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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