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My EM Residency Experience...

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#41 True Anomaly

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Posted 30 April 2016 - 01:36 PM

Congrats SN- surviving a year is a big accomplishment! And good on you for getting some of the second-years to let you help on airways already- that's where your relationships with the other residents help improve your own education.

You'll find when the new interns come in that your sense of accomplishment will feel so much more than even it is now- you got a sense of that with the Med student rotating with you. It's only going to get better.
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#42 PAjunky



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Posted 03 May 2016 - 04:13 AM

hey serenity whats the deal with not wanting to disclose your program? isn't that the point of writing a EM residency experience so that other PA students/graduates can have the ability to have informed choices instead of flying blind like most residencies out there. 




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Posted 03 May 2016 - 05:51 AM

The purpose of the blog is not to promote my specific program or help people make application decisions.  I am doing it to promote residencies and learning in general, to share some thoughts/reflections as a new grad / resident, and to help teach what I consider the most valuable topics that I've learned so far.  I decided to keep this confidential so that I can share my thoughts and reflections freely without worrying about it reflecting poorly on myself or on the program.  I can understand your frustration - if you feel that you are flying blind in your application decision, I'd recommend that you reach out to the programs you're interested in and talk to their current residents in person/phone to get a better sense of each individual program.  

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#44 Siersmar



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Posted 08 May 2016 - 05:48 PM

Thank you so much for the great information and spending time out of your busy schedule to share it with us!

#45 True Anomaly

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Posted 09 May 2016 - 01:37 AM

The purpose of the blog is not to promote my specific program or help people make application decisions.  I am doing it to promote residencies and learning in general, to share some thoughts/reflections as a new grad / resident, and to help teach what I consider the most valuable topics that I've learned so far.  I decided to keep this confidential so that I can share my thoughts and reflections freely without worrying about it reflecting poorly on myself or on the program.  I can understand your frustration - if you feel that you are flying blind in your application decision, I'd recommend that you reach out to the programs you're interested in and talk to their current residents in person/phone to get a better sense of each individual program.

Agreed- it is also why I kept mine relatively anonymous
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Posted 27 May 2016 - 07:32 AM



Another rotation done... man did it go by fast.  This residency has been passing by so much faster than what it seemed like in the beginning!  This was actually a much better rotation than I expected, though I will have to qualify that statement.  It is a undoubtedly a difficult place to work; there is very high patient turnover, a ton of things to do (just as much social work as medicine) keeping you constantly busy, and unfortunately in our hospital the obs unit has become a dumping ground for inappropriate patients that have the potential to decompensate... certainly a stressful combination.  


I remember what it was like working in the ED and not being entirely sure what was going on with certain patients, not thinking they needed a full workup, and not being entirely sure what to do, but finally discovering a "buzzword finding" that would allow me to dispo the patient.  "Oh! they've got an AKI", "Sweet we found a UTI", "No worries they've got 'ambulatory dysfunction' (more on this later)".  "...We found our reason to admit!", even if it made didn't quite make sense in the whole clinical picture.  I've heard it said, "working up the elderly is like fishing with dynamite... you might not get what you want, but you're bound to find somethin [that will give you an excuse to admit]."


Now, don't get me wrong... I am clearly EM at heart and I get it... we are extremely busy in the ED as well, and its not our job to have absolutely everything crystal clear and have done an internal medicine workup... but WOW this rotation made me realize how much of an impact the ED assessment and plan can have on an entire hospital course.  It makes sense that the path the ED starts sniffing down is what the hospitalists will ultimately follow (studies have shown this to be the case as well), so for the patient's sake and for the hospitalists sanity, we have to be very careful when we attribute everything the patient came in with to a single "buzzword finding/diagnosis".  


On this rotation, I again found myself on the other end of the ED sign out, and I can definitely see some of the reasons why medicine residents/hospitalists get frustrated with us.  Countless crappy signouts, improperly worked up patients, unclear/nonexistant plans and "buzzword diagnoses" later, and I too was getting upset with a select few of my ED friends who seemed to be habitual offenders. These issues are especially bad in the obs unit because it completely undermines what the obs unit is supposed to be about, thereby derailing the efficiency of the system.  Its meant to be a place where patients with clearly diagnosed straightforward issues, with clear plans in place, expected to stay about 1 day, can go to be managed by EM PAs (NOT internal medicine physicians).   Instead we got these patients sent up to us with a benign buzzword diagnosis and when we went to do our own HnP there would be a totally different scenario than what was signed out to us.  What do we do then?  Can't send them back to the ED unfortunately.  Can't work them up like its in the ED because the obs unit couldn't really order stat labs and imaging with priority like the ED.  At times, it was a frustrating experience to say the least.


Perhaps because of this frustration, I can say it was extremely valuable to experience this rotation.  It made me realize how some small details can have a big impact in the long run, so now I will know to look out for them right away in the ED.  I learned the importance of an appropriate workup especially when sending patients to an observation unit. I learned a lot about admission criteria, level of care decision making, and care management perspective.  It made me realize what exactly constitutes a good signout over the phone to a hospital team.  It was very valuable seeing the 'other side of things' - where exactly our patients go when we send them upstairs and what exactly happens.  And of course, it was another go at hospital medicine... I certainly got a lot of practice admitting patients, doing med recs, dealing with floor issues, discharging process, etc  - all good things to review and keep in my toolkit.  All in all, I think it was a very worthwhile rotation, and it served as another reminder of how incredibly valuable these off service rotations really are.  Being able to walk in the shoes of the people on the other side of the consult/admitting phone is simply invaluable.  I wish we could periodically do them throughout our career, because they are just that awesome.  




I found some good resources that some pretty credible sources have posted.  Some obs pathways / algorithms and practical things that were quite helpful in getting my feet wet with basic hospital medicine.  Check them out!


http://www.tamingthe...ation-protocols   *** probably the best one I found for observation protocols!




http://www.ucdenver....e 2014-2015.pdf   * good intern survival guide with bread and butter hospital medicine topics / practical tips






For the newbies out there, a signout is the verbal presentation that occurs when transitioning a patient to the next team, be it the next ED provider in the on-coming shift, or to the hospitalist team you are trying to admit a patient to, or to the night float if you are doing a medicine rotation.   Realize that it is REALLY important to get good at this skill of effective communication, and its something that takes a long time to develop well (I certainly am still developing this!).  Everyone has their own subtle differences but in general the signout can be broken down into a few key sections.  Of course, you have to use common sense (+ clinical experience) to decide how much or little of these details you are going to include. 


Always start with the CHIEF COMPLAINT (or the diagnosis if its clear) to frame everything

(nothing worse than a presentation starting with a mile long PMH followed by 'who rolled his ankle on the curb".  



 room / age / sex / super relevant PMH  / (let them know "this is your sickest patient" if relevant)



-Came in with chief complaint X, admitted for diagnosis Y, with notable supporting workup findings Z.



-Management plan for admitting diagnosis -- what still needs to be done, what you need to do this shift (things that are pending that need follow up, and contingency plans like "if negative, do this.  if positive, do that")  

-Other hospital problems that have popped up, and plans for those

-Overall dispo plan / when discharge is expected, and things holding it up.


OTHER ISSUES TO BE AWARE OF.  Give your teammate a heads-up about....

-Things that you anticipate could go wrong  ​(i.e., "I've been called 3 times today by nursing for issue X and you should know to tell them Y if it happens again", or "this patient is a flight risk but is on involuntary hold for suicidal ideation, so call security and physically restrain them if needed/etc")

-DNR/DNI status.   

-non-english language?  

-Baseline abnormalities ("she's always tachycardic to the 120s FYI"), baseline deficits (aphasic, hemiparesis), MR/cognitive delay?  

-Patient/Family upset about something that happened (before your teammate walks into the lions den)?



The bolded things are what people often forget to mention/emphasize, but they are really important!  For more info, check out the good emrap episode on sign outs.


An example of signout for admission from ED (slightly different from above structure)...

We've got a hyperglycemia patient we'd like you to consider for admission in room 5.  56yo M pmh insulin dependent type 2 dm noncompliant with meds.  Has had 3 days of URI sx progressing to polyuria/polydipsia with sugars in the high 400s.  VSN and well appearing.  No anion gap and no ketones in urine and labs/cxr otherwise unremarkable, so we think its just hyperglycemia.  IVF brought sugars down to the high 300s but we think he needs to come to obs for IVF, blood sugar control/insulin, diabetes education (if they do that at your institution).  What do you think?




AMBULATORY DYSFUNCTION... the ultimate buzzword.

I don't know if this is as much of a commonly used buzzword at other institutions as it is at mine, but it is incredibly common here.  It is a catch-all term used when elderly patients, in their long histories and positive ROS, happen to mention they've been falling or having difficulty walking or just feeling generally weak... somehow these all (and more) get funneled into the garbage can of "ambulatory dysfunction". Then, its protocol to admit them to obs purely for a physical therapy evaluation (who will determine if they need outpatient PT vs 2 weeks at a SNF).  Its the ole-reliable buzzword that we can wip out of our back pocket when we don't know what exactly is going on but don't want to send the patient home.  I've done it, my colleagues have done it... we all do it, but boy does it stink when you're on the other side of it!


So, theoretically, these patients are supposed to have purely age related degenerative MSK issues causing them difficulty with walking without any other confounding factors.  As you can imagine, the garbage can included much more than those straightforward patients.  In the last month alone, under the pretense of 'ambulatory dysfunction', I have been sent syncope patients, (occult) hip fractures, polymyalgia rheumatica flares, normal pressure hydrocephalus, critical spinal stenosis, and more!  I promised myself I would study up on this topic and do it justice when I returned to the ED; I will no longer haphazardly slap a label "ambulatory dysfunction" on inappropriate patients.  I've been reading up on it and thinking about the cases Ive seen, and I will outline a few of the most important things in the approach below...




Critical evaluations to consider before labeling someone with "ambulatory dysfunction":

What is their baseline functional status?

What exactly is different?  I need real examples/details.  

What was timeline of change?  Chronic or abrupt?

What might have precipitated the difficulty walking or the falls?  syncope/seizure? medical condition?  Any prodrome symptoms?

What resulted?  Really good trauma survey.  


Very important point to keep in mind before getting into the ddx-driven evaluation:  


Just like any other symptom, you have to rule out the secondary causes before you label someone as primary ambulatory dysfunction.  

Always ask WHY can't they walk?  WHY have they been falling?  

Keeping this in mind, let the ddx below spark your thought process of all of the different things that could be underlying a supposedly benign difficulty with walking...


MSK issues... A good history and exam can rule out the majority of these, but you have to know to look for them and examine for them in the first place.  

Intrinsic hip issue?  OA?  septic joint?  occult hip fx? AVN? Subchondral insufficiency? RA? PMR?  

Knee issue?  

Any other clearly MSK / joint cause?



Neuro issues... if there is any weakness on hx, where exactly? Anything focal? really good neuro ROS and exam.  

Brain / CVA / parkinsons / NPH?  

Cerebellar / ataxia / vertigo ?

