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My EM Residency Experience...


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#21 SERENITY NOW

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Posted 06 November 2015 - 02:20 AM

NEUROLOGY

 

I'd say this rotation has been the most enjoyable so far, in no small part because it actually had a reasonable schedule: 7am-5pm 6 days per week, and it felt like a vacation.  Whats more, the time on the job was much more relaxed because we were actually well staffed and the service wasn't exploding with patients.  I had ample opportunity to ask a ton of questions of some really smart residents and attendings.  I had a great time.  The rotation was unfortunately only 2 weeks long, so I still have a lot to learn when it comes to neurology, but I think I learned some of the most important things I set out to learn on this rotation, which I will outline below.

 

My most important goals for this rotation were to really work on my neuro exam, the approach to common neuro conditions (stroke, seizure, weakness), common medications knowledge, and how to read a head CT...

 

 

1 - THE NEURO EXAM IN THE ALTERED, SEDATED, OR UNAROUSABLE PATIENT

Before starting the neuro rotation, I honestly thought that I had the neuro exam down.  I spent quite a bit of time in school getting a hang of the routine, practicing on classmates, and using it in clinic. I was quite confident in my skills.  HA!  This seems to be a common theme for newbies: we walk into things thinking that we know what we're doing... but "you don't know what you don't know".  In this case, my error in judgement stemmed from the fact that I only learned and practiced a neuro exam meant for a normal, healthy patient. Ironically, these are the patients that odds would say might not need a neuro exam at all.  The patients who need it most are the ones who truly sick, have a difficult time following commands, are altered, or even unresponsive.  The neuro exam that I knew simply wouldn't work on these patients.  I now know that you need to know multiple neuro exams, each catered to the unique patient sitting in front of you.  Similarly, you need to know how to do a neuro exam on a mobile patient and an immobile/supine patient.  Since the exam on the altered, sedated, or unarousable patient is what I learned learned most this rotation, I'll outline it here:

 

 

Always start w/ OBSERVATION.  ABCs, vitals, head to toe sweep.

Without doing or saying anything... are the eyes open, moving all 4 extremities, any asymmetry (facial droop)?

 

AROUSABILITY and ABILITY TO FOLLOW COMMANDS - introduce yourself and ask them to open their eyes.  If they don't -> noxious stimuli.  Ask their name, AOx3.  If they don't respond or can't talk, ask "can you squeeze your hand if you understand me?".

 

EYE EXAM.  If needed, physically open their eyes.  Observe their gaze - one sided preference?

 (remember, if patient is looking away from the side of hemiparesis, assume its a stroke.  If they're looking towards the side of hemiparesis, it will almost always be a seizure).

Assess pupil size, reactivity to light.  

See if they can follow commands w/ EOM.  Try to get them to gaze past midline if they have gaze preference or neglect.

 

(eye exam continued, now assessing brainstem function, the most important part of the unarousable patient exam)

check doll's eye reflex (oculocephalic reflex) -- see youtube for this and many explanations on google.  

check corneal reflex - don't use saline; take a cotton swab and use your finger to get a make a light pointy strand of cotton.

check gag reflex w/ tongue depressor; cough reflex w/ suction thru ETT if intubated.

 

SENSORY + MOTOR.  if they can follow commands, do a normal neuro exam.  Make sure you know how to assess motor strength in very weak patients (maneuvers to eliminate gravity).  If they can't follow commands...

go extremity by extremity, assessing for A) tone, while ROMing their extremity.  B)response to pain - looking for withdrawal or posturing.  Make sure all is symmetrical.  

 

REFLEXES - DTRs.  Make sure you know how to do these on a bed bound patient (I didn't know how to do this before this rotation!) - mostly looking for asymmetry.  

Clonus, babinski, etc.   

 

I can plow through this little exam in a couple of minutes, and it is great at assessing a lot of important things. In doing this exam we can establish GCS, mental status, brainstem function, and cortical function.  I'll post my notes below that will also contain my updated "4 minute neuro exam" on the awake and normal patient.  Pretty straightforward, so I didn't think it worthwhile to post here.

Check out the EM basic neuro exam supplement podcast.  

 

I'd highly recommend that once you have the exam down you take some time looking up videos of what abnormal findings look like. This way, it will be more than just going through the motions of an exam; you will actually know what you're looking for.  Youtube always has good videos.  I've heard that neuroexam.com is good.

 

check out this great article for more of an explanation of the neurology behind the exam maneuvers.  Great website! http://lifeinthefast...scious-patient/

 

more good stuff:

http://www.ferne.org...uroexam0901.htm

 

 

 

 

2 - THE APPROACH TO COMMON NEURO CONDITIONS

For the sake of time, I won't go into a ton of depth on these.  If you'd like more info, check out my notes I made on this rotation - attached on the dropbox link below.  

 

SEIZURES

I remember seeing my first patients with seizures come into the ED when I was in PA school.  I was always terrified.  It seemed like a very intimidating thing, what with this patient thrashing around and a whole hoard of family members and nurses panicking at bedside.  The few weeks of didactic lecture we got in school didn't help at all and I always felt clueless.  I've since learned that seizures are actually somewhat straightforward.  

 

When a patient starts actively seizing in front of you, what do you do?

-First, check clock and note the time it started.  The neurologists will appreciate it if you or family gets video recording of the seizure (with consent from family), because neurologists will be able to ascertain a lot of information from seeing the seizure.  

-Call to get 2mg IV ativan at bedside (assuming you have venous access; if not consider IM versed)

-Safety: move the patient's bed to to the ground, rails up, 30 degrees head of bed elevation.

-Head to toe eval:  which way is head turned, eyes turned?  Eyes open or closed (best predictor of pseudo seizure)?  Mouth secretions, tongue biting?  Breathing pattern? Note which extremities are moving - tonic or clonic?  Urinary incontinence?

-Roll the patient to their side.  

-At this point, its probably been around 2-3 minutes.  If it hasn't resolved spontaneously by the time nurse comes back with the meds, give the ativan.  

-Check fingerstick, vitals.  

-You wait a bit and If it still hasn't stopped, repeat ativan.  Get ready for status epileptics protocols (not going to go into that here).

 

The seizure has stopped, how do you approach the workup?

The approach depends entirely upon whether the patient is known epileptic on meds or is a new onset seizure for the first time.  If its the first time, think of it like a fib in that it should be thought of as a symptom/manifestation of a secondary cause that you should seek out.  Look up the ABCDEI mnemonic for etiologies for first time seizures.  Most commonly in those under 35 is trauma, tumor, alcoholism/withdrawal, and cocaine.  For those over 35, its most commonly cardiovascular dz, metabolic derangements, alcoholism, brain tumor.  

 

There is a lot more to say about seizures.  Listen to the EM basic podcast.  Read up on seizure vs pseudo seizure as well.  Good stuff.  

 

 

STROKE PROTOCOL

I'll just talk about a few of the most important points emphasized the during the rotation.  The neurologists I worked with talked a lot about the variety of ways a stroke can present, depending on which part of the brain is being affected.  Similarly, they discussed a lot about stroke mimics (in particular, seizure or post ictal hemiparesis called Todd's paralysis, and hypoglycemia). 

https://www.uic.edu/...nsisco_0302.pdf

 

You are working in the ED and you hear a stroke alert as EMS wheel the patient to an exam room, what to do?  What are the most important things to immediately assess in a suspected stroke?

-Age of patient

-ABCs - make sure maintaining airway and will be okay for CT

-Vitals - crucial to know the BP immediately.  Flags should go off if its over 180/110 (tPA c/i)

-Blood sugar (easily ruled out mimic)

-Quick history:  Exact onset of sx.  last known normal.  Consider calling the last dialed number on their phone!

-What is their baseline? Prior deficits. 

-Rapid exam: if you are quick, you can run thru the NIHSS in 1-2 min, otherwise some just do something like the Cincinatti "FAST" exam to get a gestalt of whats going on.  Facial asymmetry when asked to smile.  Arm asymmetry/weakness when asked to raise both arms up.  Speech abnormality when repeating a sentence ("no ifs ands or buts"). Time of onset of sx.   

 

send them to the CT scanner ASAP.  

 

Then there is a many more things to do.  For a great podcast that is up to date, check out the SUNY downstate neurology podcast "stroke code".  Also, I'd highly recommend putting some time into reading up on the NIH stroke scale, watching videos of it being done (there are a bunch on youtube that have good discussions), and practicing it yourself, because there are some intricacies.  

 

There are new/revised tPA contraindications that are worth checking out.  

Also, we talked a lot about how CTA head is becoming a standard of care along with IR interventions.  Be sure to get the CTA soon after CT (often while patient is still on the table) if the NIH is 8+ and the CT head was negative and no renal dz (or HTN/DM).  

Last, neurologists go-to antiHTNsive med is labetolol.  I swear I saw labetolol 10mg IV push PRN per MAP goals on every patient.  

 

You have gathered the information and are ready to call a neurologist.  How do you present the case to them in the middle of the night?  (they like very specific presentations)

"Hi Dr X, we've got a stroke alert patient in the ED.  Patients name is Y in room Z.

AGE/SEX - and R/L Handed.  Last known normal was X.  Presents w/ s/s XYZ.  NIHSS #, no known prior deficits.  CT head negative.  BP, blood sugar XYZ.  Not on any anticoagulants.  No tPA contraindications.  What we've done so far... BP control, etc.  What do you think... should we do tPA? CTA? call IR?"

 

 

 

3 - COMMON MEDICATION KNOWLEDGE FOR NEURO MEDS

I have been thinking a lot lately about what the most valuable things you can learn while doing a rotation on a specialty's service, and I've come to the conclusion that it is the things that you would have the most difficulty learning anywhere else.  The things that only somebody living and breathing their specialty day in and day out would be able to ascertain, distill, and share with you... knowledge that can't be efficiently found in a textbook or online reference.  I wrote a whole thread post about this on the student forum actually haha.  (

 

    Anyways, a perfect example of this is medications.  I've found that trying to learn information about medications is very challenging because you look at the textbooks and uptodate and you see just laundry lists of hundreds of bits of random, impossible to memorize information.  What I've always wanted to learn is something equivalent to "the top 5 things you have to know" for any given drug.  In other words, what are the things that the specialists think about when ordering a drug?  What do they chart check before giving?  What PMH, labs, meds do they look out for?  What are the truly common side effects and the actually worrisome adverse events they look out for?  These are the things that specialists know and these are the things that are so hard to look up in the book.  Thus, I set out to make like a sponge and try to soak up as much of this information as I could from the neurologists, and I think it worked really quite well!  I'll give you an example with anti epileptic drugs, including not all the info but some important points.

 

ANTIEPILEPTIC DRUGS (AEDs)...  In general, these are a few of the things that neurologists think about whenever they see or consider an AED.  These are the things we should have running through our heads in the ED as well, because we commonly order these medications.  

 

BEFORE ORDERING AN AED...

Chart check PMH:

-Look out for psychiatric conditions -- avoid keppra in these patients (bcz it commonly causes agitation, personality changes, psychosis).  

-Look out for CKD and dialysis in the chart, because many AEDs are renally excreted and will present with AED toxicity (see below).  

-If the pt is a woman, don't forget that AEDs are generally  very teratogenic.  

