Archive for category Residency

SAEM Phoenix Was A Success!

Just returned from SAEM Phoenix — what a great conference! It was especially good for like-minded EM computer nerds. There was tweeting, there was wine and cheese, and It Was Good. Slowly but surely, I think EM physicians will catch on to tweeting, especially at conferences, and especially when there’s free Wifi available. Celebrity sightings included:

  • Nick Genes, SAEM Social Media Chair, Mt. Sinai EM attending and blogger at Blogborygmi;
  • Michelle Lin from UCSF-SFGH and blogger at Academic Life in Emergency Medicine (and with a poster about the blog, too);
  • Rob Cooney, aka @emeducation on Twitter, from Conemaugh Emergency Medicine Residency. I met Rob for the first time, and he’s really doing great stuff, sending out a daily question via Twitter and his residents respond with their answer. It’s a great, fast learning tool that I’ve already started using. He also had a poster about it.
  • Finally, I bumped into Steve Smith from Dr. Smith’s ECG Blog! Steve has an insanely huge archive of EKGs and talks through both his interpretation of them as well as some of the more subtle findings, along with the Cardiology literature that supports it.

Looking forward to hopefully meeting more EM folks in the future!

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How I E-Learn E-M

via flickr's 8bitjoystick

Yes, dorks, I’m back, and with a “Now, More Nerdy Than Ever!” post.

So I’ve realized recently that a lot of people don’t know about all the ways you can learn a ton of emergency medicine online, for free. I really enjoy learning this way, partially because there’s so many different ways to learn online that it keeps it from getting too boring, and keeps you keeping on. We’ll start with the quickest bites of knowledge, via email.

The University of Maryland Emergency Medicine Residency puts out little pearls every day, but did you know you can get them sent to you via email? Sign-up here, and you’ll  get a little bit of knowledge every day in your inbox. (I can’t count the number of times I read one of these and within a week I’m searching my inbox to remember what exactly it said. Always pertinent and always good.)

Next up: the blogs. I’ve previously listed my favorites, but I’m going to highlight the most high-yield educational ones that I love:

  • Top of that list would be Life in the Fast Lane, which literally posts so much content I can’t keep up. Take the Antidote Challenge, for example, which lists a ton of poisons and you have to go through and remember all the antidotes. High-yield, fast, great learning. I don’t know how they post so much.
  • I really like the Emergency Medicine Forum. The poster summarizes a recent case she had, what the pitfalls and critical actions of the case were in her opinion, how she managed the case, with some references at the end.
  • My Emergency Medicine Blog is kind of like the UMEM Pearls. The author takes something he learned from his shift and posts it to the blog with a reference. “Name the 4 indications for non-medical management of a Stanford B dissection,” for example.
  • I can’t leave out my friend Michelle Lin’s Paucis Verbis cards. An index card summarizing what she thinks she needs to know about any number of problems in Emergency Medicine. You can’t get more high-yield.

How do I read all my blogs, by the way? I use Google Reader. It allows you to subscribe to RSS feeds of blogs (and journals and newspapers, and anything else that offers an RSS feed) so you can read all the content in one place. (An RSS feed is a way that sites can share their content with you without you having to visit their website.)

Next up: Podcasts/Videos.

  • EMRAP is probably the most well-known (and is free for EMRA members!). But did you know there’s also a totally free video podcast version at The Mel Herbert Empire also includes some free lectures from the All LA Conference and others.
  • The EMCrit Podcast is both awesome and free, and I’ve learned a ton from it. (And Scott Weingart also posts here. So it must be good, right?) And a secret tip: if you search Google for pages on emcrit (type “” and then your search criteria, you’re bound to find something useful. For example, I found the “PAILS” mnemonic for reciprocal changes on this page.
  • I’ve also just recently started listening to Keeping Up in Emergency Medicine, by the Vanderbilt EM gurus. It’s a quick, 30-minute podcast summarizing EM-relevant journal articles where Clay Smith and Jim Fiechtl give criticism and a summary of the findings.
  • Secret tip: You can watch live USC Grand Rounds on Thursday mornings (California time) as well.
  • Hennepin County EM has a bunch of great ultrasound and procedure videos on their YouTube channel.
  • Run out of Hemocult developer? Need to irrigate someone’s eyes and don’t have a Morgan lens? Procedurettes by my absolutely fantastic attending Whit Fisher will save your butt every time.