Back / spinal cord?  radicular sx?  spinal cord ROS.   Spinal stenosis classically causes pain and ambulatory dysfunction ("neurogenic claudication"), is more common than you'd realize, so be familiar with this disease entity and how to look out for it!  If the spinal stenosis has got so bad that the patient literally can't walk (weakness)... thats a real problem and should be worked up in the ED!


generalized / systemic / other issues...  always ask AOx4 and mental status questions, and realize generalized weakness (with its own long ddx) might be the real issue underlying ambulatory dysfx.

drugs / polypharmacy?

syncope? orthostasis?

electrolytes / organ dysfx

generalized weakness / altered mental status 








Well, thats it for this month. Thanks for tolerating my rants on obs and ambulatory dysfunction.  It was a great rotation that I think will help me a lot when I go back to the ED.  Anyways, I'll be back in a few weeks after a rotation dedicated to ultrasound.  I've heard great things about this rotation and I'm looking forward to it!





-edit/update -  we've just had a whole conference dedicated to the whole signout and transitioning of care process in general because it is such an important topic.  Some incredible lecturers came to speak to us and showed the research that around 80% of medical errors and malpractice suits involve transitions of care... its a very high risk situation and requires dedicated attention and standardization.  More to follow once I get some free time!

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Posted 06 July 2016 - 05:26 PM

Finished ultrasound and OB!  Ultrasound was a great experience, and OB was… well, not so great.


I really wanted to make the most of my ultrasound rotation because I knew it would be one of those incredibly beneficial things that you can only get the full experience in a residency.  Sure, being able to go to a weekend conference dedicated to learning ultrasound and getting your numbers up by practicing on healthy volunteers is certainly valuable, but it just doesn’t compare to being immersed in it for weeks, side by side with ultrasound-fellowship trained ER doctors, seeing real pathology in real patients, and getting tons of practice doing it.  We even got to spend some mornings with the ultrasound techs (the true masters) and they taught me so much about getting the best views - really invaluable time.  It’s just impossible to learn this stuff entirely in a book, and nothing beats practicing on real patients. I made it a point to study hard at home, read the whole ultrasound textbook they gave us, and ultrasound everyone with a pulse (and even those without a pulse before ending the code!), ask tons of questions, and I do think that I made the most of it and learned a ton.  This time allowed me to hone ultrasounding technique, learn the practicalities of optimizing the ultrasound machine, really memorize all of the required views for credentialing/billing, work on comprehensiveness + efficiency, and get a good foundation on the most important pathology that we should be looking out for.  I’m still definitely nowhere near an expert, but I feel that I have a very good framework to build off of going forward and can say the rotation was extremely worthwhile.


OB, on the other hand, was probably among the poorer experiences in a rotation up to this point, unfortunately because of only a few bad eggs (OB senior residents) that spoiled the whole experience.   The vast majority of the other residents had all warned me that this has become a pretty bad rotation, but I always take that with a grain of salt because I’ve ended up really loving some reportedly bad rotations… but their assessment of this one was spot on.  It was especially a shame because OBGyn was probably one of my weaker subjects going into the rotation, so I really wanted to work hard, study hard, and try to get as much out of the rotation as possible.  While its always expected that the off-service intern will help out in the specialty’s scut work, its also expected that the scut work will be reasonable and balanced with learning opportunities and meaningful work.  This rotation was not exactly balanced, to say the least, but unfortunately it seemed that all of the scut requests came from 1-2 of the OB seniors who had no intention of changing.  I tried to share my feedback, but things didn’t exactly go well.  The whole experience left a bad taste in my mouth, and for this blog I honestly don't feel like writing about my OB learning points at this time -- maybe at a later date if there is interest.  Overall it was saddening, but I suppose it was bound to happen in what has been a largely great residency experience.  Since I am an optimist at heart, I suppose I can say it was a worthwhile rotation in that I’ve learned that even physicians are bound to have some bad learning experiences and gaps in their training knowledge, and at the end of the day its always possible to supplement learning on our own. 




Best resource to start learning ultrasound in my opinion:  Introduction to Bedside Ultrasound:  Volumes 1 and 2.  By Matthew Dawson and Mike Mallin (see their ‘Ultrasound Podcast’ below…).  This is available for free on itunes.  Really great ebook that has the most important textbook info, great images and clips, as well as video/audio explanations and their patented “1 minute ultrasound” where they summarize the most important things you need to do in each scan.  Really excellent!



Book that our residency loaned out on rotation, pretty worthwhile place to build off the basics:  Manual of Emergency and Critical Care Ultrasound, Noble and Nelson.


Book that the fellowship trained faculty had used for their training, which goes into the most depth:  Emergency Ultrasound – Ma and Mateer


Podcast highly recommended:  “The Ultrasound Podcast” by Mike and Matt, the same guys that wrote the introduction ebooks on itunes.  They have a great podcast as well.  Most of their shows are about more advanced topics and the new uses of ultrasound, but they have some great core content videos too. 



Really excellent interactive quiz hosted by ACEP that does a great job of facilitating learning points instead of just being a standardized test format:



***Nice website, written by the *PA Community* on learning ultrasound, credentialing, papers supporting our practice of ultrasound   http://www.spacus.or...ces-foamed.html


More great websites with tons of bedside ultrasound resources, tutorials, and learning plans for newbies:  









Core ultrasound scans and some of the most important take-away learning points that were emphasized to me:

Again, nothing beats hands-on experience here, but these were the most useful tips given to me


Echo – Definitely a challenging scan to learn, but it can provide a ton of useful information about not only the heart, but also about the lungs/PE and vascular status.  The hardest part is knowing how to get the best views between the ribs.  Probably the most helpful is laying the patient in left lateral decubitous (LLD) position, bringing the heart closer to the surface.  I started just putting the patient like this from the beginning and it has helped a lot!

IVC – controversial in its usefulness in determining fluid status and predicting volume responsiveness, but it seems to me that most people accept that if there is significant collapse (over 30-50%) with inspiration, you can assume its safe to give more fluids.   

Lung – most useful application is in the e-FAST and the undifferentiated SOB patient with either CHF vs COPD who is too sick to wait for the BNP to get back. 


RUQ - most everyone can find the gallbladder, which isn't too difficult (often have to go up into the ribs or lie in LLD to find it), but its not complete without seeing the CBD which everyone struggles with.  Took me a long time to be able to reliably find this, mostly because the GB and CBD is one of those pesky dynamic structures (similar to appendix) that can be positioned differently in everyone, so you won't be able to use one progression to find it every time.  At the end of the day, with experience you'll become familiar with what it is supposed to look like, find a few important landmarks (portal vein, namely), get comfortable with color flow, and you'll be able to pick it up.  We often use bedside RUQ u/s in expediting abdominal pain discharge in particular patients; whereas labs and formal u/s used to take a few hours before we could discharge, now we can walk in the room with the ultrasound from the beginning and discharge them in 30 min flat.  Typically its the patient with minimal-moderate epigastric-RUQ abdom pain (especially if postprandial), normal vitals, well appearing without serious tenderness to palpation -- this ddx is largely biliary vs dyspepsia/gastritis/ulcer -- so we would rule out biliary with the ultrasound, determine we don't need labs for dyspepsia, and send home on maalox and PCP f/u if it doesn't improve for ulcer workup.  Really nice method to clean up the ED of many of those abdominal painers that can end up clogging the ED for several hours.  Thoughts on that progression from those of you out there who have these patients without availability of bedside ultrasound?  


Renal - most often used in the patient with recurrent kidney stones who you want to avoid the CT scan radiation, but you should be ready to deal with incidental findings because you'll see them a lot.  In particular, know what normal renal pyramids look like, compared to renal cysts, compared to hydronephrosis.  

Aorta - whenever you are doing an ultrasound to workup kidney stone, you really should make the mental association of AAA at the same time and always scan the abdominal aorta.  Realize that its more than just taking a peak at the aorta and saying "well this looks good"; you have to get about 5-6 views with both cross section and long axis at various points, and you have to include specific landmarks in many of them.  Remember that the vast majority of aneurysms are infra-renal, so be sure to focus on great images for these.  Bowel gas makes it difficult and I always gave up prematurely before learning the tips on this rotation.  It helps to have really firm pressure, rocking back and forth, and ask the patient to "push your belly up into the probe", which almost always works.  Sometimes you'll need to put the patient in a decubitus position.  


Pregnancy - very important scan, probably one of the most commonly used scans in the ED, broken down into "first trimester vaginal bleeding" vs 2nd trimester and older complaints.  This is a huge topic that is explained by countless resources out there.  Get comfortable with the association of gestational age, quantitative BHCG, and expected transabdominal and transvaginal ultrasound findings.  Biggest pimping topic they ask to reinforce an important point is that our goal is to RULE IN IUP (intrauterine pregnancy), NOT exactly directly visualizing/ruling out ectopic pregnancy, and the only way to accomplish "confirming" an IUP is to see AT LEAST A GESTATIONAL SAC AND YOLK SAC AND IT MUST BE INSIDE THE ENDOMETRIUM.  A more recent issue coming up is cornual pregnancies if you are so inclined to look up more advanced topics.  

related resources:




eFAST – the ultrasound attendings emphasized that a common mistake for beginners is to think that a negative fast is somehow reassuring or sufficient to rule out intraabdominal bleed, but this is not really the purpose of the FAST exam.  It is really only useful when its positive, in the setting of trauma, it is theoretically enough to take the patient to the OR.  When its negative, it is NOT a sensitive test in and of itself to rule out intraabdominal bleeding, so it shouldn’t necessarily be reassuring or something to hang your hat on.  You can improve your sensitivity by doing serial FAST exams, but not many people actually end up doing that. 

When it comes to the exam itself, realize that you have to get very specific landmarks on each view, and in order to do a really good exam it actually takes a few minutes.  Remember in RUQ you need to see the liver tip, in LUQ you need to look for the subdiaphragmatic space (ABOVE the spleen) – these are the 2 most likely spots to find things.  In the subxiphoid, move probe to the patients right to use the liver as an acoustic window, really push down hard  and angle up (like scooping with a spoon), and have the patient take a deep breath in and out, often helping snatch that difficult view.

RUSH – Exam for the undifferentiated hypotension in a medical patient.   Pretty cool application of many different scans into a rapid flow that can give a ton of valuable information.  However, it takes experience to know when this is indicated (don’t want to spend 20 minutes scanning a hypotensive patient if the etiology is clear from physical exam alone or if it means you are pushing back resuscitation).


Okay, here are more topics below that I am not going to write about because I think I've already written too much, haha.  Let me know if you all have any questions about them.  


Soft tissue/MSK -   



Testicular torsion


Procedural uses of ultrasound.  


Other:  ocular, confirm endotracheal intubation, mark the cricoid cartilage, stopping cardiac arrests, etc. 







I noticed an interesting phenomenon while learning how to do the various scans.  While I had initially thought my best bet would be to just learn a few scans and get really good at them, I actually found that there was a compounding benefit when you learned all of the different scans.  For example, in learning the soft tissue / MSK / ortho applications of ultrasound, I found myself noticing all of the surrounding anatomy while doing ultrasound-guided peripheral or central lines – I was then able to easily identify what was muscle, tendon, and most importantly, neurovascular bundle, therefore knowing exactly what to avoid hitting!  In really practicing renal and lung ultrasounds, I was able to get a much better sense of the anatomy of the area and the subtle techniques needed to get the best images, and I was then better equipped to perform a really good FAST exam.  I noticed this phenomenon over and over again, so now I’d recommend that people at least try to learn the basics of every scan before really focusing on their favorite few. 



