My EM Residency Experience...

[agk]

Thank you SO much for taking the time to share your experiences and learning. I'm sure it's tiring and an added thing on the "To do" list, but from a second year PA currently in my EM rotation who hopes to apply to EM fellowships, I can't thank you enough. If you have any tips for the application process, I'd love to hear them. Good luck as your program continues!

[SERENITY NOW]

Hey gang,

I am glad you are enjoying the posts.  I really enjoy writing them and I'm happy to hear they're useful for some people out there.  

 

 

APPLYING TO PA RESIDENCIES/FELLOWSHIPS...

AGK, I feel like I applied ages ago so I can't remember all of the details, and I only applied to 4 programs so I am certainly no expert.  That being said, I'll try to muster up some tips for you and anyone else who may be interested.  There is definitely a lot of variability in the quality of PA residencies/fellowships out there, since we don't really have a standardizing body.  Any place can just call their position a "residency" position.  Be very careful if the program is not one of the established ones out there.  I have heard of places trying to take advantage of desperate new grads by luring them into a "residency program", when its really just fast track with long hours and low pay without any education.  Definitely try to talk to past graduates.  

 

 

Overview of the process and what to expect:

You'll search online for programs that fit your geographical zone (see EMED's sticky).  Read up on their website and download their application information.  You'll have to fill out an application packet with a bunch of important documents I will mention below and send it in via mail.  They will call you or email you to say you have an interview.  The interview day is similar to PA school interviews except much fewer people.  Typically there are 10-15 people interviewing for 2-4 spots.  They'll give you a presentation explaining the details about their program, show you around the hospital and ER, let you ask questions of current students, perform the interview, and provide lunch for you. I found out I was accepted within a few weeks of the interview.   If they give you an offer they usually give you a time limit of a few weeks to accept it before they move on to the next candidate.

 

 

General advice:

You should start getting yourself as organized as possible, and the sooner you do it the better.  The application process is very painful and will be replicated time and time again as you go throughout your career (new jobs, state licensing, etc).  Make sure you have a really good organization system on your computer to file all of your important documents: resume/CV, cover letter, references, work history with exact dates/supervisors, certifications, diplomas, IDs, immunization records, etc (if the original is a hard copy, make sure to have scanned things on your computer).  I have found that dropbox works well to have these important documents well organized, safely backed up, and very easily printable/emailable from anywhere (even my cell phone).  If you have all of these things organized well on your computer it will be 100x  easier to just print off the unique things that each program needs.  And after you make your way farther into the hiring process, you'll get countless more emails asking for random bits of important documents, and being organized will save you a ton of time.  

 

 

Qualities to assess in a program:

Location and affiliation.  Number of patients that come into the ED each year.  Demographics.

Utilization of PAs in this system in general.  Utilization of the PA residents in this system.  Fast track vs main ED.  

Your responsibility/autonomy/role... will you be expected to be efficient/move the meat?  How will your supervision be implemented?

How long the program has been established.  How well integrated they are in the hospital.  How well integrated they are into physician residency program.

Off service rotations: anesthesia/intubating, cardiology, neurology, trauma, surgery, peds EM, icu, ultrasound, ophtho (slit lamps), ENT (NPL), orthopedics, OBGYN are all rotations I have seen offered at various programs.  Think about which ones are most important to you.  

Elective opportunity and flexibility.

Built in learning and academics.  Weekly conference? What does that consist of?  Is it protected time? M&M? Procedure lab? Sim lab?  ACLS/ATLS/PALS certs?

Ultrasound education and practice.  Are there ultrasound fellowship-trained faculty?

Procedures.  How many intubations, central lines, LPs, procedural sedations (etc) did past graduates get?  

Salary.

Hours.  Scheduling.  

How is it living around that area? Cost of living? Public transport?

Past graduates available to get their feedback (definitely the most valuable).

What is unique about their program?  

 

 

The questions you should reflect on (and may be asked during the interview):

Why emergency medicine?  Are you aware of the negatives of EM?  What are they?  How will you deal with these downsides?

Why a residency program?  "You're aware its going to suck big time, right? (paraphrased)... why do you still want to do it?"  What is it that you want to get out of this residency?  What are your motivations/goals for it?

Why this program?  Make sure you really do your research and know the unique parts of that program as opposed to the others.

Why should we choose you?  What are your strengths?  What are your weaknesses?  

Tell me about your ER rotation in school.  Tell me an interesting case you had (I had to present a case, list a ddx, and explain my reasoning in one of my interviews!).

(And don't forget the classic/generic interview questions like 'tell me about yourself', 'what would you do in situation X', etc)

 

 

 

Hope this helped AGK!  

-SN

 

 

PS - I just finished my general surgery rotation, which indeed was very long hours.  Lots of good learning though.  It will take me a while before I can write it up for you all, but I'll do my best.  Stay tuned!

[SERENITY NOW]

GENERAL SURGERY

 

Overall, a surprisingly good experience.  We were well staffed and had a great group of residents working together.  My senior resident taught quite a bit and they were all very receptive to my questions.  I spent a fair amount of time holding the pager for the general surgery service, so I was the person who heard all of the phone consults coming from the ED.  Holding the pager is tough because you get tons of pages that keep you very busy, and at first I dreaded having to do it.  Now, however, I see that it was a very worthwhile experience 'being on the other side of the phone'.  I was able to see the wide range of presentations that ED providers give. Some people don't provide hardly any information, and it is clear they barely evaluated  or worked up the patient and just wanted to turf the patient to surgery.  Others gave a ton of information that was completely useless to the surgeons, which I soon got a sense for since I had to present every case to the team.  Overall it was very valuable in helping me figure out what is really important when calling a consult/presenting, and it also gave me an appreciation for why the surgeons sometimes seemed so grumpy over the phone.

 

Like I said in my prior posts, I have been gearing my learning towards things that will give me the most bang for my buck... things that are most easily learned when you are immersed in that specialty.  Keeping that in mind, my goals and most important learning points for the rotation were the following:

 

1) Abdominal stuff:  reading abdominal X-rays, 'what to order when' in abdominal conditions, what things the surgeons wanted to hear about the most common abdominal pathologies (SBO/LBO, biliary dz, hernias, appe, etc)

 

2) Post op issues:  general issues, fever, approach to the bowel resected patient, bariatric surgery patients 

 

3) Wounds wounds wounds!  I see so many acute and chronic wounds in the ED and I really wanted to learn the surgeon's approach to these.  

 

 

 

1) ABDOMINAL RELATED TOPICS

A - Abdominal imaging... what to order when?

One of the things I had struggled with on my first ED rotation was how to work up these patients who came in with abdominal pain, especially elderly patients who often have such nonspecific exams.  One of my attendings told me a pretty useful tip:  instead of trying to figure out the exact diagnosis you're suspecting based on the exam, just gestault it and ask yourself "will this person need imaging or not?"  If the answer is yes, its just a matter of figuring out what type of imaging is the most appropriate.  This is a bit easier to handle, but be aware that there are still many imaging options available.  Even if you decide they need a CT, you still have the contrast options to figure out, and its a topic that is still being debated.  The following are some general guidelines for what to order when you are suspecting the following:

 

bowel obstruction --> KUB and upright abdominal series (then probably CT)

perforation --> upright AXR + CXR (cxr is the most sensitive)

 

RUQ pain: concern for GB --> start w/ ultrasound

lower abdominal pain: concern for pelvic/gyn --> start w/ ultrasound

pregnant woman w/ RLQ pain --> ultrasound first.  if negative, may need MRI to eval appe.  

 

In general, the gold standard for evaluating abdominal pathology is CT w/ IV and PO contrast, BUT:

1) Oral contrast takes 2-3 hours of downtime before you can scan them, so we try to avoid it when possible.

2) CKD often prevents IV contrast, limiting us to PO contrast

3) sometimes contrast gets in the way of what you're trying to see (like kidney stones), 

So, contrast isn't always the answer and we like to avoid contrast if isn't needed, most typically in the following circumstances:

-Back/flank/inguinal pain: suspecting kidney stones --> CT w/o contrast.  If negative, may need to follow with IV contrast to eval appe.

-RLQ pain: concern for appe --> CT scan w/ IV contrast alone (don't need oral contrast), and may even be able to do non contrast CT in some individuals.  Thin individuals have less (peri-appendiceal) fat and are therefore harder to image without contrast, so can't do it in these patients.   (upon my reviewing this later, I'm pretty sure I had this mixed up... I think you should always have IV contrast when evaluating appe... the question is whether or not you need PO contrast which some radiologists will want I believe based on BMI, as noted above).  

 

 

 

B -  Abdominal xray interpretation:

It was incredible how many abdominal X-rays we looked at during this rotation.  We ordered them all the time on the surgery service.  I really hadn't done too many formal AXR interpretations in the past so it was great to practice them over and over again.

 

Remember the different ways to do AXRs... supine flat plates, upright abdominal series, left lateral decub.  

 

Look for the obvious things - bowel, gas patterns, fluid levels.

You see bowel with lines all the way through it, its located closer to the umbilicus, and its smaller... this is likely small bowel, and it shouldn't be greater than 3 cm.

You see bowel with lines that don't cross all the way through, its located around the periphery, has dimpling of the outside, and its bigger... this is likely large bowel, and it shouldn't be greater than 6 cm.

Look at the gas distribution, fluid levels, make sure there is gas in the sigmoid/rectum.

 

Look for the things you never want to miss... do this every time! 

Air under the diaphragm.... air in the liver (normal is homogenous)... air in the bowel wall

And practice practice practice!

 

To see the full approach, I'd recommend checking out this site:  http://lifeinthefastlane.com/investigations/axr-interpretation/

 

 

 

C - You need to consult the surgeon on a patient you think might need surgery, what things should you include in general?

Age, PMH (kidney dz, overall comorbidities to gauge if operative candidate, especially CV disease)

Meds (anticoagulants, INR, antiplatelets and when they last took the med)

PSH and which surgeons did it.  

 

From this point, it diverges depending on the specific situation.  The surgeons want to hear details that help them decide how much time they have to come see the patient and possibly take them to the OR.  The relevant details depend on the condition.  In bowel obstruction, is it an open or closed obstruction? Any indication of strangulation or systemic instability?  

