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My EM Residency Experience...

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Hi everyone,

I have been a member of the forums for a while and have found it very valuable at each step towards becoming a PA.  On this sub-forum, I really enjoyed reading about the experiences of people going through their residency in the pseudo-blog format.  I wanted to replicate that as I go through my residency. I am now one month into my program and I think it is going to be a great experience. 


Let me tell you about the way my program is set up (sorry, but I am going to omit the name of the program).  Its an 18 month program that heavily integrates me into the physician residency class.  The class has been very welcoming to me and I would now consider them to be my good friends.  We are located in a large U.S. city with the busiest ED of all the local hospitals, seeing well over 100k patients per year.  I will do rotations in anesthesiology (learning intubations), telemetry/cardiology/CCU, neurology/neuro ICU, general surgery, orthopedic surgery, radiology/ultrasound, OB-gyn/L&D, ENT, Ophtho, pediatric ED, ED Obs unit, fast track, and a community hospital rotation dedicated to learning and practicing ED procedures.  Every other month, when I am not doing an off-service rotation, I'll be working in the high acuity sections of the ED.  In addition to this, every wednesday we have protected time for conference with faculty lectures, grand rounds, tintinelli reading club (we will nearly read the entire book by the time I am done), small group practice, simulation lab, procedure practice, ultrasound training, etc. 


The first month has been going well.  It is a whole month dedicated to orientation in which we have a mix of lectures and "princess shifts" (6-8 hour shifts).  We have also taken the certification courses for ACLS, PALS, and ATLS.  The lectures have been geared towards the approach to bread and butter EM chief complaints, like chest pain, dyspnea, syncope, etc.  Our princess shifts have basically been a chance to orient ourselves with the department, learn where everything is, how to use the computer, etc.  There is no pressure to speed through patients; I havent been seeing more than 5-6 patients in an 8 hour shift!  For that I am incredibly thankful, because I am slower than molasses and never could have imagined how many little details you need to know to navigate our healthcare system and EMR. 


So that's basically the summary of my experiences so far.  I will try to keep you all updated as I go through.  My first rotation is anesthesia so look forward to hearing about that!





In addition to providing my personal experiences, thoughts, and reflections as I go through the residency, I've decided to share a bit of the most important practical medical knowledge I learn at each rotation.  My motivation for doing this goes back to the days before PA graduation when I read through the residency blogs like this.  I'd see posts like "my cardiology rotation was a great experience... I learned the most important 'take-away' knowledge like how to do a focused cardiovascular HnP, interpret troponin elevation, etc".  They'd just mention these things and I'd always yearn to hear them fleshed out, straight from the person's mouth instead of the dry textbook that never seems to be entirely clinically relevant.  So, I am going to try to do just that.  I'll list out the most important topics I learn and I'll try my best to actually go into the some of the important details underlying them.  I'll make sure to focus on the things that were emphasized to me by my attendings and real world experiences.  Last, I'll try to share some of the best resources I encounter as I my program immerses me in the world of EM.  Eventually I'd like to go into education in some way or form, so I'll treat this like a practice run for some basic teaching exercises.  I hope this is worthwhile for you all, and I'd really appreciate any feedback you're willing to give.






-----Update 2018 edition -----

More of my past educational posts for those who are interested:

Interactive patient case series

Advice to students on rotations

"The test is negative, discharged!" Occult EM. Test negative misses.

Applying to PA school tips

New PA-C To do list (practical)

Favorite physical exam findings



-----Update 2022 edition - I wrote a book! -----

Hello all!  I can't believe 4 years have passed since my last post.  A lot has happened since then... I've since gone on to become a lead PA in the ED and even founded our own EM PA/NP residency program at our group (going to keep the program anonymous as I don't want this to be viewed as advertising).  I am also very excited to share a project that I've been working on for a long time now... a guide book for PA/NP students applying to and completing residency programs!  

It is the book that I wish I had before starting my program.  As you saw through my blog, I definitely struggled through a lot of the program.  I loved the struggle, but it was still a struggle, and it could have gone much smoother haha.  The goal of this book is to give you the insider info to know what challenges to expect each step of the way and how to deal with them like a pro.  


Check out the link to the amazon page.  Let me know what you think!


Here is some of the content...

Overview of PA/NP post-graduate training programs

  • What they are, what they offer, the different types of programs you’ll find, and the pros & cons of each.
  • Checklists for key areas to assess in each program you research.
  • Deciding which program is right for you.
  • Examples of what the daily life and roles of real PA/NP residents looks like as they go through training.

The application and admission process

  • The prerequisites, components of your application, and how to become the best possible candidate.
  • The interview questions you’ll be asked, how to interview well and get a spot in your dream program.