On the other side of the coin, the rotation provided some food for thought relating to the potential disutility of ultrasound.  As you can see above, there are a TON of uses for ultrasound, and many people are hyped up about finding even more potential uses.  Some have went as far as suggesting that ultrasound will replace stethoscopes and instead we will eventually just walk into each exam room with the ultrasound to accomplish as much as possible at the point of care.  To counter this, many say there needs to be some balance to the hype, emphasizing that we still don't truly know the most appropriate and useful place for ultrasound.  This is especially true in situations in which we can get the same information as ultrasound by waiting for a lab test, or waiting for a formal study by the radiology dept.  As I was trying to look up more on a few of these situations, I actually stumbled upon a SDN thread that had some good discussions similar to the ones my attendings had with me; definitely worth the read for those newbies (similar to me at the start of the rotation) who commonly think that ultrasound is the answer to everything: 







Well, thats it for this month.  Next stop: fast track!  I'll be starting later this week and I'm actually somewhat nervous about it.  I've been in the trenches of the main ED and hospital all of this time and I haven't seen ANY sore throats, coughs, ear pains, etc-fast-track-complaints all year, nor have I been in a position where time/efficiency is truly key... time for me to keep reading and stepping it up a level!  Jumping around from rotation to rotation certainly keeps us on our feet!  

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Posted 21 July 2016 - 06:53 PM

How's it going, gang? Checking in again, this time 1 week before the fast track rotation ends because I need to switch my mindset to preparing for my first main-ED rotation of second year, where I have to be ready to be the airway/sedation resident and have all of that information memorized cold! Study time for sure.   


Fast track has been a really great rotation, IMO!  For one, it was pretty much the first exposure to the straight forward "fast-tracky" chief complaints that I had been totally protected from throughout first year, and I definitely learned a lot about how to approach/work-up these patients.  For two, it was also the first time that I was put in a position to be the one "running the (fast track) department" - really working on efficiency, prioritizing, delegating, and cranking through things as fast as possible - all things that are vitally important to develop if we are to work in any modern ED.  Another incredibly valuable skill I developed most during this fast track rotation is optimizing the EMR, which increased my efficiency at least 3-fold.  There are so many different ways to make the most of the EMR: order sets, favorite lists, pre completed notes, macros, dot-phrases, saved discharge instructions - it is absolutely invaluable to learn from as many of the tech-savvy coworkers and EMR-trainers as possible!  I was lucky enough to always be paired with very experienced PAs who were great teachers and also confident enough to let me manage things the way I saw fit, with feedback that was always spot-on.  I certainly have a long way to go, but it was a great training experience to say the least.  


I was worried at first (as you can see from the end of my last post) about seeing chief complaints that I wasn't used to seeing, especially after reading through the classic "fast track disasters" sticky in the emergency sub-forum.  However, I actually did better than I had expected - my training kicked in and I found that I did a decent job of differentiating "sick vs not sick", which really is the end goal of EM.  In the countless 'pink eyes' sent my way, I picked up a case of acute glaucoma that was scoffed off as a drug seeker by triage.  The provider I had been working with (who has been working for a very long time, by the way)  had never seen acute glaucoma - but since I've been basically living in the hospital for the past year and we always make all the residents see cases like this, I had seen acute glaucoma 3 times already and diagnosed it within 3 minutes of seeing this patient.  l picked up another case of hip AVN in another 'drug seeker' (common theme here - skepticism is a virtue!).  And in my ever-favorite, "this is another ambulatory dysfunction patient - just give them a walker and send them home", I found another case of spinal stenosis (see, I knew that ED obs rotation was totally worth it!)  Obviously I still have a long way to go, but these little wins felt pretty darn good.  When you know what badness to look out for and can convince yourself that patients don't have them, you can be a lot more confident in sending people home, even if you aren't entirely sure what likely-benign dx they have.  



Since pretty much all ED PAs who have worked in a fast track are likely comfortable with these "fast-tracky" chief complaints, I am not going to waste your time by writing the approaches that I came to use.  I think it would be more valuable for you all if I just shared the resources that I found most helpful.  





(best resources for learning how to handle the most common things)

1) Minor Emergencies, from Splinters to Fractures - Almost universally recommended from the threads I read up on, and for good reason.  This is a great resources that is entirely clinically/practically oriented as opposed to tintinelli/rosens which often end up being boards-oriented.  


2) EMRAP and UrgentCareRAP - The quintessential EM podcast that has it all.  In particular they had some really good podcasts about many fast-track chief complaints with excellent, practical commentary.  I loved the podcasts on ankle sprains, hand/finger injuries, eye complaints, and more.  


3) UpToDate - I mean come on, UpToDate is just such a great reference at the point of care.



(best resources for learning what badness to look out for in each chief complaint, how exactly to rule them out, and how to document to CYA)

4) Urgent Care Emergencies, Avoiding the Pitfalls (by Amal Mattu, the EKG guru and very well known EM figure) - This is a really excellent book and very worthwhile IMO!


5) Bouncebacks:  Emergency Department Cases (Greg Henry - an EM legend, past ACEP president, now known mostly for his teaching the legal/CYA aspects of EM).  I would consider this more in the "fun read with excellent learning points", but since its just organized by random cases its harder to make it a study/reference book.  


6) EMEDPA's Classic Thread: "It's Probably Nothing", Fast Track Disasters - A must read, for sure!  Expand that differential and always be on the lookout!   http://www.physician...rack-disasters/



On the topic of textbooks, since I probably have recommended countless of them on this blog - and I know many of you are students flooded with debt - please know that there are many ways to get these textbooks without shelling out the big bucks.  Of course the best bet is finding them in your library, through your university's online subscription (like ACCESSMEDICINE) if they have one, or through your rotation sites/preceptors.  If you have the money, of course its worthwhile to buy whatever you can.  If you aren't lucky enough to have one of these options, many of you probably already know there are "other ways" to still be able to read and learn from these textbooks.  I have never done it myself, but I know my fellow classmates/residents have found reputable, safe websites where you can read or download PDFs of probably 95% of medical textbooks and journal articles.  I don't even know what websites they're talking about so don't ask me, but I'm sure you could find them if you looked hard enough.  I don't condone this, but considering they are doing this with the goal of best caring for their patients, and considering that throughout our long academic careers we have all spent an exorbitant and ever-increasing amount on textbooks, I suppose I can sort of understand their predicament and actions.  I'll just leave it at that...






As I've said before, there are some great gems that can be found on SDN.... I found these threads to be particularly helpful discussions that gives some great suggestions: 








When it comes to EMR optimization, unfortunately it is entirely variable depending on where you work and what system you have, so I can't write much about this except to recommend that you really try to learn as much as possible from those tech-oriented coworkers and EMR-trainers.  Dedicating time to optimizing your preferences will pay huge dividends so its definitely worth the extra time up-front.   











...Tune in next month for my experiences as a second year ED resident!!!  

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Posted 22 August 2016 - 07:07 PM

Done with my first month in the ED as a second year!  I'm not sure if I explained this in a prior post, but the physician residency program here is a 4 year program where each year is dedicated to specific overarching goals:


First year - learning the basics of seeing stable ED patients, basic procedures with the one main advanced procedure being central lines, trauma secondary survey.

Second year -  (airway resident) - seeing as many sick respiratory/airway patients as possible, and being called upon to do all of the intubations in the ED.  Also start decision making in procedural sedation and post intubation sedation.  Doing some of the advanced procedures in traumas.  Now with fast track experience, they're expected to be the efficient residents seeing the most patients.  

Third year - They are the airway residents and primary survey people for traumas, start supervising interns, managing the medium acuity sections of the ED, overseeing procedural sedation, and are in charge of base command.  

Fourth year - Primary person running all of the traumas, managing the highest acuity section of the ED, supervising all residents.  


In general, I've been told that the first half of a residency is to learn the skills needed to successfully take care of patients, and in the later half its more dedicated to learning how to increase efficiency, supervise, delegate, and manage the ED.  In this sense, I think it works out well to be a PA resident for the first half of these residencies, because my main goal at this point is to learn the medicine as opposed to the skills of managing the ED, at least at this point in my career.  


Anyways, my first ED month of second year was a pretty great experience all in all.  It is always very challenging (perhaps better said 'terrifying') as everyone steps into their new role in July/August of every year.  You can see the looks of sheer terror on practically everyone's face, especially the new interns.  They weren't alone though... I had the same look of terror as everyone looked to me to intubate my first patient as they were doing chest compressions on a 300lb patient with an impossibly short neck... and unfortunately that look of terror transformed into to a look of disappointment as I failed my first ED intubation attempt haha.  Luckily I have some wonderful senior residents, attendings, and respiratory techs who really helped me see the many little things you can do to really maximize your success in ED intubation before even starting.  Aside from this, I got a lot of practice and really worked on my approach to the sick respiratory patient (asthma/copd, chf, angioedema).  All in all, a great month and very worthwhile!  



Approach to sick respiratory patients

These are high stress situations.  EMS come barging in, lines and tubes all over the place, loud respiratory machines and dials beeping, patient looking like they're dying right in front of your eyes and everyone jumps into the room to try to help.  I learned pretty quickly that the standard approach to stable patients just doesn't work for patients needing immediate action - you don't have time to ask more than 4 or 5 questions before you need to start acting, you don't have time for a good physical (and likely can't hear detailed lung sounds because of the roar of the ED), and there is no time for chart review. Yet, you still have to make conclusions about likely diagnosis, severity, and management almost immediately.  


Typically the diagnosis is easily found in these patients... EMS will tell you they're PMH of COPD/asthma vs CHF, or you'll see a dialysis access site on the patients arm, and you'll know more or less what entities you're dealing with.  If they have no PMH at all and this came suddenly out of the blue, widen the ddx to the rarer things like anaphylaxis, angioedema, smoke inhalation, PTX, PE, etc... but 95% of the time it will be one of those incredibly common entities mentioned above.  The severity is also easily obtained if you know what you're looking for, and looking is really key.  Observing for mental status is probably the most important aspect of this -- are their eyes open?  tiring out / falling asleep easily?  able to speak?  are they AOx3, talking appropriately and answering questions?  What is their overall WOB (work of breathing)?  Retractions?  belly breathing?  These are all easily ascertained within 20 seconds of observation.  When it comes to the history, you get time for maybe 4 questions before making an assessment and empiric treatment plan, so make them count with the highest yield questions you can ask... only the questions that might change management.  Oftentimes you only get yes/no answers because they're too dyspneic.  


Here are the history and physical features (to assess in tandem) that I have found to be the highest yield...

Get EMS hx / vitals / interventions while simply observing the patient (highest yield, gauge mental status / work of breathing - severity)

PMH - does this feel like your COPD/Asthma/CHF? (make dx)  Ever been intubated?  (gauge severity and likelihood of needing ett)

Pains anywhere or just SOB?  

Allergies to medications?  

Listen to lungs for rough assessment of wet/crackles vs dry/wheezy.  Since its always loud in the ED and hard to hear specific lung sounds, you may have to rely on secondary findings that help this ddx too, namely inspiratory expiratory ratio... in general, wet/pulmonary edema (CHF / renal) will have low tidal volumes but short expiratory phase because they don't have a bronchoconstrictive/obstructive process, whereas asthma/copd will have a prolonged I:E ratio with their drawn out exhalations... one of my favorite attendings taught me this and it has helped me a ton!  You can gauge this also just by looking at the patient, without having to listen to their lungs at all.  