 

One thing the surgeons consistently complained about from the ED was that the ED would consult them and then essentially forget about the patient and move on, when there are still important things that need to be addressed in the ED.  For example, in bowel obstruction, a big problem is vascular fluid shifts often leading to serious AKIs, so patients should almost invariably be started on IVF immediately in the ED.  

 

 

 

 

2) POST OPERATIVE ISSUES

Every once in a while I saw patients come into the ED who were several days-weeks post op and I think they're tough to approach if you don't know what exactly can go wrong with surgeries, both in general and specific to each unique surgery.  Perhaps the patients that scared me the most were patients who had bowel resection surgeries and bariatric patients, since these people can have complications months-years after the surgery.  

 

 

A - A patient walks into your ED with a fever and says he had surgery last week... What goes through your mind? Don't forget the 5 W's!

Since patients typically won't be coming into the ED until PODs 4 or 5 at the earliest, its most important to know what things can occur at this time.  The big ones are surgical site infections, anastomotic leaks, deep space abscesses (which may have minimal manifestations), medication effects, and DVT/PE (not all fevers are from infection!)  

 

Look at the surgical site.  Any sign of erythema, fluctuance, odor, purulent drainage?  Could be a SSI.  May need ultrasound vs CT scan to see how deep it is. Want to make sure it doesn't extend past the fascia.  Will need I&D and leave open for secondary closure.  Certainly call the surgeon.  

 

Look at the vitals, specifically for tachycardia, tachypnea, hypoxia.  If you see any of these, big red flags should be going off in your head for 2 things:  PE (obviously) and interestingly also anastomotic leak, which has been known to manifest exactly like a PE, sometimes without any abdominal pain at all.   See the discussion below for anastomotic leak, the dreaded complication of bowel surgery.  

 

 

B - Your next patient comes in complaining of abdominal pain and during your exam you see an ostomy... What do you look out for in patients s/p BOWEL RESECTION?  What things can go wrong with these surgeries and should you work them up?

-Bleeding (every patient gets a rectal + hemmocult)

-Strictures / obstruction (last stool and flatus?  feel bloated?  n/v? upright abdom X-ray) 

-Fistulas (enterocutaneous, enterovesicular, entero-entero) (always get oral contrast w/ the CT in patients who have had viscus surgeries).

-Infection (assess vitals, surgical site, etc)

-the dreaded complication: ANASTOMOTIC LEAK:  breakdown and spillage from the place where the bowel was sewed together.  Typically happens POD 5-10.  Typically causes abdominal pain, rigidity, hypotension, tachycardia reflecting the peritonitis and sepsis, BUT this is not always present.  Sometimes it only presents with SOB, tachycardia, even hypoxia, food intolerance, feeling of doom.  *This is the biggest thing surgeons worry about and should always be on your differential*.  It is a surgical emergency.  Call the surgeon early if you suspect this.  

 

Basic ostomy identification:  

Right side of abdomen, smaller, liquidy output = ileostomy.  

Left side of abdomen, bigger, stool output = colostomy.

Ostomies can have things go wrong with them too.  Most commonly obstruction, infection, ulcers.  Don't be afraid to do a pinky digital exam.

 

 

C - Your next patient comes in complaining of abdominal pain and says he had a gastric bypass 6 years ago.  That's surely too long ago to be at play now, right?  (nope!)  APPROACH TO BARIATRIC SURGERY PATIENTS:

We had an awesome bariatric surgeon give us a great lecture that on these patients that has helped me immensely.  He really emphasized the following take away points:

-BE FRIGHTENED of EVERY bariatric surgery patient that you see NO MATTER HOW LONG AGO THE SURGERY WAS (even 20 years out!)

-ALWAYS call a bariatric surgeon to run the case by them.  

-ALWAYS GIVE THIAMINE to EVERY bariatric surgery patient.  For many reasons, they are at a very high risk for thiamine deficiency and wernickes encephalopathy (numbness/tingling, visual issues, altered/psychotic), and there is no risk to giving thiamine, so just give it.  

-A recently post op (within the past month) patient should be assumed to have an anastomotic leak until proven otherwise.  

 

-90% of the time that a bariatric patient complains of abdominal pain long after their surgery, its either GALLSTONES or a peri-bypass ULCER that can be treated with standard conservative therapy (PPIs, kerafate, etc)

 

-The other 10% of the time, it will be either an INTERNAL HERNIA (may only complain of bloating; CT is not sensitive to rule this out, so just call the surgeon; it can be an emergency) or STRICTURE/BOWEL OBSTRUCTION (do not put an NGT into any bariatric patient!) 

 

-Be aware that these patients are also at an increased risk for kidney stones, iron deficiency anemia (iron is absorbed in the duodenum which is bypassed), chronic constipation, pulmonary embolism, and lots of medication problems and side effects (their BP and blood sugars improve from the weight loss but their PCP doesn't lower their medication dose so they present for syncope and hypoglycemia).

 

 

(I'll cover wounds in the next post shortly...)

[SERENITY NOW]

3 - WOUNDS!

 I see so many wounds in the ED but I've never been confident in dealing with them.  This rotation helped me to see dozens of wounds and get a good sense of what it is the wound care specialist looks for when evaluating wounds.   

 

 

Its important to know the textbook knowledge about the main chronic wound types/etiologies: Diabetic, Venous stasis,  Arterial,  Pressure/sacral, and Infectious.  Where is each typically located?  Neurovascular status for each?  Wet vs dry? Treatment options?

There are tons of good comparisons tables out there to help sort through these.  I'll attach the table I made in my notes that I think is pretty good.  I won't go into everything here for the sake of time, but the most important things to know are perhaps the location and treatment.  Chronic wounds on the sacrum are typically pressure ulcers, which are treated by offloading.  Wet wounds on the ankle (gaiter zone) are often venous, which are treated by decreasing edema measures.  Insensate wounds on the feet are often diabetic, which are treated by offloading.  Eschar wounds on the tips of cold extremities are often arterial, which are treated by revascularization.  I used to worry most about what kind of dressing to choose for any given wound, when in reality the most important/definitive treatment is specific to the underlying etiology, as mentioned above.  

 

 

Overview of the ED approach to wounds:

Chart check before going in...

-Vitals, PMH (DM, PAD and last ABI/angiography), immunocomp, venous insuffic, sickle cell, malnutrition)

-PSH, medications, allergies (abx)

 

History...

-Chronicity

-Assoc sx (pain, itch, drainage, smell, swelling, claudication, etc)

-Constitutional sx (fevers, chills, malaise)

-Curent management routine

-RFs for badness (comorbidities, poor wound care, trauma, surgery, IV drug user)

-Red flags (soil contamination, rapid progresssion)

 

Exam...

-Location (over bone? joint?)

-Size (draw a line around it and assess rate of growth). 

-How does the wound itself look?  

-How well demarcated is the perimeter? Surrounding erythema?

-Depth?  Probe the wound, assess for undermining.  

-Crepitus, odor

-Neurovascular status (always assess sensation and pulses, typically needing doppler signals)

 

Studies...

-X-rays for gas in the tissue and bony disruption

-ultrasound to evaluate if occult abscess if its not clear clinically

-if concern for infection, consider CBC, BMP, CRP - be wary of hyponatremia (can indicate nec fasc)

 

ED Assessment...

-Any high risk feature present?  comorbidities, progression, location risk (joint, bone/osteomyelitis), systemic sx?

-Ask yourself, is the wound infected? (new wound, or acutely worsening? painful?  Fevers, chills, erythema, edema, drainage? gas? crepitus? concern for nec fasc (LRINEC score http://www.wikem.org/wiki/EBQ:LRINEC_Score )

-Remember there is a range of severities when it comes to skin and wound infections... From most deadly to least deadly:

gas gangrene, necrotizing fasciitis, erysipelas, cellulitis, abscess.  Check out the podcast "university of iowa department of emergency medicine: skin infections"

 

Plan...

-Always consider etiology-specific treatment as mentioned above.  

-If it looks infected, consider need for PO vs IV antibiotics and therefore admission/disposition.

-consider surgery consult

-consider tetanus status

 

-ED wound dressing to hold them over until their wound care specialist sees them next.  Does not need to be fancy, just remember the basic principles of wound care dressings:  its all about the moisture level of the wound itself, and your dressing should be the opposite.  If you've got a sopping wet (often venous stasis) ulcer, use a dressing that will keep it as dry as possible (absorptive dressings).  If you've got a dry (often arterial) ulcer, use a dressing that will keep it moist (occlusive dressings).  For everything in the middle, and really for almost any wound as a temporary measure, a good old fashioned "wet to dry" gauze dressing is a good bet, or so I've been told.  

 

 

 

Good resources

 

Here is a good powerpoint pdf about basic wound care: http://www.palliativeinstitute.com/files/1713/9463/0137/Wounds_Wounds_Wounds.pdf

 

 

Overall best surgery resource hands down:  Surgery 101 podcast.  Simply awesome!  They have so many awesome podcasts.  I listened to them a lot in school but listening to them a second time around with a better base of knowledge and I am realizing how golden they really are. I plan on going back to them many times again in the future, because they are that good!  

 

 

Dropbox link to my (again ugly looking, thrown together) notes:   https://www.dropbox.com/sh/h33tyar7otwphbg/AACl-RV30_-xk8OexA0bYhrCa?dl=0

 

 

 

I'll be in the ED for the next couple of months, so if any of you have specific topics you'd like me to write about next, just let me know!  

 

-SN

[RuralER/Ortho]

Thank you again! Excellent info.

[chichamorada]

I am so glad that I stumbled on your journal/blog!  Your enthusiasm is contagious, and it sounds like you are really making the most of your residency.

Thank you so much for sharing your valuable learning experiences! 

[SERENITY NOW]

Hi Gang,

I hope you all had good holidays.  Time for an update for you all.  Overall, I have been feeling better about things.  I feel more aware of myself; I know what I am getting better at and I know what things are my definite weaknesses.  I feel better about the common chief complaints in stable patients... chest pain, SOB, abdominal pain, etc... I've been seeing so many patients that I've pretty much seen the majority of the permutations that these chief complaints can result in, and experience definitely helps with confidence!

