Correspondence

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American Journal of Emergency Medicine

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Implementing postgraduate training for physician assistants in emergency medicine at a major Urban academic medical center

To the Editor,

The Affordable Healthcare Act intends to provide basic medical services to all Americans and must do so at minimal cost of implementation and over a relatively short period. The reality that it takes the better part of a decade to develop a physician through medical school and postgraduate training, along with the current physician shortage in the United States, requires us to look outside of this traditional pool of providers to meet the needs of the expected number of new patients [1]. It has become apparent that successful implementation of the Affordable Healthcare Act will depend on the addition of a large number of midlevel medical providers to the workforce and will likely require increasing the Scope of practice and clinical acumen of these providers to keep pace with the needs of the multitude of new patients. As the market changes, physician assistants will work more and more in specialties requiring more specific critical thinking and clinical decision making as well as more advanced procedural skills, than what PA graduate education prepares them for.

The classic model has been that this education occurs “on the job,” but in an increasingly pressured marketplace with physicians scram- bling to keep up with their patient loads, this sort of apprenticeship is becoming foreshortened and less widespread. Additional training, therefore, should occur in the context of postgraduate education [2]. To address this need, a small number of PA postgraduate residency/ fellowship programs have developed [3]. We describe the implemen- tation of one such postgraduate training program in emergency medicine (EM) at an urban academic medical center.

In July of 2011, the Cook County Emergency Medicine Residency enrolled its first class of PA residents. This class of 2 PAs was brought in alongside the new class of PGY1 EM physician residents and undertook a course of study that was tailored toward developing the necessary skills for PAs to provide advanced care in a busy emergency department (ED). Much as the PA educational model is a condensed version of the physician education model, the residency curriculum sought to condense the EM physician residency with an emphasis on common emergency conditions appropriate to a PAs scope of practice. The curriculum consists of 4-week rotation blocks that start in July with an orientation (Table). The orientation is run in conjunction with the EM physician internship, which allowed for an overlap of activities. During orientation, the PA residents participated in lectures on EM core topics, advanced suture skills laboratory, cadaver procedure laboratory, ACLS, PALS, and ATLS training.

The didactic curriculum was developed with the intent of allowing the PA residents to be exposed to the breadth of EM. Physician assistant residents attend 4 to 5 hours per week of EM conferences, participate in EM simulation sessions and procedure laboratories,

^a Elective offerings were 2 weeks long and included such rotations as anesthesia, ophthalmology, plastic surgery, radiology, EM ultrasound, oral surgery, and ENT.

present didactic talks during the year, and assist in educating PA students rotating through the department. Lastly, they attend monthly PA-specific education and mentoring sessions with the program director with preassigned readings.

At the completion of training, both PA residents were placed in full-time ED jobs, each garnering a pay rate that was above market value for a first job [4]. They both report a high degree of Job satisfaction and feel a much greater level of competence post- training. Both have met with a very good response to their clinical skills and reasoning at their first job posttraining. They felt well prepared for independently dealing with all but critically ill patients in the ED after their residency. The second class expanded to include 4 residents, starting in July 2012. The increased numbers have improved the output of the department as a whole with minimal additional work for the program director.

Faculty response has been marked by a great degree of acceptance and appreciation for the new PA residency. The department was previously comfortable with midlevel providers and employs 9 full- time PAs. The PA residents have allowed greater flexibility in the monthly ED schedule and have allowed more opportunity for the physician residents to schedule off-service rotations that help meet their Training needs.

Our PA postgraduate program is 12 months. The Society for Emergency Medicine Physician Assistants in December 2012 pub- lished guidelines for a postgraduate program in EM, recommending 18-month programs [5]. At present, very few residencies are 18 months (3), with the majority being 12 months [6]. Our experience suggests that a 12-month program is an ample time to address learning objectives and prepare the PA for a job in EM.

In conclusion, our experience at Cook County suggests that a 12-month PA postgraduate training program in EM is relatively easy to implement and is well received by the program participants, the physician residency, and EM faculty.

John Paul Magenis PA-C Department of Emergency Medicine Baystate Medical Center, Springfield, MA

E-mail address: [email protected]

0735-6757/$ - see front matter (C) 2013

Scott C. Sherman, MD

Department of Emergency Medicine Cook County (Stroger) Hospital, Chicago, IL Rush Medical College, Chicago, IL

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.02.004

References

1. http://www.businessweek.com/articles/2012-09-27/a-looming-u-dot-s-dot-

   doctor-shortage. Retirieved January 24, 2013.

   Asprey D, Helms L. A description of physician assistant postgraduate residency training: the director’s perspective. Perspective on Physician Assistant Education 1999;10(3):124-31.

2. www.appap.org. Retrieved January 25, 2013.
3. http://www.bls.gov/ooh/healthcare/physician-assistants.htm. Retrieved January 25, 2013.
4. http://www.sempa.org/Content.aspx?id=360. Retrieved January 25, 2013.
5. www.appap.org. Retrieved January 25, 2013.

   energy drinks overdose and metabolic abnormalities-a double whammy!?^,??

