Sep 01

Episode 20 is Part 2 of Dr. Kochert’s lecture on COPD.  In Part 2, Dr. Kochert discusses the tough question regarding antibiotics in COPD exacerbations, smoking cessation in the ED, and finishes with a Q/A discussing some of the finer points of the lecture and managing COPD patients.  Thanks again to Dr. Kochert for allowing me to post his lecture.  Making a great lecture like this takes a bunch of work, and he gives a great comprehensive review.  

Here is the final summary for the whole COPD talk:

  1. Titrate oxygen on patients with COPD exacerbations to achieve saturations of 88-92%.  Want a more detailed discussion with references?  Check this out
  2. Steroids should be given for all patients with COPD exacerbations.  Prednisone 40 mg PO x 5 days seems to be a reasonable dose.  
  3. Have a low threshold for non-invasive positive pressure ventilation (NIPPV).  It has been shown to reduce mortality and intubation rates.  jump on it early.  Again, as discussed in Episode 19, there has not been any great evidence to show CPAP or BiPAP is better.  Talk with your friendly neighborhood respiratory therapist and see what the standard is at your shop.  
  4. The evidence for antibiotics is not totally clear, but, based on available evidence, give antibiotics to:
    • Patients admitted for COPD exacerbation (especially intubated patients)
    • Outpatients with purulent sputum
  5. Discuss smoking cessation in the ED.  This is a teachable moment.  As Dr. Kochert said, peri-intubation may not be the best time, but otherwise this can definitely impact patients in a positive way.  

Two Reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. Below you will find the III/Asynchronous Learning Quiz for Episodes 19/20.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  

Remember, if you have feedback, or questions for me or Dr. Kochert, I want to hear from you!

Email: bobstuntzmd@gmail.com

Twitter: @BobStuntz

Google+

References

  1. GOLD: http://www.goldcopd.org
  2. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD): http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764.pub2/abstract
  3. New, A.  Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient.  Emerg Med J. 2006 February; 23(2): 144–146.

  4. Austin MA et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ 2010 Oct 18; 341:c5462.

  5. Quon BS, Gan WQ and Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and meta-analysis. Chest. 2008; 133:756–66.

  6. Leuppi JD et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA 2013;309:2223. [PMID: 23695200]

  7. Nouira S, Marghli S, Belghith M, Besbes L, Elatrous S, Abroug F.  Once daily oral ofloxacin in chronic obstructive pulmonary disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial.  Lancet. 2001 Dec 15;358(9298):2020-5.

  8. Miravitlles M, Moragas A, Hernández S, Bayona C, Llor C.  Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment?  Chest. 2013 Nov;144(5):1571-7. doi: 10.1378/chest.13-0518.

  9. http://www.acep.org/Clinical—-Practice-Management/Smoking-Cessation/

  10. Prochazka A, Koziol-McLain J, Tomlinson D, Lowenstein SR.  Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.  Acad Emerg Med. 1995 Mar;2(3):211-6.

  11. Katz DA, Vander Weg MW, Holman J, Nugent A, Baker L, Johnson S, Hillis SL, Titler M.  The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling.  Acad Emerg Med. 2012 Apr;19(4):409-20. doi: 10.1111/j.1553-2712.2012.01331.x.

Enjoy the podcast!


Get the OK from your PD?  Get Asynchronous Learning credit for listening!

Aug 27

It is that great time of year.  Sure the kids are going back to school, but more importantly, football is back.  And with that, your ED may soon be filled with folks on backboards wearing full football attire, taped down for c-spine protection.  How do you get their helmet and those pesky shoulder pads off while maintaining c-spine precautions?  Check out the video below, which does a great job demonstrating how to do just that.  The video is courtesy of Dr. A.J. Monseau.  Dr. Monseau is the Assistant Program Director at the West Virginia University Emergency Medicine Residency, and a sports medicine specialist.  A few of the WVUEM residents show us how it is done. Make sure you are following them on Twitter:

Dr. Monseau: @EMedSportsDoc

WVUEM: @WVUEmergencyMed

Definitely give Dr. Monseau’s YouTube page a view as well - he has some great splinting videos.  

