UMEM Educational Pearls

Category: Med-Legal

Title: Teaching Physican Billing Pearls

Keywords: Academics, Billing, Teaching, Residents (PubMed Search)

Posted: 12/30/2007 by Michael Bond, MD (Updated: 10/20/2019)
Click here to contact Michael Bond, MD

Fraud (PATH audits)    (PATH = physicians at teaching hospitals)

  • As a general rule, faculty may not bill Medicare for the work of residents.
  • Faculty may bill for their own work, and may repeat a resident examination if necessary.
  • To appropriately bill under PATH audit guidelines, faculty may make reference to a resident’s history, may simply document the variance between their exam and the resident’s exam, and should document medical decision making.
  • Faculty may bill for a procedure if:
    • faculty performs the procedure
    • faculty was present for the entire procedure
    • faculty was present for the key portion of the procedure
    • faculty actively assisted the resident in performance of the procedure.

So for the residents, a lot of attendings will want to be present when you do a procedure, not because they think you will need their assistance, but because, procedures are a large revenue stream that can be lost if the attending is not present.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

Category: Pediatrics

Title: Childhood Cancer Presentation

Keywords: Childhood Cancers, Leukemia, Lymphoma, pallor, fatigue (PubMed Search)

Posted: 12/28/2007 by Sean Fox, MD (Updated: 10/20/2019)
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Pediatric Leukemia/Lymphoma Presentation in the ED

  • Pts most commonly present with c/o pallor or decreased activity
  • Physical Exam commonly demonstrates pallor, splenomegaly, fever, hepatomegaly, lymphadenopathy, and ecchymoses/petechiae.
  • CBC’s and peripheral smears are realiably abnormal
  • Patients with solid tumor more commonly present with symptoms related to tumor location (ie Abd pain, Headache, etc.)

Jaffe D, Fleisher G, Grosflam J. Detection of cancer in the pediatric emergency department. Pediatr Emerg Care. 1985 Mar;1(1):11-5.

Category: Toxicology

Title: Phenytoin: PO vs IV load

Keywords: phenytoin, anticonvulsants, loading dose (PubMed Search)

Posted: 12/27/2007 by Fermin Barrueto, MD (Updated: 10/20/2019)
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                                      Phenytoin po      Phenytoin IV       Fosphenytoin

Time to therapeutic       6.4 hrs                  1.7 hrs                 1.3 hrs

Adverse Events              0.69/pt                   1.86/pt                 1.87/pt

Cost                                   $2.83                   $88.50                $224.09
(Swadron et al. Ann Emerg 2002)

Also to take into account  is that the adverse events with IV phenytoin include soft-tissue necrosis if there is extravasation of infusion. The cardiotoxicity seen with phenytoin and fosphenytoin is largely due to the propylene glycol diluent and thus not seen with oral loading or even in oral overdosing.

You decide, at least you have the data to properly evaluate the risk:benefit ratio.

Category: Neurology

Title: Neurosarcoidosis

Keywords: sarcoidosis, neurosarcoidosis, cranial nerve dysfunction (PubMed Search)

Posted: 12/26/2007 by Aisha Liferidge, MD (Updated: 1/9/2010)
Click here to contact Aisha Liferidge, MD

  • Less than 10% of sarcoidosis cases affect only the nervous system.
  • In such cases, granulomas form within nervous tissue and usually only occurs when there is significant systemic involvement.
  • Most sarcoid exacerbations affecting the nervous system are not recurrent. 
  • Manifestations of neurosarcoidosis include:
    • 1)  Mononeuropathy - Cranial nerve dysfunction most common     (Heerfordt  syndrome = uveitis, fever, parotid gland inflammation, and facial nerve palsy).
    • 2)  Peripheral neuropathy - Sensation and/or motor dyusfunction
    • 3)  Central Nervous System -  Hypothalamus/pituitary gland, cerebral cortex, cerebellum, spinal cord (rare)

Category: Vascular

Title: Ruling out Pulmonary Embolism during the holidays?

