Emergency Medicine Cases

Dr. Anton Helman
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Emergency Medicine Cases

In-depth round table discussions with North America's brightest minds in Emergency Medicine on practical practice-changing EM topics since 2010, plus our EM Quick Hit series for a variety of short EM knowledge nuggets, and our Journal Jam series for EBM deep dives. World class Free Open Access Medical Education (FOAMed). For archived podcast episodes, show notes, quizzes, videos, discussions and an entire EM learning system, visit emergencymedicinecases.com. For donations, please visit https://emergencymedicinecases.com/donation/

  1. 2 DAYS AGO

    Ep 201 How EM Experts Think Part 2: Data Gathering, Diagnostic and Treatment Decision Making, Test Ordering and Interpretation, Documentation, Emotional Resilience

    In this Part 2 of our 2-part podcast series on How EM Experts Think with Dr. Reuben Strayer, Dr. Mike Betzner and Dr. Scott Weingart we dive deep into the nuances of practicing smarter, faster, and better in the ED. We answer questions like: How should we employ hypothetico-deductive reasoning in our daily practice of Emergency Medicine? How can we best streamline thorough data gathering for each case so that we don't miss key data points? How do the master EM clinicians perform an efficient and targeted history and physical exam? How can the concept of heuristic cycling help you avoid outdated or faulty thinking? How can we document our clinical encounter in a way that considers a differential diagnosis that prioritizes dangerous conditions and improve our thinking around cases? How can we use the 2-10% rule for pre-test probabilities and the concept of preferred error to guide our decision making for tests and treatments in the ED? What strategies can we use to avoid anchoring bias and keep your mind open to all possibilities? What’s the role of shared decision-making when navigating diagnostic uncertainty? How does understanding the vigilance pendulum help us assess our risk tolerance better? How can post-shift decision journaling, conducting pre-mortems and meditation improve our decision making and boost our emotional resilience on shift? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Rowan Helman and Anton Helman January, 2025 Cite this podcast as: Helman, A. Weingart, S. Betzner, M. Strayer, R. How EM Experts Think Part 2: Data Gathering, Diagnostic and Treatment Decision Making, Test Ordering and Interpretation, Documentation, Emotional Resilience. Emergency Medicine Cases. January, 2025. https://emergencymedicinecases.com/how-em-experts-think-part-2. Accessed January 9, 2025 Résumés EM CasesEpisode 200 How EM Experts Think Part 1: Strategies for Pre-Shift, Arrival Ritual, Staying Focused, Managing Interruptions, Cognitive Load & Negative Emotions, Resuscitation Mindset, Post-Resuscitation Recovery History taking: How EM Experts Think "We're not as concerned only about what the patient has. We're concerned about what the patient needs". -Reuben Strayer Traditional approaches to history-taking taught in medical school usually by internal medicine, often fall short in the dynamic and unpredictable environment of the ED, and fail to address the patients immediate needs. Emergency Medicine works on a hypothetico-deductive methodology, using simultaneous inductive and deductive reasoning. It involves formulating a hypothesis to make predictions, comparing predictions to observations and determining if they are consistent and finally, confirming or falsifying the hypothesis. The cardinal skill in differential diagnosis generation for EM is being able to link symptoms and signs to a list of dangerous conditions that apply to the patient in front of you. Generating a list of dangerous conditions for all common presentations to the ED at home, and them having them easily accessible via documentation templates can help hone your diagnostic skills. Data gathering Preparation before entering the patient’s room is critical. Effective pre-history strategies include: * Chart Review: Review triage vital signs, nursing notes, EMS run sheets,

    1h 23m

  2. 23/12/2024

    How EM Experts Think: Strategies for Pre-Shift, Arrival Ritual, Staying Focused, Managing Interruptions, Cognitive Load & Negative Emotions, Resuscitation Mindset, Post-Resuscitation Recovery