Also, please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

Aug 19

In Episode 19, Dr. Erik Kochert returns to the podcast to give a great talk on COPD.  There was so much good stuff, I decided to split this into two podcast episodes.  In Part 1, Dr. Kochert talks about GOLD, oxygen titration, inhaled therapies, steroids and NIPPV.  

The full write up and show notes will be posted with episode 2 next week.  Also, if you are interested, our III/Asynchronous Learning quiz will be posted with Part 2 as well.  In the meantime, you can find the reference for the article regarding oxygen titration and my thoughts on that here.

Two announcements/reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. I am going to be offering quizzes at the end of each podcast I do (For this COPD discussion, it will be posted along with Part 2 next week).  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  As usual, Academic life in Emergency Medicine has led the way with this (check it out here), and I hope this is something that catches on with other blogs and podcasts.

Enjoy the podcast!



Jul 31

In Episode 18, we take a look at the ingestions and insertions - both accidental and not - that make their way into the GI tracts of your patients.  This is by no means a comprehensive review of all things toxicology that can affect the GI system.  Rather, we focus on ingestions, foreign bodies, and whether or not GI decontamination actually helps.  

Two announcements:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. I am going to be offering quizzes at the end of each podcast I do.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  As usual, Academic life in Emergency Medicine has led the way with this (check it out here), and I hope this is something that catches on with other blogs and podcasts.  

Check out the podcast below, the show notes that follow, and if you can get credit, the quiz is at the bottom of the page!  


Download the show notes here

Case 1: Caustic ingestion - alkali or acidic ingestion (Images from Reference 3)

  1. Epidemiology
    • Kids: Usually accidental and smaller amounts, more upper injury
    • Adults: Usually intention, more severe
  2. Types
    • Acidic: Coagulation necrosis, usually limited superficial injury, pain limits ingestion
      • Studies suggest acid ingestion may have worse outcome overall
      • Tend to affect stomach more vs esophagus
    • Alkali: Liquefactive necrosis, delayed/continued injury, 
      • Usually more viscous preparations
      • More esophageal injury
    • If you can obtain the material ingested, look at contents or check pH 
  3. Management
    • Airway: Intubate early for signs of airway compromise
    • Skilled intubator
    • Have backups and surgical airway ready
    • Imaging: CXR/AXR to evaluate for pneumomedastinum or pneumoperitoneum
    • Give IV fluids if needed.  If delayed and high suspicion for perforation/mediastinitis, treat as sepsis (fluids, antibiotics)
    • Decontamination: DON’T
      • Never induce emesis
      • NG/OG tubes contraindicated initially
      • charcoal of no benefit, and risk aspiration
    • Steroids: Thought to decrease inflammation and thus stricture formation
      • Stricture formation largely depends on initial injury grading (more on that later)
      • Current research suggests likely no benefit
    • Proton pump inhibitors: Thought to decrease acid damage in stomach
      • Few studies with mixed results
      • Talk to your local GI specialist
    • Antibiotics
      • Yes if patient on steroids or immunocompromised and suspect significant injury/ingestion
      • Yes if suspect high grade injury/significant ingestion
      • Yes if toxic/septic, or evidence of perforation/mediastinitis/pneumoperitoneum/peritonitis
      • Otherwise, no
    • Endoscopy
      • Want done within 24 hours
      • Grading of injury
        • 0, 1, 2A: Good prognosis
        • 2B, 3A and 3B: Bad prognosis
    • Consultation
      • GI for endoscopy
      • May need CT surgery for esophagectomy or more intensive therapy if severe or evidence of perforation
      • May need general surgery is gastric perforation
      • Psychiatry if intentional
      • Consider child abuse/neglect



Case 2: Billy swallowed something

  1. Epidemiology
    • Kids: usually accidental
    • Adults: usually intentional
  2. Management
    • Airway: Look for signs of airway compromise (stridor, drooling, respiratory distress)
    • Imaging
      • AP/Lateral Plain films to start
        • Esophagus: Face on AP
        • Trachea: face on lateral
        • Kids: T6/cricopharyngeus
        • Adults: Lower esophageal sphincter
      • If respiratory concern in kids with a non radioopaque foreign body (hot dog), consider plain films in lateral position, look for hyperinflation (ball valve physiology) - but that’s another episode
      • If negative and concerning or unknown ingestion, consider CT
    • Removal, or let it pass?
      • Most things: Let it pass
      • Indications for urgent removal:
        • Sharp objects or very long objects (> 2 inches/5 cm)
        • Magnets
        • Disc battery in esophagus
        • Inability to swallow or handle secretions
        • Toxic
      • Button batteries
        • Remove if in the esophagus
        • If in the stomach or farther, re-image in the next 3-4 days


