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!

Feb 05

Sorry for the delay on this one everyone.  Image of the Week 007 below answers some of my time away.  Anyway, back to the case…

A 32 year old male with a history of HIV, noncompliant with his medications, presents to the ED with a fever, hypoxia, and a cough.  CXR is shown below.  Given his clinical/medical history, what does this most likely represent, and what lab value might help confirm your diagnosis?  What other clinical entity might a CXR like this represent?  What is the first line treatment, and what are the indications for steroid therapy in this patient?

This patient likely has Pneumocystis jirovecii pneumonia (formerly PCP pneumonia).  This is usually noted by diffuse bilateral infiltrates extending from the hilum on CXR.  Having a history of HIV makes this all the more likely.  LDH may be helpful in the diagnosis, as levels are usually elevated (> 250) in patients with this disease process. LDH is relatively sensitive, but somewhat nonspecific.  Highly elevated levels may indicate worse disease and prognosis.  Another prime concern in an immunocompromised patient with a similar CXR would be miliary TB.  

The first line therapy is trimethoprim-sulfamethoxazole (TMP-SMX).  Alternatively, clindamycin + primaquine can be given in patients who have a contraindication to TMP-SMX.  Steroids may be considered as an adjunct therapy that might play a role in decreasing inflammation and respiratory failure.  Indications for steroids include a PaO2 < 70 mmHg or an A-a gradient > 35.  Don’t have an ABG handy?  A pulse ox < 92% generally correlates with a PaO2< 70 mm Hg.  This is a popular test topic in regards to diseases seen in HIV patients.  #EMBoardReview

1. Emergency Medicine: A focused review of the Core Curriculum.  pp 241-242.  

2. http://emedicine.medscape.com/article/225976-overview#aw2aab6b2

Jan 03

As a graduate of 12 years of Catholic school, I learned about (and committed most of) the 7 deadly sins.  I spend much of my time now teaching residents ultrasound, and reviewing their images.  In the 7 major US categories (AAA, Biliary, Cardiac, FAST, OB, Renal, and Vascular Access), I have noticed there are common mistakes most novices make.  So what are these 7 Deadly US Sins, and how can we avoid them?

  1. AAA:  To find the aorta, do not look for the aorta.  I know…mind blown.  The aorta is anterior/anterolateral to the vertebral column, so setting your depth high initially and finding the hyper echoic vertebral body with posterior shadowing will guide you to the aorta so you do not mistake the SMA for the aorta. 
  2. Biliary: Beware the ultimate SIN - stone in the neck.  Pay special attention to the neck of the gallbladder.  Sometimes, you will not even see the stone itself, so heavy anechoic shadowing behind the neck of the GB should clue you in.  And remember, Hartman pouches can be tricky, so do not miss a stone in the neck of a Hartman’s pouch either.  
  3. Cardiac: Always evaluate the posterior pericardium.  In the subxiphoid view, this means having enough depth and far gain to get there.  In the parasternal long axis, make sure you see the descending thoracic aorta just posterior to the LA/LV.  Pericardial fluid will be anterior to this, and may split between the heart and aorta, while pleural fluid will be lateral/posterior to the aorta.  
  4. FAST: free fluid should have sharp edges and take the shape of its container.  Fluid that is encapsulated, walled off, or rounded in unlikely free fluid.  In the RUQ, the GB sandwiched in between the liver and kidney may be mistaken for free fluid, while a beverage filled stomach may throw you off in the LUQ.  
  5. OB: always find the midline stripe to make sure what you are seeing is truly in the uterus.  A fair number of ectopic pregnancy may have a pseudo gestational sac in the uterus, so remember a yolk sac is the earliest definitive sign of pregnancy.  And size does not matter, you can have a big ectopic.  
  6. Renal: Not all hydronephrosis is ureterolithiasis with obstruction.  A large AAA may compress the ureter, so remember to look for AAA in at risk patients.  Renal colic is possible misdiagnosis of aortic disasters.  
  7. Vascular access: Remember, the point of doing US guided procedures is to always know where your needle tip is.  The US probe can only see what is directly beneath it.  If you are advancing your needle but what you think is the needle is not moving on the screen, you may be looking at the needle shaft.  Stop moving your needle, and move your probe to find it.  TRV vascular access should be a two handed dynamic technique.  

2008 ACEP US Guidelines

Thank you to everyone for reading and listening.  2013 was fun, and I have some great content planned for you coming up.  As always, let me know if you have any questions/concerns/feedback.  If you like what you hear, please go to iTunes to rate and review me.  Know residents that aren’t listening?  Let them know about the blog and podcast.  If you are using a reader, I do have an RSS feed here

Also, for US residents, the In Service exam is coming up in February.  Be sure to check out www.emergencyboardreview.com, @EMBoardReview on Twitter.  Hoping to get most of the content there finished in the next few months, and have a ton there already.  Jon Schonert (@emchatter) has done a great job with this.  

Listen to the podcast:

Dec 23

Got an interesting question, and thought you might might be able to help me answer it.  Interested to hear your opinions.  Take a listen, then either leave a comment below or send me something at bobstuntzmd@gmail.com. 

You and your attending disagree.  Your attending thinks less needs to be done, and it is a significant difference of opinion.  How do you handle it?  What would you want your residents to do?  Leave a comment below, or let me know via email (bobstuntzmd@gmail.com).  