Keywords: Pulmonary Embolism (PubMed Search)

Posted: 12/24/2007 by Rob Rogers, MD (Updated: 10/20/2019)
Click here to contact Rob Rogers, MD

The PERC Rules revisted

How can I rule out PE without ANY testing, you ask? Do I have to get a d-dimer on that low risk patient?

Do these things keep you up at night like they do me?

Consider using the PERC rule (Pulmonary Embolism Rule Out Criteria)

This set of rules was mentioned in an earlier pearl, but there are now 3 large studies (and one on the way) that validate the use of these rules.

So, if you have a patient who is LOW risk for PE but you would like to document something in the chart that proves you thought about the diagnosis and clinically ruled it out:

If the patient is LOW risk for PE by your clinical gestalt and if the answer to ALL of the following questions is YES, then the patient is considered PERC negative:

  • Age < 50 years
  • Pulse < 100 bpm
  • SpO2 > 95%
  • No unilateral leg swelling
  • No hemoptysis
  • No recent trauma or surgery
  • No prior PE or DVT
  • No hormone use

PERC negative + Low Risk clinical gestalt = PE ruled out


  • Most people are comfortable with: LOW risk + negative d-dimer = PE ruled out but use of the PERC rules has not gained wide acceptance yet. Experts in this area predict this will change.
  • Clinical gestalt must be used and the patient must be LOW risk for PE
  • The PERC rule is not intended for use in moderate risk patients or in patients without an alternative diagnosis.
  • The rule is really only intended to avoid testing in the patient you were really not thinking about PE in the first place. Some experts agree that writing "PERC negative" in the chart is defensible.

Jeff Kline, PERC rule. Journal of Thrombosis and Hemostasis. 2007/2008

Category: Cardiology

Title: alcohol and heart disease

Posted: 12/23/2007 by Amal Mattu, MD (Updated: 10/20/2019)
Click here to contact Amal Mattu, MD

Here's a pearl for everyone that is "enjoying" the holidays with friends...friends named Jack Daniels, Remy Martin, and Louis XIII, among others.

It's fairly well-known that light-moderate alcohol intake is associated with reductions in cardiovascular death and nonfatal MI and also a reduction in the development of heart failure. In case you've ever wondered exactly what a "drink" is and what "moderate" intake are, here are some definitions:
a. In the U.S., a standard alcohol "drink" is 1.5 oz or a "shot" of 80-proof spirits or liquor, 5 oz of wine, or 12 oz of beer.
b. "Moderate" drinking is no more than 1 drink per day for women and 2 per day for men.
c. "Binge" drinking is > 4 drinks on a single occasion for men or > 3 for women within 2 hours.

Although some studies suggest that wine (esp. red) has an advantage over other types of alcohol, other studies (including ones we've reviewed in the cardiology update series) indicate that the type of alcohol doesn't matter. Good news for many of our patients!


Category: Pediatrics

Title: Child with a Limp

Keywords: Limp, Antalgic Gait, Trendelenburg Gait, Septic Arthritis, Legg-Calve-Perthes Disease, SCFE (PubMed Search)

Posted: 12/21/2007 by Sean Fox, MD (Updated: 10/20/2019)
Click here to contact Sean Fox, MD

Child with a Limp

  • First classify the limp:
    • Antalgic gait = shortened stance phase of the affected extremity due to PAIN
    • Trendeleburg gait = equal stance phase between involved and uninvolved side, shifted center of gravity; NOT Painful
  • Etiologies
    • Painful Limp
      • 1-3 years of age: Septic Joint, Occult Trauma, Neoplasm
      • 4-10 years of age: Septic Joint, Transient Synovitis, Legg-Calve-Perthes Disease, Trauma, neoplasm, Rheumatologic D/O
      • 11 + years of age: SCFE, Rheumatologic D/O, Trauma, (consider AVN in pts with sickle cell disease)
    • Trendelenburg Gait
      • Indicative of underlying hip instability or muscle weakness
      • Think of congential hip dislocation and Neuromuscular Diseases/Disorders

Grossman, Emblad, Plantz. Orthopedic Emergencies in Pediatric Emergency Medicine Board Review.  2nd Edition. 2006. p305.