The residency journey, the challenges you’ll face, and tools to succeed

  • How to prepare for the start of the program.
  • How to maneuver your first months in your new department.
  • Review of a few key medical topics that challenge every trainee.
  • How to write professional notes, call consults and admissions.
  • How to survive on medical, surgical, and off-service rotations.
  • How to deal with other common challenges in residency.

Graduating residency and finding your first job

  • How to write a strong CV.
  • Tips for applying and successfully leveraging your residency experience in contract negotiations.
  • Key things to look for in your job contract.

Your first job after residency training

  • Transitioning to your new role safely.
  • Risk management pearls.
  • Foundational personal finance steps to take with your first job.
  • The learning journey in medicine that lays ahead of you.





*Medical Disclaimer*
The medical information on this thread is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes by patients, students, PAs, nor any other health professional. Any information found here should not be acted upon without consideration of the primary source material and professional input from one's own health care professional, supervisor, primary resources and references.  This information may not be up to date or completely accurate, and should not be relied upon.  This information is not intended to be patient education, does not create any patient-physician-assistant relationship, and should not be used as a substitute for professional diagnosis and treatment.  The views expressed on this thread and website have no relation to those of any academic, hospital, or other institution with which the author is affiliated.  

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  • 4 weeks later...

Hi everyone.  Time for an update.


Anesthesia rotation experience:

Overall, it was a pretty good experience.  There were a lot of other CRNA students/residents/fellows and we were all competing for airways; at times it was slim pickings unfortunately.  I tried my best to get as many airways as possible, so I stayed late several days and even came in a few extra days during my vacation and ultimately got around 30-40 ETT attempts and many LMAs.  With the significant amount of free time waiting for cases, I tried to study up as much as I could about other topics relating to anesthesia, such as procedural sedation.  I think I learned a lot of the important take away lessons, which I will try to outline below.


Best resources:

General process and things to know -- Steve Carrel's EMBasic podcasts "airway", "airway update screencast", 


Practical checklist to have with you in the ED, both for intubation and procedural sedation (really good!): Reuben Strayer's website EM Updates.  http://emupdates.com - see top right column on home page. 


Scott Weingart's EM Crit has tons of great podcasts on airways and his procedural sedation podcasts were great too.  His website also has the "post-intubation checklist" if you search for it.  


I did have a chance to read Levitan's airway book and watch his "airway cam" video series.  For those who don't know, Rich Levitan is one of the world leaders in everything airway.  The video series was great (type in Levitan airway cam into youtube to get an idea of his videos), but probably not worth the very expensive price for those who'd have to pay for it out of pocket.  His book was okay and made a few important points I hadn't learned elsewhere, but also probably not worth the price.  




Main take-away learning points from the rotation:


1 - The intubation process.

Looking back now, I think the learning process I went through was quite comical.  When reading many of the textbooks, you'll see that they outline the process in a very stepwise fashion.  Step 1) open mouth.  Step 2) control tongue.  Step 3) find epiglottis.  etc etc.  But when I watched the videos of it being done by experts it looked like such a nice smooth motion!  I thought, "to heck with learning it in steps; I am going to do it by feel in one smooth motion like the experts."  I practiced on the mannequins dozens of times in this fashion and I thought I had it down. Little did I know the mannequins are MUCH easier than a real life patient.  


I went into my first case and tried to do a nice smooth intubation.... and I couldn't even get the blade all the way in the mouth.  Learning point 1), you have to REALLY crank open the mouth.  Use the scissor method, putting your fingers as far lateral on the teeth as possible so that you get the most leverage possible.  "Okay", I thought, "I just have to open the mouth up wider and then the process will go smoothly".  Wrong again.  I got the blade in the mouth and tried to find the cords, only to learn my next hard lesson:  a real human mouth (as opposed to a mannequin) is a wet, sloppy mess with a ridiculously large floppy tongue that is all over the place.  You seriously won't be able to see anything until you get control of the tongue, and there is a specific way to do this.  In my opinion, the technique that made this much easier is what I think of as "the right angle" technique.  When you insert your blade, insert it at almost a right angle, with the tip of the blade pointing much farther to your right than you'd ever imagine is right.  As you go deeper, sweep the tip of the blade back towards the midline keeping the tongue completely on the left.  


I said above that my learning process was comical because I ended up messing up at EVERY STEP in the intubation process outlined in the textbooks before I realized that they put those steps in there (and in that order) for a reason.  It is crucial when you are first learning it to conceptualize the intubation process in this stepwise fashion.  I'll copy and paste my notes on the steps in the next post...

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Well, in the meantime, I've created a dropbox account that can host some of the images of my notes.


Here is the link to my notes on intubation steps:



I apologize for it not looking the prettiest and there being random bits of images cut out.  I am taking screenshots of specific segments of my notes that I think are the most important and I don't have time to make it look perfect.  




