Tuesday, May 03, 2016

5 Ways to Add Value as an EM Sub-Intern

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As medical students it can be hard at times to find ways to contribute to the care of our patients and teams. Sure, we see and evaluate patients on our own, but that doesn't preclude a more senior member from also doing their own evaluation, work-up, and note. Most everything we do needs to be approved or observed: our orders must be signed, procedures must often be carried out under watchful eyes, and patients are sometimes (understandably so!) unwilling to let the junior members of the team practice basic skills on them. When you know that asserting yourself in the care of your patient requires everyone else to chip in, it is easy to feel like a burden rather than a team player, especially in the fast-paced and busy environment of the emergency room.

The flip side, of course, is that if you can find a way to carve out a niche for yourself by owning certain areas of your patients' care, you can work within the team to ease the workload of everyone around you and drive patient care forward. Along the way your procedural skills, confidence, and overall usefulness will grow. If you are really diligent you may even find that patients, residents, and, yes, even nurses will begin to trust you with more responsibility. With that in mind, here’s a list of 5 ways you can add value to your patients and your team as a sub-intern, with some advice to help you avoid beginner pitfalls.

1. IV Placement:
How essential is this skill? Consider that an IV is used for delivering fluids, blood products, medications, contrast, and drawing blood for lab tests. Good IV access is critical in the management of patients who require anything but the most basic work-ups or therapies. As a sub-intern, being comfortable placing IVs can drastically speed up the care and comfort of your patient (on the order of hours in some cases!) in a busy ER where sicker patients may take precedence. Having IV access means labs can now be drawn and sent, and IV pain medications can be administered while they await more definitive therapy. Two huge wins for your patient and your team.

Here is a short video that shows all the steps succinctly. For some more great advice, check out Bobby Hannum's great posts on inserting IVs and pro tips.



Now that you've seen the basics, here are some helpful tips borne of painful personal experience to ensure a successful IV placement:
  • Come prepared. Seriously. It sounds obvious, but the last thing you want to do is place your catheter then start fumbling around for the extension tubing or tegaderm, or worse yet, have to leave the room to track the missing piece down. Make sure you have all your supplies (first picture) and any necessary vacutainer tubes for labs prior to entering the room, and have them opened and assembled (second picture) to minimize the number of steps during the placement (e.g. locking the flush or vacutainer needle/hub into the extension tubing, and having your tape and tegaderm ready to go). Also, take a moment to consider whether the size of the catheter matters (are they going to need a contrast study later? Better go with the 18G). 

*Not pictured, but very useful: a blue chuck placed under the patient's arm; Patients hate when you get blood on their
sheets.
  • YOUR comfort is king. It sounds wrong, but really the patient just wants you get it over with quickly, and to do it once. Don't be afraid to position the patient, raise the bed, tie the tourniquet extra tight, or take a seat while you work. By asserting yourself you also come off as competent and experienced which can ease any anxiety the patient may have watching Doogie Howser, MD, wield a large, sharp needle at their arm.
  • FEEL for the vein. Survey both arms, ask about AV fistulas, lymphedema, or local infections. If you don't see a good vein, don't give up or stick blindly, palpate for a vein and its trajectory instead.
  • Drop your angle and apply countertraction. If you go in too steep you risk puncturing both the superficial and deep venous walls. If you got a good flash, however, retract your needle and carefully pull back on the catheter until blood flow returns, then advance just the catheter to better secure it inside the vein. 
  • Fail and move on. If you aren't successful relatively quickly, retract the needle and reset. From time to time you are going to miss your target, but if you aren't confident you can get it easily on a second attempt, it's best to put the patient's comfort first and understand your limits.
2. Laceration Repair:
In terms of adding to value to your team and your patient, this is a huge win as a sub-intern. Repairing a lac can be a time-intensive process depending on the size of the wound and after you account for the additional time needed for irrigation, local anesthesia, and counseling the patient on wound care. In an ER with lots of sick patients to see, a simple lac could end up waiting hours before being addressed by a more senior member of the medical team. By becoming familiar with this procedure, you advance the care of your patient and free up your resident to manage other, more active patients in the ED. 

