease is a rare syndrome of rhabdomyolysis thought to be caused by a heat-stable toxin associated with the consumption of seafood from fresh or brackish water. ⋯ We present the case of a patient with Haff disease who presented to the emergency department with nausea/vomiting, diarrhea, and myalgias after a seafood buffet. Initially, he was treated with i.v. fluids and antiemetics for presumed gastroenteritis, but his symptoms did not improve. He was found to have elevated aspartate aminotransferase and alanine aminotransferase, normal point-of-care ultrasound, urinalysis with large blood and no red blood cells, and an elevated creatine phosphokinase (CPK). He was admitted to the hospital to receive ongoing fluid resuscitation for rhabdomyolysis presumed to be from fish. Liver enzymes and CPK downtrended, and patient was discharged on hospital day 3. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Undiagnosed Haff disease has important clinical implications, including multi-organ failure and death. Always maintain a high level of suspicion for Haff disease in patients with symptoms suggestive of gastroenteritis, but complicated by minor liver function test elevations and dipstick positivity for heme, without significant numbers of red blood cells per high-power field, in the setting of recent seafood ingestion.
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Case Reports
Point-of-Care Ultrasonography for Hernia Reduction: A Case of Incarcerated Umbilical Hernia.
Manual reduction of an incarcerated hernia is used to avoid emergency surgery, which comes with risks of complications and death, especially in patients with severe comorbidities. However, there are no established procedures for hernia reduction. ⋯ We present the case of an 82-year-old man with refractory ascites due to nephrotic syndrome and chronic heart failure who developed an incarcerated umbilical hernia. Color Doppler ultrasonography allowed us to detect clearly visible blood-flow signals in the incarcerated bowel and rule out necrosis, which is a contraindication for reduction. Several attempts at manual reduction failed; ultrasonography-guided reduction revealed that fluid collection within the hernia sac was blocking the manual pressure directly on the incarcerated bowel toward the hernia orifice. After sac paracentesis (draining the fluid from the sac), the incarcerated bowel became palpable, leading to a successful reduction. Four days later, once the patient was in a stable condition, an elective surgery was performed to prevent the recurrence of incarceration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We believe that this is a useful report on the use of point-of-care ultrasonography for incarcerated hernia from the initial assessment of bowel viability to reasonable hernia reduction through hernia sac paracentesis according to real-time observation. An approach based on visualization by ultrasonography, and not on the operator's experience, would be rational, and we believe that this approach will be feasible for emergency physicians, who are responsible for the initial treatment of incarcerated ventral hernia.
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There are currently 5 combined residencies in emergency medicine (EM), namely EM/pediatrics, EM/internal medicine, EM/internal medicine/critical care, EM/family medicine and EM/anesthesiology. These combined programs vary from 5-6 years in length. Like categorical programs, the decision to enter a 5- or 6-year program should be an informed and comprehensive decision. We describe the history and current status of the combined EM programs, discuss the process of applying to a combined EM program, describe the life of combined EM residents, and explore common career opportunities available to combined EM program graduates.
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Observational Study
Direct Oral Anticoagulant Treatment and Mild Traumatic Brain Injury: Risk of Early and Delayed Bleeding and the Severity of Injuries Compared with Vitamin K Antagonists.
The risk of intracranial hemorrhage (ICH) in patients taking direct oral anticoagulants (DOACs) after mild traumatic brain injury (MTBI) is unclear. ⋯ DOAC-treated patients seem to have lower risk of posttraumatic intracranial bleeding compared with VKA-treated patients.