 

That being said, I have recognized that a big weakness for me at this point is seeing "sick" / unstable patients. Its fine and dandy to know the textbook knowledge about patients in shock, but its an entirely different situation when paramedics are rushing a patient back, nurses/techs are flocking over, and you try to figure out where you fit in, what evaluation needs to be done, and what orders you are supposed to be barking out.  There is a ton going on at once, and when I tried to get in on these cases without a clear systematic approach in the back of my head, I'd just get overwhelmed and freeze up.  Undifferentiated shock is still over my head at this point, so I've been trying to learn the principles of managing sick patients by picking up every patient I can with septic shock, and I think it has helped get my feet wet quite nicely.  It is a much more narrowed ddx but still helps you learn the principles of resuscitation.  Now, I realize that sepsis is an incredibly controversial topic at this point, so I am not going to be going into the details about sepsis management, but rather a general approach that applies to any sick patient.  

 

 

 

-------BASIC APPROACH TO SICK/UNSTABLE PATIENTS--------

I think its important to have a conceptual grasp of the big picture as you go through so that it doesn't feel like you're memorizing dozens of individual steps. Always start with and continually come back to the ABCs (or CABs).  Each time you go through the ABCs you can have a different perspective with them.  Start with ABC eval, then ABC immediate management, then critical Hx, then finish up D and E, then adjuncts, then ABC advanced management, etc.  Keeping it simple, systematic, and logical is the only way to be able to remember everything when the pressure is on.  Aside from this, its a matter of practicing practicing practicing until this progression is second nature.  

 

ABCs immediate eval

Circulation - grab RN/tech to get vitals, place on cardiac monitor, get IV access (x2 if needed, and low threshold for IO).  Check pulses, extremity cap refill and temp to palp.

 

Airway - quick glance in mouth, listening for upper airway sounds.

 

Breathing - put on pulse ox, look for RR, listen to lungs (equal bilat? crackles? focal? wheezes? etc) 

 

make sure everything above is done and assess them: vitals, cardiac monitor, lungs/perfusion.

 

ABCs immediate actions

Circulation - Start IVF.  Pending cardiac monitor may need to call for code cart/cardioversion/pacing pads and go down ACLS protocols.  

Since RN draws blood when first placing IV, make sure to consider need / tell them to draw rainbow labs, not to forget VBG w/ lactate (point of care machine at my ED), blood cultures, type and cross match, and have them place drop of blood on urine preg test for appropriate female patients (supposedly this is manufacture tested and approved).  

 

Airway - If not maintaining airway, start with painful stimuli, jaw tilt / chin lift, consider OPA/NPA.

 

Breathing - Start oxygen by NC or NRB.  Specific tx per lung sounds (nebs, epi, nitro, lasix, etc). Unilateral, consider needle thoracostomy.  

 

Everything above is the top priority and should be addressed in your head before moving on.  After this point, everything should be done in parallel.  

 

 

Critical hx

-Chief complaint, time and acuity of onset, prior epps/hospitalizations/intubations?

-Interventions done so far?

-PMH: heart? kidney? DM? COPD?

-Meds: anticoags?

-Allergies?

 

D - Dipstick + Disability/GCS/Neuro

Tell nurse to check dipstick

Eval eyes, verbal, motor.  Following commands?  Moving all 4 extremities?

 

E - Exposure + EKG

Strip down the patient, check all of body for skin breakdown.

Good time to do rectal exam, hemmocult to r/o GIB, check rectal temp.

Get EKG in almost all critically ill patients.  

 

Review and Adjuncts

At this point, take a step back and reassess everything. Form a gestalt of the situation.  Decide where to go from here.

 

Labs to possibly include CBC, BMP, type and screen/cross (know the difference! very important!), coags, urine preg, blood cx, UA and urine cx, troponin, all as indicated (not exhaustive list obviously).

 

CXR? FAST ultrasound? CT head, abdom pelvis?

 

Get the orders in and if your patient is truly sick get back to bedside...

 

ABCs Advanced Managements

Airway/breathing - cpap/bipap? ETT?  [learning point repeatedly emphasized to me by my attendings: the decision to intubate is NOT guided by lab results/ABGs.  Know the 4 indications to intubate and how they apply in the ER.  1) failure to oxygenate (manifests as desatting pulse ox).  2) failure to ventilate (hypercapnea is a clinical dx in ED with manifestation of somnolence/confusion/altered mental status/severe tachypnea or bradypnea... do not wait for ABG!)  3) Inability to protect airway (GCS under 8, sonorous respirations, secretions, altered patient vomiting), 4) expected clinical course necessitating intubations).  

 

Circulation - Central line? Art line?

 

Only at this point have you really got the ball rolling on all of the time critical aspects of the patients care and it is safe for you to slow down and do a complete history, physical, think through your ddx, start empiric or targeted tx.  Each time the patient decompensates, go back to the ABCs. 

 

 

Pretty good video going over some specific crashing patient situations and practical information about them.

 

 

EXCELLENT video by Reuben Strayer outlining his general overview/mnemonic for critically ill patients / resuscitation.  He does a much better job than I do, and his is probably easier than mine to remember.  Check it out!  

http://emupdates.com/2014/07/03/the-first-five-minutes-of-resuscitation/

 

 

 

A COMMON ISSUE THAT COMES UP IN CRITICALLY ILL PATIENTS...

As if the first order medical knowledge isn't challenging enough in these sick patients, the practicalities of accomplishing what you want to do almost never go smoothly in these patients.  These patients are often renal patients, vasculopaths, have been sticked a million times and have sclerosed veins, so one of the most common issues I've found is with vascular access, which can be incredibly challenging.  You'll be at the bedside trying to work your way through the ABCs but won't be able to get a line or blood, so you'll end up at a standstill feeling hopeless if you don't know how to trouble shoot.

 

DIFFICULT VASCULAR ACCESS PROGRESSION...

1 - try to get peripheral IV access.  x2 if possible.  

2 - If truly time critical, go straight to IO if there is any difficulty at all with IV.  If suspecting they'll need central line, go to non sterile crash femoral line.  

3 - If not time critical, options include EJ vs ultrasound guided peripheral IV to start.  If you think they'll need a central line (expect extensive volume resuscitation, multiple drips /pressors/ abx), go to IJ or subclavian sterile central lines.  

4 - If you have lines but they aren't drawing back and you need blood, go straight to art stick for blood.  

 

You should be very comfortable with each of the above methods, especially IO access.  Don't let your first exposure to it be during a crashing situation!  Definitely worthwhile to read up on it in Roberts and Hedges, the product websites, and youtube videos.  When placing it, the proper technique is to push through to bone without engaging drill, then once reached bone engage the drill and let it bring you into the bone (don't push!). 

http://www.teleflex.com/en/usa/ezioeducation/documents/EZ-IO_SAFIOVA-M-607%20Rev%20B-PrintVersion.pdf

 

EJs have a unique technique that you should look up.  Several good youtube videos out there from simple searching. 

 

Central line resources.  There are tons out there.  Here are my favorite 2 as a primer to the very often talked about topic of central lines.  

Good overview - http://clinicalcases.org/2009/03/central-line-placement-step-by-step.html

Overall the best teacher of everything central line is Scott Weingart; he has done a lot with this!  http://emcrit.org/central-lines/

 

 

 

 

 

Hope this was helpful to some of you out there.  I'm sure its very basic to those who have worked in the main ED for more than a few months, but I still think its a very important topic that should be reflected on early in our training.  Anyways, this week we are doing a "lab week", which has beene a great time so far.  Just 8-5 of a mixture of classroom stuff, procedure practice, simulation lab, ACLS/PALS/ATLS refreshers, and get togethers outside of work with the residency family.  Good times.  Whats even better is what awaits me next week: procedure month!  Supposedly the best rotation of the whole residency, we are sent to a neighboring hospital without a ton of residents and our only job is to do as many procedures as we can get our hands on.  No histories and physicals and best of all NO CHARTING.... just hands-on procedures all month.  Sounds amazing and I can't wait!  Life is good!

[SERENITY NOW]

----------PROCEDURES OF EMERGENCY MEDICINE----------

 I am finishing up my last few days of the procedure month.  Overall it was a very helpful month because we do procedures so much in the ED but don't often have time to slow down and focus on the details surrounding them.  I did get a lot of practice doing the bread and butter EM procedures (lac repairs, I&D, ultrasound IVs, reductions, splinting, etc), and spent the little free time I had reading up Roberts and Hedges (the EM procedure bible for those new to the field).  I also spent a lot of time outside of work reading different FOAM sites, forums (including this), and videos to learn a lot of practical tricks of the trade.  

 

Overall, I think it was incredibly worthwhile to spend a month really focusing on all aspects of procedures.  There is a lot more that goes into procedures than I had initially appreciated.  Like most things, its a learning process.  We start by seeing a procedure done a few times, read the basics of it, and grasp the overall process.  Then we are able to do the procedure several times and understand the setup, the anatomy/landmarks, the exact steps and technique, etc.  This brings us to "beginner-intermediate" zone in my mind.  I think to make it to truly 'proficient'/independent in a procedure, we have to go far beyond this.  We have to be really familiar with the process of evaluation (is my patient really appropriate for this procedure?), the potential complications that can come (what they look like, how exactly to manage them), and many other things.  Complications in particular represent a topic I think is vitally important.  We often haven't seen every complication but we still need to know these inside and out, so its so important to read/study these well.  After all, if we accidentally hurt a patient during a procedure and we don't know how to deal with the mess that results, we shouldn't be able to do the procedure at all!

 

I've created a general outline that can be applied to most procedures and helped me frame my studying:

 

Pertinent Knowledge for Every Procedure We Do:

1. Indications.  Situations/problems that necessitate this procedure, and how exactly the procedure fits into and fixes this problem.  

2. Complications/risks of the procedure.  Frequency these complications occur.  How they manifest and how to recognize/diagnose them.  How exactly to manage them.  How to prevent them.  