Eval airway - open their mouth and assess for dentures, mallampati, etc (starting to assess how easy / difficult it would be to ett)

Assess overall volume status, leg edema (bilat or unilateral)

I can typically get through this sequence in under 2 minutes and have a really good idea of the dx, severity, and path this patient is likely going to go down.   


Remember though, with these patients everyone jumps in the room at once and they're not going to wait for your 2 minutes to end before starting their actions... its your job to make sure that everything happens in tandem with sick patients.  While you are doing your expedited HnP, make sure there is somebody working on...

IV access + blood work (draw a rainbow and be sure to have them send a venous blood gas + lactate)

O2 - nonrebreather initially, but pretty much all truly sick respiratory patients could benefit from a trial of bipap/cpap, regardless of their underlying dx, at the very least as a bridge to intubation.  Call the respiratory tech to get them over and helping.  

Cardiac monitor, full set of vitals


Its also important to just get empiric interventions going even if you're not finished with your exam and evaluation.  Reuben Strayer of EM Updates has an excellent video to this end where he emphasizes that critically ill patients should have intervention options guiding our evaluation, because they need interventions asap.  I think I actually linked to this video earlier in this blog, but I'll link it again because it is just that good, and since it discusses approach to dyspneic patient it is particularly relevant to this post.  



Once you have a better idea of the entity you are dealing with, start going down your empiric treatment pathways for the specific diagnosis... this should be happening within minutes of the patient arriving, so know your algorithms pat. You have to memorize the doses of medications in these situations because there is no time to look things up with crashing patients.  Lots of information out there about these, and I am certainly no expert!  So, how about I link you to the experts:


Critical asthmatic/COPDer --  

Reuben Strayers approach - http://emupdates.com...Dv6_fullpic.png


EMCrit approach - http://emcrit.org/po...vere-asthmatic/


First10EM's approach (if I haven't raved about this website yet, let me do it now... it might be my favorite FOAM website at this time as I am trying to get more and more into the resusc of the very sick patients, and this site is just gold.  https://first10em.co...5/08/18/asthma/



Critical CHF'er






More great resources:

EMRAP has been coming up with this C3 series (core content / approaches to bread and butter chief complaints) that are EXCELLENT... seriously amazing resource for newcomers to EM looking to get practical advice for working in the ED.  They have a few episodes on approach to SOB that are definitely worth watching. 




Intubating in the Emergency Department

Here are the different scenarios to spark the situation.  "EMS in route with code blue, BLS in progress"  "EMS in route, requesting respiratory on standby", "Our asthmatic/copder is tiring out, falling asleep", "We cannot get our CHF'er above 70% O2 sat"

..." we gotta intubate!"  


Remember the indications for intubation!  Failure to oxygenate, ventilate (in ED this is a clinical dx of hypercapnea), maintain airway (diminished mental status / GCS < 8, not tolerating secretions, no gag reflex), expected clinical course (need to secure airway for studies, intoxicated/agitated, head injured needing vent controls, etc)


What you need to do to prepare:  SOAP-ME  - https://emin5.com/20...ration-soap-me/

Suction hooked up

Oxygen - get bag valve mask hooked up and ready.  Try to get 2 oxygen vials (1 for bvm, one for nasal cannula during apneic oxygenation and then for the ventilator)

Airway supplies:  Blade (4 works for all patients), Tubes x2 sizes (7.0 - 8.0 depending on sex/size) - make sure everything works.  

Preoxygenate the patient -- if needed, w/ Bipap.  

Monitoring equipment  - cardiac monitor, BP/pulse ox

End tidal CO2 - very useful!


And get your favorite backups ready:  BVM + OPA / NPA, Bougie, Video laryngoscope, LMA, Cric kit.  


Once the patient arrives:

Get them as oxygenated ("denitrogenated") as possible -- nasal cannula + NRB / bipap.  You should leave the nasal cannula on the patient while you intubate them for "apneic oxygenation", which the FOAM world has been raving about for a while now.  

Position them with head of bed elevated to about 20 degrees, and blankets under neck/shoulder so that you get the "ear to sternal notch"

Raise the bed up so that you don't have to bend much to see 

Have all of your things within arms reach, including your suction and tube.  

Have an assistant stand to your right and be ready to hand you the tube.  Also have them pull back on the patients lip for more space to pass the tube, and provide cricoid pressure if needed.  



Know your RSI meds, indications/contraindications, and dosing inside and out:

Most straightforward cases in our ED get etomidate and succ.  


​know when you shouldn't use this combo...

hyperkalemia likely? (ESRD, extensive burns/crush injury, etc) -- don't use succ.  Need roc or vec.  


know how to manage other common scenarios with unique needs in rsi meds...

asthmatic/copder?  consider ketamine for bronchodilation


hypotensive patient?   http://emcrit.org/po...-patient-shock/  .  And lots of people are now emphasizing "resuscitation sequence intubation", or "resuscitate before you intubate", because RSI and then positive pressure ventilation really makes a lot of shocky patients crump.  


I will post a helpful practice sheet for choosing RSI meds in the next post.  



You get the tube in place... don't celebrate yet!  Post-intubation sedation:

We had a great conference lecture dedicated to this topic, with the main take away points being do NOT just paralyze your patient.  You should 1) give them pain medication (fentanyl is most popular) and then 2) give them sedation (propofol is most common), all the while trying to avoid benzodiazepines which lead to prolonged ICU stays, vent dependency, and delirium.  


Order the drips for fentanyl / propofol and while the pharmacy is mixing it up you can give push dose boluses on a PRN sedation basis.  Can use benzos as short term push doses for prn sedation too, just try to avoid it if possible.  


EMCrits points mirrored a lot of what our ED-Intensivist said in her conference lecture...  http://emcrit.org/po...ation-sedation/



Vent settings:

I plan on really learning more of this next month in the ICU / CCU, but as I've been asking around for good resources to learn vents, so many people keep going back to the king of critical care... Scott Weingart / EMCrit...  he has an incredible lecture series to learn the basics of vent management and I'd highly recommend it.  





More resources

See the EMRAP podcast about "tips for the infrequent intubators"  

EMBasics many great episodes on airway management





Thats it for this month. Next month I'll be in the ICU and CCU, which I am very excited for.  I have been reading up on the ICU book, SCCM's FCCS series, EMCrit.... lots of fun stuff and I can't wait to start.  

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Posted 22 August 2016 - 10:08 PM

Good post. I would like to add 2 points for everyone's clarification. The first is mallampatti has been shown to be pretty bad at predicting a difficult airway. If your going to use it, it's only helpful when combined with thyroimental distance, prognath, and mouth opening. The only one shown to independently predict difficult airway is prognath

Secondly, you don't have to worry so much about burns increasing K+ in the ED. Burns cause increase in extrajunctional receptors which takes a minimum of 24 hours, if not 48 to create enough them to be a problem. Hour old burn? No worries. I mention this because sux has been shown to give better views faster than roc, which can be very important in the obese patient that has decrease functional reserve capacity and may only tolerate half the apneic time a normal patient might

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Posted 23 August 2016 - 08:18 PM

LTJGonealPAC - good points - I always like hearing from the experienced PAs out there.  A lot of what they focus teaching us in the beginning of the year as we step into our new roles is the "old school" fundamentals / dogmas (i.e. "avoid lido w/ epi on distal extremities", avoid succ in big burns) and then as we progress we are gradually exposed to the latest and greatest.  I also think the FOAMed world has done a great job of dispelling a lot of the old school dogmas that research hasn't really shown to be true.




I realized that I forgot to share the practice worksheet for RSI cases -- I'll post it here.  These answers also might not be totally up to date since the worksheet was made by residents, but at the very least it provides the basis for good thought experiments that you can later look up and research.  






Airway and RSI management cases

1.      47 yo ESRD on HD, missed HD for 3 days, presents in CHF, oxygen sat in 70s, comes up to 90% on a NRB, severe resp distress. 

a.     Learner should cite indication to intubate: 

                                               i.     Failure to oxygenate

                                             ii.     Medical acuity

b.      Learner should identify meds for RSI

                                               i.     Sedative prn – avoid ketamine for catecholaminergic effects

                                             ii.     Though data is divided on topic, learner should verbalize concerns for Hyperkalemia and likely avoid succinylcholine, choose Roc or Vec.


2.      66 y/o male, morbidly obese, HTN, OSA, pulm HTN, presents with altered MS of unclear etiology, somnolent.  ABG:  7.13/97/79(PaO2)/94%

a.     Learner should cite indication for airway control

                                               i.     Failure of ventilation

1.     Consider NIPPV (CPAP/BiPAP) à Patient too somnolent to cooperate, intubation required

b.      Ask for appropriate RSI meds, ASK FOR DOSES!

c.     Prompt learner for techniques to optimize high-risk intubation (ear to sternal notch, preoxygenate, alternative tools at the ready, etc.)

d.     Observe intubating technique


3.     96 y/o patient male patient with h/o recurrent UTIs, presents in obvious sepsis, HR130s, BP 90/40, Temp: 39.9, no gag reflex, pale, ill appearing, FULL CODE!!!!

a.     Learner should cite indication for intubation

                                               i.     Airway control given loss of gag

                                             ii.     Medical acuity

b.      Ask for appropriate RSI meds ASK FOR DOSES!

                                               i.     Sedative challenging given florid sepsis (etomidate has adrenal suppression, midazolam causes hypotension, ketamine catecholaminergic stim, propofol causes hypotension….if they can verbalize the thoughts, they can choose what they want, they understand the issues.  They may even take an “awake look”).

c.      As they go in the airway, tell them they see large white, straight, pristine teeth on both the maxilla and mandible.  Make them verbalize that they must remove the dentures before proceeding!


4.     49 y/o male, sudden onset of headache and RUE/RLE weakness.  2CATS called, head CT shows massive Left MCA hemmorhagic stroke with 4mm shift.  You decide to intubate.

a.     Learner should cite indication to intubate

                                               i.     Airway protection

b.      Ask learner what agents do they want for RSI

                                               i.     Learner should verbalize possible pretreatment agents (MAKE THEM KNOW DOSES!)

1.     Lidocaine (1.5 mg/kg – 100mg in 70 kg adult)

2.     Fentanyl (2 mcg/kg – 200 mcg)

3.     Vecuronium defasciculating dose (0.01mg/kg or 1 mg)


5.      66 yo paranoid schizophrenic, COPD, OSA, morbidly obese, cervical stenosis, thick facial hair, presents from psych facility for altered MS.  ABG:  7.29/109/47(HCO3)/58(PaO2)/88%

a.     Learner should verbalize understanding of blood gas (severe chronic CO2 retainer based on high pCO2 with mildly depressed pH….high bicarb also consistent with chronic CO2 retention)

b.     Learner should verbalize concerns of airway given facial hair (tough to bag), obese, cervical spine disease

c.     Learner should consider alternative airway tools ready at the bedside

                                               i.     Combitube

                                             ii.     King LT

                                            iii.     Etc.

d.      Learner should verbalize possibility of consultant (ENT/anesthesia) at the bedside for airway consultation

e.     Learner should consider narcan (at which point patient wakes up and controls airway well.   Respiratory and mental status return to normal.