 

Chart check  Med List:

-Warfarin is one of the main things my neurologists looked out for, because AEDs notoriously interact with warfarin and have been known to cause jumps in INR up to 10 in a matter of days.  If you must give a patient on warfarin an AED, they need to have very close INR checking even within 2 days of DC.  

-There are some medications that interact with AEDs and increase or decrease their efficacy.  Unfortunately I forgot the most important ones (oops!  let me know if you know them)

 

Chart check Labs:

-LFTs (most AEDs can cause liver damage)

-BMP (creatinine)

 

COMMON SIDE EFFECTS FOR MOST AEDS:

-fatigue, weight gain, headaches, dizziness/nystagmus, tremors

 

 

WHENEVER A PT W/ A HX OF SEIZURES ON AEDs COMES IN, BE WARY OF THE FOLLOWING COMPLAINTS:

Rash: These are common side effects of AEDs, however be aware that the dreaded adverse rxn for many AEDs is SJS/TENS.  This should be on your radar if one of these patients complains of a rash.  

 

"Post Ictal":  This was perhaps the most interesting thing taught to me and unbelievably important to keep in the back of your head, and it again shows the disconnect between textbook/reference information and real work clinical experience.  Some of the most common side effects, especially severe in OVERDOSE/TOXICITY of AEDs, are drowsiness, sedation, lethargy and headache.  Picture this symptom combination in your head and what do you think it resembles?  Yep... the post ictal period.  Why is this vitally important to know?  Because if a patient comes in supposedly found "post ictal" and you decide "well we better load them with their home AED because noncompliance is the likely etiology of their breakthrough seizure", you could very well be giving an already SUPRATHERAPEUTIC patient MORE aed... toxicity here we come.  Yikes!  Very easy mistake to make (the neurologists said it has been done many times!).  Take home point, whenever a patient comes in "post ictal", you had better check a drug level on them BEFORE giving them their home med AED!  

 

The meds you can check levels for:  phenytoin/dilantin, carbamazepine/tegretol, depakote/depakene/valproate, lamotrigine/lamictal (in general, the first generation AEDs). If you can't check a level on their med, you better wait until they resolve from their postictal state before giving them their home dose.  If it takes them hours and hours to resolve, it might not truly be postictal, and you should hold the med.

 

 

 

 

 

 

 

MORE GOOD NEURO RESOURCES

 

Head CT interp:  http://lifeinthefastlane.com/investigations/ct-head-scan/

 

There is actually a new ENLS (emergency neurological life support) course similar to ACLS.  I think Scott Weingart sang its praise, so maybe its pretty good!  there is a course you can purchase online to go through them in detail I believe.  http://enlsprotocols.org/pdf.html

 

 

 

I thought that this rotation was fascinating and had very helpful information.  I hope you all enjoy this info as well.  If you all would like me to cover any topics in particular that I have glossed over, just let me know and I'll do my best.  

 

-SN


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#22 SERENITY NOW

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Posted 06 November 2015 - 02:31 AM

Wow I didn't even realize how much I wrote until looking at it just now.  I guess I just enjoy writing about this stuff.  I hope you all don't mind the long posts!

 

Anyways, here is the dropbox link to the PDFs of my notes for a few of the neuro topics.  Enjoy~

 

https://www.dropbox....wxLjgAnNWa?dl=0


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#23 PA2016!

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Posted 06 November 2015 - 09:02 PM

Awesome! Cant wait to sit down and read this tomorrow! Thanks a bunch! 



#24 whoRyou

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Posted 06 November 2015 - 11:22 PM

Thank you Serenity ... Your time and effort is appreciated! rWhbljm.gif EZ9kgRZ.gif


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#25 blues91776

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Posted 13 November 2015 - 01:15 AM

Thank you! very helpful



#26 agk

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Posted 15 November 2015 - 08:14 PM

Thank you SO much for taking the time to share your experiences and learning. I'm sure it's tiring and an added thing on the "To do" list, but from a second year PA currently in my EM rotation who hopes to apply to EM fellowships, I can't thank you enough. If you have any tips for the application process, I'd love to hear them. Good luck as your program continues!



#27 SERENITY NOW

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Posted 16 November 2015 - 02:51 AM

Hey gang,

I am glad you are enjoying the posts.  I really enjoy writing them and I'm happy to hear they're useful for some people out there.  

 

 

APPLYING TO PA RESIDENCIES/FELLOWSHIPS...

AGK, I feel like I applied ages ago so I can't remember all of the details, and I only applied to 4 programs so I am certainly no expert.  That being said, I'll try to muster up some tips for you and anyone else who may be interested.  There is definitely a lot of variability in the quality of PA residencies/fellowships out there, since we don't really have a standardizing body.  Any place can just call their position a "residency" position.  Be very careful if the program is not one of the established ones out there.  I have heard of places trying to take advantage of desperate new grads by luring them into a "residency program", when its really just fast track with long hours and low pay without any education.  Definitely try to talk to past graduates.  

 

 

Overview of the process and what to expect:

You'll search online for programs that fit your geographical zone (see EMED's sticky).  Read up on their website and download their application information.  You'll have to fill out an application packet with a bunch of important documents I will mention below and send it in via mail.  They will call you or email you to say you have an interview.  The interview day is similar to PA school interviews except much fewer people.  Typically there are 10-15 people interviewing for 2-4 spots.  They'll give you a presentation explaining the details about their program, show you around the hospital and ER, let you ask questions of current students, perform the interview, and provide lunch for you. I found out I was accepted within a few weeks of the interview.   If they give you an offer they usually give you a time limit of a few weeks to accept it before they move on to the next candidate.

 

 

General advice:

You should start getting yourself as organized as possible, and the sooner you do it the better.  The application process is very painful and will be replicated time and time again as you go throughout your career (new jobs, state licensing, etc).  Make sure you have a really good organization system on your computer to file all of your important documents: resume/CV, cover letter, references, work history with exact dates/supervisors, certifications, diplomas, IDs, immunization records, etc (if the original is a hard copy, make sure to have scanned things on your computer).  I have found that dropbox works well to have these important documents well organized, safely backed up, and very easily printable/emailable from anywhere (even my cell phone).  If you have all of these things organized well on your computer it will be 100x  easier to just print off the unique things that each program needs.  And after you make your way farther into the hiring process, you'll get countless more emails asking for random bits of important documents, and being organized will save you a ton of time.  

 

 

Qualities to assess in a program:

Location and affiliation.  Number of patients that come into the ED each year.  Demographics.

Utilization of PAs in this system in general.  Utilization of the PA residents in this system.  Fast track vs main ED.  

Your responsibility/autonomy/role... will you be expected to be efficient/move the meat?  How will your supervision be implemented?

How long the program has been established.  How well integrated they are in the hospital.  How well integrated they are into physician residency program.

Off service rotations: anesthesia/intubating, cardiology, neurology, trauma, surgery, peds EM, icu, ultrasound, ophtho (slit lamps), ENT (NPL), orthopedics, OBGYN are all rotations I have seen offered at various programs.  Think about which ones are most important to you.  

Elective opportunity and flexibility.

Built in learning and academics.  Weekly conference? What does that consist of?  Is it protected time? M&M? Procedure lab? Sim lab?  ACLS/ATLS/PALS certs?

Ultrasound education and practice.  Are there ultrasound fellowship-trained faculty?

Procedures.  How many intubations, central lines, LPs, procedural sedations (etc) did past graduates get?  

Salary.

Hours.  Scheduling.  

How is it living around that area? Cost of living? Public transport?

Past graduates available to get their feedback (definitely the most valuable).

What is unique about their program?  

 

 

The questions you should reflect on (and may be asked during the interview):

Why emergency medicine?  Are you aware of the negatives of EM?  What are they?  How will you deal with these downsides?

Why a residency program?  "You're aware its going to suck big time, right? (paraphrased)... why do you still want to do it?"  What is it that you want to get out of this residency?  What are your motivations/goals for it?

Why this program?  Make sure you really do your research and know the unique parts of that program as opposed to the others.

Why should we choose you?  What are your strengths?  What are your weaknesses?  

Tell me about your ER rotation in school.  Tell me an interesting case you had (I had to present a case, list a ddx, and explain my reasoning in one of my interviews!).

(And don't forget the classic/generic interview questions like 'tell me about yourself', 'what would you do in situation X', etc)

 

 

 

Hope this helped AGK!  

-SN

 

 

PS - I just finished my general surgery rotation, which indeed was very long hours.  Lots of good learning though.  It will take me a while before I can write it up for you all, but I'll do my best.  Stay tuned!


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Posted 24 November 2015 - 01:16 AM

GENERAL SURGERY

 

Overall, a surprisingly good experience.  We were well staffed and had a great group of residents working together.  My senior resident taught quite a bit and they were all very receptive to my questions.  I spent a fair amount of time holding the pager for the general surgery service, so I was the person who heard all of the phone consults coming from the ED.  Holding the pager is tough because you get tons of pages that keep you very busy, and at first I dreaded having to do it.  Now, however, I see that it was a very worthwhile experience 'being on the other side of the phone'.  I was able to see the wide range of presentations that ED providers give. Some people don't provide hardly any information, and it is clear they barely evaluated  or worked up the patient and just wanted to turf the patient to surgery.  Others gave a ton of information that was completely useless to the surgeons, which I soon got a sense for since I had to present every case to the team.  Overall it was very valuable in helping me figure out what is really important when calling a consult/presenting, and it also gave me an appreciation for why the surgeons sometimes seemed so grumpy over the phone.

 

Like I said in my prior posts, I have been gearing my learning towards things that will give me the most bang for my buck... things that are most easily learned when you are immersed in that specialty.  Keeping that in mind, my goals and most important learning points for the rotation were the following:

 

1) Abdominal stuff:  reading abdominal X-rays, 'what to order when' in abdominal conditions, what things the surgeons wanted to hear about the most common abdominal pathologies (SBO/LBO, biliary dz, hernias, appe, etc)

 

2) Post op issues:  general issues, fever, approach to the bowel resected patient, bariatric surgery patients 

 

3) Wounds wounds wounds!  I see so many acute and chronic wounds in the ED and I really wanted to learn the surgeon's approach to these.  

 

 

 

1) ABDOMINAL RELATED TOPICS

A - Abdominal imaging... what to order when?

One of the things I had struggled with on my first ED rotation was how to work up these patients who came in with abdominal pain, especially elderly patients who often have such nonspecific exams.  One of my attendings told me a pretty useful tip:  instead of trying to figure out the exact diagnosis you're suspecting based on the exam, just gestault it and ask yourself "will this person need imaging or not?"  If the answer is yes, its just a matter of figuring out what type of imaging is the most appropriate.  This is a bit easier to handle, but be aware that there are still many imaging options available.  Even if you decide they need a CT, you still have the contrast options to figure out, and its a topic that is still being debated.  The following are some general guidelines for what to order when you are suspecting the following:

 

bowel obstruction --> KUB and upright abdominal series (then probably CT)

perforation --> upright AXR + CXR (cxr is the most sensitive)

 

RUQ pain: concern for GB --> start w/ ultrasound

lower abdominal pain: concern for pelvic/gyn --> start w/ ultrasound

pregnant woman w/ RLQ pain --> ultrasound first.  if negative, may need MRI to eval appe.  