3. Contraindications.  With complications/risks in mind, what patients are not appropriate for this procedure.  

4. Anatomy.  Textbook anatomy, surface anatomy, landmarks, imaging anatomy (ie ultrasound).

5. Prep before starting the procedure.  Appropriate sedation/pain control, often unique to the procedure.  

6. The procedural steps.  Best technique.  How to confirm your procedure succeeded?  

7. Post procedure care.  Dressings to put in ED.  Patient instructions being very specific and knowing how to handle FAQ.  Sometimes these are topics in and of themselves (how to minimize scarring, etc).  Return precautions specific to the procedure.  

(also should know how to express these in layman's terms while explaining procedure to patient)

 

 

The most valuable topics I learned during this rotation were probably related to general procedural knowledge, decision making in laceration repair, and the little tips and tricks I've learned from dozens of awesome resources.  I'll detail these topics below.  

 

 

 

GENERAL PROCEDURAL KNOWLEDGE:

There are certain topics you'll see come up time and time again regardless of the procedure, so its really important to grasp these inside and out.    

 

1. Procedural sedation.  Certainly a huge topic that warrants thorough study of Rosens/Tintinelli/RoberstsHedges.  Still, lots of great resources out there - Reuben Strayer's website has tons of good stuff on this.  http://emupdates.com/2013/11/28/the-procedural-sedation-screencast-trilogy/

 

2. Antiseptic options.  Circular motion or wiping?  Efficacy instantly or only upon drying?  Procedure specific choices? Safe on open wounds?  Each antiseptic option is unique in all of these questions.  Esoteric topic? Maybe, but considering its something we do with EVERY patient, I think its worth dedicating some time to.  

Info that my attendings have told me:

betadine/iodine: circular motion, ONLY works after dry (so dab off with sterile gauze to speed this process), the agent of choice for LPs, and impairs wound healing.  

chlorhexadine:  wiping motion, works best if dried (dries quickly though), appropriate for many procedures, unclear if impairs wound healing.  

alcohol wipes (isopropyl alcohol): wiping motion, works instantly, not appropriate for many procedures, unclear if impairs wound healing.  

I haven't been able to find a whole lot of good take-away reviews online; if anybody is more familiar with this section, please chime in!  

General sterile technique for advanced procedures  - 

 

3. Local anesthetics. I've been pimped on this so many times I lost count, and for good reason because this is an important topic!  Several of the orthopedic residents have given peds patients seizures because they didn't know the toxicity that can set in when they pump 15cc of lidocaine into a hematoma block for a pediatric forearm fracture.  Know the toxic dose for lidocaine alone and lido + epi.  Lido is toxic at 4mg/kg (lido w/ epi is 7mg/kg).  So 20kg pediatric patient x4mg/kg = 80 mg max dose.  1% lido sol'n has 10mg in every 1mL, so 80mg/10mg = toxic at 8mL!!!  Don't forget that the cardiac dose for lidocaine is as low as 1mg/kg, so you had better be careful to withdraw plunger every time you inject any significant amount of lidocaine.  

More calculation examples: https://dailyem.wordpress.com/2012/11/13/quick-er-math-max-dose-lidocaine-for-local-anesthesia/

 

Case: You are doing a lac repair on 8 year old, and just a few minutes into the procedure he reports "My tongue feels numb, I feel dizzy, and I hear a ringing noise". Since you know the sx of lidocaine toxicity (look them all up now),  what immediate actions do you take?  ABCs:  cycle vitals, cardiac monitor, IV access, start O2.  Get EKG.  Treat airway, arrhythmias per ACLS, and seizures w/ benzos.  If any of these serious complications are already present, consider lipid emulsion therapy, the specific treatment for lidocaine toxicity.

 

 

(continued to next post...)

[SERENITY NOW]

 

DECISION MAKING IN LACERATION REPAIR

I really enjoyed lac repair in school and I practiced every chance I could get.  I think my technique was fairly good (good technique for newbies =  not too close to laceration line, bisecting lac with each throw, inserting at 90 degree angle to skin, rotating wrist as main action, surgeons knot first to hold knot taught, gentle approximation not strangulation, mild eversion of wound edges, good knot tying technique, etc).  However, while I knew 'how to use the tool', I was never sure what method was most appropriate for every laceration that came in (and each laceration/patient is unique!).   I didn't fully understand the specific decision making process that underlies it all.  This rotation has really helped reinforce that there is a rhyme/reason/logic/criteria behind the decision if/how to close lacerations.  

 

Realize that the overarching goals of laceration repair are to restore function and minimize scarring, all the while avoiding infection.  These 2 tend to pull the decision making process in opposite directions.  To maximize function/cosmesis, the best method is to close the wound right away (primary intention), however primary intention will result in an increased risk of infection in certain patient populations.  Secondary intention will be more safe for those at an increased risk of infection, but they result in worse function/cosmesis, in addition to many other negatives to consider.  Understand what you are putting some patients through by subjecting them to secondary intention: http://lacerationrepair.com - great resource with short, to the point videos.

http://lifeinthefastlane.com/own-the-wound/  - yet another golden post by LITFL, gotta love them!

http://foamcast.org/2015/11/15/episode-38-lacerations/

http://manuetcorde.org/2013/05/07/to-suture-or-not-to-suture/

http://hqmeded.com/wound-care-ed/

 

 

 

 

MY FAVORITE PROCEDURAL TIPS AND TRICKS, and LOTS OF GREAT PROCEDURE VIDEOS, RESOURCES, ETC:

I had a lot of fun scouring my favorite books, websites (including this site, as you'll probably recognize some of these from EMED's golden thread "tricks of the trade/EM"), and learning from some of the veteran attendings/PAs/nurses.  Below are my favorite. 

 

Nose foreign body removal with the EMEDPA technique:  use malleable/blunt loop type ear curette, shape into hockey stick, slide along lateral wall of nares until behind the FB, then pop it forward and out.  

 

Superficial embedded FB removal: use a 2-4mm punch biopsy, irrigate, done.  

 

Fish hook removal using the string method.  Supposedly is very successful.  

 .  This video doesn't explain it but basically you get umbilical tape wrapped around the hook all the way down to the skin.  Align the hook down parallel with skin.  Push the eye of the hook down to the skin and it will disengage the barb from the undersurface of the dermis.  Give a quick short jerk on the tape and the hook will pop right out.  Try this at your own risk though, as I have heard of it failing (painfully) as well! 

 

Foley troubles.  Nurses come to you saying they can't get foley in.  The patient has not had any urologic surgery before (so, doubt stricture and its likely BPH).  Use a uro-jet and clamp meatus for 3 minutes (lidocaine jelly will lubricate and expand the urethra), then use a 18-20 coude catheter.  Still can't get it, try a 12 french silicone catheter then call urology.

 

Dental blocks like inferior alveolar block.  Its tough to inject and withdraw syringe plunger to make sure not intravasc with one hand (because your other hand is occupied with landmarks in the mouth), especially at the awkward angle in dental blocks.  Great tip is to simply put tape around your thumb on the plunger and reposition your other fingers so that you can withdraw and inject without repositioning at all.  Its basically a poor man's ringed syringe but it works great.  

 

Fingertip avulsion lacs that are bleeding a ton.  Let fingertip soak in 10-20 cc lido w/ epi in a small basin/pill cup for 5 minutes.  This does the trick a lot, but if not, can create a make-shift finger tourniquet.  Then coat the tip with dermabond.  

 

 

 

****Tons more great tips/tricks from this website "Procedurettes" by Whit Fisher. Highly recommended! http://www.procedurettes.com/Procedurettes/index.html.html

 

 

Awesome video resources as if you were there learning procedures at bedside:

****https://www.youtube.com/user/lmellick/videos?view=0&flow=grid&sort=p

Probably my favorite - by Larry Mellick.  He is always uploading great videos with nice explanations as he goes.  Check him out! 

https://www.youtube.com/user/theedexitvideo/videos?view=0&flow=grid&sort=p

https://www.youtube.com/user/cebolinha720/videos

 

 

Misc procedure related resources:

https://umem.org/page/education/residency/videos_procedures

    Great videos by UofMaryland EM program.  Procedures on cadavers. 

http://lifeinthefastlane.com/procedures/

http://www.emra.org/students/education/skill-demonstration-videos---topics-pertaining-to-em/

http://enw.org/IVStarts.htm

http://www.bd.com/vacutainer/pdfs/techtalk/TechTalk_Jan2004_VS7167.pdf

 

 

 

 

 

 

Well that is it for this month. I'll be back in the ED next week for the first time in the new year.  I am really hoping to start cranking up my efficiency and seeing a lot more "sick" patients.   They are always humbling, that is for sure!  

[dphy83]

Hi Serenity:

 

How are you evaluated or how/when do you receive feedback during this residency? Just curious. I know that you say that you haven't progressed as much as you would have liked, but I'm sure the program director(s) and faculty think you're doing just fine.

[SERENITY NOW]

@dphy83:  We receive online evaluations from our attending physicians as we go throughout the program, and we have formal in person meetings with our program director every several months.  My first one is coming up this week actually... I hope it goes okay haha!

 

 

 

 

On a side note, I have been getting some PMs from students asking about what they can do to increase their chances of getting into an EM residency, and I've been giving out the following general advice:

 

FOR STUDENTS:  INCREASING YOUR CHANCES OF GETTING INTO AN EM RESIDENCY...

At the end of the day, the best way to increase your chances of getting into a residency is to have a killer application.  Obviously, more important than just superficially "buffing" your application, you want to really know what you're getting into and learn as much of the EM foundation as possible.  Still, you want to make sure you have a great application that reflects your hard work so that you can actually get into a program.  The following are the main application components and what you can do to strengthen them:

 

1. Past experience.  If you're a pre-PA, it would be great if you could get experience as an EMT/paramedic/ER nurse/ER tech before school.  This looks great on your application and will seriously help your transition to an EM provider.  If you aren't able to do this, you will still have a chance so don't worry.  Shadowing experience is a good start to getting a sense for the way things are done in EM.  

 

2. GPA - study hard!  Higher GPAs are favored in admission committees, so don't shrug this off as unimportant in PA school if you really want to be competitive for a residency.  I don't think that your PANCE score matters at all.  