    Which elements of your current pre-shift preparation contribute most to your mental clarity and performance, and what new practices might further optimize your readiness? With interruptions shown to increase task errors and decision fatigue, how can you strike a balance between being approachable to colleagues and safeguarding your focus for patient care? When confronted with a particularly challenging or emotionally charged case, what strategies have you found most effective for maintaining professionalism and clear decision-making under pressure? How often do you debrief after high-stakes scenarios, and what impact has debriefing—whether formal or informal—had on your team’s learning, emotional recovery, and future preparedness? What strategies do you use to foster open communication and ensure all team members feel empowered to provide input during high-stakes situations? How do you mentally and emotionally shift from managing a critical resuscitation to treating lower-acuity patients without compromising your focus or energy? When faced with a complex case where diagnostic clarity is elusive, how do you prioritize your next steps while maintaining confidence in your decision-making process? How can apps, personalized workflows, or EMR tools be better utilized to minimize cognitive load and enhance clinical decision-making during shifts? These are just some of the questions we pose in this 2-part podcast series on How the Experts Think with Dr. Reuben Strayer, Dr. Scott Weingart and Dr. Mike Betzner... Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul Written Summary and blog post by Anton Helman December, 2024 Cite this podcast as: Helman, A. Weingart, S. Betzner, M. Strayer, R. Episode 200 How EM Experts Think: Pre-Shift Preparation and Arrival Ritual, Staying Focused on Shift, Managing Interruptions, Managing Cognitive Load, Handling Negative Emotions, Resuscitation Mindset and Execution, Post-Resuscitation Recovery. Emergency Medicine Cases. December, 2024. https://emergencymedicinecases.com/how-the-em-experts-think-part-1. Accessed January 9, 2025 Résumés EM CasesPre-Shift Preparation and Arrival Ritual Effective preparation ensures you start your shift focused and ready. The chaos of the ED demands that clinicians arrive mentally and physically ready to handle high decision density, frequent interruptions, and unpredictable challenges. By developing pre-shift rituals, emergency providers can start shifts with clarity and confidence. Think of yourself as an elite athlete who requires both physical and mental training to maximize performance. Key Tips: * Mental and Physical Routines: * Ride a bike or run to work or perform a quick exercise routine to clear the mind * Take a cold shower to invigorate the body and mind * Consume protein-rich foods to sustain energy levels * Set up your workspace the same way each shift to reduce cognitive strain * Arrive early to establish a flow without interruptions * Establish a ritual to leave your personal issues at the door and mentally commit to the shift * Mental Framing: * Listen to medical podcasts or inspirational music during your commute to set a positive and engaged mindset * Practice gratitude by reflecting on the privilege of being a physician * Use positive self-talk to reinforce your readiness and confidence * Visualize success and mentally rehearse procedures and challenging s...

    1h 22m

  3. 03/12/2024

    EM Quick Hits 61 TEE in Cardiac Arrest, Nebulized Ketamine, Cellulitis Update, SQ Insulin for DKA, Medicolegal DDx Documentation Tips

    Topics in this EM Quick Hits podcast Ross Prager on TEE in cardiac arrest (1:05) Justin Morgenstern on nebulized ketamine for analgesia in the ED (26:27) Hans Rosenberg & Krishin Yadav on standardizing cellulitis management (32:48) Matthew McArther on latest studies on subcutaneous insulin protocols in DKA (40:04) Jennifer C. Tang on documenting differential diagnoses medicolegal tips (52:47) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Anton Helman, December, 2024 Cite this podcast as: Helman, A. Prager, R. Morgenstern, J. Rosenberg, H. Yadav, K. McArther, M. Tang, J. EM Quick Hits 61 - TEE in Cardiac Arrest, Nebulized Ketamine, Cellulitis Update, SQ Insulin for DKA, Medicolegal DDx Documentation Tips. Emergency Medicine Cases. December, 2024. https://emergencymedicinecases.com/em-quick-hits-decemeber-2024/. Accessed January 9, 2025. Transesophageal Echo - TEE in Cardiac Arrest - Resuscitative TEE * Rational for resuscitative TEE and TEE in cardiac arrest: * Provides real-time feedback on the optimal location and quality of chest compressions in cardiac arrest (precise location of chest compressions with respect to cardiac anatomy can be observed and manipulated to optimize circulatory flow as compressions directly over the LV have been shown to be most effective); ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression (rather than LV compression), obstructing blood flow. Absence of aortic valve compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. * Minimizes chest compression interruptions in cardiac arrest * Allows identification of reversible causes of cardiac arrest - identification of obstructive pathologies including tension pneumothorax, cardiac tamponade, deep vein thrombosis with RV dilation suggesting pulmonary embolism, as well as filling status suggesting hypovolemia, pericardial tamponade, intracardiac thrombus, fine ventricular fibrillation, and to characterize the type of cardiac activity such as cardiac standstill or pseudo-PEA * Provides prognostic information in cardiac arrest - LVOT opening as identified by TEE during CPR was associated with successful resuscitation in retrospective study * For operators who are already experienced at using POCUS, Resus-TEE skills can be acquired rapidly. * Procedural guidance: * placement of an intravenous temporary pacemaker * placement of extracorporeal life support cannulae * Risks of TEE in cardiac arrest * The risks of TEE are generally related to sedation & airway management. Critically ill patients who undergo resus-TEE are already intubated and sedated, thus these risks are minimized. There are risks of esophageal trauma with insertion, however these are probably comparable to the risks of gastric tube placement. * Major complications such as serious oropharyngeal trauma, esophageal perforation, and major bleeding are rare with incidence rates between 0.01% and 0.08% * Unclear if placement of the TEE in an emergent scenario or use during electrical defibrillations and chest compressions increase risk of damage to the transducer.