 

In general, the gold standard for evaluating abdominal pathology is CT w/ IV and PO contrast, BUT:

1) Oral contrast takes 2-3 hours of downtime before you can scan them, so we try to avoid it when possible.

2) CKD often prevents IV contrast, limiting us to PO contrast

3) sometimes contrast gets in the way of what you're trying to see (like kidney stones), 

So, contrast isn't always the answer and we like to avoid contrast if isn't needed, most typically in the following circumstances:

-Back/flank/inguinal pain: suspecting kidney stones --> CT w/o contrast.  If negative, may need to follow with IV contrast to eval appe.

-RLQ pain: concern for appe --> CT scan w/ IV contrast alone (don't need oral contrast), and may even be able to do non contrast CT in some individuals.  Thin individuals have less (peri-appendiceal) fat and are therefore harder to image without contrast, so can't do it in these patients.  

 

 

 

B -  Abdominal xray interpretation:

It was incredible how many abdominal X-rays we looked at during this rotation.  We ordered them all the time.  I really hadn't done too many formal AXR interpretations in the past so it was great to practice them over and over again.

 

Remember the different ways to do AXRs... supine flat plates, upright abdominal series, left lateral decub.  

 

Look for the obvious things - bowel, gas patterns, fluid levels.

You see bowel with lines all the way through it, its located closer to the umbilicus, and its smaller... this is likely small bowel, and it shouldn't be greater than 3 cm.

You see bowel with lines that don't cross all the way through, its located around the periphery, has dimpling of the outside, and its bigger... this is likely large bowel, and it shouldn't be greater than 6 cm.

Look at the gas distribution, fluid levels, make sure there is gas in the sigmoid/rectum.

 

Look for the things you never want to miss... do this every time! 

Air under the diaphragm.... air in the liver (normal is homogenous)... air in the bowel wall

 

And practice practice practice!

 

To see the full approach, I'd highly recommend checking out this site:  http://lifeinthefast...interpretation/

 

 

 

C - You need to consult the surgeon, what things should you include in general?

Age, PMH (kidney dz, overall comorbidities to gauge if operative candidate, especially CV disease)

Meds (anticoagulants, INR, antiplatelets and when they last took the med)

PSH and which surgeons did it.  

 

From this point, it diverges depending on the specific situation.  The surgeons want to hear details that help them decide how much time they have to come see the patient and possibly take them to the OR.  The relevant details depend on the condition.  In bowel obstruction, is it an open or closed obstruction? Any indication of strangulation or systemic instability?  

 

One thing the surgeons consistently complained about from the ED was that the ED would consult them and then essentially forget about the patient and move on, when there are still important things that need to be addressed in the ED.  For example, in bowel obstruction, a big problem is vascular fluid shifts often leading to serious AKIs, so patients should almost invariably be started on IVF immediately in the ED.  

 

 

 

 

2) POST OPERATIVE ISSUES

Every once in a while I saw patients come into the ED who were several days-weeks post op and I think they're tough to approach if you don't know what exactly can go wrong with surgeries, both in general and specific to each unique surgery.  Perhaps the patients that scared me the most were patients who had bowel resection surgeries and bariatric patients, since these people can have complications months-years after the surgery.  

 

 

A - A patient walks into your ED with a fever and says he had surgery last week... What goes through your mind? Don't forget the 5 W's!

Since patients typically won't be coming into the ED until PODs 4 or 5 at the earliest, its important to know what things can occur at this time.  The big ones are surgical site infections, anastomotic leaks, deep space abscesses (which may have minimal manifestations), medication effects, and DVT/PE (not all fevers are from infection!)  

 

Look at the surgical site.  Any sign of erythema, fluctuance, odor, purulent drainage?  Could be a SSI.  May need ultrasound vs CT scan to see how deep it is. Want to make sure it doesn't extend past the fascia.  Will need I&D and leave open for secondary closure.  Certainly call the surgeon.  

 

Look at the vitals, specifically for tachycardia, tachypnea, hypoxia.  If you see any of these, big red flags should be going off in your head for 2 things:  PE (obviously) and interestingly also anastomotic leak, which has been known to manifest exactly like a PE, sometimes without any abdominal pain at all.   See the discussion below for anastomotic leak, the dreaded complication of bowel surgery.  

 

 

B - Your next patient comes in complaining of abdominal pain and during your exam you see an ostomy... What do you look out for in patients s/p BOWEL RESECTION?  What things can go wrong with these surgeries and should you work them up?

-Bleeding (every patient gets a rectal + hemmocult)

-Strictures / obstruction (last stool and flatus?  feel bloated?  n/v? upright abdom X-ray) 

-Fistulas (enterocutaneous, enterovesicular, entero-entero) (always get oral contrast w/ the CT in patients who have had viscus surgeries).

-Infection (assess vitals, surgical site, etc)

-the dreaded complication: ANASTOMOTIC LEAK:  breakdown and spillage from the place where the bowel was sewed together.  Typically happens POD 5-10.  Typically causes abdominal pain, rigidity, hypotension, tachycardia reflecting the peritonitis and sepsis, BUT this is not always present.  Sometimes it only presents with SOB, tachycardia, even hypoxia, food intolerance, feeling of doom.  *This is the biggest thing surgeons worry about and should always be on your differential*.  It is a surgical emergency.  Call the surgeon early if you suspect this.  

 

Basic ostomy identification:  

Right side of abdomen, smaller, liquidy output = ileostomy.  

Left side of abdomen, bigger, stool output = colostomy.

Ostomies can have things go wrong with them too.  Most commonly obstruction, infection, ulcers.  Don't be afraid to do a pinky digital exam.

 

 

C - Your next patient comes in complaining of abdominal pain and says he had a gastric bypass 6 years ago.  That's surely too long ago to be at play now, right?  (nope!)  APPROACH TO BARIATRIC SURGERY PATIENTS:

We had an awesome bariatric surgeon give us a great lecture that on these patients that has helped me immensely.  He really emphasized the following take away points:

-BE FRIGHTENED of EVERY bariatric surgery patient that you see NO MATTER HOW LONG AGO THE SURGERY WAS (even 20 years out!)

-ALWAYS call a bariatric surgeon to run the case by them.  

-ALWAYS GIVE THIAMINE to EVERY bariatric surgery patient.  For many reasons, they are at a very high risk for thiamine deficiency and wernickes encephalopathy (numbness/tingling, visual issues, altered/psychotic), and there is no risk to giving thiamine, so just give it.  

-A recently post op (within the past month) patient should be assumed to have an anastomotic leak until proven otherwise.  

 

-90% of the time that a bariatric patient complains of abdominal pain long after their surgery, its either GALLSTONES or a peri-bypass ULCER that can be treated with standard conservative therapy (PPIs, kerafate, etc)

 

-The other 10% of the time, it will be either an INTERNAL HERNIA (may only complain of bloating; CT is not sensitive to rule this out, so just call the surgeon; can be an emergency) or STRICTURE/BOWEL OBSTRUCTION (do not put an NGT into any bariatric patient!

 

-Be aware that these patients are also at an increased risk for kidney stones, iron deficiency anemia (iron is absorbed in the duodenum which is bypassed), chronic constipation, pulmonary embolism, and lots of medication problems and side effects (their BP and blood sugars improve from the weight loss but their PCP doesn't lower their medication dose so they present for syncope and hypoglycemia).

 

 

(I'll cover wounds in the next post shortly...)


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Posted 24 November 2015 - 02:10 AM

3 - WOUNDS!

 I see so many wounds in the ED but I've never been confident in dealing with them.  This rotation helped me to see dozens of wounds and get a good sense of what it is the wound care specialist looks for when evaluating wounds.   

 

 

Its important to know the textbook knowledge about the main chronic wound types/etiologies: Diabetic, Venous stasis,  Arterial,  Pressure/sacral, and Infectious.  Where is each typically located?  Neurovascular status for each?  Wet vs dry? Treatment options?

There are tons of good comparisons tables out there to help sort through these.  I'll attach the table I made in my notes that I think is pretty good.  I won't go into everything here for the sake of time, but the most important things to know are perhaps the location and treatment.  Chronic wounds on the sacrum are typically pressure ulcers, which are treated by offloading.  Wet wounds on the ankle (gaiter zone) are often venous, which are treated by decreasing edema measures.  Insensate wounds on the feet are often diabetic, which are treated by offloading.  Eschar wounds on the tips of cold extremities are often arterial, which are treated by revascularization.  I used to worry most about what kind of dressing to choose for any given wound, when in reality the most important/definitive treatment is specific to the underlying etiology, as mentioned above.  

 

 

Overview of the ED approach to wounds:

Chart check before going in...

-Vitals, PMH (DM, PAD and last ABI/angiography), immunocomp, venous insuffic, sickle cell, malnutrition)

-PSH, medications, allergies (abx)

 

History...

-Chronicity

-Assoc sx (pain, itch, drainage, smell, swelling, claudication, etc)

-Constitutional sx (fevers, chills, malaise)

-Curent management routine

-RFs for badness (comorbidities, poor wound care, trauma, surgery, IV drug user)

-Red flags (soil contamination, rapid progresssion)

 

Exam...

-Location (over bone? joint?)

-Size (draw a line around it and assess rate of growth). 

-How does the wound itself look?  

-How well demarcated is the perimeter? Surrounding erythema?

-Depth?  Probe the wound, assess for undermining.  

-Crepitus, odor

-Neurovascular status (always assess sensation and pulses, typically needing doppler signals)

 

Studies...

-X-rays for gas in the tissue and bony disruption

-ultrasound to evaluate if occult abscess if its not clear clinically

-if concern for infection, consider CBC, BMP, CRP - be wary of hyponatremia (can indicate nec fasc)

 

ED Assessment...

-Any high risk feature present?  comorbidities, progression, location risk (joint, bone/osteomyelitis), systemic sx?

-Ask yourself, is the wound infected? (new wound, or acutely worsening? painful?  Fevers, chills, erythema, edema, drainage? gas? crepitus? concern for nec fasc (LRINEC score http://www.wikem.org...:LRINEC_Score )

-Remember there is a range of severities when it comes to skin and wound infections... From most deadly to least deadly:

gas gangrene, necrotizing fasciitis, erysipelas, cellulitis, abscess.  Check out the podcast "university of iowa department of emergency medicine: skin infections"

 

Plan...

-Always consider etiology-specific treatment as mentioned above.  

-If it looks infected, consider need for PO vs IV antibiotics and therefore admission/disposition.

-consider surgery consult

-consider tetanus status

 

-ED wound dressing to hold them over until their wound care specialist sees them next.  Does not need to be fancy, just remember the basic principles of wound care dressings:  its all about the moisture level of the wound itself, and your dressing should be the opposite.  If you've got a sopping wet (often venous stasis) ulcer, use a dressing that will keep it as dry as possible (absorptive dressings).  If you've got a dry (often arterial) ulcer, use a dressing that will keep it moist (occlusive dressings).  For everything in the middle, and really for almost any wound as a temporary measure, a good old fashioned "wet to dry" gauze dressing is a good bet, or so I've been told.  

 

 

 

Good resources

 

Here is a good powerpoint pdf about basic wound care: http://www.palliativ...unds_Wounds.pdf

 

 

Overall best surgery resource hands down:  Surgery 101 podcast.  Simply awesome!  They have so many awesome podcasts.  I listened to them a lot in school but listening to them a second time around with a better base of knowledge and I am realizing how golden they really are. I plan on going back to them many times again in the future, because they are that good!  