Case 3: Packers and stuffers

  1. Stuffers: Running from the police, and they ingest a substance to avoid detection
    • Treat the toxidrome
    • Expected management based on what they ingested
  2. Packers: Intentional and methodical concealment of smuggled substances
    • Most commonly opioids and cocaine
    • Evaluation: Sick or not sick
      • If not sick/asymptomatic, packing likely intact
      • Otherwise, look for toxidrome
    • Imaging
      • XR: initial imaging, especially if concern for perforation
      • CT: If high suspicion or to guide clearance/surgical management/approach
    • Management
      • Treat toxidrome if present
      • Whole bowel irrigation (WBI) with PEG
      • If obstruction/perforation or symptomatic, surgical consult
      • Disposition: admit for WBI

Check out this interesting article regarding suspected body packers and the role of the police in these patients



So what about Decontamination?

  1. Ipecac: NO
  2. Gastric levage: NO
  3. Cathartics: NO
  4. Single dose charcoal
    • Minimal evidence this works at all
    • If you do it, do it within an hour of ingestion
    • No definite evidence of outcome improvement
  5. Multi-dose activated charcoal (MDAC)
    • Consider if life threatening ingestion of carbamazepine, dapsone, phenobarbitol, quinine or theophylline
  6. Whole bowel irrigation:
    • If iron, lead, zinc, or body packing, may help
    • Consider for sustained release or enteric coated drugs
    • Avoid if perforation, obstruction, hemodynamic instability, or otherwise toxic
  7. Sodium polystyrene sulfonate (SPS - kayexalate)
    • Used in Lithium ingestion to prevent absorption and increase excretion
    • Side effects: hypokalemia, GI necrosis
    • No definite clinical outcome improvement

References

  1. Brent, J et. al.  Critical Care Toxicology.  2005.  Elsivier Mosby.  
  2. Up To Date: Caustic Esophageal Injury in Adults, updated 9/11/13.
  3. Lupa, M et. al.  Update on the diagnosis and treatment of caustic ingestion.  Ochsner J. 2009 Summer; 9(2): 54–59. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096249/)
  4. Contini, S. and Scarpignato, C.  Caustic injury of the upper gastrointestinal tract: A comprehensive review.  World J. Gatroenterol.  2013 July 7; 19(25): 3918-3930.  
  5. Abaskharoun, R et. al.  Nonsurgical management of severe esophageal and gastric injury following alkali ingestion.  Can J Gastroeneterol.  2007 November 11; 21(11): 757-760.  
  6. Up To Date: Foreign bodies of the esophagus and gastrointestinal tract in children, updated 12/30/13. 
  7. Albertson, TE et. al.  Gastrointestinal decontamination in the acutely poisoned patient.  Int J of Emergency Medicine.  2011, 4(65).  

Talk to your program director and if they approve, take the test below to help you count this podcast and blog post towards asynchronous learning!

Jul 11

In this episode of the EM Res Podcast, we welcome back Dan Kaminstein, MD.  Dr. Kaminstein is our director of the section of International Medicine in the Emergency Department at Wellspan York Hospital, and a guru of ultrasound.  Dan got in touch with an old residency pal, Dr. Emory Patterson from Athens, GA to talk about all things Emergency Ophthalmology.  Lots of great leaning points and practical tips to be had.  Some of the highlights from the discussion:

  • You must know three things when you call the ophthalmologist: visual acuity, pupils, and pressure.

  • If you can’t get a visual acuity, have them count fingers, then identify hand movement, and if all else fails, ask about light perception.

