Friday, November 13, 2015

Emergency Medicine Website Update!

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The Emergency Medicine sub-internship website has been updated!!  Our goal is to expand the online resources available to you, and create a place for medical students to find help with everything from, how to succeed during your EM clerkship, applying for away rotations. how to get letters of recommendations and your ERAS application.

You can find all these new resources in the left menu under a section called 'Preparing for your EM sub-i" Don't forget to follow this blog to keep up to date on both education and application resources, and if  you have a great resource or want to share something with our EM student community please send it our way!


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Tuesday, September 01, 2015

Which Picture Do I Want?

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If dispo is king in the ED, the plan is the prince. But imaging plans can be tricky. You want to look at someone's abdomen, sure. But CT or MRI? Or is this one of the rare instances plain films help? Do they need IV contrast? PO contrast?

By no means exhaustive, the guide below outlines common points of confusion with radiology.



X-ray

-AP vs PA Lateral: The "AP" or "PA" refers to the direction the beam is traveling to the receiver - either anterior to posterior (AP) or posterior to anterior (PA). Despite this being an x-ray this matters because is changes the observed size of images. Imagine your lamp is the x-ray beam and your desk is the receiver: putting your hand close to the desk results in a small hand shadow, moving it towards the lamp increases the size of the shadow. Why we care about this happening at all is the cardiac shadow on a chest x-ray. When the beam goes AP the heart, being more anterior, casts a bigger shadow that may overemphasize the heart size and suggest cardiomegaly when there actually is none. Why get an AP at all then? It's the portable version. So make sure when you're using your system you note which is which and don't comment on the cardiac silhouette if it's a portable film.

-Plain abdominal x-ray: quick test, but not useful for everything. Okay for perforated viscus (looking for abdominal free air and pneumoperitoneum), renal caliculi if they are large (>3 mm) and radiolucent, toxic megacolon, and bowel obstruction with high suspicion (looking for air-fluid levels - see film to the right). Great for foreign objects.

-Hand films: Remember scaphoid fractures may not show up until 2 weeks after injury. MRI would be diagnostic but you'll never get that in the ED, so follow-up is the plan if x-ray is non-diagnostic.

-Hip films: Cannot rule out a fracture with a plain film. CT is necessary if there is any suspicion and x-ray is negative.



CT

-Consider IV contrast carefully: you can only give contrast once every 24 hours, and the patient cannot get contrast if they have bad kidney disease (GFR of 30 or 40 in diabetics). Another consideration is that you will need reasonable access to give the contrast. So the patient must have an IV, and something around an 18 gauge if you are evaluating for PE or Aortic dissection (because of the speed at which contrast needs to flow into the patient).

-PO contrast takes 90-120 minutes to travel through most of the bowel. Use unless you're looking for kidney stones, a retroperitoneal bleed, or a CT cystogram.

-Always order CT abdomen AND pelvis. You will be very unhappy with the coverage if you just order abdomen.



MRI

-Contraindications - pacemaker, implanted metal (potentially), or shrapnel if near something important like a blood vessel or nerve.

-Use AFTER head CT (to rule out intracranial hemorrhage) in suspected stroke patients. This includes brain parenchymal imaging, MR angiography, and MR diffusion.

-There is also evidence the MRI can be a good modality to assess for occult fractures based not only on diagnosis, but also cost effective-ness.



Ultrasound
-Transvaginal ultrasound for pregnancy must be correlated with Beta-HcG - levels above 1,000 to 2,000 are needed to be able to visualize pregnancy.





Further Reading:

The University of Virginia School of Medicine's interactive radiology guide is fantastic and comprehensive. Definitely spend time looking through it.





References:

1. Schellinger PD, Jansen O, Fiebach JB, Hacke W, Sartor K. A standardized MRI stroke protocol: comparison with CT in hyperacute intracerebral hemorrhage. Stroke. 1999;30(4):765-8.
2. Available at: http://lifeinthefastlane.com/scaphoid-fractures-the-ed-perspective/. Accessed August 20, 2015.
3. Vinson EN. Images in clinical medicine. Occult hip fracture. N Engl J Med. 2008;359(26):e33.
4. Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R. Early diagnosis of occult hip fractures MRI versus CT scan. Injury. 2005;36(6):788-92.
5. Available at: http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=178&seg_id=3758. Accessed August 20, 2015.
6. Available at: http://www.med-ed.virginia.edu/courses/rad/edus/index.html. Accessed August 20, 2015.

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Wednesday, August 26, 2015

IV Tips

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Make your sticks stick.