Category: Toxicology

Title: Ketorolac (Toradol) Toxicity - Need to Know

Keywords: NSAID, ketorolac, gastritis, renal failure (PubMed Search)

Posted: 12/20/2007 by Fermin Barrueto, MD (Updated: 10/20/2019)
Click here to contact Fermin Barrueto, MD

Ketorolac: an NSAID that gained popularity since it is not an opioid, has excellent anti-inflammatory/analgesic effects and is given IM or IV. Also has been used in renal colic secondary to smooth muscle relaxation (Prostaglandin mediated) in the ureters. You should know:

  • When given IV or IM still causes PUD and has caused GI perforations.
  • Renal Insufficiency is larger concern with this NSAID than others.
  • Consider misoprostol for GI complications.
  • Use for acute pain, limit the number doses given and don't prescribe for more than 3 days. I generally don't prescribe it at all, use another NSAID for outpatient treatment.


Corelli et al. Renal Insufficiency and ketorolac. Ann Pharmacother. 1993; 27(9): 1055-7

Category: Neurology

Title: Steroids and Spinal Cord Injury (SCI)

Keywords: steroids, spinal cord injury, SCI (PubMed Search)

Posted: 12/19/2007 by Aisha Liferidge, MD (Updated: 10/20/2019)
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  • Note that the use of steroids within 8 hours of injury for SCI is not routinely practiced worldwide and was initially based on a controversial study, the National Acute Spinal Cord Injury Study (NASCIS I & II).
  • The approved methylprednisolone dose is 30 mg/kg IV bolus over 15 min, followed by 5.4 mg/kg/h over 23 h; begin IV infusion 45 min after conclusion of bolus.

Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of
methylprednisolone or naloxone in the treatment of acute spinal-cord injury.
Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med
1990 May 17; 322(20): 1405-11.

Category: Critical Care

Title: Critical Care Monitoring - End-Tidal CO2

Keywords: end-tidal CO2, capnography, status asthmaticus, increased intracranial pressure (PubMed Search)

Posted: 12/18/2007 by Mike Winters, MD (Updated: 10/20/2019)
Click here to contact Mike Winters, MD

Critical Care Monitoring - End-Tidal CO2

  • End-tidal CO2 (ETCO2) monitoring is used to verify ETT placement, monitor procedural sedation, traumatic brain injury, and to estimate prognosis during cardiopulmonary resuscitation
  • ETCO2 concentration typically underestimates PaCO2 by 4-5 mmHg in healthy non-intubated patients
  • This relationship is less reliable in critically ill patients secondary to shunt, altered alveolar dead space, and inadequate ventilation
  • While a low ETCO2 value is less useful in the critically ill, a high value almost always correlates with an equal or higher PaCO2 value
  • This can be useful when monitoring conditions such as status asthmaticus, CHF, or increased ICPs in which a high ETCO2 may signal the need for additional aggressive treatment

Category: Vascular

Title: Secondary Causes of Hypertension

Keywords: Hypertension (PubMed Search)

Posted: 12/17/2007 by Rob Rogers, MD (Updated: 10/20/2019)
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Secondary Causes of Hypertension

Although not that common, consider the following (with accompanying history and/or physical examination findings) in patients with hypertension:

  • Renovascular hypertension (renal artery stenosis)-abdominal bruits, older patients
  • Pheochromocytoma-episodic flushing, htn, headache, new onset htn in younger patient
  • Cushing's disease-abdominal striae (not very specific in Baltimore), new onset hyperglycemia, classic electrolyte abnormality: hypokalemic metabolic alkalosis
  • Primary Aldosteronism-new onset htn and hypokalemia
  • Hyperparathyroidism-htn and hypercalcemia
  • Aortic coarctation-younger patients (even young adulthood), unequal upper and lower extremity blood pressures
  • Sleep apnea-typically obese patients (but not necessarily), excessive snoring, day time sleepiness (again, not specific)
  • Thyroid disease (hypo or hyper)-signs and symptoms of thyroid disease

Although most of the time the patient will end up having essential hypertension, these entities should at the very least be considered.