  • If the patient has a detached retina - whether mac on or off - call the ophthalmologist.
  • If you are going to dilate, use a shorter acting agent, such as 2.5% phenylephrine and 1% tropicamide,
  • There are few, if any, conditions you will diagnose in the ED that require acute topical steroids when it comes to eye complaints.  You don’t need to prescribe them in the ED for the most part, and if you need to, you should at least talk with an ophthalmologist
  • When it comes to retrobulbar hematoma - know the pressure.  Just because they have one does not mean it is causing elevated pressure, which is why you do the lateral canthotomy.  
  • Dilute proparicaine is probably not ready for primetime.  Make sure you are talking to your local ophthalmologist about stuff like this before jumping on a small amount of data.  
  • When it comes to ocular exposure to alkali or acid, anything you can flush with is better than acid or alkali.  Normal saline is fine.  So is tap water.  
Jul 08

There is a bunch out there in social media and FOAMed lately about “dogmalysis,” or the idea that some of the things we do have no evidence base, and should not be done.  I love it.  Being quite cynical and skeptical myself, I love to see us start to question our practice’s evidence base to try to come up with the best care for our patients.  But new EM residents and new EM attendings may want to take some of this content with a grain of salt.  

Here’s my take:

  • New EM Residents: Before you go quoting advanced topics and dogmalytic principles (the “I heard it on a podcast” phenomenon), make sure you are well read and understand the basic concepts first.  I think it is great people are questioning things like Kayexalate for hyperkalemia, but make sure you know how to diagnose and treat the condition otherwise.  Lay the foundation before you spend too much time on advanced topics.  
  • New EM attendings: Get the lay of the land for the first 6-8 months.  You are not going to change an entire hospital system in one day, and you may in fact hurt your chances of effecting change in the future by being known from day one as the guy who pitched a hissy fit about protonix for an upper GI bleed on your first shift out when that is the standard of care across all practices at your place.  Remember change takes time, and educating your colleagues, both within your specialty and without, takes time and trust.  


May 28

We have all answered that call from radiology or a radiology tech.  In this episode, we talk about the myths and truths behind the use of oral contrast in the ED, ED imaging in pregnancy, and contrast induced nephropathy.

1. Oral Contrast in the ED: With new generation scanners, most patient with non traumatic abdominal pain do not need oral contrast.  Multiple studies have shown that with new generation scanners, CT for appendicitis does not suffer when oral contrast is not administered. In high grade bowel obstruction, the American College of Radiology (ACR) actually says we should NOT be giving oral contrast as it is bad for the patient (potential aspiration), and may obscure radiologic evidence of bowel wall ischemia.  With motion artifact reduction in new generation scanners, it really isn’t adding much to diverticulitis, either.  







2. Imaging in pregnancy: Remember this is all about how we communicate risk.  We always want to follow the ALARA (as low as reasonably achievable) principle, but we must not punish the patient for being pregnant by not doing the appropriate study.  CT versus VQ is controversial, but I feel this guideline from the American Thoracic Society/Society of Thoracic Radiology is a reasonable approach:



Abdominal imaging can be tricky, but the answer should generally be US first in the pregnant patient, followed by MRI if possible.  Again, if they need the CT, discuss the risk/benefit ratio and educate your patients.  



3. Contrast Induced Nephropathy (CIN): The incidence of CIN is likely lower than we thought previously.  In general patients with a GFR < 30 are at highest risk, and those with a GFR between 30-45 may be at higher risk.  The majority of are patients, however, are at a minimal risk of CIN.  To prevent it in high risk patients, the best we can try is hydration with isotonic fluids and educate the patients.  But again, if you need the scan, you need the scan.   




Listen to the podcast, and let me know what you think!

May 21

A 62 year old man presents after he tripped and fell on his R shoulder.  His only complaint is of R shoulder pain, and on exam his pain is localized to the distal clavicle.  The R shoulder X Ray shows the following.  What is your interpretation?  What are the different types of this injury?  What is your treatment plan?



The above image shows an acromioclavicular (AC) joint separation.  This should be considered in anyone who falls onto the the shoulder, particularly the apex, or an outstretched hand.  If you watch (American) football, think about the running back you see who gets tackled with his arms holding onto the ball, and they land right on the shoulder pad while being driven down.  Patients may complain of generalized shoulder pain and limitation of their range of motion, but will have point tenderness over the AC joint.  As with any injury, make sure to do a full neurovascualr exam distal to the injury, palpate the entire clavicle, and evaluate the ribs for possible injury and consider pneumothorax if you suspect thoracic injury.  And, as with any upper extremity injury, determine the handedness of the patient.  