Dec 20

This patient unfortunately has suffered a comminuted, displaced fractured clavicle, a fractured scapula, and there is a fracture fragment inferior to the humeral head (red arrows).  When you get the lateral view (see blow), you also note a posterior dislocation with humeral head fracture.  The posterior dislocation is suggested on the AP view by the “lightbulb sign” (blue arrow), and by the “rim sign” (green line, medial border of the humeral head is > 6 mm from the anterior glenoid rim).  

Remember, a fracture of the scapula is a significant injury and can portend serious intrathoracic and other concomitant traumatic injuries.  CT imaging of the thorax is recommended to evaluate for further injury.  

For more information on radiographic findings of the shoulder, check this out.  

Image 006

A 32 year old male with a history of HIV, noncompliant with his medications, presents to the ED with a fever, hypoxia, and a cough.  CXR is shown below.  Given his clinical/medical history, what does this most likely represent, and what lab value might help confirm your diagnosis?  What other clinical entity might a CXR like this represent?  What is the first line treatment, and what are the indications for steroid therapy in this patient?

Dec 05

This patient appears to have an abrasion in the RUQ, likely sustained when the handlebars made a direct impact.  On further questioning, the family saw the handlebars hit directly in the RUQ, with one end hitting her belly and the other hitting the ground.  The next step in management is to evaluate for internal injuries.  A CBC would provide baseline hemoglobin and hematocrit (H/H) levels, although remember even if there is acute bleeding, the H/H will likely be normal.  You should also obtain a liver panel and lipase.  While normal values here do not rule out liver or pancreatic injuries, they may be helpful in tracking injury progression with serial levels.  In any trauma patient in whom you suspect there may be internal bleeding, consider a blood bank tube to hold or type and screen.  UA may be obtained to evaluate for hematuria.  

The next question is imaging.  The role of the FAST exam is not well defined in children, and in the otherwise stable child may not yield information, although there have been studies investigating serial FAST exams along with serial evaluation with some promise.  Ultimately, given the location and mechanism of injury with abdominal pain and an overlying abrasion, a CT scan with IV contrast to evaluate for solid organ injury would be advisable.  The most common/classic injuries seen with handlebar injuries include liver and splenic lacerations, pancreatic injuries, duodenal hematoma, and hollow viscous injuries.  

Even if the initial imaging and workup is negative, serial abdominal exams over the next twenty four hours would be advisable as trauma protocol CT scanning has poor sensitivity for hollow viscous injuries, and patients should be watched for delayed onset of peritonitis.  Your patient had a positive FAST exam, and CT showed a low grade liver laceration with elevated AST/ALT.  They did not require operative intervention and were managed conservatively.  

Beware the handlebar injury! (see reference 2).  

1. Pediatric Blunt Abdominal Trauma

2. The High Morbidity of Handlebar Injuries

Image 005

A 29 year old male arrives after falling off of an ATV.  He is complaining of left shoulder pain, and appears in moderate distress.  The following image was obtained of the shoulder.  What injuries are noted (hint: there are at least two)?  What  else should you be worried about based on the injuries/findings in this XR?  What is the next step in the management of this patient?

Nov 22

"Amateurs train until they succeed, professionals train until they fail."  -Chris Costa

In this episode, I discuss some lessons that I originally heard presented to military and law enforcement personnel in the setting of defense training.  All of these lessons can be translated to the Emergency Medicine Physician and Resident.  

Below are two links to great talks that talk about the mental approach to Emergency Medicine.  For more “Mind of the Resuscitationist” talks from EMCrit, look for EMCrit podcasts 49, 82, 87, and 90 (hopefully did not miss any).  

Weingart: Mind of the Resuscitationist from SMACC

Cliff Reid: How to be a Hero

Nov 18

Note in the image above, within the red circle, there is a oval shaped calcified area.  Given his age, and history (back pain with minimal trauma), the answer of course is…

The old saying goes that the most common fracture you miss on X Ray is the second one (because you are so focused on the first).  Similarly, we frequently miss the things we are not primarily looking for.  This calcified area measured around 10 cm, and was concerning for a possible AAA.  This X ray was ordered to evaluate for traumatic injury causing back pain.  Make sure to fully evaluate you radiographs.  Look at everything, and come up with comprehensive, reproducible ways of evaluating your images.  More on this as the weeks go on. 

Image 004

An 8 year old girl is brought in for evaluation after falling off of her bicycle.  She complains of abdominal pain, and states she thinks she went over the handlebars when she fell.  On exam, you note abdominal tenderness in the upper abdomen, and see the findings in the image below.  What is the next step in the workup of this patient?  What labs, if any, should be ordered?  What are the classic diagnoses of concern in this injury mechanism?

Nov 12

Did you know that female physicians still make less than their male counterparts?  Did you know that women comprise an alarmingly small number of EM department chairs?  Tintinalli may have written the book, but female physicians in Emergency Medicine (and medicine in general) still face a number of unique issues.  I talk with Dr. Kathleen Clem, Dr. Stephanie Abbuhl, and Dr. Esther Choo (@choo_ek) to discuss these issues, and what female physicians can do about it.  Check out the show notes below, which are chock full of great references!

Episode 13 Show Notes

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