This is a Haiku Deck full of tips from NYP ED nurses on how to get good at starting IV's. These nurses do this all day every day. They know what they're about.

Click here to go to the full version including the full length tips and tricks!


EM Bound - Created with Haiku Deck, presentation software that inspires





Further Reading:

The Anesthesia Consultant Blog with some tips for difficult sticks.

Songs or Stories on pediatric IV tips (that apply to adults equally as well).










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Tuesday, August 25, 2015

IV Basics

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One task every EM sub-I should know how to do is place an IV. But frequently the ED may be the first time you really place an IV - most patients come to the floor with an IV already in. The video will walk you through placing an IV, with a quick text summary below.


Materials:
-Fluid Bag
-Flush
-Cannula and needle
-IV Start Kit (tourniquet, tape, transparent dressing, alcohol, gauze, small extension)
-Tubing

Technique:

Before any procedure: Wash your hands and use proper protective equipment (here: gloves)

Also remember you can change the position of the patient and the lighting in the room. These can make an enormous difference in your success rate (not to mention sparing contorting yourself into uncomfortable positions).


1. Set up and flush all the lines. This means spike the bag, clamp it off, and put the flush syringe on the small extender

2. Find the vein. Place the tourniquet on to help.

3. Prep the patient. Use the alcohol to clean the site, and get your needle ready, spinning the cannula on the hub to make sure it doesn’t stick.

4. Push the needle in. Wait for flashback, then advance slightly forward and push the cannula off the needle.

5. Undo the tourniquet and retract the needle. Apply pressure proximally for hemostasis.

6. Attach the small extender and flush. If there is local swelling or the flush is not easy, you are likely not in the vein.

7. Detach the flush syringe and attach the IV tubing.

8. Open up the fluid flow. Watch for continuous drips.

9. Secure the IV tubing to the patient with tape and/or other dressings.

10. Celebrate! The IV is in. You did it. Go you.




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Tuesday, August 18, 2015

Calling a Consult

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As a sub-I you may be called on to consult a service – that is, after all, one of the two end pathways of anyone who walks into the ED (ignoring AMA). Calling a consult from the ED is just as much a skill as intubation or IV placement. It can take a whole residency to develop, but having the basics will move you away from shadowing med student towards functional sub-I. 

Below is your step-by-step walkthrough of the process at the sub-I level.

1. Know why you’re consulting. Hopefully this is your patient, but if things get busy you might be asked to help with other patients (more so if the consult should be straightforward). Know the case, and specifically what you're calling for. Do you want the team to take them to the OR urgently, do you want them to come to the ED and write a note? This is something your senior residents and attending will help you identify. Phrase it as a question: "Does this patient need an emergency endoscopy? If not, we are wondering what your recommendations for this ongoing variceal bleeding are."

2. Do your homework. Pre-plan your pitch (and make no mistake, all consults are sales pitches), and practice it a bit, especially if this is one of your first few times consulting. Always identify yourself as a sub-I (it will avoid anger later if they think you're a resident). Do not overstate your case, and do not even think about lying (they'll see the same labs and patient you have), but be declarative. Lead with your reason for calling and then fill in your logic for reaching that conclusion. 

"Hi, this is sub-I X and we have a 35 year-old female with possible cholecystitis we would like you to see. She's had RUQ pain for 2 days, positive Murphy's, elevated alk phos and bilirubins, and U/S shows gallbladder wall thickening with stones. She's febrile but without peritoneal signs."

3. Less is more. You are not presenting a patient. The point of the call is to help the consulting service triage - do they need to drop what they're doing an run down there? Or is it a stable cholecystitis that can wait until the case they're scrubbed in finishes? Give enough highlights to convince them it's their problem, but you are not helping them formulate a differential. They will ask if they need more information, so have it at hand, and try to anticipate, but it is absolutely okay if you need to refer to the chart.

4. Be nice. This goes without saying, but here we are saying it. Even if they are grumpy. Be unfailingly nice.

5. Always pass it off if necessary. Sometimes the resident on the line gets a bit belligerent, or disagrees that this is a real consult, or isn't buying your sales pitch. You can always default to your senior or attending. Don't do it at the drop of the hat, but occasionally residents don't want to hear anything from a med student. It's wrong, but it happens. Don't take it personally. Know when the consult is actually sort of soft and don't be afraid to A) admit that your attending simply wants this consult, since residents will know that feeling well, and B) hand off to said attending to make the hard sell if you don't get any sympathy.

6. Details. Get the resident's name (very important!) and a sense of when they will staff the consult. Your team will want to know. So will your patient.