 

 

Dropbox link to my (again ugly looking, thrown together) notes:   https://www.dropbox....exA0bYhrCa?dl=0

 

 

 

I'll be in the ED for the next couple of months, so if any of you have specific topics you'd like me to write about next, just let me know!  

 

-SN


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Posted 24 November 2015 - 02:51 AM

Thank you again! Excellent info.

#31 chichamorada

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Posted 09 December 2015 - 04:53 PM

I am so glad that I stumbled on your journal/blog!  Your enthusiasm is contagious, and it sounds like you are really making the most of your residency.

Thank you so much for sharing your valuable learning experiences! 


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Posted 05 January 2016 - 01:47 AM

Hi Gang,

I hope you all had good holidays.  Time for an update for you all.  Overall, I have been feeling better about things.  I feel more aware of myself; I know what I am getting better at and I know what things are my definite weaknesses.  I feel better about the common chief complaints in stable patients... chest pain, SOB, abdominal pain, etc... I've been seeing so many patients that I've pretty much seen the majority of the permutations that these chief complaints can result in, and experience definitely helps with confidence!

 

That being said, I have recognized that a big weakness for me at this point is seeing "sick" / unstable patients. Its fine and dandy to know the textbook knowledge about patients in shock, but its an entirely different situation when paramedics are rushing a patient back, nurses/techs are flocking over, and you try to figure out where you fit in, what evaluation needs to be done, and what orders you are supposed to be barking out.  There is a ton going on at once, and when I tried to get in on these cases without a clear systematic approach in the back of my head, I'd just get overwhelmed and freeze up.  Undifferentiated shock is still over my head at this point, so I've been trying to learn the principles of managing sick patients by picking up every patient I can with septic shock, and I think it has helped get my feet wet quite nicely.  It is a much more narrowed ddx but still helps you learn the principles of resuscitation.  Now, I realize that sepsis is an incredibly controversial topic at this point, so I am not going to be going into the details about sepsis management, but rather a general approach that applies to any sick patient.  

 

 

 

-------BASIC APPROACH TO SICK/UNSTABLE PATIENTS--------

I think its important to have a conceptual grasp of the big picture as you go through so that it doesn't feel like you're memorizing dozens of individual steps. Always start with and continually come back to the ABCs (or CABs).  Each time you go through the ABCs you can have a different perspective with them.  Start with ABC eval, then ABC immediate management, then critical Hx, then finish up D and E, then adjuncts, then ABC advanced management, etc.  Keeping it simple, systematic, and logical is the only way to be able to remember everything when the pressure is on.  Aside from this, its a matter of practicing practicing practicing until this progression is second nature.  

 

ABCs immediate eval

Circulation - grab RN/tech to get vitals, place on cardiac monitor, get IV access (x2 if needed, and low threshold for IO).  Check pulses, extremity cap refill and temp to palp.

 

Airway - quick glance in mouth, listening for upper airway sounds.

 

Breathing - put on pulse ox, look for RR, listen to lungs (equal bilat? crackles? focal? wheezes? etc) 

 

make sure everything above is done and assess them: vitals, cardiac monitor, lungs/perfusion.

 

ABCs immediate actions

Circulation - Start IVF.  Pending cardiac monitor may need to call for code cart/cardioversion/pacing pads and go down ACLS protocols.  

Since RN draws blood when first placing IV, make sure to consider need / tell them to draw rainbow labs, not to forget VBG w/ lactate (point of care machine at my ED), blood cultures, type and cross match, and have them place drop of blood on urine preg test for appropriate female patients (supposedly this is manufacture tested and approved).  

 

Airway - If not maintaining airway, start with painful stimuli, jaw tilt / chin lift, consider OPA/NPA.

 

Breathing - Start oxygen by NC or NRB.  Specific tx per lung sounds (nebs, epi, nitro, lasix, etc). Unilateral, consider needle thoracostomy.  

 

Everything above is the top priority and should be addressed in your head before moving on.  After this point, everything should be done in parallel.  

 

 

Critical hx

-Chief complaint, time and acuity of onset, prior epps/hospitalizations/intubations?

-Interventions done so far?

-PMH: heart? kidney? DM? COPD?

-Meds: anticoags?

-Allergies?

 

D - Dipstick + Disability/GCS/Neuro

Tell nurse to check dipstick

Eval eyes, verbal, motor.  Following commands?  Moving all 4 extremities?

 

E - Exposure + EKG

Strip down the patient, check all of body for skin breakdown.

Good time to do rectal exam, hemmocult to r/o GIB, check rectal temp.

Get EKG in almost all critically ill patients.  

 

Review and Adjuncts

At this point, take a step back and reassess everything. Form a gestalt of the situation.  Decide where to go from here.

 

Labs to possibly include CBC, BMP, type and screen/cross (know the difference! very important!), coags, urine preg, blood cx, UA and urine cx, troponin, all as indicated (not exhaustive list obviously).

 

CXR? FAST ultrasound? CT head, abdom pelvis?

 

Get the orders in and if your patient is truly sick get back to bedside...

 

ABCs Advanced Managements

Airway/breathing - cpap/bipap? ETT?  [learning point repeatedly emphasized to me by my attendings: the decision to intubate is NOT guided by lab results/ABGs.  Know the 4 indications to intubate and how they apply in the ER.  1) failure to oxygenate (manifests as desatting pulse ox).  2) failure to ventilate (hypercapnea is a clinical dx in ED with manifestation of somnolence/confusion/altered mental status/severe tachypnea or bradypnea... do not wait for ABG!)  3) Inability to protect airway (GCS under 8, sonorous respirations, secretions, altered patient vomiting), 4) expected clinical course necessitating intubations).  

 

Circulation - Central line? Art line?

 

Only at this point have you really got the ball rolling on all of the time critical aspects of the patients care and it is safe for you to slow down and do a complete history, physical, think through your ddx, start empiric or targeted tx.  Each time the patient decompensates, go back to the ABCs. 

 

 

Pretty good video going over some specific crashing patient situations and practical information about them.

 

 

EXCELLENT video by Reuben Strayer outlining his general overview/mnemonic for critically ill patients / resuscitation.  He does a much better job than I do, and his is probably easier than mine to remember.  Check it out!  

http://emupdates.com...-resuscitation/

 

 

 

A COMMON ISSUE THAT COMES UP IN CRITICALLY ILL PATIENTS...

As if the first order medical knowledge isn't challenging enough in these sick patients, the practicalities of accomplishing what you want to do almost never go smoothly in these patients.  These patients are often renal patients, vasculopaths, have been sticked a million times and have sclerosed veins, so one of the most common issues I've found is with vascular access, which can be incredibly challenging.  You'll be at the bedside trying to work your way through the ABCs but won't be able to get a line or blood, so you'll end up at a standstill feeling hopeless if you don't know how to trouble shoot.

 

DIFFICULT VASCULAR ACCESS PROGRESSION...

1 - try to get peripheral IV access.  x2 if possible.  

2 - If truly time critical, go straight to IO if there is any difficulty at all with IV.  If suspecting they'll need central line, go to non sterile crash femoral line.  

3 - If not time critical, options include EJ vs ultrasound guided peripheral IV to start.  If you think they'll need a central line (expect extensive volume resuscitation, multiple drips /pressors/ abx), go to IJ or subclavian sterile central lines.  

4 - If you have lines but they aren't drawing back and you need blood, go straight to art stick for blood.  

 

You should be very comfortable with each of the above methods, especially IO access.  Don't let your first exposure to it be during a crashing situation!  Definitely worthwhile to read up on it in Roberts and Hedges, the product websites, and youtube videos.  When placing it, the proper technique is to push through to bone without engaging drill, then once reached bone engage the drill and let it bring you into the bone (don't push!). 

http://www.teleflex....rintVersion.pdf

 

EJs have a unique technique that you should look up.  Several good youtube videos out there from simple searching. 

 

Central line resources.  There are tons out there.  Here are my favorite 2 as a primer to the very often talked about topic of central lines.  

Good overview - http://clinicalcases...ep-by-step.html

Overall the best teacher of everything central line is Scott Weingart; he has done a lot with this!  http://emcrit.org/central-lines/

 

 

 

 

 

Hope this was helpful to some of you out there.  I'm sure its very basic to those who have worked in the main ED for more than a few months, but I still think its a very important topic that should be reflected on early in our training.  Anyways, this week we are doing a "lab week", which has beene a great time so far.  Just 8-5 of a mixture of classroom stuff, procedure practice, simulation lab, ACLS/PALS/ATLS refreshers, and get togethers outside of work with the residency family.  Good times.  Whats even better is what awaits me next week: procedure month!  Supposedly the best rotation of the whole residency, we are sent to a neighboring hospital without a ton of residents and our only job is to do as many procedures as we can get our hands on.  No histories and physicals and best of all NO CHARTING.... just hands-on procedures all month.  Sounds amazing and I can't wait!  Life is good!


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Posted 04 February 2016 - 12:27 AM

----------PROCEDURES OF EMERGENCY MEDICINE----------

 I am finishing up my last few days of the procedure month.  Overall it was a very helpful month because we do procedures so much in the ED but don't often have time to slow down and focus on the details surrounding them.  I did get a lot of practice doing the bread and butter EM procedures (lac repairs, I&D, ultrasound IVs, reductions, splinting, etc), and spent the little free time I had reading up Roberts and Hedges (the EM procedure bible for those new to the field).  I also spent a lot of time outside of work reading different FOAM sites, forums (including this), and videos to learn a lot of practical tricks of the trade.  

 

Overall, I think it was incredibly worthwhile to spend a month really focusing on all aspects of procedures.  There is a lot more that goes into procedures than I had initially appreciated.  Like most things, its a learning process.  We start by seeing a procedure done a few times, read the basics of it, and grasp the overall process.  Then we are able to do the procedure several times and understand the setup, the anatomy/landmarks, the exact steps and technique, etc.  This brings us to "beginner-intermediate" zone in my mind.  I think to make it to truly 'proficient'/independent in a procedure, we have to go far beyond this.  We have to be really familiar with the process of evaluation (is my patient really appropriate for this procedure?), the potential complications that can come (what they look like, how exactly to manage them), and many other things.  Complications in particular represent a topic I think is vitally important.  We often haven't seen every complication but we still need to know these inside and out, so its so important to read/study these well.  After all, if we accidentally hurt a patient during a procedure and we don't know how to deal with the mess that results, we shouldn't be able to do the procedure at all!

 

I've created a general outline that can be applied to most procedures and helped me frame my studying:

 

Pertinent Knowledge for Every Procedure We Do:

1. Indications.  Situations/problems that necessitate this procedure, and how exactly the procedure fits into and fixes this problem.  

2. Complications/risks of the procedure.  Frequency these complications occur.  How they manifest and how to recognize/diagnose them.  How exactly to manage them.  How to prevent them.  

3. Contraindications.  With complications/risks in mind, what patients are not appropriate for this procedure.  

4. Anatomy.  Textbook anatomy, surface anatomy, landmarks, imaging anatomy (ie ultrasound).

5. Prep before starting the procedure.  Appropriate sedation/pain control, often unique to the procedure.  

6. The procedural steps.  Best technique.  How to confirm your procedure succeeded?  

7. Post procedure care.  Dressings to put in ED.  Patient instructions being very specific and knowing how to handle FAQ.  Sometimes these are topics in and of themselves (how to minimize scarring, etc).  Return precautions specific to the procedure.  