It is important to know that there are different grades for AC injury.  The common classification is known as the Rockwood classification, and describes six types of AC injury.  To understand them, we must understand the anatomy involved.  



The Rockwood classification system requires interpretation of a few things:

  1. The acromioclavicular ligament
  2. The coracoclavicular ligament
  3. The AC joint capsule
  4. The deltoid
  5. The trapezius
  6. The relation of the clavicle to the acromion

There are six types of AC injury (Type I -VI).  A great description of each of the above factors in each type can be found here.  If pictures are more your thing, this will help: 



It is important to know what type it is as it relates to treatment.  Types I-II are generally treated conservatively with a sling and no surgical intervention, although severe type II injuries may require surgical intervention depending on occupation, severity, and clinical course.  Management of Type III is controversial, but may require operative intervention as well.  Types IV-VI require operative correction, and probably warrant more urgent orthopedic evaluation and consultation at the time of injury.  If you suspect an AC injury, but your film does not show a clear unobstructed view of the AC joint that allows you to evaluate the relationship of the inferior border of the acromion and the clavicle, consider a Zanca view (the XR gets a bit of cephalic tilt to allow clear visualization of the AC joint).  

So what about our patient?  The image shows that the inferior border of the clavicle is elevated when compared to the inferior border of the acromion, but does not pass its superior border, so this is likely a type II AC Joint injury.  The patient should be placed in a sling, given analgesia, and referred for urgent orthopedic evaluation.  

References:

  1. http://emedicine.medscape.com/article/92337-overview
  2. http://radiopaedia.org/articles/acromioclavicular-joint-injury-classification-rockwood
  3. Macdonald PB, Lapointe P.  Acromioclavicular and sternoclavicular joint injuries.  Ortho Clin North Am.  2008 Oct; 39 (4): 535-545.  
Apr 28

A 14 year old presents to your ED after a fall on an outstretched hand during a basketball game.  He is complaining of left wrist pain.  He is tender diffusely over the distal radius and ulna with associated soft tissue swelling, but is neurovascularly intact throughout the left upper extremity with no pain above or below the wrist.  He denies snuffbox tenderness, or wrist pain with axial loading of the thumb.  You obtain the following radiographs.  Click each question below for the answer.  




[ Open All | Close All ]

1] How would you describe this fracture to your orthopedic colleagues?
There are two major abnormalities here, one involving the distal radius, and one involving the distal ulna. There is a comminuted distal radius fracture at the metaphysis that extends to the physis, and is approximately 25% displaced dorsally with minimal angulation. There is also an ulnar styloid fracture with probable physeal injury here as well.

2] What are the important features you need to include when describing fractures to your colleagues?
There are a few important features you should be able to tell your colleagues, and that will be important for your orthopedic specialist to know. There are various mnemonics out there that try to help you remember what to look for and describe. I am not a big believer in mnemonics, as I find people often have trouble remembering the mnemonic itself, much less what it aims to help you describe or remember. So here is what you need to talk about when describing a fracture:
  • What is their hand dominance? Consider this with all upper extremity injuries. Much like you start an OB presentation with the G’s and P’s, let your orthopedist know if the patient is Right or Left hand dominant.
  • What kind of fracture is it (i.e. transverse, oblique, buckle, etc.). Is the fracture comminuted or not?
  • What is the location of the fracture - midshaft, distal, metaphyseal, etc.
  • Is the fracture displaced, and if so in what direction? Remember, this refers to the relation of the distal segment with the proximal segment. So in the case above, the distal segment is displaced dorsally. You describe this with a percentage of the distal segment that is displaced.
  • Is the fracture angulated? Again, this is described by the direction and angle of the distal segment, and the angle of the distal segment compared to the axis of the proximal segment.
  • Is the fracture rotated or impacted?
  • Is the fracture open? It is crucial to take any dressings down to identify any signs of an open fracture.