Odds and ends:

At NYP (and other institutions) consults are ordered through the EMR like a prescription. You may not have access to do this yourself. Either way, make sure you're listening for your name (or whoever ordered the consult) to come over the PA. 

One way to make friends with consulting services as a sub-I that a lot of EM residents cannot accomplish is by having a very good note in the EMR around the time you call. EM residents may not fully flesh out their note until the consult is seen, but you are unlikely to be working that hard. Consult services really appreciate it, especially in potentially complicated patients.

As with everything in EM, follow-up. Keep an eye out for the consult to occur, and try to catch the resident right after seeing the patient to get a sense of their thoughts so you don't need to wait for a note to come in. Done well this last can be very impressive to a team.

If it's a surgery consult, it's best if you have a diagnosis for them. Even if that diagnosis is "acute abdomen" (meaning there's peritonitis on exam).



Further Reading:

A deconstructed analysis of what a good consult - the actual talk on the phone - entails. "The Science Behind A Successful Consult Call"





And last, some tips for making the 2 a.m. consult call less painful.










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Thursday, August 13, 2015

Presenting

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Whether anybody likes it or not, the truth is in EM you will be graded mainly on your presentations to attendings. Following on the heels of our discussion of thinking EM, what makes a good EM presentation?

First, brevity. Nobody - absolutely nobody - in the ED wants to listen to even a quarter of a medicine presentation. This isn't just personal preference - there are too many patients with too high of an acuity to waste time. Is the patient nice, personable, have a really cool job? Save it for after the presentation during downtime. Which brings us to:

Keep it relevant to the chief complaint. You'll hear this a lot without much explanation. The truth is this kind of communication is a skill that will become easier as your knowledge increases - how relevant is past surgery to nausea and vomiting? This is complicated by the fact different attendings will consider some things "relevant" that others don't. This will come with experience, but in the meantime, decide for yourself what you think is relevant and present that (but know all the information in case you're asked).

Importantly, remember to ask why they came to the ED today. They may have had a week of abdominal pain, but what caused them to finally call 911? This is something that both students and residents will gloss over, but it is important to know the most proximate reason someone finally presented.

Relevant review of systems, past medical history, past surgical history, and family history should be in your HPI. Always mentioned medications and drug allergies. Always mention vitals, but tailor your physical exam to the complaint.

Last, make sure you have a thought out plan and disposition. These are king in the ED and many attendings will judge your clinical knowledge through these two things.


Practice tips:

1. After you interview the patient, stop and take time to organize your presentation before going to an attending. Actually taking this time is what will separate you from your peers and improve your skills.

2. Commit. Commit to a differential, commit to a plan, commit to your history and physical. Always admit if you don't know something. Being wrong is okay, but don't waffle. By the time you present it's too late for that kind of wishy-washiness anyway - you're not going back to the patient once you start.

3. Ask questions at the end. Asking for feedback can be difficult, but at a minimum ask any questions you have about the patient's presentation or treatment. It's not assumed you know everything, and this is the only way to improve your future presentations.



Further reading:

Below are two papers that go more in depth about oral presentations in the ED, and systems a student can use to get a better grasp on them.





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Tuesday, August 04, 2015

Chest X-ray Basics

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The only thing you'll see more than chest x-rays in the ED will be EKGs. Even if you've never seen a specific pathology before you need to be able to read it.

In other words, you need a system!

In the end, whatever works for you is important, but this is one I learned: Technical ABCDE.

Technical
This is all the non-anatomy parts of the film.

ID: name, type of image, position of image (AP vs PA), correct date and MRN tend to be skipped, though some attendings will like to hear them. You should still verify these regardless.

Image: Inspiration (can you count 8-10 posterior ribs), penetration (usually less of an issue with digitally captured x-rays), and rotation (look for symmetric angle of clavicles with sternum in non-rotated film).

Patient: Any tubes, wires, catheters you see - especially note where central lines, PICC lines, and ET tubes end.

A
Airway: Is the trachea midline or deviated?

B
Bones: Look for overt fractures, dislocations, and lytic lesions

C
Cardiac: Check heart size (less than half the width of the chest space is normal - AP films are not as reliable as PA films for this), silhouette and edges, mediastinum and aortic knob.

D
Diaphragm: Check for a right hemidiaphragm (right diaphragm elevated), sharp costophrenic angles, and air under the diaphragm (including normal gastric bubble).

E
Everything else (soft tissues): Look for soft tissue swelling or mass.

After you've done that, then and only then do you proceed to the paydirt: the lung fields. Check for lung marking to the perimeter, opacities, masses, haziness. Especially in EM don't forget to check the apices for pneumothorax.