(also should know how to express these in layman's terms while explaining procedure to patient)

 

 

The most valuable topics I learned during this rotation were probably related to general procedural knowledge, decision making in laceration repair, and the little tips and tricks I've learned from dozens of awesome resources.  I'll detail these topics below.  

 

 

 

GENERAL PROCEDURAL KNOWLEDGE:

There are certain topics you'll see come up time and time again regardless of the procedure, so its really important to grasp these inside and out.    

 

1. Procedural sedation.  Certainly a huge topic that warrants thorough study of Rosens/Tintinelli/RoberstsHedges.  Still, lots of great resources out there - Reuben Strayer's website has tons of good stuff on this.  http://emupdates.com...encast-trilogy/

 

2. Antiseptic options.  Circular motion or wiping?  Efficacy instantly or only upon drying?  Procedure specific choices? Safe on open wounds?  Each antiseptic option is unique in all of these questions.  Esoteric topic? Maybe, but considering its something we do with EVERY patient, I think its worth dedicating some time to.  

Info that my attendings have told me:

betadine/iodine: circular motion, ONLY works after dry (so dab off with sterile gauze to speed this process), the agent of choice for LPs, and impairs wound healing.  

chlorhexadine:  wiping motion, works best if dried (dries quickly though), appropriate for many procedures, unclear if impairs wound healing.  

alcohol wipes (isopropyl alcohol): wiping motion, works instantly, not appropriate for many procedures, unclear if impairs wound healing.  

I haven't been able to find a whole lot of good take-away reviews online; if anybody is more familiar with this section, please chime in!  

General sterile technique for advanced procedures  - 

 

3. Local anesthetics. I've been pimped on this so many times I lost count, and for good reason because this is an important topic!  Several of the orthopedic residents have given peds patients seizures because they didn't know the toxicity that can set in when they pump 15cc of lidocaine into a hematoma block for a pediatric forearm fracture.  Know the toxic dose for lidocaine alone and lido + epi.  Lido is toxic at 4mg/kg (lido w/ epi is 7mg/kg).  So 20kg pediatric patient x4mg/kg = 80 mg max dose.  1% lido sol'n has 10mg in every 1mL, so 80mg/10mg = toxic at 8mL!!!  Don't forget that the cardiac dose for lidocaine is as low as 1mg/kg, so you had better be careful to withdraw plunger every time you inject any significant amount of lidocaine.  

More calculation examples: https://dailyem.word...cal-anesthesia/

 

Case: You are doing a lac repair on 8 year old, and just a few minutes into the procedure he reports "My tongue feels numb, I feel dizzy, and I hear a ringing noise". Since you know the sx of lidocaine toxicity (look them all up now),  what immediate actions do you take?  ABCs:  cycle vitals, cardiac monitor, IV access, start O2.  Get EKG.  Treat airway, arrhythmias per ACLS, and seizures w/ benzos.  If any of these serious complications are already present, consider lipid emulsion therapy, the specific treatment for lidocaine toxicity.

 

 

(continued to next post...)


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Posted 04 February 2016 - 12:32 AM

 

DECISION MAKING IN LACERATION REPAIR

I really enjoyed lac repair in school and I practiced every chance I could get.  I think my technique was fairly good (good technique for newbies =  not too close to laceration line, bisecting lac with each throw, inserting at 90 degree angle to skin, rotating wrist as main action, surgeons knot first to hold knot taught, gentle approximation not strangulation, mild eversion of wound edges, good knot tying technique, etc).  However, while I knew 'how to use the tool', I was never sure what method was most appropriate for every laceration that came in (and each laceration/patient is unique!).   I didn't fully understand the specific decision making process that underlies it all.  This rotation has really helped reinforce that there is a rhyme/reason/logic/criteria behind the decision if/how to close lacerations.  

 

Realize that the overarching goals of laceration repair are to restore function and minimize scarring, all the while avoiding infection.  These 2 tend to pull the decision making process in opposite directions.  To maximize function/cosmesis, the best method is to close the wound right away (primary intention), however primary intention will result in an increased risk of infection in certain patient populations.  Secondary intention will be more safe for those at an increased risk of infection, but they result in worse function/cosmesis, in addition to many other negatives to consider.  Understand what you are putting some patients through by subjecting them to secondary intention: http://practicalplas...ractical_10.pdf

 

So, logically, the first step in the decision making process is to determine if our patient fits under the "high risk for infection" profile, in which case we would NOT want to close this wound at first, and instead let it stay open to heal via granulation (secondary intention).

 

All of the following will classify your patient as "high risk for infection":

-an "old" laceration, over 8 hours prior to arrival.  There is not an evidence based "golden period" with magical hour X under which is okay, but 6-8 hours is the dogma nonetheless.  Some new school thought extends it out to 12 hours, but I don't know of any evidence backing that up.  For face / scalp, which are very well vascularized with much lower risks of infection, this time is often extended longer.  

-high risk mechanism including crush injury, animal bite (especially cat or humans) or deep puncture wound.

-length of laceration is over 5cm.  

-a "dirty" wound, grossly contaminated, high chance for foreign bodies, location of body.

-a high risk PMH, namely diabetes.  Also PAD, CKD, immunocompromised, but DM is by far the highest risk.  

 

Don't forget there are other situations to evaluate that will also make you think twice before closing yourself (complicated wound, over joint/bone/nerve/blood vessel/tendon, underlying fracture, eyelid.

 

With these considerations made, we can answer the first big question: to close primarily or not?  If the answer is yes, we encounter the second consideration: which method is the best to use?  Lots of options here and its too much for me to go into detail here.  There is a good chapter in Roberts and Hedges worth reading.  

 

Also check out these websites for some great laceration repair resources:

http://lacerationrep...e point videos.

http://lifeinthefast...otta love them!

http://foamcast.org/...38-lacerations/

http://manuetcorde.o...-not-to-suture/

http://hqmeded.com/wound-care-ed/

 

 

 

 

MY FAVORITE PROCEDURAL TIPS AND TRICKS, and LOTS OF GREAT PROCEDURE VIDEOS, RESOURCES, ETC:

I had a lot of fun scouring my favorite books, websites (including this site, as you'll probably recognize some of these from EMED's golden thread "tricks of the trade/EM"), and learning from some of the veteran attendings/PAs/nurses.  Below are my favorite. 

 

Nose foreign body removal with the EMEDPA technique:  use malleable/blunt loop type ear curette, shape into hockey stick, slide along lateral wall of nares until behind the FB, then pop it forward and out.  

 

Superficial embedded FB removal: use a 2-4mm punch biopsy, irrigate, done.  

 

Fish hook removal using the string method.  Supposedly is very successful.    .  This video doesn't explain it but basically you get umbilical tape wrapped around the hook all the way down to the skin.  Align the hook down parallel with skin.  Push the eye of the hook down to the skin and it will disengage the barb from the undersurface of the dermis.  Give a quick short jerk on the tape and the hook will pop right out.  Try this at your own risk though, as I have heard of it failing (painfully) as well! 

 

Foley troubles.  Nurses come to you saying they can't get foley in.  The patient has not had any urologic surgery before (so, doubt stricture and its likely BPH).  Use a uro-jet and clamp meatus for 3 minutes (lidocaine jelly will lubricate and expand the urethra), then use a 18-20 coude catheter.  Still can't get it, try a 12 french silicone catheter then call urology.

 

Dental blocks like inferior alveolar block.  Its tough to inject and withdraw syringe plunger to make sure not intravasc with one hand (because your other hand is occupied with landmarks in the mouth), especially at the awkward angle in dental blocks.  Great tip is to simply put tape around your thumb on the plunger and reposition your other fingers so that you can withdraw and inject without repositioning at all.  Its basically a poor man's ringed syringe but it works great.  

 

Fingertip avulsion lacs that are bleeding a ton.  Let fingertip soak in 10-20 cc lido w/ epi in a small basin/pill cup for 5 minutes.  This does the trick a lot, but if not, can create a make-shift finger tourniquet.  Then coat the tip with dermabond.  https://www.youtube.com/watch?v=nIXvt-LWetU

 

 

 

****Tons more great tips/tricks from this website "Procedurettes" by Whit Fisher. Highly recommended! http://www.procedure...index.html.html

 

 

Awesome video resources as if you were there learning procedures at bedside:

****https://www.youtube....ow=grid&sort=p

Probably my favorite - by Larry Mellick.  He is always uploading great videos with nice explanations as he goes.  Check him out! 

https://www.youtube....low=grid&sort=p

https://www.youtube....linha720/videos

 

 

Misc procedure related resources:

https://umem.org/pag...deos_procedures

    Great videos by UofMaryland EM program.  Procedures on cadavers. 

http://lifeinthefast...com/procedures/

http://www.emra.org/...rtaining-to-em/

http://enw.org/IVStarts.htm

http://www.bd.com/va...2004_VS7167.pdf

 

 

 

 

 

 

Well that is it for this month. I'll be back in the ED next week for the first time in the new year.  I am really hoping to start cranking up my efficiency and seeing a lot more "sick" patients.   They are always humbling, that is for sure!  


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#35 dphy83

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Posted 04 February 2016 - 01:08 AM

Hi Serenity:

How are you evaluated or how/when do you receive feedback during this residency? Just curious. I know that you say that you haven't progressed as much as you would have liked, but I'm sure the program director(s) and faculty think you're doing just fine.

#36 SERENITY NOW

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Posted 09 February 2016 - 05:49 PM

@dphy83:  We receive online evaluations from our attending physicians as we go throughout the program, and we have formal in person meetings with our program director every several months.  My first one is coming up this week actually... I hope it goes okay haha!

 

 

 

 

On a side note, I have been getting some PMs from students asking about what they can do to increase their chances of getting into an EM residency, and I've been giving out the following general advice:

 

FOR STUDENTS:  INCREASING YOUR CHANCES OF GETTING INTO AN EM RESIDENCY...

At the end of the day, the best way to increase your chances of getting into a residency is to have a killer application.  Obviously, more important than just superficially "buffing" your application, you want to really know what you're getting into and learn as much of the EM foundation as possible.  Still, you want to make sure you have a great application that reflects your hard work so that you can actually get into a program.  The following are the main application components and what you can do to strengthen them:

 

1. Past experience.  If you're a pre-PA, it would be great if you could get experience as an EMT/paramedic/ER nurse/ER tech before school.  This looks great on your application and will seriously help your transition to an EM provider.  If you aren't able to do this, you will still have a chance so don't worry.  Shadowing experience is a good start to getting a sense for the way things are done in EM.  

 

2. GPA - study hard!  Higher GPAs are favored in admission committees, so don't shrug this off as unimportant in PA school if you really want to be competitive for a residency.  I don't think that your PANCE score matters at all.  