    1 hr

  4. 12/11/2024

    Ep 199 Trauma Airway and Airway Trauma

    In this EM Cases main episode podcast, we tackle the complexities of trauma airway management, including direct trauma to the airway. We discuss indications and timing of intubation, penetrating neck trauma, the head injured patient, the agitated patients and the soiled airway. The critical question is: when should we deviate from, delay or modify RSI, and how do we navigate the unique challenges presented by trauma airways and airway trauma? Dr. George Kovacs and Dr. Andrew Petrosoniak answer this and other questions such as: how should we re-sequence the trauma resuscitation depending on immediate life-threats? When is immediate vs delayed intubation recommended? How useful are the Zones of the neck in penetrating neck trauma? What is the optimal dosing of airway medications in the sick trauma patient? How should we modify our airway strategy for the severely head injured patient and/or agitated patient? When should we consider ketamine facilitated fiberoptic intubation in the trauma patient? and many more... Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul Written Summary and blog post by Sara Brade, edited by Anton Helman November, 2024 Cite this podcast as: Helman, A. Petrosoniak, A. Kovacs, G. Trauma Airway & Airway Trauma. Emergency Medicine Cases. November, 2024. https://emergencymedicinecases.com/trauma-airway. Accessed January 9, 2025 Résumés EM Cases Case study: Penetrating neck trauma Consider a 25-year-old woman who presents with a stab wound to the anterior neck. She arrives with a heart rate of 145, oxygen saturation at 90%, and audible gurgling sounds, indicating potential airway compromise. This is a high-stakes scenario where every decision, especially regarding airway management, could have life-altering consequences. The injury, located just off the midline in the anterior neck, immediately raises concerns about airway obstruction, major vascular injury, or both. Re-sequencing the trauma airway: A paradigm shift While working through the standard ATLS approach of A then B then C can be a helpful memory tool, our trauma resuscitations often require simultaneous assessment and management of all three or a total re-ordering of priorities. Some traumas may require a CAB approach or a CBA approach. Intubation is not always the first priority in trauma and, in fact, it may worsen outcomes if done prior to adequate resuscitation. Instead of focusing on letters, we should be focusing on identifying and managing the most immediate threat to life for each patient. Look for and immediately manage the following: * Massive hemorrhage: For example, a spurting artery that needs immediate management/compression or an unstable pelvis that needs binding. * Severe airway compromise: * Dynamic airway: If you wait even minutes, you may miss the opportunity to secure an airway. For example, expanding neck hematoma. * Critical hypoxia: Despite maximum noninvasive ventilation, O2 saturation is still 90%. * Obstructive shock: * Tension pneumothorax/ hemothorax: Consider bilateral finger thoracostomies/ chest tube before airway management. * Cardiac tamponade: Very high-risk intubations, should likely be done in the OR if patient still has a BP. If cardiac arrest, consider thoracotomy if your resources allow. The decision to intubate the trauma patient