Finally, Journal Articles. This only kinda-counts, but here’s a bunch of great online resources:

  • EBMedicine. Insanely great, evidence-based diagnostic and management summaries on almost every EM topic by now.
  • I heart The Emergency Medicine Clinics of North America. Shorter than EBMedicine but provide a great overview of many topics, and each issue focuses on a certain theme. You can access them as well if you’re a member of mdconsult.
  • ACEP also provides its Critical Decisions in Emergency Medicine series, which are probably the shortest of all these options, but pretty good as well.

So, you’re asking yourself, how do I keep track of all of this? A private blog, of course. Whenever I read a good article or find something useful that I don’t want to forget, I summarize everything on the private blog and link or upload the PDF of the article I read it in. This way, I can always have access to the information as long as I have an internet connection. If I tried to store it all away in a notebook, it’d either get lost, fall apart, or I’d just forget it at home and be none the wiser.

(And one final tip, you can now save PDFs that you’re viewing with Google’s PDF reader to your Google Docs account.)

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Start a Commotion

Advocacy: The act of pleading or arguing in favor of something, such as a cause, idea, or policy; active support.

the lincoln memorial

I am very excited to be attending the ACEP Leadership and Advocacy Conference this week in Washington D.C.  It took a lot of maneuvering of my schedule to be able to take the time to get away on a non-vacation month, but I think in the end it will be well worth it.  I just know that the opening series of lectures this morning left me both frightened of the future of medical care and also inspired to not just sit back and let things happen around me.

One of the early speakers reminded us that we are advocates for our patients every day.  How many times during a shift do you call an admitting service, a consult, or a primary physician and outline a plan of care which you think is in the best interest of your patient?  Now, stop and think of how many times you do something equally powerful to stand up for your profession…

Of course, during residency when we’re on off-service rotations we fight for our specialty.  In academic medicine it’s always “our team is better than your team.”  When the cardiology attending bashes the E.D. for what he calls “sloppy care” of a CHF exacerbation or when the surgery resident makes a statement about E.D. docs only being interested in “moving the meat” and not doing a full work-up, we stand up for our profession.  We argue the current literature which we follow, and we tell them some patients don’t need a CT scan to prove they have appendicitis.  Ok, who am I kidding… of course we’ll get the CT scan.

Anyway, I was pleased to hear that this year’s conference is the most attended so far, and I am looking forward to tomorrow when the real meat of the conference will begin.  From what I’ve seen, it’s proving to be a very eye-opening and worthwhile experience so far…

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Would you like to know your Ranking?

As an emergency medicine resident, I remember taking tests and wondering where I stood compared to my peers. I would review different materials and focus on areas that I did not feel strong in. As a resident, I took the Ohio Acep review course and took their 700 question CD and reviewed all the explanations. I later was able to review the quiz questions and make suggestions.

Interesting enough, I was able to create the iPhone, Ipod Touch, * iPad edition of the quiz question for Ohio Acep. The app was just released and should show up on the app store in the next 48hrs. The app allows users to take the test and review each answer. It allows the user to focus on the questions or course materials they need to work on by creating custom test. The app also allows users to “know their ranking”, the app will ask users for an alias and will upload their test scores on each section of the test and will give an overall rank based on the users that have already taken the test. The ranking will update every time someone takes the test and clicks on ranking. To see the current ranking of beta testers and updated ranking please click here. To download the app or to see screen shots of the app click here.

* on iPad you will be able to double the size of the screen but the images might be slightly distorted.

Below I have included more information about the app.


Emergency Medicine Quiz Questions
On Sale for limited time, Price is 20% off.

Includes a new, 50-question pictorial review! Contains 700 review questions and referenced answers in an easy-to-use multiple choice format.

** “New Rankings feature, only users to see where they are ranked compared to their peers around the world. The app will rank each person based on subject and overall ranking depending on percent correct! Visit our website for more information.” **

The Emergency Medicine Review Course held annually by Ohio ACEP offers a comprehensive review for the physician preparing for the Qualifying examination, ConCert examination or continuous certification, or who simply desires an intensive review of emergency medicine. Attended by hundreds of physicians each year from across the country, this premier review course promotes high pass rates and receives high compliments.

Email us your feedback so we can make this app even better.

They have created this CD based on years of experience with preparing Emergency Medicine Physicians. The CD edition of this program retails for 100$ US Dollars.

