My EM Residency Experience...

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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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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:

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 -


-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. - the Haber method which is becoming a very popular method for many to simplify acid base interp.  -- 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


- - 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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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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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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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:


***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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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 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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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:





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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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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Job well done SN. Thanks for paving the way for those of us interested in pursuing a career in Emergency Medicine. Good luck with the job hunt.


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Thanks Serentity! Your blog was definitely the inspiration to pursue my residency following graduation (albeit in a different specialty-- just started orientation today!)


Best of luck in your career and I'm sure you will crush it!


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