3] What should I document in terms of an exam?
It is important to identify a few things. Obviously, if someone shows up with a deformed limb, make sure to do a full H/P, and identify any other injuries. Once you are focusing on the suspected (or confirmed) fracture, you want to inspect at least the joint above and below the area of injury. Document pain, swelling deformity, and range of motion. You also want to document a good neurovascular exam. Remember, the vascular exam should include skin color, temperature, capillary refill, and pulses. Neurologically, make sure you document motor and sensory function. Also, be sure to document any skin findings over or around the area of injury. Breaks in the skin, bruising, swelling or deformity are all important to note.

4] Why all the fuss? Can’t I just call this a Colles fracture and be done?
I guess you could, but that fails to describe some important information. A Colles fracture is technically a radial fracture about an inch from the radiocarpal joint with dorsal displacement and/or angulation, but just saying a Colles fracture tells you nothing of how displaced, comminuted or not, the neurovascular status, or any other bony involvement. Being as descriptive as possible helps paint the picture for our colleagues. In general, I hear mixed things from my orthopedic colleagues about fracture eponyms. Colles is well known, but do you know a Barton or Rolondo off the top of your head? Know the difference between a Jones and a Pseudo-Jones? These things often are taught and come up on board exams, but at 2 AM describing the fracture as above paints a much better picture and keeps you from calling a Monteggia a Galeazzi.


I would advise that in order to best learn how to interpret plain radiographs, read them yourself, and do so before you read the radiology interpretation.  At many EM training programs we have  24 hour radiology coverage, and the tendency is to wait for the radiologist’s interpretation.  Try reading it, make a commitment to a read, and see how radiology interprets it.  Many places you will eventually practice do not have real time reads for plain films, and your staff and patients will be counting on you to get it right.  

Questions, comments, additional thoughts?  Feel free to let me know below, or send an email to bobstuntzmd@gmail.com

Apr 13

As we gear up for a new group of fourth year medical students rotating through our ED’s, hoping to eventually match in Emergency Medicine, we are all also starting to look forward to recruiting and interviews later this year.  One of the common things I know gets asked of our medical students between June and December of each year is this: “Why do you want to go into Emergency Medicine (EM)?”  We usually hear some standard stuff.  I love the variety, I like to see all complaints, the undifferentiated patient, etc.  Sometimes we hear less thoughtful answers.  I’ve heard everything from “Well, its a good lifestyle,” to “I wanted to do procedures but surgery has too much call.”  (On a side note, if you find yourself answering this question this way, strongly reconsider your decision to go into EM).  

I worked a shift recently that I think warrants some discussion, and sheds light into what it really means to be an Emergency Physician (EP).  No specific patient details will be provided, and this is not really about the medicine involved. The cases were interesting on their own, but this is about the bigger picture.  

I was working an 8 hour shift, and the first 5 hours or so had been relatively smooth.  We were double covered with attendings, and thus far everything had been relatively straightforward, with relatively bread and butter dispositions and treatment plans.  Of course there was a diversity of patient population, chief complaints, and workups involved.  And then, as often does, it hit the fan. A critically ill patient arrived, who required a significant resuscitation.  This involved an entire team: nurses, assistants, our unit clerks, the patient representatives, multiple consultants, respiratory therapy, and of course a resident and me.  As is usually the case, simple ACLS was not good enough.  Tough decisions had to be made, things evolved and changed rapidly over the course of the next hour.  The family was distraught, and multiple discussions had to take place from their standpoint as well.  We have these discussions with people every day, and nothing that I was saying was something I had not said before.  But for some reason, I really identified with this family, and it touched an emotional nerve.  We also had to get consultants to come in from home (this was later on a weekend night), and convince them what we thought was going on was correct.  An hour after I first met this patient and family, they were taken to get further care in another part of the hospital.  

If you have listened to Scott Weingart and Cliff Reid’s great podcast discussing the book “Combat Physiology,” Then you will have a good idea of what may happen next.  Having been running on chatecholamines for an hour, and having some heavy family discussions, I hit a wall, emotionally and physically - the true definition of a post adrenaline crash.  I was fortunate to be able to step out of the department and compose myself for about 5 minutes.  Upon returning, sure enough another sick patient that required immediate intervention had arrived.  Over the next two hours until the end of my shift, another two patients would arrive that were also complex patients requiring resuscitation.  All the while, the less critical patients were still showing up, and the ones we had seen previously still needed dispositions. My colleague had to stay almost an hour after their shift as they had helped run the department while we were in resuscitation number one, and I was there about an hour after my shift trying to get another patient stable for sign out and the ICU involved.  I only live about 5 minutes from my job, so I do not have much decompression time before I get home.  When I did, I was not the most fun person to talk to for awhile, as I’m sure my wife can attest, and then as soon as I went to bed I passed out, completely zonked.  