Take away learning point number 2:  The importance of bag valve mask ventilation.

good resource that mirrored a lot of what the anesthesiologists told me: Reuben Strayer's video on BVM: http://emupdates.com/2012/01/11/11-minute-screencast-emergency-ventilation/


If there was one thing that was emphasized to me more than anything else during this entire rotation with the anesthesiologists, it was this: ​the most important thing you should learn is how to properly BVM.  BVM is what will save people's lives when things go south; this is what will be your vitally important "backup parachute" when your main parachute (intubation) fails to deploy.  While it may seem like a very straight forward and easy skill, its actually deceivingly difficult.  At first I really struggled learning this skill, even more so than intubation itself.  I am not kidding!  Part of the difficulty is that every anesthesiologist has their own way of doing it, so they're constantly making you change.  But, I did find some common rules of thumb amongst all of the different techniques, and some techniques that worked especially well for me:  


1 - PATIENT POSITIONING:  Successful BVM starts before you even put the mask on the patient.  Get them into the "sniffing position":  base of neck is flexed anteriorly (put blankets under their neck), and the atlantooccipital joint is extended (chin lift maneuver).  

2 - use both hands to JAW THRUST, then maintain the jaw upwards with the one-handed technique either with your pinky at the angle of the mandible or your 3rd and 4th fingers gripping up under the mandible midline (pulling back towards you in a chin-lift type motion).  

3 - place the mask first at the nasal bridge and roll down until its at the mouth, then position your first and second fingers in the 'C' position on the mask.  

4 - you are now in position... CRUCIAL POINT: THIS POSITION SHOULD FEEL LIKE YOU ARE BRINGING THE CHIN/MOUTH UP TO THE MASK, NOT PUSHING THE MASK DOWN INTO THE FACE.  If you were to push the mask down into the face without any jaw thrust/chin lift, you'll just be occluding the posterior pharynx and you won't be able to ventilate well.  The only pressure coming from on top of the mask (the 'C' fingers) should be a side to side rocking of the mask to address a leak on either side.  


At this point, you'd be able to start bagging the patient.  You'll be able to tell how well you are doing because

1 - the chest will rise

2 - you'll hear if air is obviously escaping from one side or the other, and you'll feel like its too easy to bag (because its not a good seal)

3 - you'll see waveform capnography readings (in the OR at least)


If you aren't able to BVM at this point, you can troubleshoot a few ways.

A - Keep repositioning your hands.  Perhaps go straight to two handed BVM if you're in the ED.  See video above for technique on 2 handed BVM.  If you can tell that all of the air is escaping on the R side (this is the most common because your C fingers will be on the left), you can turn the patient's head so that its looking to the left, which really helps make a better seal on the right.  

B - if a beard is what's causing the problem, you could put surgilube or some other viscous liquid on the beard to help make a seal.  

C - could Insert OPA or NPAx2.  

D - could Insert LMA.  


Also, when it comes to rate and volume of BVM ventilation, we are all notorious for doing way too much.  The proper rate is around 10 breaths per minute, and you should only be squeezing the bag until you see a little bit of chest rise.  This should not be be any more than squeezing the bag 1/2 way.  The breaths should be slowly in and slowly out.  This helps to minimize insufflation of the stomach and lowers aspiration risk. 




Take-away learning point #3:  Troubleshooting common problems in sedated patients.

One of the anesthesiologists was nice enough to walk me through a good systematic approach to dealing with common problems that arise during sedation.  I thought it was really helpful, specifically the one about the desatting patient, so I wanted to share that with you all.


Immediate steps to take in the sedated patient who starts to desaturate: (common occurrence when we over-sedate in ED)

1 - Rapid scan: ABCs + vitals and crank up O2 flow.

2 - Give painful stimulation - helps to jumpstart the breathing reflex.  Could be anything: sternal rub, pen in knuckles trick, etc.  One technique I've heard Scott Weingart mention but I am not totally sure what he was referring to was a technique of putting pressure behind the ear, at the mastoid area.  This provides a lot of pain without the family members in the room seeing it AND this location has been shown to reduce laryngospasm.  

3 - Head tilt + jaw thrust +/- nasopharyngeal airway

4  - BVM -- this is technically considered a "complication of sedation".  Just remember not to BVM too hard and fast.  

5  - Consider any one of the following as further options:  CPAP/BiPAP, LMA, narcan or flumazenil, and last resort is intubation.