6.     3 y/o presents with severe respiratory distress secondary to asthma.  3 hours of nebs, steroids, magnesium, terbutaline, subcutaneous epinephrine and the patient remains tachypneic, ill appearing, and now is becoming progressively somnolent.

a.     Learner should cite indication to intubate

                                               i.     Ventilator failure

                                             ii.     Medical acuity

b.      Learner should cite medications for intubation

                                               i.     PRETREATMENT WITH ATROPINE – Know Dose 0.02 mg/kg

                                             ii.     Etomidate/Succinylcholine

c.      Learner should know methods for calculating tube size

                                               i.     Pinky finger vs. age+16 divided by 4


7.     6 y/o male with progressive sore throat, fever, now in mod respiratory distress, mild stridor.  Soft-tissue lateral neck shows thumb-print sign c/w epiglottitis.

a.     Learner should verbalize desire to keep child calm, assume a position of comfort

b.     Have patient become less responsive

i.FIRST MOVE FOR LEARNER SHOULD BE TO BAG PATIENT!!!  Patient should be easy to bag and maintain sats when proper BVM technique is demonstrated

                                             ii.     If learner asks, first look is with direct laryngoscopy and needle crichothyrotomy is attempted only if direct laryngoscopy fails, but this case should demonstrate that BVM is often a successful technique to manage such patients

                Learner should call for emergent ENT support

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Posted 30 September 2016 - 12:49 AM


CCU and MICU are over and done!  These were definitely tough rotations with early mornings and lots of work to do.  I can understand why many residents don't really enjoy a lot of the typical medicine floor work, but despite that I really loved these rotations.  In fact, it may have been among my favorite rotations so far.  Perhaps the part I enjoyed most about it was the intensivist's way of thinking through things.  We were faced with very sick patients with tons of comorbidities and ongoing hospital problems, but they approached these patients in a simplified and systematic fashion.  What's more, the intensivists were always going back to the physiology/pathophysiology underlying the situation, so I felt more than ever that I was starting to really understand these diseases and the targeted therapeutics.  I saw for the first time how incredibly inter-locked all of the different organ systems really are, since we would see time and again the cascade of one organ failure toppling into the others in very common patterns.  


Our daily rounds had all kinds of smart people working together, from the intensivists to the fellows to the ICU pharmacists... and it was all very geared toward learning from all of the different perspectives.  With all of our great procedural training in the ED, I was among the most experienced at placing lines between even the senior medicine residents, so I was able to place several of them during this rotation.  We even got to place a couple trialysis lines, which is always fun.  I also realized how great our ED ultrasound training is, even compared to the critical care fellows.  All in all, critical care was a very enjoyable experience, and I can understand why a lot of EM physicians and PAs are starting to combine the two and work in both settings. 




There are a several bread and butter scenarios that we all try to focus our learning on during our critical care rotations.  I will try to touch on some of the highest yield pearls that I was taught on these topics and sprinkle in my favorite relevant resources...


CCU Topics

-HTNsive emergency, antihypertensive drips, etc


-Flash pulmonary edema.  We saw this a TON this past month, and it was really helpful seeing all of the different variations of this. A lot of patients came in with pulmonary edema and it was just related to missing dialysis, which the cardiologists always hated because there is really nothing more to do for them other than supportive care and dialysis.  We had a great cardiologist who explained pulmonary edema like this:  it is most likely from either volume overload (chronic CHF vs renal failure/nephrotic syndrome - tends to be more gradual in onset - overall not as worrisome) or ischemia (MI causing stiff heart and abrupt heart failure - tends to be more rapid in onset - very concerning and needs to have a cath). There are other things to keep in mind as well... infection/ards, critical aortic stenosis, etc.  From an ED perspective, its not as important to differentiate the two because the vast majority are empirically treated the same way:  Bipap + nitro + diuresis.  But be aware of the pitfalls with nitro (see below).   


-Cardiogenic shock, hemodynamics, swan-ganz, right heart catheterization.  Since the evidence has not show any mortality benefit, the swan-ganz catheter has definitely been going out of favor, but it is still done on a somewhat regular basis, and right heart caths (which give you essentially the same information) are done very regularly.  At the very least, realize that it is still highly emphasized to understand the concepts and derangements expected in disease because it will offer you a much better conceptual grasp of cardiovascular and pulmonary disease states and rational treatment. As a quick review for newbies, left heart cath is when they go through the femoral/radial artery and feed contrast into the coronary arteries as they look for plaque rupture in the workup of chest pain.  Swan gang catheters and Right heart cath goes through the femoral vein and assesses the pressures of the RA, RV, Pulmonary artery, and the "wedge" (pulmonary capillary wedge pressure, which is a reflection of LA pressure)  to calculate cardiac output, pulmonary vascular resistance (in pulmonary HTN), systemic vascular resistance (to differentiate the various causes of shock), and volume status. There is a *WONDERFUL* review of this topic by the Louisville Internal Medicine lecture series.  This series was highly highly recommended by many residents and I watched a lot of their videos and they are definitely great.  They have a website, youtube, and are also available on iTunes.  Here is the hemodynamics one:  https://www.youtube....h?v=337B_oz_5Ds

And here is their website with overview of all of their videos:



-Cardiorenal syndrome.  In school, I always imagined it must be near impossible to treat an AKI and a CHF exacerbation at the same time, because its not like you typically see people give fluids in CHF or diuretics in AKI.  But after seeing dozens of these cases and having cardiorenal syndrome explained to me, it now makes much more sense.  So, there are several "types" of cardiorenal syndrome, based on which is the principle underlying insult and how the other organ is affected, but just know that the heart and the kidneys are intricately intertwined and directly affect one another, and we often see derangements in both CHF and Renal fx at the same time.  The critical point is to evaluate the volume status and perfusion.  Rarely, they are dry and cold, and you probably have to give some fluids and inotropes to perfuse the kidneys and body.  However, the vast majority of the time, people refer to cardiorenal syndrome in the context of volume overloaded chf that actually requires diuresis (and even excessively high doses because the kidneys become more resistant in this condition) to help not only the heart but also to improve renal function.  It seems counterintuitive to give diuretics to someone with an AKI, but thats what they do!  


-Arrhythmias - http://www.louisvill...1-with-dr-brown


-STEMI and post cath care


-Assessment of volume status.  A topic of daily discussion on every ICU rounds  



-Common ED pitfalls that we saw.  

-Giving CCBs or BBs for rate control in tachyarrhythmias in patients without a known EF/CHF.  We saw this a few times over the past month and the cardiologists would always go into rants about how they see this all the time.  Basically in the ED we love giving cardizem for rate control because it works so well, but it is harmful for those with CHF or low EF and can precipitate an acute decompensated heart failure and shock.   They emphasized we should always look into prior records for an echo or at the very least look for stigmata of heart failure on exam before giving CCBs/BBs.  

 *** check out the interactive student case I did on our forums based on one of these patients to get a sense of how these cases actually happen *** 



-Giving nitro to chest pain / pulmonary edema / htnsive emergency in patients who are preload dependent (aortic stenosis, right sided MI, pulmonary HTN), also with the potential to precipitate decompensation and hypotension, and also something that we saw several times.  They again emphasized how important it is to check an EKG and do a good exam listening for aortic murmur before starting nitro.  





MICU Topics

-Respiratory failure: hypoxemic vs hypercapneic.  A-a gradient vs FiO2/PaO2.  Acid base and ABGs in respiratory disease. ventilator management.  These are all definitely a huge component of what makes up the MICU.  They are very systematic about their approach to these, and it all relates heavily to underlying pathophys.  They are very particular about dividing hypoxemia from hypercapnea because each are unique processes with unique etiologies.   These are big topics that take time to understand.  Check out a variety of resources recommended to me:







-Approach to the hypotensive/shock patient.  pressors and inotropes.  Another huge topic in critical care.  Main emphasis here is that the approach to the hypotensive patient should be to try to put them into one of 4 'boxes': hypovolemic (hemorrhagic or volume depleted), distributive (sepsis or anaphylaxis or neurogenic), cardiogenic, or obstructive.  



Perhaps most important physical exam maneuver you can do to help differentiate is to feel the temperature of the extremities, cap refill, etc perfusion.  Warm extremities will most likely be distributive/sepsis, rarely neurogenic;  and cold extremities will either be hypovolemic or cardiogenic or obstructive, and typically the clinical picture makes it clear.  This is the clinical manifestation of the pathophysiological systemic vascular resistance.  For further diagnostic refining, bedside ultrasound has become hugely integrated into the hypotensive patient (see "rush protocol").  Then you have your ddx within each box, but more importantly, you know what kind of management you can start empirically.  If hypovolemic, give blood or fluids.  Give distributive shock levophed/norepi.  Give cardiogenic inotropes.  Give neurogenic phenylephrine/vaso.  Each of the inotropes / pressors have their mechanism of action that you really do need to know... autonomics is an incredibly important physiologic topic that keeps coming up time and time again - really have to know this backwards and forwards!



-sepsis management.  antibiotics.  Definitely a different perspective than what I was used to in the ED, infectious disease was heavily integrated into everything we did, and they taught us the outline and progression of ID:  suspect infection --> draw cultures --> start empiric therapy based on likely pathogens (and refine as you continue)--> gram stain results --> bug identification --> susceptibilities.  The majority of our patients, after being in hospital for 1-2 days, would only have gram stain, so it was really important to review the morphology / organisms (gram positive rods in pairs, etc).  There is also the topic of decelerating antibiotics which we talked about every day in rounds.  The book "Antibiotics Simplified" was highly recommended to me and in reading through it, I thought it was really excellent summary of everything.    


-end organ damage as a result of shock.  (i.e.  shock liver, DIC, acute renal failure).  Hugely important.  


-metabolic acid base disorders and systematic abg interpretation.  severe dka.  Another behemoth topic in critical care and emphasized every day.  


https://www.ncbi.nlm...les/PMC1002945/ - the Haber method which is becoming a very popular method for many to simplify acid base interp.  


http://fitsweb.uchc....ham/Case_1.html  -- really really good practice cases that walk you through each step!




-chronic liver failure / complications.  Our intensivist said the patients he is scared most about is the acute liver failure patients (typically from tylenol OD).  


-critical GI bleeders


-cva / sah / ich


-status epilepticus





General Critical Care Resources.  A variety of resources that have been repeatedly recommended to me.  

-The ICU book by Marino -- one of the most popular for fundamental ICU topics, though somewhat controversial since some topics aren't exactly evidence based but rather author opinion.  

-Critical Care Medicine: The Essentials by Marini

-Intensive Care Medicine By Irwin and Rippes - one of the ICU bibles/core texts for fellows.  


-EMCrit Podcast  *Best Podcast*

-Louisville Internal Medicine lecture series *Best Podcast*

-The ICU network  / podcast

-ICU Rounds podacst


-Society of Critical Care Medicine, who has a ACLS-esque course called FCCS Fundamentals of Critical Care Support


-http://www.nejm.org/...l-care-medicine - Really really good NEJM review series on common critical care topics.






I am back in the ED this month... 2nd to last ED rotation!   

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Posted 05 October 2016 - 07:31 PM

This blog has been, by far, one of the most interesting and educational things I've read in a LONG time. It makes me really want to do a residency program and wish we had one nearby. Thank you for sharing all your knowledge.

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Posted 08 October 2016 - 09:15 PM

Thank you for the kind words.  I really enjoy writing and teaching, and it feels even better to know that people are getting something out of it.  I appreciate the feedback!