The iPhone app is easy to use.

Topics include:
Endocrine, Metabolic & Nutritional Disorders
Infectious Disease
LifeLong Learning Self Assessment (LLSA)
Pictorial Review
Rheumatology/Soft Tissues

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Devil In Disguise

Taz the Tasmanian Devil

Working at the County facility, I come in contact with prisoners regularly.  We have a very active telemedicine service that is connected with most all of the prisons in the New York state system.  We get several telemedicine connections a shift where we evaluate prisoners for a variety of complaints such as chest pain, sports injuries, falls, seizures, etc.  We can give some medical direction to the nurses in the infirmary, and we decide if and where a prisoner will transfer to if they need more definitive care.

A lot of those prisoners come through our emergency department.  We also get a number of patients from the city jail holding center.  Most of the time, those patients are trying to prolong their impending incarceration for as long as possible by complaining of chest pain, shortness of breath, abdominal pain, faking seizures, etc.

I never wanted to know what any of those prisoners had done.  I used to be curious.  A polite young man, covered in prison tattoos, showed you where he got hit on the side of the head with a pillowcase full of cans.  He converses pleasantly while I sew his ear and the side of his face back together.  You send him off with instructions and think maybe he’s in prison for something simple.  He stole a car.  Maybe a drug dealer.  Then you find out he killed someone, stuffed their body in a truck, dismembered it and spread it around several areas.  Yeah… now I just don’t want to know.  Let me deal with their medical issues and not think about anything else.

How do we manage to keep working a case objectively when faced with people who have committed such crimes?  I don’t know that I’ve ever had an ethical dilemma when it comes to treating the gang banger who just shot the innocent bystander and both are in the trauma rooms.  I don’t think twice about giving pain relief to the drunk driver with the broken arm who crashed into another car whose passengers are now rolling into the E.D.  You think about the trauma.  Fix what’s broken.

I thought about this recently as I gently cleaned the self-inflicted wounds on a murder suspect.  After they had described their actions in a chilling flat affect which left me knowing a hot shower and several glasses of wine would be required later that evening, I went back to the desk and sat staring at the patient chart.  What would I write?  What should I write?  After a few minutes of staring at the blank sheet I started, “Patient presents with… ”  Back to the medicine.  Back to a place where I could feel safe again.

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New Sports Medicine Lecture Series Available

ACEP Sports MedLooking to fill a curriculum gap, ACEP’s Sports Medicine Section created a lecture series on the most common and the most serious medical illness and injuries associated with athletes and physically active individuals.

Topics inlcude:

  • Cardiac Conditions in Athletes 
  • Head and Neck Injuries in Athletes
  • Musculoskeletal Examination
  • Overuse Injuries 
  • Pediatric Sports Injuries 
  • and more

See the series online.

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“If you didn’t document it, it didn’t happen.”

While I sat in the courtroom over the last week listening to a Plaintiff’s attorney chide me for everything from failure to document and time every single time I went into a patient’s room for a follow-up exam to failing to diagnose a condition that even his expert witness had to look up (and who only found one similar case report), I thought back to the “Malpractice Ball” traditionally held every year by the Marquette Medical, Law and Dental Schools.  It’s a mixer to help bring the students from the different disciplines together in the hopes of forming friendships, making contacts, and encouraging them to play nice if only for an evening.  Too bad we all had to grow up and become like predator and prey;  a fox and a hound who though similar are enemies due to circumstance.

If there’s one thing I learned from this whole legal experience – it’s to treat every document I touch as though someone else  five years from now will be looking at it.  Just like the lab books we kept in organic chemistry, that Someone Else should be able to accurately follow our thinking and be able to draw the same conclusions.  They should be able to concede that given those circumstances, they would have gotten the exact same results.

I asked my lawyer what common lawsuits are brought up against Emergency Physicians.  He told me that missed diagnoses by far surpass any other suit.  He said the suits that are successfully won by the physician are the ones in which it’s clearly documented that the physician ordered the appropriate tests and arranged for the proper continued medical care.  He also noted that sometimes families will sue because they have questions about what led to a patient’s situation and just want to know what happened.  He states that many times physicians don’t take the time to discuss a lab result, a diagnosis, a patient condition.  A few extra moments can save a lot of people a lot of time and money.