So there you have it folks.  Those 3 things were probably the most important take aways learning points of the rotation for me.  EMEDPA is right in that real hands-on experience is the king with procedural stuff like this.  At the same time, if I would have been able to read this before going in, I think it would have helped me get up to speed much faster.  If any of you are interested in looking through all of the notes I took with this rotation, I'll post a dropbox link to the PDF below.  Again, the notes won't be pretty and I can't even promise that they're accurate/uptodate because I took notes from some old sources, but take a look if you'd like.  I'll be back after a month in the ED!



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  • 4 weeks later...

Time for an update.   I just finished my first full month in the ED.  It has been a much bigger learning curve than I ever would have imagined.  There is just so much to learn to be able to do this job.  There is the EMR, the hospital system + statewide policies and procedures, and of course the medicine itself.  One of the reasons the medicine is so challenging is the extremely wide range of pathologies that can walk through the ED doors.  From 10 days old to 100 years old, and from severed extremities to guillan barre... there is just so much to know!  And as if that isn't hard enough in and of itself, the patients that get filtered into the part of the ED that we work in (the sickest part of the ED) never come in with an isolated chief complaint... there are always confounding factors and a laundry list of symptoms.  It seems like every one of my patients has renal failure, CHF, COPD, polypharmacy, and/or cancer of some sort.  I've found myself feeling overwhelmed and wishing there was a way to learn the straightforward approaches to these chief complaints before jumping into the sick/complex patients of this ED.  To make it even more difficult, the hours we've been working have been brutal!  The shifts themselves are technically 12 hours, but we are expected to be there early and I never leave sooner than 1 hour late to finish up charting... add in 30 min commute both ways and its easily 14 hour days x6-7 days in a row.  I am so tired by the end of the day that I have little energy to read up on the things I saw.  When the 3 days off finally comes, the first day is spent catching up on sleep after the night shift, 2nd day on charting and practical life things you let slide the past week, and 3rd day to finally study, read tintinelli assignments, and sneak in a phone call to loved ones.  Anyways, I recognize that these feelings are likely just because its my first month and I'm feeling overwhelmed with it all - I know it will get better.  I am not going to give up, thats for sure!


On the bright side, the people here are wonderful and they make it all worth it.  The nurses are nice here.  The techs are great.  The fellow EM residents/seniors have been very kind and outgoing, always willing to slow down to teach me things and help me with procedures.  The same has gone for almost all of the attendings.  I've been doing a ton of procedures like splinting, complex suturing, central line placement, and tons of ultrasounds. Ultrasound is really cool.  Its awesome to be able to admit/discharge a pt w/ abdominal pain home within 20 min of coming to the ED, all with POC testing.  


I have been really enjoying our Wednesday conference lectures.  We have been making our way through tintinelli, reading high yield journal articles, and listening to some pretty awesome lecturers.  If there is one thing I know about myself, its that I will forever be a student at heart.

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As I did before, I'll try to outline the an important practical thing I learned this month that has helped me deal with these patients.  



Dealing with renal failure/dialysis patients (aka, dealing with the typical inner city patient (aka, thank you uncontrolled DM + HTN))

I saw so many patients with renal failure it amazed me - and scared me - because while they taught us basic principles of ESRD and dialysis in school, its entirely different with these very unique patients sitting in front of you and realizing just how many ways they can get very sick very easily... its somewhat overwhelming at first.  However, I made it a point to read up as much as I can and asked a lot of questions on shift, and I think the following is the most important things that helped me make sense of what to do with these patients.  They're also the things I was pimped on and emphasized repeatedly by my attendings.  


remember the things that go wrong in renal failure; these are the things you look out for:

-fluid overload, peripheral and pulmonary - listen for crackles, leg exam.

-strong RF for coronary artery dz/MI, HTN - take chest pain very seriously!  but don't be surprised if their troponin is elevated because ESRD pts chronically leak troponins even without ACS - they often need serial trops and tele admission.

-metabolic acidosis (uremia has an anion gap, unless if its renal tubular acidosis which won't gap)

-*hyperkalemia* --> almost every renal pt gets a BMP + EKG for this reason!!  All of their Ks are through the roof.  Look for peaked T waves, widening of QRS, prolonged PR interval (can conceptualize the changes as if someone were pulling up on the T waves and stretching the ekg out)  --> and this can mean impending (deadly) dysrhythmias!  

-anemia of ckd - often chronic, and may be on EPO.  

-uremia --> gastritis/n/v, pancreatitis, encephalopathy (confusion/altered)pericarditis (new dyspnea --> consider echo to rule out cardiac effusion), peripheral neuropathies

-WBC dysfx = renal pts should be treated as immunocompromised.  be worried if they come in febrile and start a septic workup.

-platelet dysfx + frequent flushes w/ heparin = high bleeding risk, very high head trauma risk.  


-dialysis clears their meds -- > often subtherapeutic


-acute complications of dialysis: hypotension is most common, cramping 2nd mc, n/v, HA, chest pain.  Patients are often sent to the ED from the dialysis center for these things.  