Okay, I have not finished my ED rotation but I just had to post early because I have stumbled onto a tool that I think has the potential to REALLY optimize all of the incredible medical resources out there and I wanted to share it with you all.  


You all know how much I love the FOAMed community.  For those of you not yet acquainted, it stands for free open access medical education - basically it encompasses the wave of medical blogs, podcasts, youtube channels, etc, that have been flourishing over the past several years.  They have come together and formed a community of people who really see our modern technology as a way to revolutionize medical education... moving from traditional boring powerpoint lectures and dry (expensive) textbooks to unique, entertaining, up-to-date and free mediums for learning medicine.  Emergency medicine certainly has been one of the biggest drivers of this movement and there are now TONS of resources out there - you all have seen many of these resources as I plug them into this blog, but realize that there are many many more and it keeps growing every day.  The massive amount of resources is a good thing, but it also carries challenges with it, because its hard to sort through it all and figure out how to utilize these amazing resources to our advantage when we want to answer a clinical question or learn more about a specific topic.  


Enter in my girlfriend, who is quite a bit of a techy herself, who showed me how to tap into google's horsepower with Google Custom Search Engines, and I feel like I have found an excellent tool to aid us in optimizing this process.  Its so simple that I'm surprised I haven't seen it applied in this use before.  Basically it just allows you to perform google searches for your clinical questions/topics just like you would in any other google search, but instead of getting back a million hits for random websites like wikipedia or yahoo answers that don't help you, it will only search the websites you program into the search engine.  You can then add even more filters to further optimize your search - lets say you wanted to search for DKA management, but you'd like to hear about it from the perspective of critical care - you can filter your choice websites to show the critical care ones at the very top.  


So, I made a custom search engine that only searches FOAMed websites and other related websites (i.e. UpToDate, prescribers letter, etc) that we would find most helpful in learning medicine, and added filters for my favorite EM websites, critical care, pharmacology, basic science, etc.  I just started using this last week, and honestly I love it.  I have never been able to so easily aggregate my favorite resources on a given topic in such a succinct and efficient manner.  It is still a work in progress, but check it out below and see if it helps your learning. Like I said, it really lends itself to personalization, so I'd recommend you all to start keeping track of your favorite websites/filters and then make your own custom search engine... its incredibly easy to do!



SerenityNow's FOAMed Custom Search Engine Link:











Of course, after I think that I was the one who stumbled upon this great new tool, I later find out that it has already been done haha... isn't that the way it goes!  Still, I plan on using my own CSE (and I think you all should make your own if you'd like) because I can customize it exactly the way I like it, with my own filters for my favorite websites and all.  


Here is the "official" FOAMed google custom search:




Another take on optimizing your FOAMed experience via this really nice overview pdf on emcrit:


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Posted 18 November 2016 - 07:30 AM

Hello everyone!


Pediatrics is under my belt... and only 3 more rotations left!!!  They have had me working in every part of the pediatric ED, from fast track to high acuity.  To be honest, because so few kids are seriously ill, the whole ED felt like one big fast track at times... it was a lot of vigilance for those rare sick kids, and even more reassurance for those worried well.  This was one of those rotations where I walked away wishing that I could stay longer, because there really is a lot of unique knowledge and pathology relating to pediatrics, and its just impossible to learn it all in 1 month.  That being said, I do think I learned the most important points to take away from this experience.... the general approach to the pediatric patient in the ED (and how to interpret the "red flags")... how to accomplish things that would be otherwise routine in adults (bloodwork, procedures, etc)... and the best resources to help us learn the rest.




Peds is definitely a challenging field.  At each stage of development, there are unique normals, unique pathologies, unique chief complaints.  Its really hard to know it all, and I doubt that I ever will.  Luckily, as long as certain general areas have been assessed (regardless of age), the majority of emergent badness can be ruled out.  This becomes apparent after working in the peds setting for even a few days, you'll hear the same things over and over dozens of times in interviews / presentations... "they're tolerating PO, making wet diapers q4 hrs, fussy but consolable" etc etc etc.  I'll try to outline the general pediatric approach that has been ingrained into my head after being asked these things dozens of times by the peds attendings...


General approach to the peds EM patient:

As with every ED patient, your first step, even if brief, should be the ABCs... in peds its actually the "pediatric assessment triangle"  



This is something that the pediatricians actually use and reference; its not just a textbook gimmick.  This is basically the "sick vs not sick" tool and it works quite well.  Appearance issues would be labelled as "toxic / nontoxic" and is typically quite obvious without much scrutinization needed.  Circulation issues are much more subtle, but quite rare.  Work of breathing, however, is something that comes up in countless pediatric patients every day, so its really important to dedicate your time and energy to honing this skill.  Most important thing to do: undress the child! (I see many students just listening through clothes for lung sounds, when, to be honest, in peds the lung sounds aren't the most important part and don't change dispo in as many cases as the work of breathing!)   Let them sit in the parent's lap and don't bother them at all - just watch them breath while you get the history from the parents.  Get in the habit of systematically observing your way down from head to toe... nasal flaring?  sniffing position / tripoding?  drooling?  supraclavicular retractions?  intercostal retractions?  subcostal retractions / belly breathing?  It can be really subtle when you are only seeing the kid in that snapshot in time and you don't know what has changed from their baseline...   Kids who are in significant respiratory distress can be sitting in front of you as calm and happy as a clam as long as something is distracting them like a TV show or phone.  


Second part to this eval is reviewing your vitals signs...

There are a TON of different reference ranges and tricks to help you calculate normals your own way... you can choose your own preference.  I do however like the BP rule of thumb...    BP:  low normal is 70 + (2 x age).  This only applies for children 1 or older.  


If you determine they are sick, go down the pathway of resuscitation.  Get out your broselow tape if needed and get moving!  



If they're stable and you have a well appearing child sitting in front of you, you can go through your standard historical evaluation with the "pediatric ROS" that will soon get ingrained in your mind...


Chief complaint / HPI.

ROS - Vomiting - bilious (red flag) ?  Temp - how high / how checked?  Cough - barky (croup) ? whoopy (pertussis) ?  Stridor (croup) ?

Wheezing - asthma formally diagnosed? , recurrent wheezing, strong family hx / atopy (the more that are present, the more likely we are to call you reactive airway / asthma as opposed to bronchiolitis) 


What is the most bothersome sx?  

How have you been treating them?  Tylenol / motrin?  At what dose?  When was last dose before coming in?  

Sick contacts? Similar sx?

Tolerating PO liquid?  solids?   "My kid can't keep ANYTHING down"... a complaint heard ubiquitously... as long as they can keep some water/fluids down, and adequate UOP, and moist mucous membranes, not tachycardic or toxic... its probably OK!

Making wet diapers (UOP)  ?  Should have 4-8 wet diapers in past 24 hrs.  

Fussy?  Consolable?   "They've been crying for 3 days nonstop... completely inconsolable!"  Ask them, when you comfort them do they quiet down even for a few minutes?  If so, that is consolable fussiness.  Labeling someone as inconsolable is a huge red flag requiring extensive workup and should be reserved for children who are hysterically crying without calming at all after being consoled.  Be careful what you chart!

Have they been acting appropriately (or altered) ? "They've been totally lethargic!  Basically comatose sleeping all day!  Normally they're bouncing all over the house and now they're not at all acting like themselves!"  Okay, so they're sleeping a lot, but when you wake them up and interact with them, are they doing things that make sense or do they seem like they're really confused, doing inappropriate things? Parents will admit that its not like they're acting like that.  



Born full term?

Issues w/ delivery?  Postpartum?  NICU? ETT?

Freq hospitalizations or issues up until now?

Immunizations up to date?

Integrated with pediatrician and can get close f/u appt?  



I highlighted above some of the things that we would hear constantly from the "worried well" parents.  We had a great old-school attending who explained it like this... If you were to just write down in the chart exactly what the parents tell us on history, half  the time it would be a description fit for a MICU admission (or, PICU admission in this case haha)...

"3 yo child with a 5 day history of a tactile temperature to at least 105, severe headache, frank purulent foul smelling nasal congestion, lethargy and altered mental status and completely inconsolable, not eating or drinking anything, barely making any UOP, etc".  These are seriously the kinds of stories that parents will tell us, but then we look down and see a snot-nosed kid running around the room and coloring all over the walls and laughing like a maniac and you know that we don't have a MICU admission on our hands.  Point being:  don't just write down what the parents tell you.  You are not a scribe.  You need to take the whole clinical picture into account and write down your impression, as a medical profressional, of what the parents think is going on.  Big difference between the two, and a really important point I have been learning along the way, but I just really liked the way that the attending explained that concept.  


Of course, there are a few exceptions, most notably intussusception.  If the parent tells you their child looked like they were in terrible abdominal pain, vomiting, pulling their legs up, etcetc ... even if the child looks great in front of you, you should still consider intussusception, which is known to be intermittent / recurrent.  





I think we have all seen those parents who look absolutely horrified and about to syncopize themselves as we restrain their child for an IV (always with 2 missed attempts).... then maybe even a straight cath.... then maybe even a spinal tap!  The parents become a mess, and for good reason - nobody likes to see their kid shrieking in discomfort and just stand by and watch.  We were asked frequently if we could sedate the child for things like an IV / cath / tap. The general consensus in this ED is that you don't sedate a sick young child for these routine things... the risk is too high in an already high risk patient, most of the crying is because theyre restrained, and they won't remember it anyways (we all had them done as kids and we turned out fine!)... and parents usually can accept that.  Tell them that if it upsets them, they can stand outside and we will let them know "when they can go in for the rescue" to console their child after we are done.  


Some tips for the pediatric IVs that I learned from some great PICU nurses.... for every case, use hot packs to blow the veins up, go in there with at least 2 people for holding, and use distraction techniques (favorite show, etc).  Generally our nurses started at the hands -> antecub like normal.  If unsuccessful, they often went for the ankle saphenous vein (not contraindicated in kids!).  If this fails, can try ultrasound guided, EJ, or scalp veins.  If time critical, many will jump to IO after 2 failed PIV attempts... IOs are excellent choices in peds, just remember to get the right size to not go through the other side of the bone!  


​Your nurse comes up to you, "we got the IV but do we really have to straight cath this kid?!  Cant we just put the bag on him?".  This is a tough question that I haven't seen a perfect answer to yet, because there is a lot of conflicting data and opinions out there.  I'm curious what all of your practice styles are related to this.  David Newman did one of his old famous segments basically saying cathing and UTI treatment in general is technically only recommended to prevent long term complications like renal scarring and hypertension, which newer evidence has NOT shown a strong correlation.  It seems to me that several attendings here took the following approach:  if it is a high risk situation (sepsis, fever under 2-3months, high risk for UTI patient / uncircumcised), than they should get the straight cath.  If not a high risk situation, you can tell the nurses they are more than willing to try the bag sample (after extensively cleaning and sterilizing the skin around it), BUT if the sample comes back positive or equivocal it could be contamination so they'd have to follow up with a formal straight cath anyways.  If its negative even w/ the higher chance from contamination, then they lucked out!  Just put the decision in their hands!




