Posts Tagged Residency

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 EMRAP.tv? 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 “site:emcrit.org” 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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iPad and Medicine

The future of health care

iPad Medic

After Apple announced the iPad device, I immediately began to think of   all the medical applications that could be used for this device.

Currently the app store has about 140,000 apps and is growing at an amazing rate. The medical app store has about 1,920. Health apps number about 3,100. According to Apple, most of these apps should work on the  iPhone and will transfer to the iPad as long as you use the same login. It will be interesting to see what the apps that were created initially for the  iPhone will look like on the new iPad device. It is interesting also to note that the device does not have a camera, however the iPod Nano does. My guess is the device would take up more  bandwidth if it had a camera.

I am curious to see if the iPad will  work with apps like Skype and Google Voice.  If they do, then with a $20, 3g plan, you could use the device as a  2nd phone. For example Google Voice allows you to set up a local  phone number that others can use to call you. If you do not answer then you will get a transcribed text with the first couple of lines of  the missed callers message!

What medical applications can we expect from this device?

Blausen Medical App

Patient education company Blausen makes an amazing product that has short video animations on multiple medical diseases. They are very basic and range from half a  minute to two minutes. Electronic medical records would be interesting. You have to wonder how they would work in the ER. I cannot imagine keeping up with an expensive device in the ER. At least one I can’t put in my pocket. I can see myself losing it during a code or dropping it as I run to the floor for a “code blue.”

I am interested in hearing from our readers and seeing how other ER  doctors use technology at work. Currently, I use Pepid, although it is expensive, it has almost everything I need in the app.

Feel free to post if you are likely to purchase the next iPhone (new cell phone carrier to be announced in June), iPad wifi only will  be out around March 27 and the iPad with wifi/3g service around late  April in the United States. The rest of the world will get it after  June which will be just in time for the new iPhone.

I look forward to your emails and post,

Harvey Castro MD

Picture from iPhone life magazine.

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I’m Baaack!

Super Fail Sorry for the long hiatus, faithful one reader remaining. Sorry for the holiday lapse in posting, busy with family and presents and eating and then working and working. But I have a lot of new ideas for the new year, and I’m ready to start ranting again!

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Trick of the trade: Essential skills for the pimpee


Thanks to Dr. Rob Roger’s podcast on EM-RAP Educator’s Edition series, I learned of one of the funniest publications EVER in a medical journal. It was published on April 1, 2009 in JAMA. The article focuses on teaching medical students the essential skill set — how to survive “pimping”.

Pimping traditionally occurs when an attending physician poses a difficult question to a learner in a public forum, such as board rounds or in the operating room. As a student or resident, you know that this will happen during your training, and you should be prepared. If you think of pimping as a form of battle, you will need a good defense, and you should mix it up to be successful.

Which of these techniques have you used in the past?

Avoidance

Don’t make eye contact with the teacher. Stay very still. Lower your head as if you are deep in thought. But don’t look like you are sleeping and not paying attention. Bottom line is to not draw attention to yourself while appearing to listen. It’s a fine line to walk.

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The Muffin
Hold a large muffin in front of your mouth, as if you are going to take a bite. If you don’t know the answer, take a big bite. If you still get called on, pretend to choke. I would go one step further and say – If desperate, syncopize..

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Hostile Response
The best defense is a good offense. Take a tone and body posture of hostility. Say “I — DON’T — KNOW.” Personally, as a teacher, I’d be afraid of asking this student questions — ever — again.

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The List
If asked to contribute to a list of answers, you can repeat a response from earlier pretending that you didn’t hear it, because you were busy with patient care responsibilities (answering pages, working on your medical charting)..

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Honorable Surrender
Tell the teacher that you are uncomfortable with the open forum of questioning.

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Pimp Back
Another version of – the best defense is a good offense. Ask questions in a sub-specialized area which the teacher may not be as familiar with. Careful – this technique may totally backfire, since pimpers often know and don’t appreciate when they are being pimped back.


Politician’s Approach
Don’t answer the question asked, but rather answer a question you would have preferred to answer.


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Use Personal Digital Assistant
Use your handheld device to find answers in real-time.