I think for those training in Emergency Medicine, and those thinking about pursuing this career, there are some important considerations here.  For those not in Emergency Medicine, I think it gives an important insight into what goes on in an ED on a daily basis.  

For EM residents, and sudents thinking about EM as a career, think about what it took for each case.  You of course are managing multiple patients at a time.  Then someone incredibly sick shows up.  You are meeting them and their families for the first time, working on limited, dynamic information, and making rapid critical decisions based on this limited information.  You have to wear many hats in addition to being a “smart doctor.”  You have to be an effective team leader, managing a team of people with multiple backgrounds, stress levels, comfort levels, and knowledge.  You have to be an effective manager, making sure the different pieces of a resuscitation run smoothly, You need to be an effective communicator with consultants, recruiting them and mobilizing them to the common task of doing what is best for your patient.  You also have to be able to talk to patients and their families.  Sometimes, this means telling someone that you just met 10 minutes ago that their loved one is sick, or dying, and do so in a way that is caring, empathetic, and understanding, but also straightforward enough so that they understand the situation.  This may involve taking care of someone or talking to people that strike a personal cord with you, but you must remain objective.  We are giving people the worst news imaginable, and we only just met them.  

If you are not the one in resus, then you have to be able to change gears, picking up the slack your colleagues leave behind when their patient takes a turn.  You have to work as a team.  This may mean staying late.  We all know about the nights, weekends, and holidays the job requires, time away from families, and the cumulative toll the job takes.  Burnout is a real problem.  The job can have physical effects.  When you are in a high catecholamine situation like this, you crash afterwards.  And when you are done, you may have to start doing it all over again, or even manage multiple teams with multiple patients at a time.  As residents, this is sometimes difficult to appreciate as there are usually multiple residents at a time in the ED.  When you are out on your own, however, it may just be you with multiple sick patients, or supervising multiple residents with multiple sick patients.  Wellness outside of work is of tremendous importance, and will be discussed in further detail in future posts and podcasts.  

You will note, the medicine is but a piece of the bigger picture.  At CORD and other discussions amongst educators of EM residents, it is often said we as educators really need to point out when we are teaching.  Remember that teaching and learning does not just happen when someone asks you a board style question, and is not just simply the nuts and bolts knowledge of EM.  Managing a sick patient, running a resuscitation, talking to a consultant, giving bad news to a family - these are all incredible teaching and learning opportunities.  Pay attention to them, get feedback, and learn as much as you can from these situations.  The medicine is interesting, but each one of our patients and their families have so much more to teach us.  If you have a chance, debrief after big resuscitations, and not just about the medicine.  Talk about the good and bad of the non-medical aspects of that patient’s care.  

So am I trying to depress you, or drive you away from EM?  Not at all.  After a good night’s sleep and some time with my wife and kids, I felt back to normal.  I am learning a bunch thinking about the cases, mentally debriefing.  And ultimately, I am extremely appreciative of the people I work with, and proud of the job that we do.  There are few places in the hospital that could manage that number of crashing patients and the complicated social situations and non-medical work surrounding them on such limited information.  Few in medicine are as lucky as we are.  We have the chance to take care of many different types of patients, and help them through the worst day of their lives.  It does not always have a happy ending, but we do an important job that makes a huge difference.  We should never lose sight of this important responsibility.  I firmly believe that nowhere in the hospital is there such a cohesive team that is so good at resuscitating sick patients, and coordinating all of these different aspects of their care.  Ultimately, it takes a lot to do our job, but we have much to be proud of, and the sacrifice is worth it.  I can not say it any better than Cliff Reid when he talked about what we do and how we can be heroes.    

Residents, think of all the learning opportunities you get managing these cases day to day.  Learning is so much more than the boards and learning how to do procedures.  There is really an art to what we do.  And for the medical students, if this sounds like your bag, than you might make a great EP.  Just don’t tell me you are going into EM to make money without taking call - you can do better than that!

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