Triage comes up to you, "we've got a bad laceration that will need a lot of stitches - I think you'll have to sedate this kid who is freaking out"

On a scale from lower to higher pain control /  sedation, here is what is commonly used:


LET x2 - will pretty much completely numb up most local areas.  
LMX - another topical option shown the be the best option while doing LPs, and interestingly also for abscesses (it has been shown to have an increased rate of helping abscesses drain spontaneously without needing to cut them open).


Nitrous oxide / "laughing gas" - great great choice to provide mild anxiolysis in an otherwise minimally painful procedure.  Extremely safe and well studied.  


Intranasal versed - one step above nitrous.  popular choice here - onset in about 5 minutes and lasts around 30 minutes.  Dose at 0.2 mg/kg (technically max dose is 8-10mg but we would avoid going over 6mg) - divide the dose in 2 syringes and squirt into each nostril with atomizers.  


Ketamine - the beloved drug of the ED, used by PEMs for a long time now - excellent safety profile but still will give you deep ("dissociative") sedation a la "David at the dentist".  Dose at 1-2mg/kg IV, or 3-4 mg/kg IM.  There are so many review podcasts on the use of ketamine... take your pick and learn it inside and out, because its a great drug!


Also don't forget the procedural adjunct the "Papoose" - a staple of every pediatric ED - basically any device that wraps around them so they can't kick and punch.   




There are a ton a really excellent PEM resources out there!  Here are a few of my favorites:


***best podcast***  

Pediatric Emergency Playbook -  I absolutely loved these podcasts... it might be in my top 3 favorite for all EM podcasts.  Just excellent discussions regarding the approaches to common chief complaints and issues in pediatrics.  


Searchable on iTunes and on website: pemplaybook.org


***best on-the-job online reference*** 

Children's Hospital of Philadelphia (CHOP) Clinical Pathways - Excellent algorithms that several of my attendings referenced regularly to help ensure they weren't forgetting anything.  Great for new learners and experienced folk alike.  



Pedistat - a really nice phone app where you can plug in the childs weight and it will give you an easily searchable list of medication doses, airway intervention / RSI, etc.  Its basically like an electronic broselow.  


EM Cases Digest Volume 2 - Pediatric Emergencies -- A great, free PDF aggregate of several EM cases segments that have been written up into a nice chapter / book form.  Great stuff.



Harriet Lane's Pediatric Reference - what pretty much all of the PEM attendings carried around as their go-to reference book.  











Thats it for this month everybody.  Next up... ENT!

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Posted 17 December 2016 - 04:34 PM

Second to last rotation done!  One more to go and I can't believe its all almost over!  ENT and ophtho were excellent experiences and I learned a ton.  During these types of rotations in particular, where we are on a very focused specialty service, it typically is just our job to learn a few core skills - in this case, how to use the NPL (nasopharyngeal laryngoscopy) and how to use the slit lamp.  Those skills are certainly important and the main focus of the rotation, but if you decide to be passive about the rotation and just go through the motions, those basic skills will be the only thing you take away from it.  As I've said on a few of my prior posts, you have to really be active about squeezing as much of that juicy knowledge as possible out of the specialists and patients/pathologies, because you'll never get these opportunities of so much distilled specialty experience again.  I came up with a ton of questions for the residents/attendings and really made it a point to see as many patients/pathologies as possible, and it definitely makes all the difference between just a good rotation and a great learning experience.  


Of everything I learned, I'd say that the most important within ENT would have been how to use the NPL, when/why to use the NPL and when not to use it, and the approach to sudden hearing loss.  Within ophtho, my most important take aways were how to use the slit lamp, the nuances of the "ophtho vital signs", and the ophthalmologists approach to eye trauma.  




Being able to use the NPL well definitely takes some work, but its pretty straight forward after a few days of practice.  We would give everyone a spray of afrin and topical anesthetic (another option is the nebulizer of 2cc of 4% lidocaine w/o epi and preservative free like found in code cart; also cetacaine and know the overdose methemoglobinemia syndrome to look out for!), let it kick in for approx 5-10 minutes, have them blow their nose and then start.  It helps to have the patient's head level.  In terms of maneuvering the scope and recognizing anatomical landmarks, check out the great website below and in particular check out the very last video titled "Episode 4 - exam of the larynx".  These videos walks you step by step for each section of the NPL.  In particular, you need to be able to recognize septum, turbinates, vallecula, epiglottis, cords, arytenoids, posterior pharynx, and the "post-cricoid" space.  Some tips and tricks to help - you may need to have the patient bring their chin to their chest to open up the nasopharynx, and sticking their tongue out sometimes helps open up the pharyngeal space as well.  To evaluate the cords, ask the patient to sniff in (to watch symmetrical opening of the cords) and to say "E" (to watch complete closing).



After practicing for a few days, you can pretty much get the motions and landmarks down, but as with any tool, its probably even more important to know when you're supposed to make use of it and why you're choosing that tool.  


In our ED, probably the most common reason for using it is in angioedema evals.  We see a surprisingly large number of patients (at a minimum we see this once a week) on ACE-I coming in with idiopathic oropharyngeal swelling / angioedema workups.  Most people want to jump to the NPL to take a look, but be careful and use your judgement. If a patient appears to have true angioedema to the point of their airway decompensating, you do NOT want to NPL them because you can't really accomplish anything except for observation.  Instead, you should be considering the route of the "awake intubation" (with assistance of ENT/Anesthesia) in which you take a bronchoscope (with an ETT loaded around it), lots of topical anesthetic and anxiolysis/ketamine/versed/etc but NOT RSI level sedation/paralysis until you pass the bronchoscope through the cords and the ETT over it like a bougie.  So, really NPL is only indicated for angioedema in the patient who looks otherwise comfortable that you don't suspect critical airway edema.  In these cases, you are specifically looking for any evidence of swelling past the lips/tongue into the pharynx or larynx to convince you otherwise. 


Theoretically, another indication for NPL in the ED would be to diagnose suspected epiglottitis, but again we encounter the question of whether or not its really the best idea.  In kids with true epiglottitis, tripoding on the brink of airway collapse, the last thing we want to do is force an invasive procedure on them that will make them upset, hysterically thrashing around until they loose the last bit of airway they were subconsciously stenting open.  In this case again, you have to get a big team on board (ENT, anesthesia, surgery) so that we have all measures available before any interventions take place.  In adults with this presentation, I think NPL would be much safer and very helpful to confirm epiglottitis, but again after consideration of the patients anxiety level and ability to calmly tolerate this somewhat invasive procedure.  


Other indications for NPL in ED:  identification of non-obvious epistaxis sources, FBs, and laryngomalacia (the omega shaped epiglottis), and vocal cord dysfunction / spasm.


ED approach to sudden hearing loss

This topic is near and dear to me since my father actually had this happen to him many years ago... he developed this episode of vertigo and sudden hearing loss, but it was after a long day of work so he just went to sleep instead of going to ED.... and was too stubborn to get evaluated for the week afterwards... and now he is completely deaf in one ear and 80% diminished in the other ear and is hearing aid dependent.  With our training we might have been able to prevent the understandably devastating loss of the human body's senses - we really don't appreciate how lucky we are to have them until they are gone.  It was kind of fun to learn some of the intricacies of this workup because its one of those chief complaints that relies on good exam skills and not necessarily the "tunnel of truth" CT scanner to answer everything.  


-Remember to categorize hearing loss in your mind into the big overlying categories of "conductive" (the one we hope to rule in) and "sensorineural (SN) " (the true hearing loss we'd like to rule out).  


-Ask about the things that clearly change our workup, like trauma, neuro s/s and vascular RFs (strokes can manifest with hearing loss).

-Cover the basics, like unilateral/bilateral, abrupt/gradual, OLDCARTS etc.  

-Very important to ask about associated sx:  infectious sx, tinnitus, fullness sensation, whooshing, ear pain, vertigo, systemic illness, PMH, meds/ototoxic (diuretics, nsaids, abx aminoglycosides, vanc, erythromycin, polymyxin B neomycin, chemotherapies)


-Physical exam is very important here...do your general exam but specifically look out for cerumen impaction, OME, TM perforation, etc.  

-Just when you thought you could forget some of those seemingly esoteric exam maneuvers you learned in school, think again!  The tuning fork is actually the key test to differentiate those big categories of sensorineural vs conductive.  A quick test you can do if you don't have tuning fork is just ask the patient to hum -- if they hear it louder in the affected ear, its more likely conductive; if they hear it louder in the unaffected ear, its more likely SN.  The same principle applies to the weber test with tuning fork placed in the middle of skull/bony transmission.  The rinne is also helpful as a confirmatory test.  


If you go through all of this, don't see any evidence of a conductive cause on exam, with the weber/rinne also pointing towards the SN issue, then take this seriously as a true hearing loss.  Bad predictors for irreversible HL are severe hearing loss, presence of vertigo, and advanced age. I would consult ENT and discuss starting high dose steroids, acyclovir (debatable utility but relatively little harm potential), and very close ENT f/u if they can't be seen in the ED.  


My approach above is abbreviated... for a more thorough discussion, check out these:







A few more ENT pearls the specialists taught me

Cerumen impaction in the ER... while I think that irrigation is definitely the easiest route, they noted that you can't rule out perforation and its technically contraindication if perfed, so they said they'd be fine with us just rx'ing debrox and having them f/u with ENT in clinic.  Clearly experienced PAs can do whatever they want, but it was nice to know this is an option especially if its a busy ED shift and I don't want to waste my time on a non emergent procedure.


Otitis externa tx... whereas I was taught and many people used to use the cortisporin *suspension* (not solution) because it theoretically is thicker and would be okay even if there were a perforation, this is now not recommended because they say it can still get past perforations, is ototoxic, and also has a pretty significant risk of hypersensitivity reaction that can mimic OE and in follow up might fool you into thinking they're developing a complication.  The best route is to use oflaxin or better ciprodex drops, BUT it is very expensive.  So, their go-to route is to rx opthalmic solutions of ciprofloxacin and dexamethasone individually, which are both generic and cheap and just as effective.  


What to do when a patient complains of tinnitus in the ED?  Only life threatening ddx of tinnitus that you need to worry about in the ED is aspirin toxicity, carotid artery dissection/aneurysm (would be a "pulsatile" tinnitus) , and severe anemia.   Most of these can be ruled out clinically.   




Ophtho post to follow shortly...

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Posted 17 December 2016 - 05:24 PM

Congrats Serenity, Blog has been great!

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Posted 17 December 2016 - 06:53 PM



Slit lamp exam

Learning the slit lamp is another important skill that definitely took me a while to get good at, and I'll be honest that I was a little skeptical of the utility of it prior to this rotation.  My main exposure to eye complaints was during our fast track rotation, and I really thought that it would take so much time to set up the slit lamp and do a full exam that I didn't know if it was really worth it most of the time.  I always wondered why I couldn't just use our magnifying glass in combo w/ the wood's lamp to be able to see the important things, which would be so much faster.  I now know the benefits of the slit lamp (which I will list below), and can certainly run through an exam much faster than before, but I guess I still don't have enough experience to be able to say in which cases the slit lamp is absolutely needed, or when the simple magnifying glass/woods lamp approach is sufficient... any experienced PAs have any thoughts on this?  


