SERENITY NOW

Lots and lots of gel is key. I often squirt a whole cup of gel on the anterior abdomen before starting the exam, then I scoop up plenty onto the probe for each individual scan. You wouldn't have to press on the abdomen at all if you have enough gel contiguous with the transducer. The exception as noted above is the subxiphoid view (agree with switching to PSL if they're too tender).

So I'm at the advanced EM bootcamp conference in Vegas and we had a great lecture on "serious illnesses that can present in a benign fashion"... A wolf in sheep's clothing". Great lecture by Dr Diane Birnbaumer, who is a wonderful teacher that presents things in a unique way compared to many other lecturers. If you ever have a chance to hear her speak, take it! Her cases definitely fell into the umbrella of test negative or occult EM, so I figured I'd periodically share some of them here for you all to learn from too. 13. 22 year old F had a severe headache while she was sitting down at work yesterday, with the severe intensity lasting around the first 15 min, she took tylenol and went home. No hx of headaches / migraines in past. It has since resolved and she feels fine now, and is asking for a work note. Do you give her note and discharge her? 14. 28 year old M presents with R knee pain and swelling since yesterday "while playing basketball" (though no injury and he didn't feel like he tweaked it while playing). He now can't move his knee. XR neg for fx. DDX? HnP that would help? Workup from here? 15. 36 year old F presents with fever, sore throat, hoarse voice. On exam her oropharynx is clear. Strep test is negative. DDX? HnP that would help? Workup from here?

Sounds like an awesome opportunity. Agreed that it would be very difficult to find the same setup as a PA outside of new age academic EDs, but I would totally do it if I were in your shoes! A year will pass in no time and you'll take that experience with you for your whole life. I would see if you could get some shifts in the ED throughout the year though, since you'd be surprised at how quickly things atrophy after you leave the ED and put all of your attention to a new specialty.

Great idea. I'd be happy to help. I had already been accruing the basic "things to do after graduating" list over the past couple years, which was made into a sticky in the hidden sticky section. I think it would be a great idea to add more topics (like below) that would cover the spectrum of things to learn and challenges for new grads. Would be good to keep this sticky actually on the front page here because we do see so many questions on these topics. Just off the top of my head, I can think of several topics that I wish I had a brief primer on when first starting out.... -practical first steps (process of getting state license, DEA, keeping logs, etc) -choosing a specialty (general forum pearls like trying to stay general first) and considering residencies -process of applying for jobs. Where to go, qualities to look out for, questions to be ready for, and questions to ask them, etc. -business of medicine, know what you are worth! Basics of metrics and what we are now judged on. -malpractice risk and insurance - different types of insurance, ensuring you have occurrence or tail coverage, etc. basics of identifying highest risk situations, risk avoidance, charting. -starting your first job - biggest challenges when starting practice: interacting with consultants, transitioning from didactic resources to practical clinical resources, etc.

And of course, during your learning process, if you stumble upon any particular lectures or resources that really stand out as being superb, you could share it with the rest of us... on a website like FOAMest.com And while you are there, you can check out the resources that others have found to be the most helpful too. This is one of the educational projects I've been working on, since I remember how frustrated I was as a new grad wading through all of the countless resources out there. I hope it helps~

When I first started out in EM, I found that I had to learn with a much different perspective than in school. Its not about learning the details from a disease-centric perspective (ie heart failure causes these symptoms and is treated this way) its all about the approach to the chief complaint (ie how do I work up a patient with shortness of breath). Very different perspective to go about your learning... it replicates what you are doing on the job. You are given a chief complaint from triage, and have to know the relevant emergency ddx, and based on that, know the relevant HnP, and the tests to order to rule out those emergencies. That is 90% of what we do in EM. Once you establish a dx, just uptodate it on the spot for the treatment details... no need to memorize treatments at first since they will just be drilled into you over time anyways. Best resources to study the approach to chief complaint... -#1, bar none --> emrap C3 (continuous core content) -- Many resources are academic and not what we actually do, but emrap C3 is spot on.... its simply the best I've seen. They start with a real patient case and have a discussion about each step in the process of working up and managing the most common patient scenarios. -Beginning chapters of Rosens (one of the EM textbook bibles) focus on approach to chief complaint. -Minor emergencies is excellent for on the job reference of practical "what do I need to do", but perhaps not really geared towards studying and understanding the principles of what you're doing. -to practice your learning with a practical EM simulation app, check out EM Gladiator's app called "resuscitation" -- it is interactive, very good content and provides feedback on what you missed. It is free as well. One of my colleagues had a great idea that I adopted and am very glad I did when first starting out... As you are learning from the above resources, especially if you have access to your EMR, start to make your note templates with the learning points written into them. Ie if you are learning about chief complaint "back pain" and studying the resources, you can have your HPI already prepopulated with things like "patient denies saddle anesthesia, bilateral radiation down legs, incontinence, retention, immunosuppression, IVDU, etc" which are targeted to the ddx and can spark your memory if you are taking care of a patient down the road and forget what is important to ask (I chart in the room so its right in front of me while examining). So with this method, studying is helping you learn the essentials, making your evaluations more thorough on shift, and making your charting more efficient... killing 3 birds with one stone.