Journal of Hypertension 2007

Category: Misc

Title: Coding and Billing Pearls

Keywords: Coding, Billing, Reimburshment (PubMed Search)

Posted: 12/16/2007 by Michael Bond, MD (Updated: 10/20/2019)
Click here to contact Michael Bond, MD

The insurance companies are always trying to down code our visits so that they can save money, and unless we diagnosis the patients with the appropriate jargon it can cost us a lot of money.  Here are some coding suggestions as written by Sharon Nicks, President and CEO of Nicks & Associates in EP Monthly .


Consider Diagnosising  It this, if the condition fits
  • Acute Chest Pain
  • Acute febrille illness with cough
  • Acute tracheobronchitis
  • Acute severe abdominal pain
  • Acute dehydration (volume depletion) secondary to nausea/vomiting
  • Electrolyte imbalance
 Flu/Viral Ilness
  • Acute viremia
  • Acute febrile illness
 Musculoskeletal Pain
  • Acute cervical pain
  • Acute chest wall syndrome
  • Acute strain or pain to a specific (i.e: lumbar) due to a MVA or fall
Otitis Media
  • Acute febrile illness secondary to acute otitis media
  • Otalagia


The moral of this pearl is try to use words like Acute, Severe, Sudden, Serious, Distress, Pain, or Fever so that it is clearer to the insurance companies that the patient warranted a visit to a physician (i.e.: an ED) before their PCP could see them in a week.

Category: Cardiology

Title: AICDs

Keywords: AICD, shock (PubMed Search)

Posted: 12/16/2007 by Amal Mattu, MD (Updated: 10/20/2019)
Click here to contact Amal Mattu, MD

What do you do if a patient with an AICD presents to the ED with a shock? 

If the patient receives a single shock and is otherwise asymptomatic and fine, there is probably no need for intervention (or even an ED visit). For the patient in the ED, monitor them and discuss with their cardiologist. Consider checking some labs, but emergent pacer evaluation is not generally necessary (unless there are other concerning issues--abnormal rhythms on monitor, complaints of lightheadedness and preceding chest pain, etc.). You should manage and treat the patient for other symptoms and signs, but not for the shock itself.

If the patient received multiple shocks, however, device interrogation is generally required. Also search for the underlying cause--ischemia, electrolyte abnormalities, etc. Bear in mind that most of the time, multiple shocks are later deemed to be inappropriate (device error).

Post-shock ECG will likely show ST segment changes but they normalize within 15 minutes.

15-20% of the time there will be some TN-I elevation for up to 24 hours due to a shock.


Category: Pediatrics

Title: Child Abuse

Keywords: Child Abuse, Fractures (PubMed Search)

Posted: 12/14/2007 by Sean Fox, MD (Updated: 10/20/2019)
Click here to contact Sean Fox, MD

Child Abuse

  • An estimated 2,815,600 children are harmed or endangered by their caretakers annually
  • Fractures are among the most common injuries seen in these children and are frequently highly specific for a diagnosis of abuse.
  • No fracture is pathognomonic of abuse
  • Some are suggestive:
    • Spinal fx
    • Digital fx
    • Complex skull fx
    • Spiral Long Bone fx
    • Scapular fx
    • Sternal fx
    • Metaphyseal fx
    • Periosteal separation
  • Some are more specific:
    • Posterior Rib fx
    • Acromioclavicular Fx
    • Multiple fxs of different ages
  • Infants < 1 year of age with fractures have a high prevalence of abuse.

    C Y Skellern, D O Wood, A Murphy, M Crawford (2000). Non-accidental fractures in infants: Risk of further abuse. Journal of Paediatrics and Child Health 36 (6), 590–592.

    K. Nimkin, P. Kleinman. IMAGING OF CHILD ABUSE. Radiologic Clinics of North America, Volume 39, Issue 4, Pages 843-864

Category: Toxicology

Title: Drugs that Alter the Thyroid

Keywords: thyroid, hypothyroid, hyperthyroid (PubMed Search)

Posted: 12/14/2007 by Fermin Barrueto, MD (Updated: 10/20/2019)
Click here to contact Fermin Barrueto, MD

Lithium: Hypothyroidism (5-15% of pts) and goiter (37% of pts), mechanism unclear

Amiodarone (37% Iodine by weight): Hyper or Hypothroidism

Beta-Blockers: by blocking peripheral conversion of T4 to T3 cause hypothyroidism

Corticosteroid: same as beta-blockers but can also cause transient thyrotoxicosis (Jod-Basedow effect)

Iodine, Iodinated contrast, radiactive iodine all can cause hypothyroidism but iodinated contrast material can actually induce thyrotoxicosis and thyroid storm from unknown mechanism.