The way I see it, the unique benefits of the slit lamp are:

magnification -- can see very small FBs, corneal abrasions (and the pattern, to rule out dendritic lesions)

anterior chamber depth / angle measurement - in acute glaucoma eval

cells and flare - especially important in patients with blunt eye injuries to diagnose traumatic iritis/uveitis 


Some helpful references for learning how to use the slit lamp are listed below.  In general, they recommend having a systemic approach typically starting from the periphery and working your way in.  The cornea is clearly one of the critical points of evaluation and requires some maneuvering of the knobs.  While you start out most of your exam with a high, wide beam, after you want to go to the narrow "slit beam" at an angle to evaluate the areas of interest on the cornea.  Similarly, to evaluate for anterior chamber depth and cells and flare, you need to have the light at an angle, so over time you'll get a sense of how to swivel the light source around appropriately.  

-Podcast:  Ophthalmology eye video lectures - "the slit lamp exam" - very entertaining and helpful overview and a great place to start to understand the components.  You can also check out his website: http://www.rootatlas...amp-exam-video/





The "Ophtho Vital Signs"

If there was one thing ingrained into me more than anything, it was really diving into the core ophtho evals, the nuances in evaluating them, and really understanding what we are looking for and why.  They attendings basically said that they are happy to help with any ED consult, but they get upset when one of these aren't done when its indicated.  I'll outline a few of their pearls relating to each.  


1) Vision.  

A)Visual acuity - try to get the best one possible, because that's really all that matters.  Let the patient hold the near-vision eye chart wherever they want, you don't have to force it.  Encourage them to guess, and if they get 50% correct, it still counts as passing that level.  Use the "pinhole method" if they forgot their glasses, because this typically takes out the refractive error -  you can have them look through the direct ophthalmoscope or make your own pinholes.  

B)Visual Fields / peripheral vision.  We all know how to test this but it had been a while since I learned in school all of the different visual field deficits that can manifest, but it is something they talk about all the time and it is important.... it can point you towards thinking CVA after all.  


2) EOMs.  Via the "H" pattern.  This is especially important in eye trauma or known orbital fx, which are most often inferior and in entrapping the inferior muscles will cause a restricted eye elevation / diplopia.  


3) Pupils.  We clearly all check for the PERRL, but I can't say I've seen too many people checking for an APD (afferent pupillary defect) with the swinging light test in the ED.  I guess this is a mistake on our part, because my goodness the ophthos talked about APDs constantly.  The importance of identifying it was repeatedly crammed into our heads.  Make sure you know how to test for this correctly - have the patient focus on far away (don't want near accommodation to falsely change pupil), and swing light so that it only hits one eye at a time.  Remember, normal patients should have NO CHANGE in pupil size when swinging back and forth; if you  note that one eye dilates with light and swinging to the other eye constricts, the side of the dilated eye has the APD.  One noteworthy phenomenon that I saw several times was "hippus" in which bilateral pupils seem to "bounce" between dilated and constricted (2mm max) - but it is symmetric on both sides -- this is also a normal variant and isn't an APD.  The ophthos emphasized that the presence of an APD is definitely a game changer in terms of management... patient with a small retrobulbar hematoma, normal VA, normal pupils.... no problem just watch... but if its the same patient with an APD, that is one of their indications for a lateral canthotomy.  


4) Fundoscopy.  Definitely challenging in the ED where we typically don't dilate patients and most of our patients are elderly with senile miosis.  In terms of technique, know that you should have them fix on a distant target to help dilate their eyes and keep them still, and you should get as close as possible to their eye.  Get comfortable changing the dial to get the vessels in focus, which is critical for most older patients.  I really focused on honing my examination of the optic disc to be able to get a baseline to compare to papilledema, and the retina in general to compare to the pale appearance of CRAO or the stormy appearance of CRVO.   


5) Eye Pressure.  They measure it via slit lamp tonometry ("applonation" technique or something like that), but we all pretty much use the tonopen in the ED.  Be aware that since its not used much, you have to go through a specific calibrating process where you are holding it in different configurations, and oftentimes you'll need to tap several times to get a reliable average.  


The above are considered the "vitals", but of course they'll want us to do a Slit lamp examination, flourescein, etc as mentioned above.  




Ophtho approach to Eye Trauma:

We covered many ED and floor consults for patients with blunt trauma to the orbit with anything from eye pain to blowout fractures to retrobulbar hemorrhages to open globes.  In general, they always went through their routine of getting the "ophtho vitals" mentioned above, and then evaluated for the the following:


corneal abrasion -- flourescein exam and slit lamp


ruptured globe -- something they constantly talk about ruling out, but I never got a good answer as to if there is any definitive test to rule it out.  Certainly it should be high on your ddx if there is a concerning history (projectile, sharp objects, etc), red flags (decreased VA, APD), or signs of it:  peaked or prolapsed pupils, circumferential subconjunctival hematoma, very narrow or wide anterior chamber angles, siedel's sign (leak through fourescein), or decreased IOP (if you accidentally checked for this, which you're not supposed to until ruling out ruptured globe).  But they say oftentimes it will rupture posteriorly, which I'd imagine can be hard to pick up.  I know that CT can rule out an intraocular FB, and B-mode ultrasound in a very experienced person (so as not to put any pressure on globe at all) can sometimes help, but I don't think either of these is 100% sensitive to rule it out... 


hyphema -- clearly evident macroscopically or on slit lamp, graded based on the % of anterior chamber it fills up in relation to pupil.


traumatic iritis / uveitis -- a very common diagnosis after blunt trauma.  Patients will complain of eye pain, photophobia, red eye, maybe blurry vision.  On exam your pupil assessment should point you in this direction, because when you shine the light in the unaffected eye, the affected pupil will constrict and cause them "direct and consensual photophobia".  You confirm this diagnosis by seeing cells and flare on slit lamp:  set a somewhat wide, high-powered beam diagonally crossing the black space of the pupil to have a backdrop of being able to see the cells which are in focus in the anterior chamber.  The cells essentially look like dust particles floating over a black background.  This is treated with cycloplegics to stabilize the iris for pain relief, topical steroids (pred-forte), and close ophtho f/u within 1-2 days.  


orbital fracture (dx via CT) and entrapment -- via EOM and restriction / diplopia noted clinically.  Give them the standard precautions:  head of bead to 30 deg, no blowing nose, afrin x3 days, keflex or augmentin ppx


traumatic retinal detachment -- typically their s/s would clue you in (decreased VA, flashes, floaters, curtain coming down, etc), but some ophthos say all significant eye trauma patients should have a dilated eye exam in very close follow up to definitively rule this out.  


retrobulbar hemorrhage --  proptosis should clue you in, and should be evaluated with a CT max / facial.  Once identified, they evaluate the ophtho vitals, optic nerve function (APD, color and light vision, VA, etc)





Other Ophtho Pearls


Vision loss has a large ddx, but some helpful rules of thumb to at least point you in the right direction.  First, always get the best visual acuity possible as mentioned above.  Ask about pain or not, which is a big help in the ddx.  

-Transient --> TIA

-Flashing lights / floaters --> RD.  

-Under 50 y.o (and especially so if female) --> optic neuritis.  To further workup, know that optic nerve dysfx will manifest as an APD (marcus gunn pupil), color perception and light perception (cover their eyes one by one and ask if it looks different)

-Over 65 y.o and with a headache --> GCA / TA - palpate their temporal region and check ESR/CRP


When performing direct ophthalmoscopy to rule out papilledema, look out for disc margins (a blurred/hazy points to papilledema),  cup:disc ratio (a very low one points to it), and look for spontaneous venous pulsations, which effectively rules out papilledema







Well thats it for this month.  On my next (and final) rotation, I'll start out with our yearly "lab week" (great lectures, sim labs, and procedural practice), then 1 week of vacation, and I'll end with my final 2 weeks in the ED as a resident!!!!  Wow, how time flies... I can't believe its almost over!!!

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Posted 17 January 2017 - 05:30 AM





A Residency in Review...


What have I learned?

-The people of EM... all sharing in a pretty unique culture and personality that draws us to this field.  

-The patients of EM... and the incredible effects inner city poverty has on patients' physical well being and as well as their mental well being.  

-The flow of EM.  The pace, thought processes, multitasking, and decision making overload/fatigue.  

-The range of EM.  From the nonverbal neonates to the nonverbal elderly and the oftentimes overly-verbal in-between.  



What I didn't learn and still need to work on?

-I recognize that in general I still have a ton to learn, but I do know that I have significant gaps in some parts of OB Gyn, neonatology, running/leading traumas, advanced airway control (fiberoptic/awake intubation/etc), just to name a few areas.  That is okay though, because I knew from the beginning that these 18 months would not teach me everything there is to know; I chose medicine because its a field that will let us learn for life.  



What benefits did I take away that I hadn't foreseen before starting?  

-The great friends.  I never would have guessed how much as residents we would form into a giant family around the hospital as we rotate on everyone's services, sharing the immense workload and all the ups and downs that come with it.  You form a bond, and as a result I've made incredible friends for life.


-Stemming off of this, I now have great friends who will go on to be orthopedic surgeons, intensivists, nephrologists, etc in nearly every specialty that I can always call on in the future whenever I have tough cases that I'd like their feedback on, concepts I don't understand, etc - this is a HUGE benefit in my opinion.  


-On a similar note, when you join into a residency family, you are joining into a massive network of residents and alumni who have dispersed throughout the entire country and will be the invaluable "foot in the door because you know somebody who knows somebody".  


-The incredible versatility that perhaps only an EM residency can provide.  The breadth of emergency medicine alone is wide enough to apply to nearly all other specialties, not to mention the advanced procedures, the ultrasound training, and the off service rotations working on the front lines with the specialists themselves.  If the night shifts, high stress and burn out that affects so many people ever gets to me, this residency has equipped me with skills that would help with so many other specialties... critical care, trauma/surgery/ortho, hospitalist, interventional radiology, urgent care/primary care, etc.


-The enormous number of educators you are exposed to.  The residency provides dozens of faculty and senior residents in EM and in each off service rotation as well that ends up totaling to hundreds of educators that you are exposed to... at least 5 fold more than I had as a student.  Being exposed to so many people helps you find more of those rare people that just seem to *click* and really resonate with you... these people are the ones who you truly look up to and are inspired by, and in residency these educators are there by choice so I've found that they are happy to take you under their wing as a mentor.  I have been more motivated to learn by those that I truly admire and look up to in my every day life than by the most expensive conference / textbook / national "thought leaders" out there.  Such invaluable opportunities!




​How did I feel when I walked out of the hospital after my last shift (a pretty representative night shift that I only mustered a couple hours of sleep prior to starting)?

-Exhausted, physically and mentally from this 18 month journey.  

-Bittersweet, as I thought about all of the friends I'd have to leave behind as they continue the grind with the residency family.  



Am I glad I did it?   Heck yes!

Would I do it again?  Ugh


Where do I go from here?  Vacation!!  Then we will be moving out to Seattle, where I'm not personally from, so I'd love to meet any of you all out in the pacific NW (PM me!).  Also, I haven't signed for any jobs yet, so let me know if you all hear of any opportunities that pop up in the greater Seattle / Tacoma / NW area!  


I've said it before and I'll say it again - I have really enjoyed writing this blog.  It has been a chance to reflect on this crazy experience, review some of the medicine / pearls to commit them to memory, start to develop some basic teaching skills, and get a bit more integrated into our PA community.  I've loved all the messages, PMs, and support from you all along the way... thank you for joining me in this journey!    





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Posted 17 January 2017 - 05:48 AM

SN: Thank you for letting us taking a peak in your residency world

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