3 most important things to always look out for, because they're the 3 most common causes of renal pt death:


     -cardiac (MI + arrhythmias - often from critical hyperkalemia)

     -GI hemorrhage




remember the basics of access types and their implications:  its important to know which your patients has.

A - dialysis catheter ("permacath") -- temporary solution.  most likely to get infected


B - AV fistula -- artery sewn directly to vein.  lowest risk of infection. 


C - AV graft -- device made that connects arteries to veins.  also higher infection risk. 


ALL access types can get infected, clotted off, bleed, steel phenomenon.  So, you should always examine their sites - infected? thrill? bruit?

DONT inject anything into the access site unless its an emergency or okay'ed by neph.  



Renal patient evaluation/approach/HnP:


Dialysis issues:  whats typical dialysis schedule? MWF? compliant w/ diet?  Who is their nephrologist?  Access surgeon? Where do they dialyze?  

volume status?  dyspnea? listen to lungs for plum edema.  wet weight vs dry weight /  weight change?

dialysis access site.  feel for thrill and listen for bruit.  may need formal ultrasound.  redness/swelling/drainage? 

look for infection:  access site, lungs, skin, uti, etc

look for bleeding, intracranial or otherwise.  

look out for the other things mentioned above. 


EKG -- peaked T waves, widened QRS?  ischmia?

always order and look at BMP - creat, lytes, anion gap.  



when is emergent dialysis needed?  This is a common situation we consider in the ED and you have to know this well before bugging the nephrology attending in the middle of the night!




1. Acidosis thats unresponsive to HCO3


2. Electrolytes namely K over 6.5-7 OR if any EKG changes.  Lack of EKG changes is NOT sensitive to say you don't need dialysis.  Can go from no EKG changes to arrest without classic progression of peaked T waves --> wide QRS --> pattern.  

also sodium level under 115 or over 165.

you still will want to try to temporize it yourself (see below for hyperkalemia tx).


3. Ingestions/tox.  lithium, salicylates, ethylene glycol, methanol, theophylline are all dialyzeable drugs.   


4. Overloaded w/ fluid.  CHF, pulmonry edema that is intractible to diuretics.  or persistent hypoxia.  


5. Uremic syndromes --> pericarditis/arrhythmias and encephalopathy are the big ones.   



We probably call most frequently for people who come in after missing dialysis for several days/week and they have critical hyperkalemia.  Our typical conversation with renal might go something like, "hey we've got a dialysis patient of Dr X's here with significant hyperkalemia.  typically MWF dialysis but has missed 2 sessions. asymptomatic at this time but K is up to 8 while baseline is usually in the 5s.  No EKG changes, VSN and he is otherwise stable.  We started calcium, insulin and kayexalate but we think he needs dialysis - what do you think?"




how to tx hyperkalemia (anything over 6) in the ED:  see EMCRIT podcast on this!!  you definitely have to know this forwards and backwards!

-first thing to do: use calcium to stabilize cardiac membrane and prevent arrhythmias -

calcium gluconate (non emergent situations, small peripheral IVs are okay, 2-3 gms)


calcium chloride (emergent/code situations, large bore IV or central line (high risk of necrosis if IV blows), 1gm).  Will need to redose these q30 minutes.


-then, to lower the blood potassium:  1) insulin 10 units + glucose 1-2 amps of D50.  2)  albuterol 20 mg (yes, 4 times the asthma dose).  3) bicarb not really recommended anymore; can use it if acidotic.


-and to enhance elimination:  1) lasix (+ NS if not fluid overloaded).  2) kayexalate 30 g to help them poop.  3) dialysis (see above)




mnemonic for this, easily remembered when you "see big K".  "C-BIG-K"

Calcium gluconate/chloride








Check out the "On the Ward" podcast (from New Zealand) on ESRD for a nephrologists take on the most important things to know.  Great podcast!




Next week I'll start my telemetry rotation, which I hear from my internal medicine resident friends is also brutal.  Supposedly the service has been out of control busy lately and I can expect to manage 7-10 patients right off the bat.  I am pretty nervous since I haven't handled inpatients since my first rotation of PA school when I didn't know much of anything... and now I'll be handling pretty sick cardiac patients (considering all of our low risk chest pain rule outs go to ED obs and our sick cardiac patients w/o STEMis go to tele here).  Any tips/tricks and practical recommendations would be highly appreciated!!  