 

3.  Letters of recommendation - The best way to get the best LOR is to really shine on your EM rotation, which requires you to really know your EM stuff...  During didactic year, focus on EM topics, really prepare for and do well in your procedure labs, and consider starting to listen to EM podcasts on free time/commutes.  Start with the podcast 'EM Basic'.  Also, develop a relationship with your PA program director, and make sure they can see your passion for EM.  Many residencies require one LOR to be from your program director, and it will look a lot better if it isn't a generic cookie cutter LOR!  During clinical year, work really hard on your EM rotation, come in early and stay late, show initiative and be active about learning from your preceptor.  Definitely dive into the EM podcast scene; its a lot more fun way to learn IMO - listen to as much of EMBasic as possible, then check out FOAMcast too.  Get as many EM-related electives as possible (trauma, ortho, peds EM, ICU).  If you stick with all of these things, you'll be an EM stud on your rotation and will get a shining LOR. Please see the copy/paste below from a prior post I made about more tips for making the most of your rotations.

 

4.  "Buffing the resume" - show a specific interest in EM and do activities that reflect that.  Does your PA program have a unique track dedicated to acute care?  Perhaps a student "EM interest group"?  Opportunities to learn about bedside ultrasound, advanced procedures, ACLS/ATLS/PALS?  Opportunities to go to EM conferences around the area?  Consider joining SEMPA as well.  

 

5. Personal essay and Interview skills - be prepared, practice, and articulate yourself well.  See my earlier post about interview questions to reflect on. 

 

 

 

 

ADVICE TO CLINICAL YEAR STUDENTS: HOW TO MAKE THE MOST OF YOUR ROTATIONS...

I wrote this post a while back on the student forums and I think it is very relevant here.  If you know you want to go into EM, you can further focus this general template to be more EM specific.  

 

(copy/past)

"Hi Gang,

I tend to do some reflecting on this crazy process of learning medicine and every once in a while I come to a realization I think is worth sharing.  The past few months I've been thinking about rotations...

 

There is really so much that goes on during rotations.  You try to learn your way around a new hospital, you try to learn the job/responsibilities assigned to you, and you try to learn the basic textbook medicine related to that specialty so that you can cram it in your head for your EORs. Now that I have graduated, however, it has become abundantly clear that real practice requires much more than those things.  Since I am doing a residency program, I am continuing to do rotations and I have found myself changing the way I approach my learning while on a rotation.  More and more I am asking myself, 'what will I need to know about this once I am in practice in my own specialty?'.  The basic outline is as follows:

 

General Learning Goals for Rotation on Specialty X... 

-What are the most common chief complaints and diseases for this specialty.  What are the uncommon diseases that this specialty is commonly consulted to rule out?  There are often diseases that in the ED we are not great at identifying/ruling out/managing because they're uncommon, but the specialists see it all the time so you in a great position to really become comfortable with these entities.  Really dive into learning about each of these topics, learn the subtleties that the specialist looks out for and their approach to rule in/out.  (Example: back pain, consult ortho to rule out cauda equina.  Posttraumatic swelling, consult ortho to rule out compartment syndrome, etc).  

-The perspective/approach with which the specialist thinks about and works through the chief complaint/consults. 

-Really practice the ddx, widen it, and internalize it by seeing as many cases as possible.

-The history questions that really target the ddx, and what is the best way to ask these questions (learn this by listening to the way the specialists ask questions).

-The systematic physical exam, the technique, and getting a feel for what pathology looks like and feels like.  Also, how do they objectively describe and document their exam findings?

-The orders for workup.  Getting a sense for sensitivity and specificity of these tests.  How much weight does the specialist actually put on the results of these tests?  ​What is the systematic approach to reading the studies (ekg, cxr, head CT, etc) and practice practice practice with the specialist while you still can.

-The most common treatments used in this specialty.  What are the things that the specialist has in the back of their head when they order this?  Chart checks they do before ordering (pmh, labs, etc), C/Is, interactions important enough that they bother memorizing, common side effects and worrisome adverse reactions they know to look out for.  

-How to perform the most common procedures of this specialty, and lots of practice doing them. 

-When is it appropriate to refer these patients, what do they want us to do first, and how do they want to hear the consult/presentation?

 

As you can imagine, its not possible to learn it all when you are on your rotation.  So, its really important to prioritize, and this is the second part of my realization: the most important things to learn on rotations are the things that you'll have the most difficulty learning while practicing on your own.  

 

You'll be able to look up the majority of the above things like ddx, history questions, orders, etc.  However, you won't be able to look up what it feels like to have your hands on a patient with ascites, what the fluid wave actually feels like and what the shifting tympany actually sounds like.  With this in mind, on my current rotations I have been focusing much more on honing my physical exam skills and truly trying to internalize what abnormal looks and feels like.  Another example: if you want to commit to memory the most important "take away" points for a given drug, good luck searching a textbook or uptodate... you'll just find lists of side effects and contraindications a mile long which will be utterly worthless.  With this in mind, I now realize that my preceptors/specialists have 'lived and breathed' these medications for years, and have internalized the most important take-away knowledge about these meds.  All it takes is a few good questions and they'll share this invaluable knowledge with you.  In essence, you should realize the value of being immersed in a wealth of specialty knowledge and being in a position where you are allowed/encouraged to ask questions... take advantage of it!  You likely won't ever get this chance again!  So, in the outline listed above, I have italicized the things that I consider knowledge you'll be able to obtain MUCH easier while on your rotation than when you are out in practice.  These should be the things you really try to seek out while on your rotations.  

 

As I said above, with these realizations, I've been approaching my rotations much differently and I think my learning experience has become much more productive as a result.  Instead of passively scanning through a review book, I now have an outline of things I am actively seeking to learn and my retention is much better.  In the past, when my preceptor and I would have down time, I'd try not to bother them and couldn't think of good questions anyways.  I now always have high yield questions ready for moments of down time and I've been able to learn invaluable information as a result.   

 

I wish I would have made this realization before starting rotations in PA school, since I think I would have gotten a lot more out of my school rotations.  It is what it is, I suppose.  At the very least, I hope I can pass some perspective on to you students going through it now so that you can make the most of your journey!  

 

 

 

 

 

(I hope this helps you students out there reading this forum/blog.  The residency experience is a great one that I'd highly recommend, and I wish you all good luck in getting in!  Please let me know if you have any other questions.  -SN)

[Disciple3]

Thanks for all the work on this, bookmarked for a later time :)

[SERENITY NOW]

I am coming up on the last week of this ED block.  I now have 7 months of the residency under my belt, and as I hoped, I think overall things are starting to come together.  I am not as nervous picking up sicker patients, I've got a much better sense of the flow of the ED, I know how to interact effectively with consultants, and my efficiency is increasing.  The procedure month definitely helped me with my confidence in advanced procedures... the past week I did several complex lac repairs and even threw in 4 crash femoral lines... they went in like a breeze and it was a pretty awesome feeling!  Also importantly, I've gotten into a manageable routine of integrating my learning as I go, instead of being overwhelmed and pushing the learning/reflection to the side just to keep my head above water.  I've come up with a little system of basically making condensed notes (just enough to jog my memory later) of high yield learning points on the side of my note paper, and at the end of every shift before going home I spend 15-20 minutes to reflect on them, quickly read up on them, and commit them to memory.  While it is very challenging to spend more time after a long/exhausting shift, I think a reflection process is extremely important to make the most of our time in the ED.  My reflection process has helped me realize some common themes in the mistake I have been making and techniques I feel help me counteract them.  I'll dedicate the first part of my post to this topic.  

 

Also, this month for whatever reason has been a month filled with tons of psych patients.  Perhaps its the cold weather pushing a lot of the homeless into the ER.  Either way, I've had to learn how to deal with psych patients, and perhaps the most challenging for me as a newbie are the agitated ones.  I'll write about this in the second part of the post.  

 

 

COMMON THEMES IN DEALING WITH ER PATIENTS:

Approaching ER patients is extremely challenging.  We are exposed to every type of patient, every chief complaint, every medication, every social situation, etc... and its incredibly easy to get overwhelmed.  How should we start learning in a field like this?  Where is the best place to start?  When I first started, I found that I got the most "bang for my buck" by learning about each chief complaint: chest pain, SOB, abdominal pain (etc). With more experience I've been honing this down even further with subtype chief complaints: postprandial abdom pain, pleuritic chest pain, wheezing predominant SOB.  This is extremely valuable and necessary in the beginning, but I've realized that it has resulted in some common mistakes for me.  I have found myself walking into patient rooms with the triage chief complaint painting my vision and obscuring everything that I see.  As a result, I'd do my extremely focused HnP and go out to present the case, only to find that I missed perhaps a subtle finding (outside of the realm of my 'approach to chief complaint X') that completely changed the management of the case.  

 

I'll give you some examples.  In the past months, I've had several 'abdominal pain/nausea/vomiting' patients that have ended up having blood sugars in the 600s that I didn't think to check for because I was too focused in on the abdomen.  Or epistaxis patients that had arrhythmias from the vagal tone that I would have noticed if I had thought to put them on the cardiac monitor.  Or slightly older patients (60s) who I thought I could trust their history because they seemed to be answering questions appropriately, yet if I had just asked a few AO screening questions I'd find that they really thought its the 1980s, and I can't really trust anything that they told me (I've been astounded at how lucidly some altered patients can answer questions).  

 

I've developed a basic outline of things I have learned to address in every patient, regardless of their chief complaint.  The outline contains the things most likely to change the management of the case, regardless of the chief complaint.  This helps me to not 'miss the forrest through the trees' from being narrow minded thanks to the chief complaint.  Also, I think its very important for efficiency's sake to integrate the things we will want to know later when we go to put in medications for sx control, contrast radiological studies, etc.  That way, we don't have to waste time later going back to the bedside to ask these questions again. 

 

 

Evaluation to consider in every patient:

Questions for EMS:  

Where was patient found, or where did patient come from?  How/why was EMS called in? Is family coming (especially for the old/altered who can't provide history)?  Patient able to ambulate?  Vitals?  Actions done in route?  