    1h 44m

  5. 22/10/2024

    EM Quick Hits 60 Post-Tonsillectomy Hemorrhage, Post-CABG Infections, Bougie Tips, Pelvic Fracture Bleeds, Debriefing: Why, When & How

    Topics in this EM Quick Hits podcast Kevin Wasko on post-tonsillectomy hemorrhage management (1:06) Brit Long on assessment and management of post-CABG surgical incision infections (15:40) Anand Swaminathan on evidence, pitfalls and tips on using Bougies (23:07) Leah Flannigan on when to suspect vascular injury in patients with low energy mechanism pelvic fractures (31:05) Andrew Petrosoniak on debriefing after cases: why, when and how (38:35) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Anton Helman, October, 2024 Cite this podcast as: Helman, A. Wasko, K. Long, B. Swaminathan, A. Flannigan, L. Petrosoniak, A. EM Quick Hits 60 - Post-Tonsillectomy Hemorrhage, Post-CABG Infections, Bougie Tips, Pelvic Fracture Bleeds, Debriefing: Why, When & How. Emergency Medicine Cases. October, 2024. https://emergencymedicinecases.com/em-quick-hits-october-2024/. Accessed January 9, 2025. Post-Tonsillectomy Hemorrhage Management Best of University of Toronto EM * Primary vs. Secondary post-tonsillectomy hemorrhage: * Primary post-tonsillectomy hemorrhages occur within the first 24 hours post-op, usually related to intraoperative factors like surgical technique or undiagnosed coagulopathies (e.g., von Willebrand disease). These bleeds are more likely in the immediate post-op period. * Secondary post-tonsillectomy hemorrhages occur after 24 hours, typically around post-op days 5 to 7, but can occur up to 14 days. They are caused by the sloughing off of the fibrin clot, exposing underlying tissue, which can lead to ongoing oozing or trickling bleeding. These are more insidious and can escalate quickly into life-threatening hemorrhages. * Key point: * Even if the bleeding is minor, like a small trickle, it should be considered a potential herald bleed—a precursor to a larger, more dangerous bleed. In these cases, early ENT consultation is crucial as definitive source control is needed, especially if bleeding persists for several hours. * Management approach (3-pronged): * Resuscitation: * Ensure the patient is sitting upright in a comfortable position to prevent aspiration and make visualization easier. * Establish IV access and consider starting IV TXA 1-2g in adults, 15mg/kg in children if appropriate. * Get help early: * Contact ENT early, especially if you’re in a rural or resource-limited setting where transfer may be delayed. * Arrange for transport to a tertiary care center if no ENT is available locally. * Temporizing measures (until definitive management in the operating room): * Direct pressure with gauze and topical medications: Use lidocaine spray for local analgesia, and gauze soaked in epinephrine and/or TXA * Tranexamic Acid (TXA) options: * Nebulized TXA: Consider while other preparations are made. It’s a low-risk, easy intervention. * Topical TXA: Soak gauze in TXA and apply it directly to the bleeding site. * IV TXA: 15 mg/kg in children or 1-2 grams in adults over 10 minutes. * While evidence is limited, it is a reasonable adjunct in these cases, given the low risk of harm. * Airway Management in the post-tonsillectomy bleed * If the patient starts to aspirate blood, or if bleeding becomes severe enough to cause respirator...