Nice work, team. Sorry I haven't been able to post recently but have been busy with work, but the questions were discussed just fine. This patient ended up having ED stabilization of BP, blood sugar, head of bed, coags and we called a neurosurgery consult. They took him to OR for a crani, was in the ICU for some time, and I believe in the end had a poor outcome. It is very unfortunate that this was a bad outcome, but it is a case that certainly has a lot of teaching points at each step of the way, so I hope you all found it valuable as well. If you enjoyed these cases and this format, let me know since I am happy to do more. If you have a particular chief complaint or condition that you struggle with, let me know and I can gear future cases to those needs. Thanks for following along! -SN

I have been recommended to keep a log of all of my advanced procedures that I do in EM. I track it all under the "patient list" feature in epic, with a category of procedures. It saves mrn, procedure, date performed, etc. My credentialing team with the hospital wanted us to provide proof that we have performed every procedure at least 2-3 times in the past 2 years, and that is all of the info they would need.

Really enjoy your posts - thanks for sharing. If it makes you feel any better, I felt like I didn't know anything throughout the entirely of my residency program and honestly I still feel that way today a year and a half out. Imposter syndrome is very real, especially for us as PAs trying to kick it in EM and critical care with the docs. But then again, I see physicians who have been doing it for years find themselves in situations where they feel like they don't know anything either. I think that is probably a healthy feeling that fuels us to never stop learning. Put one foot in front of the other and don't sweat it...

Right on the money! CT is where unstable patients go to die... must have ABCs covered before going to CT, and an altered stroke patient uncontrollably vomiting should have their airway taken. So, you tell the nurses to bring the patient back. He seems to be decompensating... now his eyes aren't open, and he is not following any commands. Sternal rub gets him to stir slightly but overall you are very concerned. You perform another critical evaluation piece: scan the chart for code status and advance directives! He is full code and okay with intubation / mechanical ventilation; nursing staff calls family in. Very good thoughts regarding ICP... assume the worst and choose RSI medications that will not raise ICP (which meds would be good choices and which bad choices?). You successfully intubate him, confirm placement CXR, and make sure everything is stable post intubation, because often unstable patients can crump after intubation (hence the saying "resuscitate before you intubate"). Luckily he is stable post intubation... you whisk him off to CT scan and your concerns come true... a large subdural hemorrhage with midline shift. We have our diagnosis, now what do you do from here? How do you manage his intracranial hemorrhage? Lab workup is starting to come back and so far looks unremarkable. CBC wnl, platelets wnl, BMP unremarkable aside from mild hyponatremia and blood sugar 260, coags wnl.

Great answers! I'm sure if you asked 5 different docs / PAs you'd get 5 different perspectives on topics like these. My perspective is the following (and I'm not even sure if it is 100% concordant with the book answers).... if I don't have a definitive last seen normal time, I don't know if a code neuro is appropriate, which is why it is part of the critical information you must have before calling the code neuro. In this case, we had our nurse call the living facility who had to track down the CNA who finally told us that this patient's last seen normal was several hours ago (over 6 hours ago). With this new information, we did not call a code neuro but instead just called down to CT to get him expedited. A non contrast head CT is always going to be a safe answer in acute stroke sx workup. You can't go wrong with it. However, many stroke neurologists and ER providers are switching to CT angio, especially for NIHSS over 8, since its protocol still includes a nonctontrast head CT eval AND it can identify high grade occlusions amenable to IR intervention regardless of the time of onset of symptoms. There is new research showing that our imaging modalities (CT and MR perfusion scans) can be more helpful at determining the potential benefit from intervention than the time of onset can. There have been reports of improvement up to 24 hours from time of onset! So, you proceed to order a CT angio on this patient, who had a very high NIHSS and prolonged sx duration, nor any hx of renal problems. So, everything has been stable, CT tech says that they cleared their table and are ready for your patient. The nursing team starts wheeling them down the hallway and you go to see your next patient, when..... "Hey its Lynn (the nurse), our patient was just about to be transferred to the CT table and he started vomiting all over the place. Is it okay if we just try to get this CTA quick and get him back right after?" How do you proceed?