 

Immediately upon entering the room:  

Quick ABC assessment, get vitals going, likely place on cardiac monitor.  Assess if this is a situation necessitating immediate resuscitation over the traditional medical evaluation.  

 

While getting initial HnP:

Important PMH (always ask kidney / heart dz), Meds (blood thinners, immunosuppressants), allergies, social (alcohol or drugs tonight?).  

Recent hospitalizations / bad complications

Sx control - What/when have you already tried today?  In general what works/doesn't?  allergies?  

All women - chance of pregnancy? LMP?  low threshold to get UPreg.

All older adults - really important to do a quick mental status exam.  As said above, I've been fooled several times by seemingly-lucid adults who are actually altered or demented, and it definitely changes the management, because it effectively means you can't use their history to rule out badness.  There are many validated tools out there (MMSE, CAM, etc) but I think an abbreviated version of them is fine for screening purposes.  I assess AOx3 and if any concern, I'll add cognition (object naming, "whats 2 quarters plus a dime") and attention ("squeeze my hand when you hear me say the letter A in a series of letters") .  

Also important to do neuro exams in all altered patients (extension of the above), because they won't come out and tell you they can't move their R arm.

Extremity exam - patients' pants often hide swelling, PVD/diminished pulses, skin infections.

Rectal exam ( if indicated) - heme pos stools will certainly send you down a different diagnostic/management pathway!  

While you go about your evaluation, if there are crucial things you want to make sure you address before they leave, write a square 'check-box' on the side of your notes and circle it.  

 

While nurses are doing their thing, what things aside from the basics should you consider asking them while they are in room: (they are busy people and if you let them leave the room they'll be busy with the next of a hundred tasks and it will be a minimum of 20 minutes before your request gets done)

fingerstick

rectal temp (especially if the patient is tachypneic, they will have a falsely low oral temp)

cardiac monitor +/- ekg

urine preg or blood preg

unique blood work you suspect you'll need, have them draw it the first time instead of prompting the need for a second stick - rapid vbg w/ lactate, coags, type and cross, blood cx, etc (these things often aren't drawn on their "rainbow" draws).  

 

Before you leave the room, make sure these have been done and you have assessed them:

VITALS, VITALS, VITALS!!  Undoubtedly the most important of this entire list, and easy to forget in the patient who looks great sitting in front of you, but a resting HR of 120s will undoubtedly change your management, regardless of the chief complaint!

Cardiac monitor

Take a quick second to think about the case, your ddx, your tx plan, and what other questions would help you.  I always find myself remembering important questions when I am sitting down putting in orders into the computer. Don't waste time and get them all the first time through.  

 

Before discharging a patient:

Look at my notes, make sure I've checked all of the checkboxes I've made so that I don't forget the critical parts of management and follow up.

Reassess the last vitals placed into the computer.  Make sure these are normal or addressed.  This is a common issue that many people screw up!

 

By following this general outline, I've been able to cut down on a lot of the little mistakes and oversights I had been making up to this point.  This is especially important as things get crazy busy in the ER... gotta have a systematic approach!

 

 

 

CHEMICAL RESTRAINT OF THE AGITATED PATIENT

 

This will be basic for those of you veterans out there, but as a newbie its definitely a topic I had to review heavily because of how commonly this situation happens, and because of how chaotic it can seem in the heat of the moment if you don't really know your stuff.  There is definitely more to know than just the "B-52 bomb everything" approach, haha.  

 

Agents available for our use:

 

NEUROLEPTICS/ANTIPSYCHOTICS... in general are more tranquilizing than they are sedatives/snowing agents (compared to benzos).  Also in general they are safer than benzos.  Before giving them, if you have a bit of time, go through a mental checklist of considerations/contraindications:  Quick assessment of patient to make sure they're not already in dystonic crisis (neck spasm/turned head, hand spasm/movement, rigidity, oculogyric crisis), Check PMH to avoid in epileptic patient or alcohol withdrawal patient (they lower seizure threshold) and to avoid in prolonged QTS patient (they prolong QT).  They are generally category C in pregnancy (vs category D for most benzos).  In general, these are given with antihistamines (benadryl or cogentin/benztropine) to prevent dystonia, but a few don't recommend this.  Most commonly used drugs of this category:

 

Haldol 0.5-10 mg PO/IM/IV.  Most use 5mg to start.  onset 20-30 min.  This is the tried and true tranquilizer for the past several decades, but not perfect because of the long time till onset, strong EPS side effects, and other SEs (seizure, QT).  

 

Geodon (ziprasidone) - 10mg -40mg PO/IM.  Most use 10mg to start.  Fast onset, doesn't over sedate, reduced EPS, easy transition to PO dosing.  This is a newer agent and gaining favor in the younger generation, but also some recent studies showing they might not be as safe as we anticipated.  Avoid in elderly and QT (increases QT more than all others).   

 

Zyprexa (olanzapine) - 2.5 - 20 PO / IM.  

 

 

 

BENZOS... in general are more sedating, so be careful not to snow the patient.  I've been told to think of benzos like you would alcohol... don't give it to any patient you wouldn't want getting a triple shot of vodka:  Geriatrics (worsens delirium), drunk patients (resp depression), pregnant patients (category D) being the most commonly cited.  These are pimped over and over again, so really gotta know these cold.  The nice thing about benzos is that they are faster acting.  Most commonly used drugs of this category:

 

Ativan/Lorazepam 1-2 (0.1 mg/kg with max 3-4) mg IM/IV.  Most use 2mg to start.  Onset in 15-30 min, redoes Q15 min if no effect.  The pharmacodynamics of IM ativan are very poor, so try to use IV ativan or go to IM versed if needed. 

 

Versed/Midazolam 2-5 mg (.02-.1 mg/kg) IM /IV, can give in 2mg doses redosing Q5 min.  Onset is within 5-10 min.  This is the IM benzo of choice because of water solubility it is quickly absorbed from muscle as opposed to ativan.

 

 

Specific patient situations:

The completely undifferentiated patient - The old school cocktail is the B52 - Benadryl 25 IM, Haldol 5 IM, Ativan 2 IM. Many prefer cogentin over benadryl for less sedating properties, given that you are already giving a benzo. Some now say you should only mix Benzo + neuroleptic when you know its a psych issue, but if you don't know you should stick with one or the other.  New school is often going with geodon 10-20mg IM.  

 

The agitated psych patient - Can mix benzos and neuroleptics - Haldol 5 mg IM/IV, Ativan 1 mg IM/IV, cogentin 2mg IM/IV.  Again, many new schoolers vote for geodon as a great choice for the known psychotic w/o hx of long QT.   

 

Drunk and thrashing patient - Stick with neuroleptics - Haldol 5mg, wait 5, 2nd dose at 10mg.   IM is okay, IV is better.  Monitor for QT.  AVOID BENZOS (resp repression).

 

Drug induced agitation (PCP, K2, bath salts), sympathomimetic presentation, or ETOH withdrawal - Stick with benzos - In general, versed 2-5mg IM push repeating x5 min is a good bet.  or ativan 1-2mg IV q15 min.  May need very big doses for the big ones like meth, bath salts, etc.  AVOID NEUROLEPTICS (lowers seizure threshold).  

 

Demented agitation (sundowning) - Stick with neuroleptics - Haldol is really the only option (second gen antipsychotics are not approved for demented patients).  start at very low doses.  0.25 - 1mg haldol.  AVOID BENZOS (worsens delirium in elderly).  

 

 

 

Lots more to cover in this general topic.  ddx, HnP, toxicology stuff, dispo, tips and tricks.  One of these days I need to dedicate some study and questions for my seniors/attendings to learn the nuances of involuntary restraint both for psych and for agitated delirium / organically sick patients.  On a somewhat related note, I want to learn about the subtleties of our legal/medical/hospital rights to kick out people who are violating the code of conduct.  And of course, the discharge "against medical advice" is a controversial topic with a lot of nuances and a ton to learn about.     Lots of things to get into... someday!

 

 

 

 

Thats it for this month, folks.  I'll be starting my ortho rotation next, which I have heard great things about.  Definitely looking forward to it! 

[SERENITY NOW]

The ortho rotation has come and gone.  What a great time.  I essentially was paired up with the ortho intern, we carried the pager, saw all of the consults in the hospital, and did all of the ED/floor procedures.  I was able to do plenty of joint aspirations, reductions, splinting, etc.  I even got to scrub into a few hand surgery cases at my request because we see so much hand injuries/lacerations in the ED and it was great to get a better sense of all of the important anatomy to look out for when exploring their wounds.  The ortho intern did a lot of the dirty work (care management, discharge summaries, etc), freeing me up to really focus on reading up on the things we saw and asking the ortho seniors all kinds of questions.  These people live and breath this stuff and are great teachers.

 

As a result, I learned a ton on this rotation!  I learned general ortho knowledge (how to present, the "ortho lab cocktail"), how to critically interpret X-rays (determining if the studies are adequate, the findings to look out for, and specific measurements that guide management like 'acceptable reduction limits'), a good focused ortho exam (axial vs peripheral neuro exam), procedures procedures procedures (arthrocentesis, joint/fx reduction + splinting), approach to ortho emergencies as well as the commonly seen ortho chief complaints that can be deceptively challenging.  Definitely too much to cover in one blog post, but I'll try to touch on the most important points.

 

 

GENERAL ORTHOPEDICS:

1.The orthopods had a very specific way they wanted to hear presentations during their ortho rounds (though we can condense the story during phone consultations)...  

Age/Sex

RvsL handed / community ambulator with cane / baseline deficits  (as relevant to the case)

presents with X injury (i.e. posterior hip dislocation, closed distal radius fracture) 

as a result of mechanism (fall from standing, front impact mvc upgraded to level 2 trauma, etc)

now complaining of pain at XYZ location.  Denies numbness, tingling, weakness.  

relevant PMH / PSH / meds (they want to hear about anticoagulants, *steroids*, bisphosphonates)

Exam with normal vitals, AO, open/closed skin, neurovascular status (axial or peripheral), compartments.

Xray revealing (bone X) (intra/extraarticular) (transverse/oblique/spiral) fracture with (displacement/shortening) and (angulation/rotation).  