    52 min

  6. 01/10/2024

    Ep 198 Understanding and Improving Culture in Emergency Medicine: Key Insights

    There is a culture problem in medicine. 70% of us are disengaged, more than 50% contribute nothing to our departments and more than 15% actively work against a healthy culture in our departments. What makes an Emergency Department run like a well-oiled machine with staff that find meaning in their work and who are grateful for serving the public? There are individual skills; there are team skills; there is the admin, and then there is the oh-so-important culture which permeates all of these and can make them great or can drive them into the ground. The culture of an ED can make it or break it. In this EM Cases podcast Anton chats with Dr. Peter Brindley and Dr. Leon Byker who have a deep interest in the Culture of Medicine to explore what culture in medicine is, why culture is so important, and then drive home 10 strategies to improving the culture in our departments emphasizing the importance of human connection, empathy, open communication, and a willingness to learn from mistakes in creating a positive and fulfilling work environment, so that we love our work, we love our department, we love taking care of our patients and our patients have better outcomes... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman October, 2024 Cite this podcast as: Helman, A. Byker, L. Brindley, P. Episode 198 Understanding and Improving Culture in Emergency Medicine: Key Insights. Emergency Medicine Cases. October, 2024. https://emergencymedicinecases.com/improving-culture-emergency-medicine. Accessed January 9, 2025 Résumés EM CasesWhat is culture in medicine? Culture in medicine integrates values, beliefs, behaviors, and interpersonal dynamics. Gert Hofstede’s framework outlines five key indices to evaluate cultural health in organizations: power distance, individualism vs. collectivism, assertiveness, uncertainty avoidance, and long vs. short-term orientation. Understanding where your department stands on these scales can illuminate pathways for cultural improvement. Hofstede’s 5 Dimensions of Culture * Power differential – the degree of inequality that exists and is accepted between people with and without power * Individualism vs collectivism – the strength of the ties that people have to others within their community * High IVD – high value placed on people’s time and need for privacy and freedom, an enjoyment of challenges, and expectation of individual rewards for hard work – in these communities should encourage debate and expression of people’s ideas and don’t mix work life with social life too much * Low IVD – emphasis on building skills and becoming a master of something, people work for intrinsic rewards, maintaining harmony among group members is important, wisdom is important, avoid giving negative feedback in public * Uncertainty avoidance index – how well people can cope with anxiety * Long vs short-term orientation * Indulgence vs restraint Why culture in medicine matters The culture of an ED shapes every aspect of its operation, from teamwork to patient care. It is critical for fostering a supportive environment that allows medical professionals to thrive. Culture is often intensified in high-pressure situations typical of Emergency Medicine, making it imperative to assess and enhance cultural dynamics actively. It can be a challenge to foster teamwork in a culture that often prioritizes individualism and status.

    1h 29m

  7. 10/09/2024

    EM Quick Hits 59 Traumatic Coronary Artery Dissection, Proper Use of Insulin, Mesenteric Ischemia, Exercise Associated Hyponatremia, AI for OMI

    Topics in this EM Quick Hits podcast Ian Chernoff on traumatic coronary artery dissection (1:05) Anand Swaminathan on proper use of insulin in DKA and in hyperkalemia (15:50) Brit Long & Hans Rosenberg on mesenteric ischemia pearls and pitfalls in diagnosis and management (21:47) Dave Jerome on managing exercise-associated hyponatremia and heat illness (33:47) Jesse McLaren on the Queen of Hearts AI model in helping identify occlusion MI on ECG (50:50) Podcast production, editing and sound design by Anton Helman Podcast written summary & blog post by Brandon Ng, edited by Anton Helman, September, 2024 Cite this podcast as: Helman, A. Chernoff, I. Swaminathan, A. Long, B. Rosenberg, H. Jerome, D. McLaren, J. EM Quick Hits 59 Traumatic Coronary Artery Dissection, Proper Use of Insulin, Mesenteric Ischemia, Exercise Associated Hyponatremia, AI for OMI. Emergency Medicine Cases. September, 2024. https://emergencymedicinecases.com/em-quick-hits-september-2024/. Accessed January 9, 2025. Traumatic Coronary Artery Dissection - Best of University of Toronto EM Traumatic coronary artery dissection is a rare, but often fatal injury that is challenging to diagnose and requires specific knowledge of it's clinical features. Clinical clues for traumatic coronary artery dissection include: * History of blunt force chest trauma ranging from low to high energy mechanisms (direct blow to the chest, high speed motor vehicle crash) * Possible delayed presentation by many hours to days to weeks * Typical angina symptoms in young patient with no cardiac risk factors * Wall motion abnormalities on cardiac PoCUS * Elevated troponin * ECG ischemic changes Why is traumatic coronary artery dissection difficult to diagnose? * Cardiac injuries ranging from contusions to dissections occur in 5-15% of blunt chest trauma; traumatic coronary artery dissection comprises a small proportion of these patients * Symptoms may not present for days to weeks after inciting event * May occur even with low energy mechanisms * Most often occur in young patients who are not at risk for cardiac ischemia – 82% under age 45 and have been reported in as young as age 14 * Often overlooked due to low index of suspicion in the context of other concurrent traumatic injuries Traumatic coronary artery dissection vs SCAD (Sontaneous Coronary Artery Dissection) * There are some corollaries with SCAD and traumatic CAD in that both have historically been under-recognized;h owever, whereas SCAD has now belatedly been recognized as the leading cause of MI in women under age 50, traumatic CAD continues to be under appreciated Workup of traumatic coronary artery dissection * Patients complaining of chest pain after sustaining blunt chest trauma should undergo prompt cardiovascular workup * Current Eastern Association for the Surgery of Trauma (EAST) guidelines propose an ECG as well as cardiac markers should be performed on any patient in which one suspects blunt cardiac injury; doing so appears practitioner dependent A key pitfall in chest trauma is assuming that a borderline ECG and positive troponin is due only to cardiac contusion, which does not warrant activation of the cath lab.