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how to tx the hyperkalemia (anything over 6) in the ED:  see EMCRIT podcast on this!!

first thing to do: stabilize cardiac membrane:  calcium gluconate (non emergent situations, small peripheral IVs are okay, 2-3 gms) or calcium chloride (emergent/code situations, large bore IV or central line (high risk of necrosis if IV blows), 1gm).  Will need to redose these q30 minutes.


lower the blood calcium:  1) insulin 10 units + glucose 1-2 amps of D50.  2)  albuterol 20 mg (4 times the asthma dose).  3) bicarb not totally recommended anymore; can use it if acidotic.


enhance elimination:  1) lasix (+ NS if not fluid overloaded).  2) kayexalate 30 g to help them poop.  3) dialysis.  



Using NS can hypothetically worsen the hyperkalemia via a hyperchloremic acidosis and can worsen AKI if present.  Plasmalyte/normosol are better options, but I've never seen them used in the ED.

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Using NS can hypothetically worsen the hyperkalemia via a hyperchloremic acidosis and can worsen AKI if present. Plasmalyte/normosol are better options, but I've never seen them used in the ED.

True. Bicarb is almost never used anymore either unless a severe acidosis but those patients are followed by nephrology by that point. The point of EM treatment in hyperkalemia is to stabilize the patient and prevent the life threatening arrhythmias. Other acid base disturbances can be fixed later and usually more slowly as patients tend to need dialysis. It sounds like the resident has learned the major points on treating hyperkalemia and will do a fine job at managing in the emergent setting.

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  • 4 weeks later...

Telemetry / Cardiology


Overall, it was a pretty good experience but very hectic at times.  It was great being exposed to a lot of pathology and being able to work with some great cardiologists, but at the same time our cardiology service is so busy that I was running around almost nonstop from 6am to 7pm, 6 days per week.  It seemed to be more of the same theme I mentioned before: the work is so fast paced with such long hours that its challenging to find the time/energy to let it all soak in and study to reinforce things.  



Cardiology Basics

General things to know on every cardiac patient (especially when consulting/presenting/admitting):

-Chief complaint

-HnP -- exact onset/timing/chronicity, exertional component, if chest pain - typical vs atypical? 

-PMH (espec CKD, DM) + Meds (BP meds, diuretics) + soc hx (smoker, cocaine, alcohol, MEDICATION COMPLIANCE)

-Last cards workup (2D echo, stress test, cath --> what disease was found, what intervention done, *what intervention NOT done* (i.e., did they note a 70% stenosis of RCA but elected not to stent at the time?)

-Workup thus far: ekg, trop, cxr -- AND PRIORS FOR COMPARISON.  

-Other labs: creatinine, tsp, mg, K

-What has been done so far.


An admission to tele, or a cardiology consult, might sound like this:  

"I've got a chest pain patient we'd like you to consider for admission in room X.  63yo diabetic man with an LAD stent placed earlier this year and baseline stable angina presents with typical chest pain radiating down L arm that came on at rest about 2 hours PTA.  EKG, trop negative. We gave ASA and nitro x3 which relieved his pain.  He is currently stable, normal vitals, chest pain free, but we think he should come into tele.  What do you think?"  





~~~Learning point number one:  Telemetry: "The Big Four"

There are essentially 4 types of patients that go to telemetry/cardiology floor, and each have their own unique approach/workups: chest pain, CHF, arrhythmia, syncope.  I'll sprinkle in some resources relating to each topic.  



1) Chest pain, ACS workup / rule out.

Approach... Hx to determine typical vs nontypical chest pain.  Assess RFs.  Serial EKGs.  Trend troponins.  Echo to see EF and wall motion abnormalities (indicators of ischemia).  Get prior records to see most recent cath/stress/echo.  Calculate timi score. 


After this information is learned, assess the situation and decide if an "ischemic workup" is needed: either stress test (if low-moderate risk), or LHC ("Left heart cath" - if high risk).  


--> amal mattu has a great podcast on interpreting ST elevations on EKGs and a good approach.  iTunes search amal mattu ST elevation.  


--> see the variety of podcasts out there on the HEART score as a relatively new decision making tool to help with one troponin rule outs.  Amal Mattu has a podcast overview on his "updates in resuscitation podcast - is the HEART score the answer..." 

Related to this is an integration with shared decision making:



--> see the smart EM podcast on stress testing for a historical perspective on the subject.  for a word summary: http://emcrit.org/wp-content/uploads/2012/03/SMART-EM-Stress-Testing-Summary.pdf




2) CHF - either HFrEF/systolic or HFpEF/diastolic.  Ischemic vs nonischemic cardiomyopathy. Left sided vs Right sided.

Approach.... HnP to place into the "wet vs dry" and "warm vs cold" classification system, try to figure out what pushed them into exacerbation (90% of the time its diet vs med noncompliance, 10% of time ischemia/htn/etc).  Workup with echo.  Diuresis w/ lasix or bumex.  If advanced, consider workup with RHC (Right heart cath, which has an entirely different purpose than the LHC - read up on the difference if you're not familiar) and CHF team considers placing on inotropes for symptomatic control.  Make sure the patient is on optimum heart failure meds.  The meds that decrease mortality: ACE-I, BB (or  hydralazine + nitrates), Spironolactone.  Don't forget ICD if EF under 30%.


good overview of the textbook stuff to know --  




3) Arrhythmias - Afib, aflutter, VT.  

Approach... HnP to assess exact onset (>/< 48 hrs), chronicity, anticoagulation, etiology (think of a fib as a symptom - learn the ddx for etiologies).  Labs for electrolytes, magnesium, phosph, tsh.  Echo to assess EF and structural heart damage.  Tele monitor.  ICD interrogation.  Rate control w/ metoprolol/lopressor/toprol vs cardizem.  Calculate chads-2-vasc score and determine long term AC.  Consult EP for possible ablation or ICD placement in VT/tachyarrhythmias, or for a PPM for bradyarrhythmias.


Lots of time spent into determining if wide complex tachy is VT or SVT w/ aberrancy.  Life in the fast lane has some good articles on this specific approach.  http://lifeinthefastlane.com/ecg-exigency-013/  https://dl.dropboxusercontent.com/u/5247611/Supraventricular%20Tachycardia%20%28SVT%29%20Aberrancy%20vs%20Ventricular%20Tachycardia%20%28VT%29%20Brugada%20Criteria.pdf




4)  Syncope - cardiac?  arrhythmia?  vascular?  neuro/seizure?

Approach... HnP to assess prodrome (sudden, no warning syncope in elderly = VT/arrhythmia), meds, neuro sx/seizures sx, etc.  Orthostatic vitals.  Lab workup.  Tele monitor.  ICD interrogation.  

Specific things to look for on EKG in patient w/ syncope:  long QT, WPW, brugada, HCOM, PE, wellen's syndrome.  