Visit Closing the Gap. The website has a wealth of resources including: basic suturing technique, tying knots, wound irrigation data, and aftercare data. The author presents techniques in short, digestible videos, and backs up all his conclusions with the most up-to-date evidence available. Once you've explored the site, here are some helpful tips when repairing a laceration:

  • Come prepared. Just as with IV insertion, gather all your supplies ahead of time and discuss your plan with a resident or attending. Important things to consider: What type of stitch? What type/size suture? Should I inject lidocaine with or without epinephrine? And how much irrigation should be performed?
  • Get comfortable. You are going to be at the bedside for a while so make sure you are comfortable. Raise the bed, take a seat, and position the patient such that you have an optimal space and vantage point to work from. Have a strong light source above the field. You should also make sure the patient is in a comfortable position as they will need to remain still while you are working. Included in this is being honest and realistic with the patient about how long the process will take - shortchanging the estimate will only lead to you looking bad when you inevitably go over the time you set, and the patient will be more likely to think something is going wrong.
  • Anesthetize first, and TEST your work. Local anesthesia with lidocaine should be performed with a small gauge needle to limit pain. Insert the needle inside the wound edge at one of the corners and along the long axis of the wound until the needle is fully inserted or at the opposite corner. Pull back on the plunger to ensure you are not in a vessel and inject lidocaine as you withdraw the needle. It is helpful to prepare the patient for the initial burning sensation. Repeat along the opposite wound edge. Once the anesthetic starts to take effect, walk the needle tip along the skin edge to ensure adequate anesthesia in the desired area. This short video will give you a good idea of how to go about this process.
  • Irrigate with pressure. A recent study in the BMJ showed that sterile saline offers no benefit vs. tap water in properly selected patients (non-immunocompromised, within 9 hours of trauma, not bite wounds, no tendon/bone involvement, no currently using antibiotics). However, you should use whatever is available and your team is comfortable using (usually 500 ml of sterile saline). Use a 35 ml syringe with 18G angiocatheter to supply appropriate pressure while irrigating.
  • Bisect the wound with your stitches. Starting in the middle of a laceration can yield a more precise re-approximation of the skin edges and prevent bunching at the end of your suturing.
3. Arterial Blood Draw:
Some patients, classically patients with chronic kidney disease or severe hypovolemia, can be very difficult to perform venipuncture on. This can make drawing initial diagnostic labs a nightmare for nurses. However, the radial artery can be a reliable way to access blood for testing and cultures in even the most difficult of patients. Having the skill to quickly access the radial artery and draw blood can really advance your patient's care and save the more senior members of the team time. Here are some tips to help you successfully draw blood from the radial artery:


  • Come prepared. I sound like a broken record, I know, but this point is so important in so many different settings it bears repeating. Come with all the supplies you need (see first picture below). I prefer to use the larger 21G (green) butterfly needle for this procedure as arteries, like veins, can constrict and roll out from under the needle during the procedure; a bigger needle prevents this and also is less likely to hemolyze your sample in this high pressure vessel. Finally, open and assemble everything together (second picture below) and have your vacutainer tubes handy as you will need to manipulate everything with one hand while you secure the needle in the artery.

*Not pictured, but very useful: a blue chuck placed under the patient's arm; Patients hate when you get blood on their