So, the neuro exam can be challenging on these altered patients. After all, the neuro exam we learn in school is geared towards the patients who are awake, talking, and essentially interacting normally.... aka the type of patient who probably doesn't even need a neuro exam to begin with. Be ready to apply the neuro exam to all sorts of patients, from altered to unconscious. His neuro exam: overall alertness - he is awake and seems to be looking around purposefully. You try to assess some cortical function by asking basic questions with nodding yes and no - he is able to nod his head appropriately, but for some reason he is only answering your questions and not to the nurses who are asking him questions on the other side of the bed (why might this be? And how could you confirm your suspicion?). You assess sensation - he can nod his head that he does feel you touching him on all extremities. You assess motor function - he is only moving his L arm and leg - his R upper and lower extremities are flaccid. He does not have an appreciable facial droop. At this point, your concern is clear --- this is a suspected CVA until proven otherwise, and time is of the essence. You call over to CT scan to get them ready and you try to get a quick NIHSS but encounter your first issue... how do you document an NIHSS on a patient like this who is nonverbal and unable to be tested for several of the areas of the test? (he cannot answer LOC / orientation questions, visual loss questions, nor extinction). Do you omit the sections that can't be tested or count them towards the total points? You also wonder to yourself, should I be calling a "code neuro" or not? (A "code neuro" is what is called over loudspeaker of hospital for those who are tpa candidates to mobilize a large team to expedite workup, neurology consultation, and tpa administration)? How do you make that determination? What are the critical things you need to know when dealing with a neuro / stroke case? How would you go about getting this information in this case given that the patient is nonverbal? And last food for thought, which of you would order a non contrast head CT vs a CT angio head / neck, and why?

Great thoughts @pastudentw ! For this patient, ABCs are intact, Accucheck 198. Lung sounds clear, chest rise present, skin / extremity exam is without signs of infection, pulses symmetric. I'm going to wait on giving workup results at this point until we get a little more feedback. We make a quick determination at this point, 2 minutes into his evaluation... sick or not sick? Stable or unstable? He appears to be sick, but stable. Acutely altered elderly patients often have very bad things going on. This is not the time to hold back on ordering tests. After the ABCs / basics, its common practice to 'shotgun a bunch of tests while you continue to try to sort things out at bedside. The challenging thing is that these patients often need a lot of orders, and it can be easy to forget important ones. I find it helpful to make note of "unique features" that pop up throughout the case that each have their own workup considerations, and be sure to address all of them (I use check boxes on my patient note sheet). This way I am systematically going through a checklist and its much harder to miss important parts of the eval and orders. This case has several unique features... What evaluation (HnP) might you do, and what orders might you include for each of the following features in this case? -found down patient -syncope vs seizure -altered mental status (AMS) -neuro eval (a subheading under AMS) - bonus question: pretend you are at bedside and ask yourself specifically how would you go about getting a neuro exam on a nonverbal and altered patient? -vasculopathic patient Answers don't have to be perfect! We are just discussing some points as we work through this case. I'm hoping to provide a little bit of the framework as we go.

You, the intrepid new grad PA, arrive for another busy ED shift. You are working in the main ED, and EMS comes in bringing in a 70 something year old man from assisted living facility who is awake on the stretcher. EMS gives the report, "This is a tough one. The facility wasn't able to give much of a report, and the patient hasn't said a word to us. The paperwork they gave us said that the patient only has a PMH of HTN, DM, MI and he is usually functional. The staff nurse found him passed out laying on the ground in the middle of his room and his extremities were shaking for a few seconds before he woke back up. Since waking up, he has remained nonverbal which is not typical for him, but they didn't give us any further details." Your team mobilizes without you needing to say a word and things happen in parallel while EMS is giving the report... -Vitals: 194 / 104. HR 98. RR 12. O2 94% Temp 99 oral. -peripheral line placed -placed on cardiac monitor: normal sinus rhythm The team now looks to you, "What's the plan, boss?" Do you have a systematic approach for this type of situation? (hint, you should!) What is your approach? I will provide details/answers to fit whatever approach you put forth to make this interactive as we walk through the case. (This is based on a case I had in residency a couple of years back.)