~~~Learning point number two:  the classic/quintessential cardiology take-away:


It isn't a cardiology rotation if you don't hear "did you know TROPONINS are NONSPECIFIC" a hundred times.  Another one you will hear (when they don't realize you are an ER resident) is "the ER docs ordered another troponin on a renal failure patient with GERD, dangit!"  So, an important take away point from this rotation was to know inside and out the many different possible causes for a troponin elevation.  


-SUPPLY ISCHEMIA: *ACS* (the #1 reason we order it), coronary vasospasm (cocaine, meth, prinzemetals), dissection.  

-DEMAND ISCHEMIA: severe htn, anemia, HCOM, tachyarrhythmia (ie svt commonly leaks troponin - not necessarily dangerous)

-DIRECT HEART DAMAGE: blunt cardiac trauma, cardioversion, chemotherapy, infection (endo/myo/pericarditis - so its okay to order it in infectious/pleuritic chest pain if its for this eval).

-HEART FAILURE/exacerbation, volume overload - CHF pts often chronically leak trops, so compare to priors.  

-NONCARDIAC: *CKD/renal failure*, PE, sepsis, hypovolemia, neuro (stroke, subarachnoid - often discussed in neurology)


Of all of the above, the most common non ACS cause is CKD/renal failure.  Every cardiologist I worked with, after being told a patient had elevated trops, would then immediately ask "whats their creatinine?" - so make sure you know this before calling for a tele admission!


Take away point:  Yes, troponins are nonspecific.  To combat this, you have to take clinical context into account and trend the troponins to determine if there is ischemia/NSTEMI going on or not.  Also very valuable to look at old admission trop levels in your EMR to get a sense for how much the patient may chronically leak at baseline.  


-see the article "interpreting elevated cardiac troponin levels" for a journal review on the topic.  