sheets.
  • YOUR comfort is king. Once again, the patient just wants you to quickly access the artery, draw the blood, and move along. It's going to hurt and be uncomfortable for the patient no matter what, and that has little to do with where you position their arm. Raise the bed so you aren't hunched, abduct and supinate the patient's arm, and hold the wrist in extension to bring the artery closer to the skin.
  • Palpate where the pulse is strongest and target that area. Unlike venipuncture, you won't be able to see the radial artery underneath the skin. Make sure you are confident of the pulse prior to inserting the needle.
  • Go in steep with bevel pointed against the blood flow (away from the hand). Once you break the skin, be patient. Make small adjustments without removing the needle entirely. If you get a flash and lose flow carefully advance the needle farther, and if no flow is observed slowly pull back, you may have gone entirely through the vessel. Here is a video of a true ABG using an ABG kit and syringe. The process is basically the same for a butterfly needle except you need to be a bit more dexterous after you puncture the artery to manipulate the vacutainer tubes, syringes, and blood culture bottles while you hold the needle in place. You may find you have an easier go of it if you bring help during this part.
  • Hold pressure. Unlike a veins, arteries are high pressure systems that can cause local bleeding when you remove your needle. You will need to hold firm pressure over the puncture after withdrawing the needle for several minutes to prevent hematoma formation - you may need to access that artery again, and a hematoma could prevent you from doing so!
4. Place a Patient on Cardiac Monitor:
You may come across a patient who was triaged for a different complaint entirely, but is now experiencing palpitations or chest pain while you are in the room interviewing them. A more likely scenario is that a patient will come to the ED while coding or in a dangerous arrhythmia (e.g. new onset AFib) and you can help out the team by placing the patient on telemetry while CPR is continued, access is established, and medications are administered. Having this skill in your back pocket can instantly give you a way to contribute when emergent patients roll through the doors. Here is an easy way to remember which leads go where:

  • Although the limb leads traditionally are placed on the limbs themselves, in this case, since we are going to leave the patient hooked up, it is necessary to place the leads on the torso so that the wires are more centralized and easier to manage. The limb leads should be placed on the anterior aspects of the shoulders and in the right and left lower quadrants as picture to the right. A simple way to remember which color corresponds to each of the five electrodes: imagine a man driving a car, his left arm is black from exposure to the sun out the window, his left leg is red on the brake, his right leg is green on the gas pedal, his right arm is white from no exposure to the sun (also remember the rhyme white on the right), and the remaining brown lead (V1) is chocolate so it is closest to his heart.
  • Pro Tip: Attach the wires to the electrodes prior to sticking them on the patient, as it can be difficult to snap the wires into place once the electrodes are on the patient's body due to the give in the patient's tissues.
5. Ventilate Using a Bag-Valve-Mask:
This is something that can't wait for an experienced person once it is needed, and in a chaotic ED with lots of sick patients you could be the only person close enough to do the job, or at least the most available to free up other members of the team. In other words, having the ability to do this correctly could be the only thing that allows the patient to adequately oxygenate her/his tissues until more help arrives or more definitive treatment is initiated. Knowing the correct technique is essential. Watch the video below; you may be very glad you did some day:




That's it! 5 ways you can add value to your team as a sub-intern. I hope this gives you at least a sense of how to integrate yourself into the team structure, and as your comfort level with emergency medicine grows over the course of the rotation, you will find more and more ways to contribute to the care of your patients.

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Tuesday, March 08, 2016

Review: HINTS to Diagnose Stroke in the Acute Vestibular Syndrome

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AVS is characterized by rapid onset of vertigo, nausea/vomiting, and gait unsteadiness with head motion intolerance and nystagmus.  The most common cause tends to be viral in nature, affecting the inner ear.  While this may be the domain of our esteemed neurology colleagues, there are 2.6 million ED visits for dizziness or vertigo annually in the United States, where the differential between a benign viral cause of vertigo or dizziness must be delineated from potentially lethal causes such as brainstem or cerebellar strokes.

Vertigo and dizziness, especially in cases of labyrinthitis, is caused by inflammation along the semicircular canals, affecting the flow of fluid throughout the system and causing the brain to interpret tilt or head spinning when there is none.  However, these same systems can be disrupted by central nervous pathologies that affect the vestibulocochlear nerve or the pons, which CN VIII enters.  Acute stroke in the vertebrobasilar circulation along the brain stem can present with damage to CN VIII, the brain stem itself, or the cerebellar and surrounding structures that maintain balance.  This paper attempts to delineate a series of clinical tests that can be easily performed at bedside to help aide in diagnosis of vertebral stroke.