Now that I have spent my time being grilled both under direct and cross-examination, I can tell you that I never again want to go through the feeling of having my character, my medical decision-making, my very honesty brought into question and exposed for everyone to see.  While a fellow doctor understands that you don’t automatically write down every aspect of a patient encounter, when it’s questioned whether something really happened or not based on a gap in the record, you have to wonder if the store clerk sitting on the jury panel really gets it.  We don’t write everything down.  If my physical exam hasn’t changed from the prior hour’s physical exam, I’m not going to note it… although now I am considering it.  I wonder how much one of those helmet cams costs…?

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A Means To An End

… was my initial, no-pun-intended explanation about why I needed to disimpact my patient; luckily his sense of humor (and the 10 of valium I gave him) helped. After the fact (and washing my hands), also inappropriate would have been:

  • It stinks that you’re constipated.
  • Can I log this procedure?
  • It’s hard to get it all.
  • What a crappy job.
  • So this is Brownian motion.

See also: Whit Fisher’s Rectal Regrets Procedurette on how to gown up appropriately.

(Side note: An attending once told me the most awkward thing he’d heard during a disimpaction was his patient, saying, “What, you aren’t going to take me out to dinner and a movie first?”)


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Number 27: The Answer is C

(Or: Give Me The Right Answers, ABEM!)

courtesy Wikimedia Commons

Today we residents are post-inservice exam, put together by The American Board of Emergency Medicine, and I can say this about the test: I’m glad I’m not an intern anymore. I’ve obviously still got a lot to learn, but it’s nothing like the feeling of overwhelmth (yes, just made that up) you feel halfway through your internship thinking, “I’m supposed to know the answer to this?”

But today I’m not writing about those mushy-gushy feelings and experiences. No no. Today, I want answers.

I was always annoyed with standardized medical tests (primarily the USMLE) where you left the exam with a) no idea how you performed and b) no real feedback for several months. At this point, I don’t really care if I missed a question about cyclic GMP on USMLE Step I, but for the inservice exam, it’s a different story. This is stuff that I apparently need to know. And so, please, ABEM: I want to know the right answers.

If the point of the inservice and the boards is knowledge and learning and requiring a certain level of competency of emergency physicians, then why not give us feedback so we don’t actually screw something up with an actual patient? What, the answer wasn’t ceftriaxone? Why not? What is it that I’m not understanding about the case that you thought it so important a concept as to test it? If a resident answers that he or she wants to use an ABG to rule out a pulmonary embolism, or decide to get abdominal films as the test of choice for right lower quadrant pain, shouldn’t we be telling that resident (or his or her program) that there’s some serious educating that needs to happen?

ABEM: I want an email with feedback on the questions I missed, or wasn’t sure about. Have me optionally fill out my email address in bubble format, and when you scan through my answers and calculate my percentage, email me the answers. Or, if you don’t want to share the questions because you recycle them, email me the specific topic. Not just “management of status epilepticus,” but “second and third line agents for status epilepticus.” Not just “tick borne disease,” but “treatment of pediatric lyme disease.”

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Keep On Learning

As I cram in some studying time this week for the upcoming EM Inservice, I find I am thinking more about a point in my life when I said I wanted to be a professional student.  What I really wanted was to stay forever in college… taking class after class;  never mastering one area, but learning a little about everything.

Little did I know at that time that I was going to be a doctor.  And, significantly an Emergency Medicine physician who knows a lot about a lot of things.  And, the learning never ends.

I think the reality of actually being a professional student hit about the time I took Step I of the medical boards.  My family was very excited when I actually completed my second year.

“No more of those hard tests, right?”  No, actually, I explained, I still have to take Step I, and there are shelf exams for every rotation.

“And then no more tests?”  Well, no, then there’s Step II (I was in the era before the practical) and then Step III once I finish my internship year.

“Then you’re done with tests, right?”

I shook my head.  We have inservice exams every year, and then when I graduate from my residency, I will have to prepare for written then oral boards.

“But, no more tests after that…?”

Um, well, there’s the recertification in 10 years, and I have to do a certain amount of continuing medical education every year.

“So, when do you actually finish and become a doctor?”  Well, when I graduate from medical school.

“Then why do you have to take so many tests after that?”  Because… see, oh, never mind.  Let’s just say I’m training to be a professional student.

To my fellow residents, “Good luck on the Inservice!”

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