 

3.  Letters of recommendation - The best way to get the best LOR is to really shine on your EM rotation, which requires you to really know your EM stuff...  During didactic year, focus on EM topics, really prepare for and do well in your procedure labs, and consider starting to listen to EM podcasts on free time/commutes.  Start with the podcast 'EM Basic'.  Also, develop a relationship with your PA program director, and make sure they can see your passion for EM.  Many residencies require one LOR to be from your program director, and it will look a lot better if it isn't a generic cookie cutter LOR!  During clinical year, work really hard on your EM rotation, come in early and stay late, show initiative and be active about learning from your preceptor.  Definitely dive into the EM podcast scene; its a lot more fun way to learn IMO - listen to as much of EMBasic as possible, then check out FOAMcast too.  Get as many EM-related electives as possible (trauma, ortho, peds EM, ICU).  If you stick with all of these things, you'll be an EM stud on your rotation and will get a shining LOR. Please see the copy/paste below from a prior post I made about more tips for making the most of your rotations.

 

4.  "Buffing the resume" - show a specific interest in EM and do activities that reflect that.  Does your PA program have a unique track dedicated to acute care?  Perhaps a student "EM interest group"?  Opportunities to learn about bedside ultrasound, advanced procedures, ACLS/ATLS/PALS?  Opportunities to go to EM conferences around the area?  Consider joining SEMPA as well.  

 

5. Personal essay and Interview skills - be prepared, practice, and articulate yourself well.  See my earlier post about interview questions to reflect on. 

 
 
 
 
ADVICE TO CLINICAL YEAR STUDENTS: HOW TO MAKE THE MOST OF YOUR ROTATIONS...
I wrote this post a while back on the student forums and I think it is very relevant here.  If you know you want to go into EM, you can further focus this general template to be more EM specific.  
 
(copy/past)
"Hi Gang,

I tend to do some reflecting on this crazy process of learning medicine and every once in a while I come to a realization I think is worth sharing.  The past few months I've been thinking about rotations...

 

There is really so much that goes on during rotations.  You try to learn your way around a new hospital, you try to learn the job/responsibilities assigned to you, and you try to learn the basic textbook medicine related to that specialty so that you can cram it in your head for your EORs. Now that I have graduated, however, it has become abundantly clear that real practice requires much more than those things.  Since I am doing a residency program, I am continuing to do rotations and I have found myself changing the way I approach my learning while on a rotation.  More and more I am asking myself, 'what will I need to know about this once I am in practice in my own specialty?'.  The basic outline is as follows:

 

General Learning Goals for Rotation on Specialty X... 

-What are the most common chief complaints and diseases for this specialty.  What are the uncommon diseases that this specialty is commonly consulted to rule out?  There are often diseases that in the ED we are not great at identifying/ruling out/managing because they're uncommon, but the specialists see it all the time so you in a great position to really become comfortable with these entities.  Really dive into learning about each of these topics, learn the subtleties that the specialist looks out for and their approach to rule in/out.  (Example: back pain, consult ortho to rule out cauda equina.  Posttraumatic swelling, consult ortho to rule out compartment syndrome, etc).  

-The perspective/approach with which the specialist thinks about and works through the chief complaint/consults. 

-Really practice the ddx, widen it, and internalize it by seeing as many cases as possible.

-The history questions that really target the ddx, and what is the best way to ask these questions (learn this by listening to the way the specialists ask questions).

-The systematic physical exam, the technique, and getting a feel for what pathology looks like and feels like Also, how do they objectively describe and document their exam findings?

-The orders for workup.  Getting a sense for sensitivity and specificity of these tests.  How much weight does the specialist actually put on the results of these tests?  â€‹What is the systematic approach to reading the studies (ekg, cxr, head CT, etc) and practice practice practice with the specialist while you still can.

-The most common treatments used in this specialty.  What are the things that the specialist has in the back of their head when they order this?  Chart checks they do before ordering (pmh, labs, etc), C/Is, interactions important enough that they bother memorizing, common side effects and worrisome adverse reactions they know to look out for.  

-How to perform the most common procedures of this specialty, and lots of practice doing them. 

-When is it appropriate to refer these patients, what do they want us to do first, and how do they want to hear the consult/presentation?

 

As you can imagine, its not possible to learn it all when you are on your rotation.  So, its really important to prioritize, and this is the second part of my realization: the most important things to learn on rotations are the things that you'll have the most difficulty learning while practicing on your own.  

 

You'll be able to look up the majority of the above things like ddx, history questions, orders, etc.  However, you won't be able to look up what it feels like to have your hands on a patient with ascites, what the fluid wave actually feels like and what the shifting tympany actually sounds like.  With this in mind, on my current rotations I have been focusing much more on honing my physical exam skills and truly trying to internalize what abnormal looks and feels like.  Another example: if you want to commit to memory the most important "take away" points for a given drug, good luck searching a textbook or uptodate... you'll just find lists of side effects and contraindications a mile long which will be utterly worthless.  With this in mind, I now realize that my preceptors/specialists have 'lived and breathed' these medications for years, and have internalized the most important take-away knowledge about these meds.  All it takes is a few good questions and they'll share this invaluable knowledge with you.  In essence, you should realize the value of being immersed in a wealth of specialty knowledge and being in a position where you are allowed/encouraged to ask questions... take advantage of it!  You likely won't ever get this chance again!  So, in the outline listed above, I have italicized the things that I consider knowledge you'll be able to obtain MUCH easier while on your rotation than when you are out in practice.  These should be the things you really try to seek out while on your rotations.  

 

As I said above, with these realizations, I've been approaching my rotations much differently and I think my learning experience has become much more productive as a result.  Instead of passively scanning through a review book, I now have an outline of things I am actively seeking to learn and my retention is much better.  In the past, when my preceptor and I would have down time, I'd try not to bother them and couldn't think of good questions anyways.  I now always have high yield questions ready for moments of down time and I've been able to learn invaluable information as a result.   

 

I wish I would have made this realization before starting rotations in PA school, since I think I would have gotten a lot more out of my school rotations.  It is what it is, I suppose.  At the very least, I hope I can pass some perspective on to you students going through it now so that you can make the most of your journey!  

 

 

 

 

 

(I hope this helps you students out there reading this forum/blog.  The residency experience is a great one that I'd highly recommend, and I wish you all good luck in getting in!  Please let me know if you have any other questions.  -SN)


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#37 Disciple3

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Posted 09 February 2016 - 08:59 PM

Thanks for all the work on this, bookmarked for a later time :)


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Posted 29 February 2016 - 02:50 AM

I am coming up on the last week of this ED block.  I now have 7 months of the residency under my belt, and as I hoped, I think overall things are starting to come together.  I am not as nervous picking up sicker patients, I've got a much better sense of the flow of the ED, I know how to interact effectively with consultants, and my efficiency is increasing.  The procedure month definitely helped me with my confidence in advanced procedures... the past week I did several complex lac repairs and even threw in 4 crash femoral lines... they went in like a breeze and it was a pretty awesome feeling!  Also importantly, I've gotten into a manageable routine of integrating my learning as I go, instead of being overwhelmed and pushing the learning/reflection to the side just to keep my head above water.  I've come up with a little system of basically making condensed notes (just enough to jog my memory later) of high yield learning points on the side of my note paper, and at the end of every shift before going home I spend 15-20 minutes to reflect on them, quickly read up on them, and commit them to memory.  While it is very challenging to spend more time after a long/exhausting shift, I think a reflection process is extremely important to make the most of our time in the ED.  My reflection process has helped me realize some common themes in the mistake I have been making and techniques I feel help me counteract them.  I'll dedicate the first part of my post to this topic.  

 

Also, this month for whatever reason has been a month filled with tons of psych patients.  Perhaps its the cold weather pushing a lot of the homeless into the ER.  Either way, I've had to learn how to deal with psych patients, and perhaps the most challenging for me as a newbie are the agitated ones.  I'll write about this in the second part of the post.  

 

 

COMMON THEMES IN DEALING WITH ER PATIENTS:

Approaching ER patients is extremely challenging.  We are exposed to every type of patient, every chief complaint, every medication, every social situation, etc... and its incredibly easy to get overwhelmed.  How should we start learning in a field like this?  Where is the best place to start?  When I first started, I found that I got the most "bang for my buck" by learning about each chief complaint: chest pain, SOB, abdominal pain (etc). With more experience I've been honing this down even further with subtype chief complaints: postprandial abdom pain, pleuritic chest pain, wheezing predominant SOB.  This is extremely valuable and necessary in the beginning, but I've realized that it has resulted in some common mistakes for me.  I have found myself walking into patient rooms with the triage chief complaint painting my vision and obscuring everything that I see.  As a result, I'd do my extremely focused HnP and go out to present the case, only to find that I missed perhaps a subtle finding (outside of the realm of my 'approach to chief complaint X') that completely changed the management of the case.  

 

I'll give you some examples.  In the past months, I've had several 'abdominal pain/nausea/vomiting' patients that have ended up having blood sugars in the 600s that I didn't think to check for because I was too focused in on the abdomen.  Or epistaxis patients that had arrhythmias from the vagal tone that I would have noticed if I had thought to put them on the cardiac monitor.  Or slightly older patients (60s) who I thought I could trust their history because they seemed to be answering questions appropriately, yet if I had just asked a few AO screening questions I'd find that they really thought its the 1980s, and I can't really trust anything that they told me (I've been astounded at how lucidly some altered patients can answer questions).  

 

I've developed a basic outline of things I have learned to address in every patient, regardless of their chief complaint.  The outline contains the things most likely to change the management of the case, regardless of the chief complaint.  This helps me to not 'miss the forrest through the trees' from being narrow minded thanks to the chief complaint.  Also, I think its very important for efficiency's sake to integrate the things we will want to know later when we go to put in medications for sx control, contrast radiological studies, etc.  That way, we don't have to waste time later going back to the bedside to ask these questions again. 

 

 

Evaluation to consider in every patient:

Questions for EMS:  

Where was patient found, or where did patient come from?  How/why was EMS called in? Is family coming (especially for the old/altered who can't provide history)?  Patient able to ambulate?  Vitals?  Actions done in route?  

 

Immediately upon entering the room:  

Quick ABC assessment, get vitals going, likely place on cardiac monitor.  Assess if this is a situation necessitating immediate resuscitation over the traditional medical evaluation.  

 

While getting initial HnP:

Important PMH (always ask kidney / heart dz), Meds (blood thinners, immunosuppressants), allergies, social (alcohol or drugs tonight?).  

Recent hospitalizations / bad complications

Sx control - What/when have you already tried today?  In general what works/doesn't?  allergies?  

All women - chance of pregnancy? LMP?  low threshold to get UPreg.

All older adults - really important to do a quick mental status exam.  As said above, I've been fooled several times by seemingly-lucid adults who are actually altered or demented, and it definitely changes the management, because it effectively means you can't use their history to rule out badness.  There are many validated tools out there (MMSE, CAM, etc) but I think an abbreviated version of them is fine for screening purposes.  I assess AOx3 and if any concern, I'll add cognition (object naming, "whats 2 quarters plus a dime") and attention ("squeeze my hand when you hear me say the letter A in a series of letters") .  

Also important to do neuro exams in all altered patients (extension of the above), because they won't come out and tell you they can't move their R arm.

Extremity exam - patients' pants often hide swelling, PVD/diminished pulses, skin infections.

Rectal exam ( if indicated) - heme pos stools will certainly send you down a different diagnostic/management pathway!  

While you go about your evaluation, if there are crucial things you want to make sure you address before they leave, write a square 'check-box' on the side of your notes and circle it.  