    59 min

  8. 19/08/2024

    Ep 197 Acute Heart Failure Risk Stratification and Disposition

    We’d like to think that we’re getting better at identifying acute heart failure and making good disposition decisions. But the facts are, ED physicians are only about 80% accurate diagnosing acute heart failure, and 30-day mortality outcomes and readmission rates for acute heart failure have been about the same in North America for the last few decades – plus we often send home patients who should be admitted and admit patients who should be sent home. This is because there are many challenges for EM docs when it comes to acute heart failure. First, the diagnosis can be tough, and often is only made once the patient is admitted. There is no one clinical feature that is a slam dunk for the diagnosis, and even combinations of features are not great. There are many flavours of heart failure – diastolic, systolic, right-sided, left-sided, SCAPE, cardiogenic shock - just too complicate things further. Even if we’ve made an accurate diagnosis, the decision of whether to admit or send home can be challenging. We have risk stratification decision scales to help, but are they good enough? Are we using them appropriately? In this podcast, with the help of Dr. Doug Lee, cardiologist and researcher at Sunnybrook Hospital in Toronto and Dr. Clare Atzema, our go to EM Atrial fibrillation expert, an EM doc and researcher also from Sunnybrook Hospital, with a special appearance by Ian Chernoff on the role of PoCUS in the diagnosis and risk stratification of acute heart failure, we’ll dig into how to improve our diagnostic accuracy of acute heart failure in the ED and how to improve our disposition decision making so that just the right number of people are admitted and just the right number of people of sent home safely... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Ryan O'Reilly and Anton Helman August, 2024 Cite this podcast as: Helman, A. Episode 197 Acute Heart Failure Risk Stratification and Disposition. Emergency Medicine Cases. August, 2024. https://emergencymedicinecases.com/acute-heart-failure-risk-stratification-disposition. Accessed January 9, 2025 Résumés EM CasesAccuracy of initial evaluation findings in the diagnosis of acute heart failure  Source: King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012 Jun 15;85(12):1161-8. Value of NT-pro-BNP in risk stratification of acute heart failure remains controversial Based on our in depth review of the world's literature in 2018 in this Journal Jam podcast, and as detailed on First10EM, BNP has limited, if any, value in risk stratification of acute heart failure in the ED. However, a subsequent study and guidelines suggest that NT-pro-BNP is highly accurate at the extremes (NT-pro-BMP 450 * 50-75 - >900

    1h 15m
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About

In-depth round table discussions with North America's brightest minds in Emergency Medicine on practical practice-changing EM topics since 2010, plus our EM Quick Hit series for a variety of short EM knowledge nuggets, and our Journal Jam series for EBM deep dives. World class Free Open Access Medical Education (FOAMed). For archived podcast episodes, show notes, quizzes, videos, discussions and an entire EM learning system, visit emergencymedicinecases.com. For donations, please visit https://emergencymedicinecases.com/donation/

Information

  • Creator
    Dr. Anton Helman
  • Years Active
    2010 - 2025
  • Episodes
    369
  • Rating
    Clean
  • Copyright
    © Medicine Cases
  • Show Website
    Emergency Medicine Cases

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