SERENITY NOW

Nice thoughts @fishbum. The answer to the "trick question" of #8 is that the ddx doesn't really change and the real error is the ordering of the head CT in the first place. Head CT really rules out very little in a non traumatic headache patient. The test is still for some reason part of the "standard workup" for so many docs/PAs/NPs. I think it actually hurts our case when a well appearing patient who you think will be fine has a "just to be safe" head CT come back negative and you go on to discharge the patient... would have been better off not ordering it at all. We have these discussions on our M&M / quality committee all the time... the plaintiff attorneys say things like "the PA clearly knew something was wrong so they ordered a head CT, but they didn't know how to finish the workup to confirm the diagnosis". The test begets a follow up test if it is negative, like an LP, CT angio, MRI, etc etc. So, I am always careful about first thinking what it is on the ddx that I am able to clinically rule out, what specific disease I am still considering, and what rule out tests that needs. CT is almost never the sole answer... so be careful with it!

If I were back in the shoes of residency applications I would strongly favor joining a residency program that puts you in with physician residency classes, which all start in July. I know its competitive so I'd probably apply everywhere I'd be willing to live, but I'd definitely prefer the traditional ones. Its possible to fast track licensing and hospital onboarding in many states and you could graduate, finish pance, and be working within a period of a month or two. I think having even 4-5 months of experience before going into a residency would be valuable - read the first few posts from my blog to get a sense of how overwhelming it was going from student with no responsibilities to managing main ED patients within the period of a month. Not to mention the fact that truly sick patients are challenging for everyone, it was the million little things that you don't do as a student that all heap on you at once... hospital policies and procedures, EMR maneuvering, charting, interacting with consultants, etc... it was very overwhelming and even having a few months of normal job experience under your belt will help you sort out a lot of those things before jumping into the deep end of sick residency patients. Of course I agree it would be crappy for the place hiring you to only stay for 4-5 months, so because of that I would definitely be up front with them about your plan. It would likely be tough to get a job in the first place making it a moot point, but it can't hurt to apply and if you do luck out with a job, I think it would help. Might also be more realistic to reach out to the residency program you get accepted to and see if they have staff PAs/NPs working in their ED - you'd probably have a better chance having their group hiring you since they'll think you have a much higher chance of staying after residency. Can't hurt to try!

I'd try to get a job in your field before hand if you are able. Not only will it give you a nice headstart on loans, it will give you a good base of experience so that you can jump into the deep end in residency and really make the most of it. That being said, what field are you going into? A march start seems odd for a standard residency which typically will have a summer start.

Thanks for replying ERCat! Good answers too. The more perspectives, the better. I'll share a few more cases that have come up.... keep on guessing folks, and feel free to share away your own! 7) 42 year old M comes in with hand and finger pain after falling last night while drinking, she doesn't remember the details, hand and pointer finger are swollen and painful --> triage hand/finger X-rays negative --> ? ddx / plan / why? 8 ) 32 year old F comes in with a new / unique headache compared to her prior migraines --> head CT negative --> ? (this is almost a trick question but bear with me) 9) 32 year old F comes in 3 days postpartum with a severe headache --> head CT negative --> ? 10) 87 year old F comes in immediately after a mechanical fall with head injury, on warfarin, is asymptomatic --> CT head / neck negative --> ?

In the spirit of EMED's great "its probably nothing, fast track disasters" thread, I've thought of a similar ongoing thread topic that I hope will provide some more good learning content and food for thought. I've found that a lot of newer students / interns / APPs (myself included) often fall into the trap of thinking, "well, the tests are all negative, so that's all there is to it" and discharge the patient. "What else could I even do for this abdominal pain patient with negative labs, CT, etc... surely we've ruled everything out!" Well, I've been spending a lot of time with our ED quality committee, aka morbidity and mortality team, which reviews high risk cases and misses that have went through the group... it really has been a great learning experience - I'd recommend everyone check it out if they haven't yet. The line of thinking noted above is a common pitfall that we see, because there are still emergencies that can be missed even after the "standard workups" come back negative. With that in mind, I made an evernote document on my phone about a year ago where I've been keeping track of situations that arise in practice that fit this general theme... I've got it organized like this: The situation --> the negative test --> it can still miss XYZ targeted ddx for relevant emergency medicine conditions --> so, what to do (and don't forget that you need to document in the MDM to say why you don't think those are occurring) --> why its important, or what are the risks of missing those conditions. Here's a classic example: FOOSH injury --> triage ordered hand and wrist X-rays that are negative --> ddx: occult scaphoid fracture, elbow fractures, proximal humerus fractures --> plan: examine those areas, X-rays other areas if needed, rarely advanced imaging if very high suspicion, otherwise place in thumb spica splint and follow up in 1 week for repeat exam and repeat X-rays --> Why? Because missed scaphoid fractures are a common miss and lawsuit potential because of the bad outcomes and chronic issues that result from them. .................................................................................................. Alright team, in the same fashion as Emed's thread, lets see how you do with a few of the cases I've complied... 1) elderly fall from standing with back and hip pain and not ambulating --> back and hip X-rays negative --> whats your ddx / plan / thoughts / reasoning? 2) closed head injury with significant mechanism, noting head and neck pain --> CT scan head / neck is negative --> ? 3) soccer injury - traumatic knee pain and swelling, unable to ambulate --> knee X-rays negative for fx --> ? 4 - A) RLQ abdominal pain and tenderness in a 23 yo M x 6 hours --> labs, CT scan neg --> ? vs 4 - B) RLQ abdominal pain and tenderness in a 23 yo F --> labs, preg test neg, CT scan neg --> ? 5) Periumbilical and epigastric abdominal pain in a remote roux-en-y gastric bypass patient --> labs and CT negative --> ? 6) infectious / viral syndrome (fever, congestion, cough) with pleuritic chest pain --> CXR negative --> ? Theres probably no specific right or wrong answer to these, but let me know what you'd include for answers and I'll share mine, and hopefully we'll all learn as a result. I've got quite a bit more where these came from... would love it if others would share similar situations that they encounter to make this an ongoing learning thread. -SN