Wednesday, July 29, 2015

Thinking Emergency Medicine

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):

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

Video Source:

Monday, July 27, 2015

EM Skills -- Deep Cuts

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.