For example, Xray revealing a distal radius extraarticular transverse fracture with dorsal angulation but no displacement.  

Plan is XYZ.

 

(example phone consult).  "Hi there we've got a consult for a hip fx in room X.  73 yo F community ambulator with a L intertroch fx after fall from standing about 2 hours ago.  PMH CHF, ESRD.  Exam with normal vitals, no open skin, neurovasc intact.  Xray doesn't look terribly displaced or shortened. Anything else you'd like to know?"

 

2. On any ortho consult related to infection, they always ask for ESR and CRP.  They love these markers and can't move forward until they get them back.  I didn't know the intricacies of these markers before this rotation, but I've learned a lot now.  A lot of the info can be summarized well in this worthwhile read:  http://www.bpac.org.nz/resources/campaign/crp_esr/bpac_crp_vs_esr_poem_2005_wv.pdf

 

3. An EXTREMELY valuable part of this rotation is seeing how much the orthopedists really scrutinize X-rays.  They always start out by asking if there are enough X-rays.  They have to have 2 orthogonal views of the bones/joints above and below the injury.  There are also views that techs are notorious for skipping because they don't want to hurt the patient; most commonly the axillary lateral in shoulder pain patients.  They pounded into my head out crucial it is to get the axillary lateral to definitively say if there is a dislocation, towards which direction, and if there is any intra/periarticular fracture that would impact reduction.  Once they determine they have enough X-rays, they are extremely attentive to detail in determining if the studies is adequate.  They look for specific things on each X-ray and if not everything is there, they send the patient back.  The X-ray techs hate them and its quite comical.  I personally don't think that in the ED we have the time or the necessity to be quite as anal as ortho is when it comes to these things, but it still is valuable nonetheless to see how much level of detail ortho puts into their scrutiny.  Last, they taught me how to use the many tools on the X-ray reading system, emphasizing the importance of changing contrast brightness based on what you're looking at.  They also taught me how to objectively measure for separation, angulation, etc, and the situations in which its important because it changes even ED management.  Orthobullets.com is their go-to place to find acceptable limit parameters - great website that is highly recommended!

 

Of course, the details they look for in each joint X-ray is unique and too much to cover here.  I was lucky enough to have an amazing radiologist lecturer in PA school who everyone loved (we voted him to his 4th time of winning the best lecturer of the year award), and we all are lucky enough to have his lectures available online if you are looking to learn what details to look for in each specific X-ray.  Sit back and enjoy this guy.... highly highly highly recommended!  

https://www.radiology.wisc.edu/people/schreibman/lectures.php

(go to the video links on the far right)

 

 

THE ORTHOPEDIC PHYSICAL EXAMINATION and COMMON PROCEDURES:

(always start 1 joint above and finish 1 joint below)

Inspection - open wounds

Palpation - really localizing the tenderness to specific surface anatomy key spots.  Feeling compartment fullness and presence of effusions. 

Range of motion - active and passive.  Being sure to do this correctly at the hands (isolating DIP and PIP), and correctly grading the degrees of ROM vs expected.  

Ligamentous laxity/stress testing - learning how to do this well is an art.  

Special testing specific to the joint in question.  (check out orthobullets videos for joint specific exams).

Vascular exam - pulses, doppler if needed, cap refill.  

 

Neuro exam - they really emphasized that you should have 2 different neuro exams: one for peripheral trauma (assessing peripheral sensory and motor nerves) and one of axial trauma (assessing spinal cord + nerve roots sensation and motor).  I think we all know the spinal cord exam for dermatome and myotome leveling; if not, check out this great overview and charting guide from the spine association: 

http://www.frontiersin.org/files/Articles/76963/fnhum-08-00141-HTML/image_m/fnhum-08-00141-g001.jpg

 

What I learned a lot about was the peripheral nerve exam.  I don't have time to go into all of the details, but I'd highly recommend you all spend a couple of hours reviewing this topic and memorizing it.  There are lots of resources for this online.  With regards to documentation, their upper extremity peripheral nerve exam would look like this..

+SILT (sensation intact to light touch) R/U/M (radial/ulnar/median).

+Motor intact AIN/PIN/U - A/PIN stand for anterior/posterior interosseus nerve, which are the terminal branches of the median (AIN) and radial (PIN).  Instead of testing every single median nerve function, they can test this terminal nerve function (AIN tested w/ the "A-okay sign") and rest assured that all proximal median nerve fx is intact.  PIN (radial nerve terminal branch) fx is tested with the "rocker" symbol with wrist back and thumb/index/pinky fingers extended. 

 

 

Arthrocentesis

One of those things that you definitely need in-person practice on real patients, but realize that there are specific surface anatomy landmarks that you have to find in order to localize your point of injection, and there is a correct injection direction/plane as well.  UpToDate has a great overview of the common joint aspirations with good pictures.  

 

 

Joint / fracture reduction and splinting

Definitely an art!  In general, the steps are as follows:  pull traction, accentuate the angle (to unhinge) before pushing back into the correct alignment and position, then mold a splint onto it with "3 point" pressure.  The ortho bible for all things fractures is Rockwood and Greene, which goes into specific reduction technique and splinting.  Unfortunately, its very big and expensive and has a ton of extraneous info for ED providers.  So, another really good reference for proper techniques is the "Handbook of Casting and Splinting" - All of the ortho residents carried this in their locker and referenced it when on call.  I bought the kindle version for reference later in the ED.  http://www.amazon.com/Handbook-Splinting-Casting-Mobile-Medicine/dp/0323078028

 

Unfortunately, this is one of those things that even with book reading, nothing is quite as good as being right there with the ortho team and seeing all of their tips and tricks to make reductions go smoothly and applying really good splinting technique.  If you ever have a chance to do an inpatient ortho rotation that covers the ED, TAKE IT!  Its absolutely invaluable.  

 

 

APPROACH TO ORTHOPEDIC EMERGENCIES AND NONEMERGENCIES...

Aside from the cases that are clearly an ortho etiology and "ortho to handle entirely" (fractures, certain dislocations, etc), there are several scenarios that ortho was commonly consulted on to "rule out ortho emergency".  These are things that perhaps aren't seen super commonly in the ED and as such we are not great at identifying or dealing with them.  The following scenarios fall in this category:  back pain - rule out cauda equina, atraumatic joint pain - rule out septic joint, hand infection - rule out FTS (flexor tenosynovitis), foot trauma - rule out lisfranc injury. Posttraumatic swelling - rule out compartment syndrome.   We were consulted on these ALL THE TIME, I spent a ton of time dedicated to really learning each individual topic, and I discussed them all at length with the ortho team...and I now feel so much more confident in handling them.  I know I wouldnt' have gotten this far without this rotation, making me realize just how invaluable these off service rotations (and the residency in general) really are!  I'll share a few of the salient points for each topic.  

 

Cauda equina syndrome- Urinary retention is the most sensitive clinical finding and present in over 90% of CAS.  So, you absolutely have to check a PVR on each patient.  Aside from this, get a really good physical exam and if there are objective deficits you should be able to localize the spinal cord level.  Don't forget to do a good perirectal sensation and sphincter tone.  If you truly have some objective findings, you need a stat MRI straight from the ED.  

 

Septic joint rule out.  Most sensitive finding is limited ROM, so if a patient can fully range the joint, its not septic.  Ask about important risk factors / red flags (preexisting joint dz like gout or RA, loss of ANY skin integrity like wounds/ivdu/dialysis, immunocompromised like DM/steroids/RA immunomodulator drugs).  Don't forget about hematogenous spread - ask about sexual activity and STD risk.  Order X-ray cbc bmp esr crp blood culture. Tap the joint and send for cell counts, gram stain, culture, crystal eval.  

 

Hand infections / FTS.  There is a great podcast on iTunes if you search for "hand infections", given by Duke's EM residency hosting an orthopedic hand surgeon.  Learn the kanaval's signs and learn how to assess for these really well.  The ED attracts many dramatic patients who will unintentionally fool you into thinking they have kanaval's signs from a simple paronychia, but true FTS is quite bad and the exam findings will not be distractible.  

 

Foot trauma / lis franc.  This is a challenging topic even for the ortho docs, but its worthwhile to spend some time towards learning this because the outcomes are terrible if you miss it.  Red flags should be going off in your head if you see significant mid-foot swelling in a patient presenting after fall from height / crush injury, twisting sports injury, or the classic 'weight/axial load onto a plantar flexed foot'.  Do a really good neurovasc exam (neurovasc bundles run thru lisfranc joint) and order X-rays (normal AND weight bearing if possible, which are the best to assess lisfranc injuries).  Look up the specific X-ray things to look for when evaluating this - there are a few 'anatomic lines' to look out for that should not be disrupted, like the line from medial aspect of 2nd MT to the medial aspect of medial cuneiform.  If after all of this you don't see any evidence of lisfranc injury but patient still has bad pain/swelling and is unable to weight bear, consider/rule out compartment syndrome of the foot, and splint/NWB/close ortho f/u.  

 

Compartment syndrome (CS).  This is a big, important topic that definitely requires additional study.  You can't appropriately assess for this if you don't know the anatomy  - what are the compartments in each part of the body, what area do they cover longitudinally, what muscles/tendons run through them, and how can you stress them accordingly.  Your physical exam should be targeting each specific compartment and associated muscle/neurovasc group.  One of the biggest mistakes the ED would make is see a big swollen area that is localized around the injury site, worry that its compartment syndrome, and stop their exam.  In doing a thorough exam and knowing the nature of compartment syndrome/anatomy, you won't be fooled into thinking that localized/post-traumatic swelling is CS if the rest of the compartment is soft (you can't have compartment syndrome localized to one pole of a compartment because the compartments are open longitudinal structures).  We saw a few cases of missed CS on the ED's part, and the ortho team discussed some of the common ED pitfalls in not recognizing the high risk fractures (tibial fractures, long bone fractures, etc) as well as the confounding stories with high risk underlying mechanisms (subacute crush injuries, as seen in the hip fx patients down for days and the piss drunk patients found down sleeping on an extremity for many hours).  