 

While nurses are doing their thing, what things aside from the basics should you consider asking them while they are in room: (they are busy people and if you let them leave the room they'll be busy with the next of a hundred tasks and it will be a minimum of 20 minutes before your request gets done)

fingerstick

rectal temp (especially if the patient is tachypneic, they will have a falsely low oral temp)

cardiac monitor +/- ekg

urine preg or blood preg

unique blood work you suspect you'll need, have them draw it the first time instead of prompting the need for a second stick - rapid vbg w/ lactate, coags, type and cross, blood cx, etc (these things often aren't drawn on their "rainbow" draws).  

 

Before you leave the room, make sure these have been done and you have assessed them:

VITALS, VITALS, VITALS!!  Undoubtedly the most important of this entire list, and easy to forget in the patient who looks great sitting in front of you, but a resting HR of 120s will undoubtedly change your management, regardless of the chief complaint!

Cardiac monitor

Take a quick second to think about the case, your ddx, your tx plan, and what other questions would help you.  I always find myself remembering important questions when I am sitting down putting in orders into the computer. Don't waste time and get them all the first time through.  

 

Before discharging a patient:

Look at my notes, make sure I've checked all of the checkboxes I've made so that I don't forget the critical parts of management and follow up.

Reassess the last vitals placed into the computer.  Make sure these are normal or addressed.  This is a common issue that many people screw up!

 

By following this general outline, I've been able to cut down on a lot of the little mistakes and oversights I had been making up to this point.  This is especially important as things get crazy busy in the ER... gotta have a systematic approach!

 

 

 

CHEMICAL RESTRAINT OF THE AGITATED PATIENT

 

This will be basic for those of you veterans out there, but as a newbie its definitely a topic I had to review heavily because of how commonly this situation happens, and because of how chaotic it can seem in the heat of the moment if you don't really know your stuff.  There is definitely more to know than just the "B-52 bomb everything" approach, haha.  

 

Agents available for our use:

 

NEUROLEPTICS/ANTIPSYCHOTICS... in general are more tranquilizing than they are sedatives/snowing agents (compared to benzos).  Also in general they are safer than benzos.  Before giving them, if you have a bit of time, go through a mental checklist of considerations/contraindications:  Quick assessment of patient to make sure they're not already in dystonic crisis (neck spasm/turned head, hand spasm/movement, rigidity, oculogyric crisis), Check PMH to avoid in epileptic patient or alcohol withdrawal patient (they lower seizure threshold) and to avoid in prolonged QTS patient (they prolong QT).  They are generally category C in pregnancy (vs category D for most benzos).  In general, these are given with antihistamines (benadryl or cogentin/benztropine) to prevent dystonia, but a few don't recommend this.  Most commonly used drugs of this category:

 

Haldol 0.5-10 mg PO/IM/IV.  Most use 5mg to start.  onset 20-30 min.  This is the tried and true tranquilizer for the past several decades, but not perfect because of the long time till onset, strong EPS side effects, and other SEs (seizure, QT).  

 

Geodon (ziprasidone) - 10mg -40mg PO/IM.  Most use 10mg to start.  Fast onset, doesn't over sedate, reduced EPS, easy transition to PO dosing.  This is a newer agent and gaining favor in the younger generation, but also some recent studies showing they might not be as safe as we anticipated.  Avoid in elderly and QT (increases QT more than all others).   

 

Zyprexa (olanzapine) - 2.5 - 20 PO / IM.  

 

 

 

BENZOS... in general are more sedating, so be careful not to snow the patient.  I've been told to think of benzos like you would alcohol... don't give it to any patient you wouldn't want getting a triple shot of vodka:  Geriatrics (worsens delirium), drunk patients (resp depression), pregnant patients (category D) being the most commonly cited.  These are pimped over and over again, so really gotta know these cold.  The nice thing about benzos is that they are faster acting.  Most commonly used drugs of this category:

 

Ativan/Lorazepam 1-2 (0.1 mg/kg with max 3-4) mg IM/IV.  Most use 2mg to start.  Onset in 15-30 min, redoes Q15 min if no effect.  The pharmacodynamics of IM ativan are very poor, so try to use IV ativan or go to IM versed if needed. 

 

Versed/Midazolam 2-5 mg (.02-.1 mg/kg) IM /IV, can give in 2mg doses redosing Q5 min.  Onset is within 5-10 min.  This is the IM benzo of choice because of water solubility it is quickly absorbed from muscle as opposed to ativan.

 

 

Specific patient situations:

The completely undifferentiated patient - The old school cocktail is the B52 - Benadryl 25 IM, Haldol 5 IM, Ativan 2 IM. Many prefer cogentin over benadryl for less sedating properties, given that you are already giving a benzo. Some now say you should only mix Benzo + neuroleptic when you know its a psych issue, but if you don't know you should stick with one or the other.  New school is often going with geodon 10-20mg IM.  

 

The agitated psych patient - Can mix benzos and neuroleptics - Haldol 5 mg IM/IV, Ativan 1 mg IM/IV, cogentin 2mg IM/IV.  Again, many new schoolers vote for geodon as a great choice for the known psychotic w/o hx of long QT.   

 

Drunk and thrashing patient - Stick with neuroleptics - Haldol 5mg, wait 5, 2nd dose at 10mg.   IM is okay, IV is better.  Monitor for QT.  AVOID BENZOS (resp repression).

 

Drug induced agitation (PCP, K2, bath salts), sympathomimetic presentation, or ETOH withdrawal - Stick with benzos - In general, versed 2-5mg IM push repeating x5 min is a good bet.  or ativan 1-2mg IV q15 min.  May need very big doses for the big ones like meth, bath salts, etc.  AVOID NEUROLEPTICS (lowers seizure threshold).  

 

Demented agitation (sundowning) - Stick with neuroleptics - Haldol is really the only option (second gen antipsychotics are not approved for demented patients).  start at very low doses.  0.25 - 1mg haldol.  AVOID BENZOS (worsens delirium in elderly).  

 

 

 

Lots more to cover in this general topic.  ddx, HnP, toxicology stuff, dispo, tips and tricks.  One of these days I need to dedicate some study and questions for my seniors/attendings to learn the nuances of involuntary restraint both for psych and for agitated delirium / organically sick patients.  On a somewhat related note, I want to learn about the subtleties of our legal/medical/hospital rights to kick out people who are violating the code of conduct.  And of course, the discharge "against medical advice" is a controversial topic with a lot of nuances and a ton to learn about.     Lots of things to get into... someday!

 

 

 

 

Thats it for this month, folks.  I'll be starting my ortho rotation next, which I have heard great things about.  Definitely looking forward to it! 


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#39 SERENITY NOW

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Posted 03 April 2016 - 03:47 AM

The ortho rotation has come and gone.  What a great time.  I essentially was paired up with the ortho intern, we carried the pager, saw all of the consults in the hospital, and did all of the ED/floor procedures.  I was able to do plenty of joint aspirations, reductions, splinting, etc.  I even got to scrub into a few hand surgery cases at my request because we see so much hand injuries/lacerations in the ED and it was great to get a better sense of all of the important anatomy to look out for when exploring their wounds.  The ortho intern did a lot of the dirty work (care management, discharge summaries, etc), freeing me up to really focus on reading up on the things we saw and asking the ortho seniors all kinds of questions.  These people live and breath this stuff and are great teachers.

 

As a result, I learned a ton on this rotation!  I learned general ortho knowledge (how to present, the "ortho lab cocktail"), how to critically interpret X-rays (determining if the studies are adequate, the findings to look out for, and specific measurements that guide management like 'acceptable reduction limits'), a good focused ortho exam (axial vs peripheral neuro exam), procedures procedures procedures (arthrocentesis, joint/fx reduction + splinting), approach to ortho emergencies as well as the commonly seen ortho chief complaints that can be deceptively challenging.  Definitely too much to cover in one blog post, but I'll try to touch on the most important points.

 

 

GENERAL ORTHOPEDICS:

1.The orthopods had a very specific way they wanted to hear presentations during their ortho rounds (though we can condense the story during phone consultations)...  

Age/Sex

RvsL handed / community ambulator with cane / baseline deficits  (as relevant to the case)

presents with X injury (i.e. posterior hip dislocation, closed distal radius fracture) 

as a result of mechanism (fall from standing, front impact mvc upgraded to level 2 trauma, etc)

now complaining of pain at XYZ location.  Denies numbness, tingling, weakness.  

relevant PMH / PSH / meds (they want to hear about anticoagulants, *steroids*, bisphosphonates)

Exam with normal vitals, AO, open/closed skin, neurovascular status (axial or peripheral), compartments.

Xray revealing (bone X) (intra/extraarticular) (transverse/oblique/spiral) fracture with (displacement/shortening) and (angulation/rotation).  

For example, Xray revealing a distal radius extraarticular transverse fracture with dorsal angulation but no displacement.  

Plan is XYZ.

 

(example phone consult).  "Hi there we've got a consult for a hip fx in room X.  73 yo F community ambulator with a L intertroch fx after fall from standing about 2 hours ago.  PMH CHF, ESRD.  Exam with normal vitals, no open skin, neurovasc intact.  Xray doesn't look terribly displaced or shortened. Anything else you'd like to know?"

 

2. On any ortho consult related to infection, they always ask for ESR and CRP.  They love these markers and can't move forward until they get them back.  I didn't know the intricacies of these markers before this rotation, but I've learned a lot now.  A lot of the info can be summarized well in this worthwhile read:  http://www.bpac.org....oem_2005_wv.pdf

 

3. An EXTREMELY valuable part of this rotation is seeing how much the orthopedists really scrutinize X-rays.  They always start out by asking if there are enough X-rays.  They have to have 2 orthogonal views of the bones/joints above and below the injury.  There are also views that techs are notorious for skipping because they don't want to hurt the patient; most commonly the axillary lateral in shoulder pain patients.  They pounded into my head out crucial it is to get the axillary lateral to definitively say if there is a dislocation, towards which direction, and if there is any intra/periarticular fracture that would impact reduction.  Once they determine they have enough X-rays, they are extremely attentive to detail in determining if the studies is adequate.  They look for specific things on each X-ray and if not everything is there, they send the patient back.  The X-ray techs hate them and its quite comical.  I personally don't think that in the ED we have the time or the necessity to be quite as anal as ortho is when it comes to these things, but it still is valuable nonetheless to see how much level of detail ortho puts into their scrutiny.  Last, they taught me how to use the many tools on the X-ray reading system, emphasizing the importance of changing contrast brightness based on what you're looking at.  They also taught me how to objectively measure for separation, angulation, etc, and the situations in which its important because it changes even ED management.  Orthobullets.com is their go-to place to find acceptable limit parameters - great website that is highly recommended!

 

Of course, the details they look for in each joint X-ray is unique and too much to cover here.  I was lucky enough to have an amazing radiologist lecturer in PA school who everyone loved (we voted him to his 4th time of winning the best lecturer of the year award), and we all are lucky enough to have his lectures available online if you are looking to learn what details to look for in each specific X-ray.  Sit back and enjoy this guy.... highly highly highly recommended!  

https://www.radiolog...an/lectures.php

(go to the video links on the far right)

 

 

THE ORTHOPEDIC PHYSICAL EXAMINATION and COMMON PROCEDURES:

(always start 1 joint above and finish 1 joint below)

Inspection - open wounds

Palpation - really localizing the tenderness to specific surface anatomy key spots.  Feeling compartment fullness and presence of effusions. 