   To the Editor,

   The article by Dikici et al [1] is interesting. There are increasing reports regarding adverse effect of energy drink (ED) in current literature. Energy drink use has been anecdotally linked with seizure, and there is paucity of evidence-based literature in support of this association. This raises a debate whether the risk is negligible or it is underestimated, due to inadequate reporting [2].

   In the case reported, there was no mention of laboratory values of Serum electrolytes. It is well known that alteration in both sodium and potassium ion gradients across the cell membrane has direct and indirect effects on neuronal discharge and may facilitate epileptiform activities [3]. We have reported severe symptomatic hyponatremia, after consumption of large quantities of “Diet Coke” probably due to dilutional or diuretic effect of the content [4]. Hypokalemia is the predictable laboratory abnormality subsequent to caffeine intoxica- tion. Unlike other electrolyte imbalances, hypokalemia rarely causes Neurologic manifestations. However, hypokalemia predisposes to tachyarrhythmia, which could theoretically cause seizures, through secondary cerebral anoxia. Furthermore, there is tendency to combine ED with alcohol, for example, the “Vodka Red Bull” as also reported in this case. In this situation, caffeine functions as a stimulant, thus reducing the depressant effects of alcohol. Moreover, the patient did not develop seizures when he consumed small volumes of ED, which suggests that these stimulant drinks have a dose-dependent effect. In contrast, when large volumes were consumed on an empty stomach with alcohol, there is increased risk of adverse effects, as seen in this report.

   In our observation, we have also reported hyperglycemia, hypophosphatemia, hypocalcaemia, metabolic acidosis, and ketonuria in our ED-overdose patients. We also found that ED-induced seizures respond well to benzodiazepines. However, if Seizure activity is refractory to benzodiazepines, barbiturates are recommended. Phe- nytoin is not useful in treating these kinds of seizures [5].

   Diet and substance use histories should include screening for episodic/chronic ED consumption, both alone and with alcohol. Health care providers and media should educate families about potential adverse outcomes [6]. More evidence-based scientific

   ? Financial support-Nil.

   ?? Conflict of interest-Nil.

   literature needs to be generated to determine safe levels of consumption, establish effects of long-term use, and better under- stand adverse health effects of ED.

   Subramanian Senthilkumaran MD

   Department of Emergency & Critical Care Medicine Sri Gokulam Hospitals & Research Institute, Salem, Tamil Nadu, India

   E-mail address: [email protected]

   Suresh S. David MS

   Department of Emergency Medicine Christian Medical College and Hospital, Vellore, India

   Namasivayam Balamurugan MD, DM

   Department of Neurosciences, Manipal Hospital, Salem

   Tamil Nadu, India

   Ponniah Thirumalaikolundusubramanian MD

   Department of Internal medicine Chennai Medical College and Research Center

   Irungalur, Trichy, India

   http://dx.doi.org/10.1016/j.ajem.2013.02.016

   References

   Dikici S, Saritas A, Besir FH, Tasci AH, Kandis H. Do energy drinks cause Epileptic seizure and ischemic stroke? Am J Emerg Med 2013;31:274.e1-4.

6. Ferlazzo E, Aguglia U. Energy drinks and seizures: what is the link? Epilepsy Behav 2012;24:151.
7. Riggs JE. neurological manifestations of electrolyte disturbances. Neurol Clin 2002;20:227-39.
8. Senthilkumaran S, Chandrasekaran VP, Balamurugan N. Soft drinks: are they really soft? JIST 2008;4:41-2.
9. Blake KV, Massey KL, Hendeles L, Nickerson D, Neims A. Relative efficacy of phenytoin and phenobarbital for the prevention of theophylline induced seizures in mice. Ann Emerg Med 1988;17:1024-8.
10. Gunja N, Brown JA. Energy drinks: health risks and toxicity. Med J Aust 2012;196: 46-9.

    Wandering spleen presenting as Small bowel obstruction

    To the Editor,

    We read with great interest the article by Singla et al [1]. “Wandering spleen presenting as bleeding gastric varices,” which describes about a rare clinical manifestation of wandering spleen. In this letter, we want to describe another extremely rare presentation of this entity.

    A 22-year-old man presented with colicky abdominal pain and distention since 2 days before admission. He had no history of previous laparotomy or any underlying disease. Physical examination revealed severe Abdominal distention with hyperactive bowel sounds. Plain abdominal x-ray showed multiple air-fluid levels. Computed tomographic scan demonstrated multiple distended bowel loops, absence of the spleen in the left upper quadrant (Fig. 1), and an infracted ectopic spleen in the left lower quadrant (Fig. 2). At surgery, the spleen was located in the left lower abdomen; small bowel loops were very dilated; and the spleen was mobile, infracted, and had necrosis due to torsion around its long pedicle. So, splenectomy was performed, and the patient recovered uneventfully.

    A wandering spleen, defined as a spleen without peritoneal attachments, is a rare entity [2]. Patients may be asymptomatic or may present with a palpable mass in the abdomen or with acute, chronic, or intermittent symptoms due to torsion of the wandering spleen. Because