-listen to the the SMART EM podcast about troponins to get some more historical perspective/insight into the troponin controversy.




~~~Learning point number three: The art of the cardiovascular history/interview...


A lot of the above 2 points were things that I already knew pretty well, so I initially felt that I wasn't learning much.  That being said, I knew them on a textbook level, and I never realized how poorly my textbook knowledge translated that into practical bedside application.  In the past, I'd try to assess for things like CHF symptoms but would ask very low yield questions like "do you feel short of breath when you exert yourself" (this stupid question had a specificity of .00001; everyone would answer yes to this!).  So, perhaps the most useful part of the rotation for me was listening to how my attendings would ask patients questions in the right way.  I'll give you some examples...


"What activities can you do comfortably?  (ask about common household activities - vacuuming, carrying groceries, climbing stairs) What happens when you push yourself?  chest pain/tightness/pressure?  What makes you short of breath?  Exactly how many stairs can you walk before you have to stop to catch your breath?  How long have you felt like this? Gradual or abrupt change?

"Do you sleep flat at night?  How many pillows? Had to increase number of pillows recently? Ever wake up gasping for breath (PND vs OSA)?  How has your appetite been / bloating / abdom discomfort (often forgotten right sided CHF symptom) ?  I found the responses I got to questions worded as such were so much more helpful than the responses to my old questions.  


Also, its not enough to ask "are you compliant with your meds and diet?".  If you really want to see if they're compliant, you have to ask them exactly which meds they take, how many times per day do they have to take meds, what exactly did they eat over the past few days, etc.  One of my favorite cardiologists, after being told a patient is noncompliant, would always follow with the question, 'why is he noncompliant?'.  If its a financial issue, only giving him generic rx's will be the best treatment you can offer him.  If its an issue of forgetfulness or too complicated of a dosing regiment, only giving him once daily dosing so he only has to remember once a day will help the most.  If its an issue of not caring enough, make sure you spell out the risks, because providers often avoid taking the time to discuss the real risks/prognosis, instead saying things like "the stent that was placed fixed the narrowing in your heart (i.e., "youre cured!").  Of course, changing around medications and doing caths is not in our scope in EM.  Still, this cardiologist showed me that if we truly want to help people, we have to think outside the narrow minded medicine box of Disease X gets Treatment Y, and realize that the best treatment you can offer some people may require some creativity/personalization and end up being something else entirely.  




~~~Good resources:




EM Basic podcasts... chest pain approach, Noninvasive ventilation


SmartEM podcasts... good talks on troponin, stress testing.  He gives a good historical perspective of these tests and where they are going in utility.  


great podcast on pacemaker overview:  "beyond anesthesia board review pacemakers" in iTunes. 


https://quizlet.com/68342389/cardiology-flash-cards/  (not my set but I thought they were pretty good)






I hope this has been helpful to students or new residents/PAs out there.  Feel free to give any feedback!


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


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




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



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

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


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


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

 (I was taught the following: if patient is looking away from the side of hemiparesis, assume its a stroke.  If they're looking towards the side of hemiparesis, it will often be a seizure).

Assess pupil size, reactivity to light.  

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


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

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

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

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


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

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


REFLEXES - DTRs.  Make sure you know how to do these on a bed bound patient - mostly looking for asymmetry.  

Clonus, babinski, etc.   


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

Check out the EM basic neuro exam supplement podcast.  


I'd highly recommend that once you have the exam down you take some time looking up videos of what abnormal findings look like.  Specifically, know what cerebellar signs look like (ataxia, dysmetria, past-pointing), rigidity / cog wheeling, abnormal posturing (decorticate etc), etc.  This way, it will be more than just going through the motions of an exam; you will actually know what you're looking for.  Youtube always has good videos.  I've heard that neuroexam.com is good.  


check out this great article for more of an explanation of the neurology behind the exam maneuvers.  Great website! http://lifeinthefastlane.com/ccc/examination-unconscious-patient/


more good stuff:







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



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


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

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

-Call to get 2mg IV ativan at bedside (assuming you have venous access; if not consider IM versed), but our neuro team said you don't have to necessarily give it right away.  

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

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

-Roll the patient to their side so if they vomit they don't aspirate.

-At this point, its probably been around 2-3 minutes.  If it hasn't resolved spontaneously by the time nurse comes back with the meds, give the ativan.  The thought is that most seizures stop spontaneously within a few minutes, so they often won't need any medications.  The counter argument to this is that the likelihood of seizure progressing to status increases if it lasts 5 minutes and then it can be harder to abort... so some people do recommend giving the benzo asap... I'm not sure which is the right thing to do, but our neuro service would wait around 2-3 minutes before giving any meds.

-Check fingerstick, vitals.  

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


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

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


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




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



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

-Age of patient

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

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

-Blood sugar (easily ruled out mimic)

-Quick history:  Exact onset of sx.  last known normal (most important piece of information!).  Consider calling the last dialed number on their phone!

-What is their baseline? Prior deficits. 

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


send them to the CT scanner ASAP.  


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


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

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

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


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

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

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





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


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


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



Chart check PMH:

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

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

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


Chart check  Med List:

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

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


Chart check Labs:

-LFTs (most AEDs can cause liver damage)

-BMP (creatinine)



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




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


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

The meds you can check levels for will vary based on your lab, and sometimes they won't even come back same day, but here are following often check-able:  phenytoin/dilantin, carbamazepine/tegretol, depakote/depakene/valproate, lamotrigine/lamictal (in general, the first generation AEDs). If you can't check a level on their med, you better wait until they resolve from their postictal state before giving them their home dose.  If it takes them hours and hours to resolve, it might not truly be postictal, and you should hold the med, and consider AMS workup.  







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


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




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



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


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



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