Range of motion - active and passive.  Being sure to do this correctly at the hands (isolating DIP and PIP), and correctly grading the degrees of ROM vs expected.  

Ligamentous laxity/stress testing - learning how to do this well is an art.  

Special testing specific to the joint in question.  (check out orthobullets videos for joint specific exams).

Vascular exam - pulses, doppler if needed, cap refill.  

 

Neuro exam - they really emphasized that you should have 2 different neuro exams: one for peripheral trauma (assessing peripheral sensory and motor nerves) and one of axial trauma (assessing spinal cord + nerve roots sensation and motor).  I think we all know the spinal cord exam for dermatome and myotome leveling; if not, check out this great overview and charting guide from the spine association: 

http://www.frontiers...-00141-g001.jpg

 

What I learned a lot about was the peripheral nerve exam.  I don't have time to go into all of the details, but I'd highly recommend you all spend a couple of hours reviewing this topic and memorizing it.  There are lots of resources for this online.  With regards to documentation, their upper extremity peripheral nerve exam would look like this..

+SILT (sensation intact to light touch) R/U/M (radial/ulnar/median).

+Motor intact AIN/PIN/U - A/PIN stand for anterior/posterior interosseus nerve, which are the terminal branches of the median (AIN) and radial (PIN).  Instead of testing every single median nerve function, they can test this terminal nerve function (AIN tested w/ the "A-okay sign") and rest assured that all proximal median nerve fx is intact.  PIN (radial nerve terminal branch) fx is tested with the "rocker" symbol with wrist back and thumb/index/pinky fingers extended. 

 

 

Arthrocentesis

One of those things that you definitely need in-person practice on real patients, but realize that there are specific surface anatomy landmarks that you have to find in order to localize your point of injection, and there is a correct injection direction/plane as well.  UpToDate has a great overview of the common joint aspirations with good pictures.  

 

 

Joint / fracture reduction and splinting

Definitely an art!  In general, the steps are as follows:  pull traction, accentuate the angle (to unhinge) before pushing back into the correct alignment and position, then mold a splint onto it with "3 point" pressure.  The ortho bible for all things fractures is Rockwood and Greene, which goes into specific reduction technique and splinting.  Unfortunately, its very big and expensive and has a ton of extraneous info for ED providers.  So, another really good reference for proper techniques is the "Handbook of Casting and Splinting" - All of the ortho residents carried this in their locker and referenced it when on call.  I bought the kindle version for reference later in the ED.  http://www.amazon.co...e/dp/0323078028

 

Unfortunately, this is one of those things that even with book reading, nothing is quite as good as being right there with the ortho team and seeing all of their tips and tricks to make reductions go smoothly and applying really good splinting technique.  If you ever have a chance to do an inpatient ortho rotation that covers the ED, TAKE IT!  Its absolutely invaluable.  
 
 
APPROACH TO ORTHOPEDIC EMERGENCIES AND NONEMERGENCIES...
Aside from the cases that are clearly an ortho etiology and "ortho to handle entirely" (fractures, certain dislocations, etc), there are several scenarios that ortho was commonly consulted on to "rule out ortho emergency".  These are things that perhaps aren't seen super commonly in the ED and as such we are not great at identifying or dealing with them.  The following scenarios fall in this category:  back pain - rule out cauda equina, atraumatic joint pain - rule out septic joint, hand infection - rule out FTS (flexor tenosynovitis), foot trauma - rule out lisfranc injury. Posttraumatic swelling - rule out compartment syndrome.   We were consulted on these ALL THE TIME, I spent a ton of time dedicated to really learning each individual topic, and I discussed them all at length with the ortho team...and I now feel so much more confident in handling them.  I know I wouldnt' have gotten this far without this rotation, making me realize just how invaluable these off service rotations (and the residency in general) really are!  I'll share a few of the salient points for each topic.  
 
Cauda equina syndrome- Urinary retention is the most sensitive clinical finding and present in over 90% of CAS.  So, you absolutely have to check a PVR on each patient.  Aside from this, get a really good physical exam and if there are objective deficits you should be able to localize the spinal cord level.  Don't forget to do a good perirectal sensation and sphincter tone.  If you truly have some objective findings, you need a stat MRI straight from the ED.  
 
Septic joint rule out.  Most sensitive finding is limited ROM, so if a patient can fully range the joint, its not septic.  Ask about important risk factors / red flags (preexisting joint dz like gout or RA, loss of ANY skin integrity like wounds/ivdu/dialysis, immunocompromised like DM/steroids/RA immunomodulator drugs).  Don't forget about hematogenous spread - ask about sexual activity and STD risk.  Order X-ray cbc bmp esr crp blood culture. Tap the joint and send for cell counts, gram stain, culture, crystal eval.  
 
Hand infections / FTS.  There is a great podcast on iTunes if you search for "hand infections", given by Duke's EM residency hosting an orthopedic hand surgeon.  Learn the kanaval's signs and learn how to assess for these really well.  The ED attracts many dramatic patients who will unintentionally fool you into thinking they have kanaval's signs from a simple paronychia, but true FTS is quite bad and the exam findings will not be distractible.  
 
Foot trauma / lis franc.  This is a challenging topic even for the ortho docs, but its worthwhile to spend some time towards learning this because the outcomes are terrible if you miss it.  Red flags should be going off in your head if you see significant mid-foot swelling in a patient presenting after fall from height / crush injury, twisting sports injury, or the classic 'weight/axial load onto a plantar flexed foot'.  Do a really good neurovasc exam (neurovasc bundles run thru lisfranc joint) and order X-rays (normal AND weight bearing if possible, which are the best to assess lisfranc injuries).  Look up the specific X-ray things to look for when evaluating this - there are a few 'anatomic lines' to look out for that should not be disrupted, like the line from medial aspect of 2nd MT to the medial aspect of medial cuneiform.  If after all of this you don't see any evidence of lisfranc injury but patient still has bad pain/swelling and is unable to weight bear, consider/rule out compartment syndrome of the foot, and splint/NWB/close ortho f/u.  
 
Compartment syndrome (CS).  This is a big, important topic that definitely requires additional study.  You can't appropriately assess for this if you don't know the anatomy  - what are the compartments in each part of the body, what area do they cover longitudinally, what muscles/tendons run through them, and how can you stress them accordingly.  Your physical exam should be targeting each specific compartment and associated muscle/neurovasc group.  One of the biggest mistakes the ED would make is see a big swollen area that is localized around the injury site, worry that its compartment syndrome, and stop their exam.  In doing a thorough exam and knowing the nature of compartment syndrome/anatomy, you won't be fooled into thinking that localized/post-traumatic swelling is CS if the rest of the compartment is soft (you can't have compartment syndrome localized to one pole of a compartment because the compartments are open longitudinal structures).  We saw a few cases of missed CS on the ED's part, and the ortho team discussed some of the common ED pitfalls in not recognizing the high risk fractures (tibial fractures, long bone fractures, etc) as well as the confounding stories with high risk underlying mechanisms (subacute crush injuries, as seen in the hip fx patients down for days and the piss drunk patients found down sleeping on an extremity for many hours).  
 
 
Good ortho resources to peruse if you have down time:
 
One noteworthy mention:  Vumedi ( https://www.vumedi.com/accounts/login/ )is a website I hadn't heard about until this rotation; its dedicated to surgeons/residents for providing tons of high quality intraoperative videos and other great surgery-related videos on examining, boards, etc.  I watched several of the hand surgery videos in addition to the cases I saw in-person to really reinforce hand anatomy/trauma, which I have been seeing a ton of in the ED.  
 
 
 
So thats it for this month.  I'll be back in the ED on Monday and hoping to keep picking up the pace.  I'll see you all next month!
 
 
-ps, I am sorry if there are spelling errors or some random words that just don't make sense in the context... for some reason my computer or browser autocorrects certain words (especially medical terminology) and I haven't been able to turn this feature off... very frustrating.  

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Posted 29 April 2016 - 09:57 PM

Hello everyone - update time!  

 

Just finished my last ED rotation of the first year of this residency!  Overall it was a good month.  I spent a lot of time in the highest acuity part of the ED and I tried to really do as much as I could.  Despite not typically being a first year duty, I pushed myself into as many of the traumas and codes as possible and did several central lines, trauma procedures, and even started dabbling in the airway management things with some of the second years.  I tried to start picking up as many of the "2nd year" patients, like the angioedema patients or those in significant resp distress.  I picked up the pace and was able to get to our first year goal of picking up at least 1 patient per hour which quickly leads to us juggling 4-5 patients at a time.  Ive gotten much more comfortable dealing with our fellow medicine residents, some of which will do everything in their power to block every admission.  Last, I've really been on a roll when it comes to establishing difficult IV access -- many of the nurses now consider me one of the go-to guys when they know its a really tough patient, and that feels pretty cool.  

 

Since it is my last ED rotation of first year, it has been a time of reflection for me in many ways... I read back through some of my earlier posts in this thread, and I remember all too well the overwhelmed feeling of dealing with our sick, complicated patients.  I now feel much better in dealing with these patients.  I've gotten a sense of how to sort through all of the distractors and determine what is really important.  I have come a long way in being able to determine 'sick vs not sick', 'stable vs not stable', etc -- geared with these skills, I have been able to calm down quite a bit and have been enjoying my shifts a lot more.  Being able to relax has helped me open up and continue making friends with residents from all sorts of different services.  In fact, since I've done rotations all over the hospital at this point, I have met SO many people and I'd say some have become really good friends!  Its a great feeling to be able to walk around the hospital and wave / chat / catch up with nearly everyone you see walking down the hallway.  I had no idea how much fun it would be to become part of this big resident family, AND I had no idea how much easier it would make admission/consult interactions in the ED when you are already know the people.  I guess overall it really hit me when they paired a 4th year medical student with me for a day, and I realized how far I have come.  The student really struggled with basic EM concepts, presenting, procedures, and even basic maneuvering around the department and its people, which reminded me of myself just 1 year ago.  Its incredible how much we can learn in just a year's time!  

 

Of course, I still am very aware that I have a ton more to learn.  While I've been feeling better overall, there are definitely still plenty of shifts that I walk out feeling like I still have a ways to go.  I've been seeing 'sick' patients, but I still have yet to get into the realm of  the 'unstable requiring immediate lifesaving resuscitation' type of patient.  I still struggle with some specific topics like OB.  I still have to learn the intricacies of ruling in / out those uncommon/complex diseases that don't have well thought-out ED approaches.  I still have a way to go in the realm of optimizing efficiency in seeing patients and charting. I still have a lot to learn about other intricacies of medicine like billing while at the same time minimizing patient costs (in choosing the cheapest rx's, for example) without sacrificing high quality care.  And of course there is the whole topic of protecting ourselves from litigation that is its own huge topic by itself.  No matter how much I learn, I keep realizing how there will always be more and more to learn.... but this excites me.  How awesome is it to be in a field where we can never run out of things to learn?   

 

 

 

I have 2 more months of off-service rotations before our 2nd year begins -- look forward to posts on ED obs, ultrasound, and OB in the next couple of months!

 

-SN


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