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Program Leadership

After six years of dedicated service to the Thomas Jefferson University Emergency Medicine Residency Program, I am sad to share that Dr. Ronald Hall will be stepping down as Residency Program Director.

During his tenure as Program Director, Dr. Hall was instrumental in advancing the educational mission of our residency. He has served as the quintessential mentor, educator, and role model for six classes of EM graduates. He has selflessly and tirelessly dedicated his faculties to the advancement of Emergency Medicine at Jefferson; and has successfully chaperoned our program to a point of innovative approaches to medical education, healthcare delivery, and simulation-based safety initiatives.

Moving forward, we are fortunate to have Dr. Hall continue his academic and clinical work as a faculty member in the Department of Emergency Medicine. As he transitions out of this role, he will be leading the simulation program in our Department and work on advancing simulation-based educational opportunities for trainees, in our Department and across the institution.

Over the last several months, the Department conducted an extensive national search for his successor; and we are ecstatic to announce that Dr. Robin Naples will be taking over the reins as our new Program Director, beginning January 1st, 2017.

Dr. Naples graduated from Temple University School of Medicine in 2004; completed her residency in Emergency Medicine at the University of Virginia in 2007, where she also completed a Cardiovascular Fellowship in 2008. Dr. Naples has been actively involved in the Emergency Medicine Residency Program at Temple University as the Associate Program Director. She will be joined in this role by our wonderful and esteemed Assistant Program Directors, Drs. Nicholas Governatori and Kory London.

We could not be more fortunate to to have such a strong team of educators, leaders, and innovators for our residency program’s leadership. As we enter the 2016-2017 interview season, our residency leadership is committed to ensuring a smooth transition for our existing residents and our prospective candidates. To that effect Dr. Naples will be fully involved in the interview process at Jefferson as we recruit the Class of 2020.

I ask that the CORD community join me in thanking Dr. Ronald Hall for his six years of outstanding service to Jefferson and our field, and congratulating Dr. Robin Naples as she transitions into her new role.

Warmest regards,

Dimitri Papanagnou

Blakemore Now – Bleed Less Later

Gregory Wanner, DO, PA-C
Emergency Medicine Resident, PGY-3

Dimitrios Papanagnou, MD, MPH, EdD(c)
Assistant Professor, Emergency Medicine

It’s 3 am on a Saturday and you’re covering the emergency department at a community hospital. You hear a nurse’s firm but slightly nervous-sounding voice down the hall “umm, I need some help in here.”

You enter the room and find a geyser of blood erupting from the mouth of a middle-aged male patient. His family informs you that he is a heavy drinker and has “liver problems.”

After applying a triple-G (gown, gloves, and goggles) you walk into the room and begin to perform the critical actions of securing the airway, placing large bore IV access, transfusing blood, starting octreotide and calling GI. GI is unavailable and the patient keeps bleeding. He is now severely hypotensive.

  • What else can you do?
    The patient is exsanguinating from a likely esophageal variceal bleed. You have tried all other options and GI is not able to help. At this point the use of a gastroesophageal balloon tamponade (GEBT) tube can be considered. The GEBT—more commonly known as a Sengstaken-Blakemore tube or Minnesota tube—is infrequently used and rarely practiced with, but potentially life-saving in certain situations.

    TubeInsert

  • What is a GEBT tube?
    Two types of GEBT tubes are most often available: The 3-lumen Sengstaken-Blakemore tube (often just referred to as a “Blakemore”) or the 4-lumen Minnesota tube. The Blakemore includes a gastric balloon, esophageal balloon, and a gastric aspiration port. The Minnesota tube adds an esophageal aspiration port as well. The function of both tubes is similar—to apply internal pressure in an attempt to stop gastric or esophageal variceal bleeding.
  • When would I consider using a GEBT tube?
    This device is considered as an option of last resort. A “Hail Mary” play when other treatments have failed and the patient has a high risk of mortality. Starting medications (octreotide), volume replacement (blood products), and a discussion with GI should, ideally, occur before using a GEBT tube. Major complications from the GEBT tube, such as esophageal perforation, occur in up to 16% of patients. Mortality directly related to GEBT tube use is 3-6%. Variceal hemorrhage mortality, however, ranges from 20-80% depending on the reference. [1-2]
  • How do I use a GEBT tube?
    Attempting to learn how to use a GEBT tube while a patient is actively hemorrhaging in front of you is not ideal. A better method would be to review some teaching materials beforehand.

Here are some resources:

Review these items now (before the exsanguinating patient comes in).

Where is the GEBT tube at Jefferson?
Our GEBT is in the far bed of the trauma/resuscitation bay (room 33T) in the cabinet labeled “Blakemore Tube” for easy recognition, although we actually have a Minnesota 4-lumen tube (image 1). In the cabinet we now have a kit which includes the Minnesota tube plus step-by-step instructions and supplies needed to begin using the tube (image 2).

References
  • Cook D, Laine L. Indications, technique, and complications of balloon tamponade for variceal gastrointestinal bleeding. J Intensive Care Med. 1992; 7(4): 212-218. PMID: 10147943
  • Winters ME, Panacek EA. Balloon Tamponade of Gastroesophageal Varices. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Saunders Elsevier; 2014: 831-836.
  • Wanner G, Papanagnou D. Massive Upper Gastrointestinal Bleeding with Gastroesophageal Balloon Tamponade. MedEdPORTAL Publications; 2015. Available from: https://www.mededportal.org/publication/10177
  • Weingart S. Blakemore Tube Placement for Massive Upper GI Hemorrhage. EMCrit website. http://emcrit.org/procedures/blakemore-tube-placement October 13, 2013. Accessed March 5, 2016.

Pediatrics Joint Conference: Bruising

<2% of children under the age of 6 months will have any bruising at all.
Accidental bruising is common in children >9 months of age but not in children <9 months of age. Accidental bruises are not clustered, not patterned, and are usually found over bony prominences. Common locations include the anterior lower leg and forehead. Bruises involving the buttocks, back, ear, neck, and torso are more likely to be non-accidental.
Beware of any history that does not explain the bruising seen on exam.

Hematologic disorders can cause bruising as well.
vWB disease is the most common bleeding disorder (1% prevalence in general population).
Ask for family history of easy bruising, bleeding after dental procedures, heavy menstrual periods,
excessive bleeding with circumcision, etc.
If you have a low suspicion for non-accidental trauma, but bruising is present on exam,
consider a workup for hematologic disorders – CBC, PT, PTT.
If you have concern for non-accidental trauma as well, pursue both diagnoses.
Consider skeletal survey, CT head if appropriate, and a thorough exam including genital, anal,
intra-oral, and a close look at the ears, behind the ears, and inside skin folds.

References
CDC Statistics on Child Abuse
Nearpod Questions
ACEP Article on Child Abuse