 

 

Good ortho resources to peruse if you have down time:

https://sites.google.com/site/sportsmedicineresources/

https://www.youtube.com/user/ORTHOfilms/videos?flow=grid&sort=p&view=0

https://www.med.unc.edu/ortho/mededuc/medical-students/minitext.pdf

http://gpsaem2013.weebly.com/orthopedic-curriculum.html

 

One noteworthy mention:  Vumedi ( https://www.vumedi.com/accounts/login/ )is a website I hadn't heard about until this rotation; its dedicated to surgeons/residents for providing tons of high quality intraoperative videos and other great surgery-related videos on examining, boards, etc.  I watched several of the hand surgery videos in addition to the cases I saw in-person to really reinforce hand anatomy/trauma, which I have been seeing a ton of in the ED.  

 

 

 

So thats it for this month.  I'll be back in the ED on Monday and hoping to keep picking up the pace.  I'll see you all next month!

 

 

-ps, I am sorry if there are spelling errors or some random words that just don't make sense in the context... for some reason my computer or browser autocorrects certain words (especially medical terminology) and I haven't been able to turn this feature off... very frustrating.  

[SERENITY NOW]

Hello everyone - update time!  

 

Just finished my last ED rotation of the first year of this residency!  Overall it was a good month.  I spent a lot of time in the highest acuity part of the ED and I tried to really do as much as I could.  Despite not typically being a first year duty, I pushed myself into as many of the traumas and codes as possible and did several central lines, trauma procedures, and even started dabbling in the airway management things with some of the second years.  I tried to start picking up as many of the "2nd year" patients, like the angioedema patients or those in significant resp distress.  I picked up the pace and was able to get to our first year goal of picking up at least 1 patient per hour which quickly leads to us juggling 4-5 patients at a time.  Ive gotten much more comfortable dealing with our fellow medicine residents, some of which will do everything in their power to block every admission.  Last, I've really been on a roll when it comes to establishing difficult IV access -- many of the nurses now consider me one of the go-to guys when they know its a really tough patient, and that feels pretty cool.  

 

Since it is my last ED rotation of first year, it has been a time of reflection for me in many ways... I read back through some of my earlier posts in this thread, and I remember all too well the overwhelmed feeling of dealing with our sick, complicated patients.  I now feel much better in dealing with these patients.  I've gotten a sense of how to sort through all of the distractors and determine what is really important.  I have come a long way in being able to determine 'sick vs not sick', 'stable vs not stable', etc -- geared with these skills, I have been able to calm down quite a bit and have been enjoying my shifts a lot more.  Being able to relax has helped me open up and continue making friends with residents from all sorts of different services.  In fact, since I've done rotations all over the hospital at this point, I have met SO many people and I'd say some have become really good friends!  Its a great feeling to be able to walk around the hospital and wave / chat / catch up with nearly everyone you see walking down the hallway.  I had no idea how much fun it would be to become part of this big resident family, AND I had no idea how much easier it would make admission/consult interactions in the ED when you are already know the people.  I guess overall it really hit me when they paired a 4th year medical student with me for a day, and I realized how far I have come.  The student really struggled with basic EM concepts, presenting, procedures, and even basic maneuvering around the department and its people, which reminded me of myself just 1 year ago.  Its incredible how much we can learn in just a year's time!  

 

Of course, I still am very aware that I have a ton more to learn.  While I've been feeling better overall, there are definitely still plenty of shifts that I walk out feeling like I still have a ways to go.  I've been seeing 'sick' patients, but I still have yet to get into the realm of  the 'unstable requiring immediate lifesaving resuscitation' type of patient.  I still struggle with some specific topics like OB.  I still have to learn the intricacies of ruling in / out those uncommon/complex diseases that don't have well thought-out ED approaches.  I still have a way to go in the realm of optimizing efficiency in seeing patients and charting. I still have a lot to learn about other intricacies of medicine like billing while at the same time minimizing patient costs (in choosing the cheapest rx's, for example) without sacrificing high quality care.  And of course there is the whole topic of protecting ourselves from litigation that is its own huge topic by itself.  No matter how much I learn, I keep realizing how there will always be more and more to learn.... but this excites me.  How awesome is it to be in a field where we can never run out of things to learn?   

 

 

 

I have 2 more months of off-service rotations before our 2nd year begins -- look forward to posts on ED obs, ultrasound, and OB in the next couple of months!

 

-SN

[True Anomaly]

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

 

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

[PAjunky]

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

[SERENITY NOW]

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

[Siersmar]

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

[True Anomaly]

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

 

Agreed- it is also why I kept mine relatively anonymous

[SERENITY NOW]

ED OBSERVATION UNIT

 

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

 

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

 

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

 

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

 

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

 

 

ED OBS / HOSPITALIST RESOURCES

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

 

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

http://www.tamingthesru.com/clinical-practice-guidelines/

http://www.mmc.org/observation-unit-protocols

http://medicine.mikearef.com/home/practical/admission-orders

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/intmed/imrp/Documents/Intern%20Survival%20Guide%202014-2015.pdf   * good intern survival guide with bread and butter hospital medicine topics / practical tips

http://www.dphu.org/uploads/attachements/books/books_1403_0.pdf

 

 

 

WHAT CONSTITUTES A GOOD SIGNOUT?

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

 

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

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

 

THE PATIENT

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

 

WHY THEY ARE HERE

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

 

OVERALL PLAN AND HOSPITAL COURSE

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

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

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

 

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

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

-DNR/DNI status.   

-non-english language?  

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

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

 

 

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

 

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

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

 

 

 

AMBULATORY DYSFUNCTION... the ultimate buzzword.

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

 

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

 

 

 

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

What is their baseline functional status?

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

What was timeline of change?  Chronic or abrupt?

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

What resulted?  Really good trauma survey.  

 

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

AMBULATORY DYSFUNCTION IS A SYMPTOM, NOT A DIAGNOSIS/DISEASE.  

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

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

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

 

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

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

Knee issue?  

Any other clearly MSK / joint cause?

 

 

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

Brain / CVA / parkinsons / NPH?  

Cerebellar / ataxia / vertigo ?

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

 

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

drugs / polypharmacy?

syncope? orthostasis?

electrolytes / organ dysfx

generalized weakness / altered mental status 

 

 

 

 

 

 

 

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

 

 

 

 

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

[SERENITY NOW]

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

 

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

 

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

 

 

ULTRASOUND RESOURCES

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

https://itunes.apple.com/us/book/introduction-to-bedside-ultrasound/id554196012?mt=11

 

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

 

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

 

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

http://www.ultrasoundpodcast.com

 

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

  http://www.emsono.com/acep

 

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

 

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

http://sonospot.com

http://highlandultrasound.com

https://123sonography.com

 

 

 

 

 

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

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

 

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

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

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

 

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

 

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

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

 

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

related resources:

http://radiopaedia.org/articles/early-pregnancy

https://dl.dropboxusercontent.com/u/5247611/Ultrasound%20Pregnancy%20Transabdominal.pdf

 

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

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

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

 

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

 

Soft tissue/MSK -   

DVT 

 

Testicular torsion

 

Procedural uses of ultrasound.  

 

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

 

 

 

 

 

 

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

 

 

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

http://forums.studentdoctor.net/threads/ed-ultrasound-when-is-it-useful.1204456/

 

 

 

 

 

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

[SERENITY NOW]

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

 

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

 

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

 

 

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

 

 

GREAT RESOURCES FOR LEARNING FAST TRACK CHIEF COMPLAINT WORKUPS:

 

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

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

 

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

 

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

 

 

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

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

 

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

 

6) EMEDPA's Classic Thread: "It's Probably Nothing", Fast Track Disasters - A must read, for sure!  Expand that differential and always be on the lookout!   http://www.physicianassistantforum.com/index.php?/topic/30-its-probably-nothing-fast-track-disasters/

 

 

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

 

 

 

SOME HELPFUL READS ON INCREASING ED EFFICIENCY and EMR:

 

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

 

http://forums.studentdoctor.net/threads/efficiency-flow-seeing-2-3-pph-and-getting-documenting-done.1149299/

 

http://forums.studentdoctor.net/threads/improving-efficiency-as-attending.778323/

 

http://forums.studentdoctor.net/threads/epic-and-efficiency.1182775/

 

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

 

 

 

 

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

[SERENITY NOW]

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

 

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

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

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

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

 

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

 

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

 

 

Approach to sick respiratory patients

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

 

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

 

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

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

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

Pains anywhere or just SOB?  

Allergies to medications?  

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

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

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

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

 

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

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

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

Cardiac monitor, full set of vitals

 

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

 

 

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

 

Critical asthmatic/COPDer --  

Reuben Strayers approach - http://emupdates.com/wp-content/uploads/2011/12/MOLTAITEDv6_fullpic.png

 

EMCrit approach - http://emcrit.org/podcasts/severe-asthmatic/

 

First10EM's approach (if I haven't raved about this website yet, let me do it now... it might be my favorite FOAM website at this time as I am trying to get more and more into the resusc of the very sick patients, and this site is just gold.  https://first10em.com/2015/08/18/asthma/

 

 

Critical CHF'er

http://emcrit.org/podcasts/scape/

http://socmob.org/2013/04/evidence-based-management-of-acute-heart-failure-forget-lmnop-think-pond/

http://lifeinthefastlane.com/ebm-acute-pulmonary-oedema/

 

 

More great resources:

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

 

 

 

Intubating in the Emergency Department

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

..." we gotta intubate!"  

 

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

 

What you need to do to prepare:  SOAP-ME  - https://emin5.com/2015/08/31/intubation-preparation-soap-me/

Suction hooked up

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

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

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

Monitoring equipment  - cardiac monitor, BP/pulse ox

End tidal CO2 - very useful!

 

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

 

Once the patient arrives:

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

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

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

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

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

 

 

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

Most straightforward cases in our ED get etomidate and succ.  

 

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

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

 

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

asthmatic/copder?  consider ketamine for bronchodilation

 

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

 

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

 

 

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

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

 

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

 

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

  

 

Vent settings:

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

 

http://emcrit.org/archive-podcasts/vent-part-1/

 

 

More resources

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

EMBasics many great episodes on airway management

 

 

 

 

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

[LT_Oneal_PAC]

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

 

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