This paper focused on 101 patients with AVS who presented with new onset vertigo or dizziness, with the majority (59) coming from the emergency department directly and many others (37) being referred from affiliate hospital emergency departments.  Of these patients that were deemed “high risk” for stroke (70% with >2 risk factors for stroke, the other 30% with 1 risk factor), 25 had acute peripheral vestibulopathy while the remaining 76 had a central lesion diagnosed on MRI (of which there were 69 iscehmic strokes, 4 hemorrhages, 2 demyelinating, and 1 anticonvulsant toxicity).  Of the patients with a central lesion, 100% had at least one of three clinical signs: a normal h-HIT, or head impulse test, horizontal nystagmus with a change in direction in eccentric gaze, or skew deviation of the eyes.  These can be remembered via the acronym INFARCT (Impulse Normal, Fast-phase Alternating, Refixation on Cover Test).  Of these, the study found that a “normal” or benign HiNTS (Head impulse – Nystagmus – Test-of-Skew) was sufficient to rule out all given central causes of vertigo.  As such, they suggest the use of HiNTS exam as a screening tool to effectively rule out central causes of vertigo in affected patients.

The benign HiNTS exam relies on three clear exam maneuvers to determine the cause of the vertigo and dizziness.  The first maneuver, the “head impulse” test, is performed by standing in front of the patient, holding their head firmly, and using a rapid movement to the left or right while the patient is told to maintain focus on your nose.  A normal head impulse results in the patient maintaining strict focus on your nose due to the adjustment of the vestibular system to maintain smooth movement of the eye.  However, in peripheral causes of vertigo, this will be altered such that the eye will fail to fix on the patient and make a corrective saccade to refixate on your nose.  In that case, it is an abnormal head impulse test, but this also rules out a central cause of vertigo in that case.  The second test for the HiNTS exam is a simple test for extraocular motion, looking for a beating nystagmus in the vertical or horizontal directions.  The third maneuver is to check for skew deviation, which can help attend for function of the brain stem.  This is done via a simple cover-uncover test to see if there is any movement of the eyes.  However, this should be performed with care as the patient may have a baseline deviation due to previous strabismus or other condition leading to deviation of the eyesight.  The test for skew deviation is very specific for a brain stem lesion in the patient.  With these three signs together, you can call a HiNTS exam benign if there is a 1, abnormal head impulse test, 2, no nystagmus on extraocular motion exam, and 3, no deviation of the eyes on cover-uncover testing.

However, it becomes important to understand the limitations of the study.  The initial tests were performed with experienced neuro-ophthalmologists performing the exam in an outpatient setting as opposed to by EM physicians in the ED setting.  Also, it is important to note that in order to be considered “high-risk” for a stroke and have this study apply to you, you would need at least one stroke risk factor of smoking, hypertension, diabetes, hyperlipidemia, atrial fibrillation, eclampsia, hypercoagulable state, recent cervical trauma, prior stroke or myocardial infarction and not have any history of recurrent vertigo or auditory symptoms.  However, with increased training and awareness, this could become a vital skill for EM physicians in the diagnosis of stroke.

This study provides the basis for a vital tool for evaluating vertigo and dizziness in the ED and preventing the catastrophic results of misdiagnosing a lethal or debilitating disease as something benign.  The results of the study are impressive: a positive HiNTS was reported as having an initial sensitivity of 100% and a specificity of 96%.  Though we should be aware of the difficulties of this study, the HiNTS exam provides a valuable tool to help screen patients in the ED and is a useful skill to put in the toolbox of any practicing EM physicians.





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Monday, February 01, 2016

Giving Good Sign-out

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Whether it is in the Emergency Department or on the floor, the patient hand-off is one of the most dangerous times in a patient's hospital stay. A review of the causes for medical error finds that problems with communication during transitions in care is a common source of mistakes: vital information gets lost, forgotten, or communicated incorrectly leading to potential safety issues. 
eD-PASS is a standardized tool to help you give clear and consistent sign-outs during your rotation in the ED. You can download it onto your mobile device here.

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