The idea is that you delay looking at the thing you are naturally drawn to, the reason you got the CXR, until you've taken care of everything else. How can you have any pudding if you don't eat your meat?




Further reading:

This isn't something you learn from one blog post. It takes repetition and actually reading x-rays. The green chart below will link to a LITFL post on the same basics with a slightly different mnemonic. A video lecture with images can be found here.



The next link is to a fantastic University of Virginia SOM website on chest x-rays that includes actual x-rays demonstrating all the aspects of a CXR.







Double secret bonus: You never want to take the leading CXR in this post - it is a tension pneumothorax, which should have been diagnosed clinically and treated immediately since it is an emergency. Don't delay for an x-ray!




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Saturday, August 01, 2015

EM BOUND. A place for medical students interested in Emergency Medicine

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Welcome to EM BOUND. A blog for medical students interested in pursuing emergency medicine as a career.  As program directors for the sub-internship in emergency medicine @NYPEM we've been noticing a need for more trusted, student focused, and curated online content.

The EM BOUND project is designed to fulfill that gap. It is a collaborative project run by medical students and the NYPEM faculty to give you a high yield focused view of the EM bound process.  Here you will find regular posts relevant to where you are in your career when you need it.

To start we have created an EM Handbook on Flipboard filled with curated and original content that will help you plan your fourth year, succeed in your sub-internships, and get your  ERAS and interview skills honed to perfection. Please follow along and stay tuned for more great EM BOUND educational content in the days ahead.


The EM BOUND Team
@NYPEM


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Wednesday, July 29, 2015

Thinking Emergency Medicine

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No matter how much you eagerly anticipate your first shift in the ED as a medical student, it is also intimidating. For the first time you are presented with a completely undifferentiated patient and asked to come up with a differential, plan, and disposition. No more "Go see the COPD exacerbation in the ED" or "Why does this CT show a case of appendicitis?"

Medical school does not train you to think like an emergency physician. Completing a history and physical, then ordering lab tests and imaging, waiting for them to arrive, interpreting them, and finally making a diagnosis and treating the patient is not an option when they are bleeding out before your eyes (or having a stroke, or an MI, not breathing, seizing, possibly bleeding in their brain, foaming at the mouth, loss of consciousness, etc.).

In the ED, it is not your job to come up with an iron clad diagnosis, it is your job to rule out life threatening conditions or treat them if they exist. And to do that effectively, you need to think differently. Tips for the new EM sub-I:

1. Before every patient, sneak a look at the chief complaint. Physically write down a differential for what could kill a patient with this complaint. List your specific data for inclusion or exclusion of those diseases. If you get nothing else from your encounter but this data, consider it a success.

2. Leave the interview and write down what needs to be done for this patient *now*. What treatments need to be started? Which labs are crucial? This will get you in the habit so you are prepared when you see higher acuity patients.

3. Get your hands dirty. Get involved in the care of your patient. Set up the O2. Draw the labs. Get an IV started. If you don't know how to do it, ask for guidance. The right attitude is an important part of thinking emergency medicine.


Further Reading:
Craving more to shift your brain into thinking emergency medicine? Step into the thought process of an attending emergency physician (audio resolves after 90 seconds):


video


If all else fails, think like Darth Vader, courtesy of Life in the Fast Lane:





Video Source:
https://vimeo.com/14983747
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Monday, July 27, 2015

EM Skills -- Deep Cuts

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One of the skills most frequently taught and asked for by EM bound students is suturing. It's also one of the ways to shine as student rotating in the Emergency Department. Repairing lacerations is a common task for most emergency physicians on an average shift and is part of our core knowledge, but it is also time consuming. Offering to assist is a great way to help your EM team on shift.

In many academic centers complex lacerations involving the face and other cosmetically important areas might involve a plastics or OMFS consult, but not always. On one shift in a rural hospital I covered I once spent two and half hours suturing an ear back together that had been blown apart by a firecracker.

Here are some key pieces of advice and my favorite online resource to get you started so you're ready to jump in and help on your next shift.

  1. Spend some time at home learning and practicing. You won't be much help if you don't have at least some of the basic skills under your belt. 
  2. Be proactive and offer to help or repair any laceration that comes in.
  3. Know your limits and ask for help when you need it. It's better to ask than to have your supervising resident or attending have to come an redo your work. 


Here is my favorite resource to get you started.
Closing the Gap is created by Dr Brian Lin, an EM physician in the Bay Area and it has everything you need to hone your skills from basic to advanced techniques. 

Repairing lacerations well can be a very satisfying part of an ED shift. Now is the time to get good at it.
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