Category: Neurology

Title: Intra-arterial (IA) Thrombolysis

Keywords: Ischemic Stroke, Intra-arterial Thrombolysis, IA tPA, Intra-venous Thrombolysis, IV tPA (PubMed Search)

Posted: 12/13/2007 by Aisha Liferidge, MD (Updated: 10/20/2019)
Click here to contact Aisha Liferidge, MD

  • IA lytics for stroke emerged to increase the 3-hour window for treatment.
  • IA tPA may also be indicated for:

              --  candidates with severe neurological deficits (NIHSS score > 10)

              --  candidates with a recent history of major surgical procedures

              --  candidates with occlusion of major cervical or intracranial vessels

  • Early IA lytic trials utilized urokinase and tPA, usually within a 6-hour window, though some reports extended the window to 12 hours for posterior circulation ischemic strokes.


Zaidat OO, Saurez JL, Santillan C, et al.  "Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion."  Stroke 2002, 33:  1821-1826.

Bellolio MF, et al.  "Stroke Update 2007:  Better Early Stroke Treatment (BEST)," Emergency Medicine Practice, Augst 2007, Volume 9, Number 8.

Category: Critical Care

Title: Unilateral pulmonary edema

Keywords: pulmonary edema, aortic dissection, heroin (PubMed Search)

Posted: 12/11/2007 by Mike Winters, MD (Updated: 10/20/2019)
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Unilateral Pulmonary Edema

  • unilateral pulmonary edema is a well recognized and well documented entity
  • although there are several causes, the most likely scenarios for EPs are severe mitral valve insufficiency, aortic dissection (with compression of the pulmonary artery), airway obstruction, and heroin use
  • even though radiology will read the xray as likely pneumonia, if the story/exam fit with edema then treat as such

Category: Vascular

Title: Subarachnoid hemorrhage

Keywords: subarachnoid hemorrhage (PubMed Search)

Posted: 12/10/2007 by Rob Rogers, MD (Updated: 10/20/2019)
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Subarachnoid hemorrhage: Unilateral or bilateral headache?

Pretty good evidence exists that most patients with subarachnoid hemorrhage will have a bilateral headache.

In fact, unilateral headache is helpful in the history in ruling out SAH in most cases. Presence of an unruptured aneurysm, however can be present with a unilateral headache.

J NeuroSurg 2006

Category: Cardiology

Title: gender differences in ACS presentation

Keywords: Acute coronary syndromes, women (PubMed Search)

Posted: 12/9/2007 by Amal Mattu, MD (Updated: 10/20/2019)
Click here to contact Amal Mattu, MD

Women are more likely to present with atypical presentaitons for ACS.

Women are more likely to present without chest pain, but instead with middle or upper back pain, neck pain, jaw pain, dyspnea, vomiting, indigestion, weakness/fatigue, loss of appetite, cough, or palpitations than men.

Category: Med-Legal

Title: EMTALA (Part Two)

Posted: 12/1/2007 by Michael Bond, MD (Emailed: 12/8/2007) (Updated: 10/20/2019)
Click here to contact Michael Bond, MD

EMTALA (Part Two)

  • Hospitals may not delay screening examinations to inquire about payment.
  • Emergency departments should not contact HMOs before completion of the screening examinations and stabilizing treatment.
  • Triage does not constitute a MSE.
  • For the purposes of EMTALA, a patient has come to the ED when he arrives on hospital property.
  • EMTALA does not apply to offsite clinics unless (1) the clinic is licensed as an emergency department, (2) the hospital advertises the clinic as an ED, or (3) during the preceding year, 1/3 of all outpatient visits were for EMCs.
  • EMTALA does not apply to inpatients, unless the hospital admitted the patient in bad faith.
  • Since Nov. 2003, a specialty represented at the hospital does not always have to be on call.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.