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Don’t Sulk or Cry
Pimpers rarely remember who gave incorrect answers – this happens all the time. But sulkers and weepers definitely are memorable. Whatever you do, don’t be labeled as one who loses composure. I feel like Emergency Medicine trainees do well in this area. We are constantly barraged by stressors, and it takes a lot for us to lose our composure.

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Reference
Detsky AS. The art of pimping. JAMA. April 1, 2009; 301(13): 1379-81.

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How to Save a Life

M*A*S*H

Henry explains the rules of war

“Look, all I know is what they taught me at command school. There are certain rules about a war, and rule Number One is young men die. And, rule Number Two is doctors can’t change rule Number One.” Henry Blake

While I can’t say that M*A*S*H is the reason I went into medicine, I can say that I loved the series, and that several times during my training I have found myself going back to certain episodes that seem especially relevant to a recent patient experience.  Like the one from which this quote is taken.

It’s upsetting to have a patient die after knowing you did everything you could.  It’s especially frustrating to have a patient die and not know why.  What did you miss?  What could you have done differently?  What else should you have done?

I recently had an experience like that.  A patient with multiple medical problems came in with a cough… and, chest pain.  I grabbed the chart and thought, “Oh, great.  Pleuritic chest pain.  Tessalon perles and a chest x-ray.  Probably a pneumonia.  No problem.”  Two hours later as I was writing for a Dopamine drip and calling the ICU, my pulse still normalizing after coming very close to having to do a surgical airway, I was thinking, “What the heck is wrong with this patient?”

Even after the intensivist took over, I continued to keep up with the patient’s progress.  Labs gave no answers.  X-rays and scans gave no further information.  We had cultured every fluid possible, sent off a rapid flu, and empirically started antibiotics, but somehow it didn’t seem like enough.  As my shift progressed, I heard as another pressor was started.  A few hours later, another.  This patient was dying, and I didn’t know why.

Due to bed availability, the patient ended up boarding in the E.D. and died early the next morning.  I came in a day later and asked if the family had asked for an autopsy.  They had.  No saddle embolism, no major coronary blockage, no missed dissection.  Some labs and cultures were still pending.  Still no answers.

I’ll check cultures during my next shift.  I kept a sticker from the patient.  I keep stickers from all my patients.  They help me log my procedures.  They make me think about what I did and what I could do better.  They make me follow-up and see if I missed anything.  They make me remember and not forget certain cases… as if I could.  I fight the war against Rule Two every day.

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Trust (Part Three)

courtesy wikimedia commons

courtesy wikimedia commons

Boy do patients trust their physicians. I write this, truly, without a drop of sarcasm. (And that last line without one, too. No, seriously.)

Despite the variation in the patients we see every day, it’s often easy to clump them together. “Oh, another cocaine chest pain,” or “Pregnant vag bleeder,” or “Fever, headache, rule-out meningitis.” But every so often there’s something special about the patient — perhaps their name, face, or mannerisms — that makes the patient encounter a little deeper, a little more personal.

Recently it was another one of those “Fever, headache, need-to-LP” patients for me. My “younger than her stated age”, stylish, yoga-enthusiast patient spoke with a cute slighty-European accent, and with her neck stiffness, I figured I had to stick a needle in her back. While I was consenting her, talking through the procedure, and how I avoid the spinal cord, it dawned on me that this was a pretty remarkable amount of trust she was giving me by signing on the line. This idea of trust was something I thought greatly about in pre-clinical medical school, where the patient is an abstract concept. A theory, an idea. A “doctor-patient relationship.” But as I go further down the rabbit hole of becoming a full-fledged, root’n toot’n attending, this trust is something you simply acknowledge and accept. Waxing philosophic does not a successful procedure make, and certainly does nothing to treat or diagnose meningoencephalitis.

Putting myself in her shoes for a minute, she’s meeting a young, ravishingly handsome, courageous and beneficent physician for the first time.* She’s never met this person — for all intents and purposes, a complete stranger — before. He says he’s going to get me feeling better (yes please), do some blood work (okay, I guess), give me some fluids (sure, fine), and also stick a long needle in my back in between my back bones to make sure I don’t have meningitis (wait, whaaat?).

*This is, of course, how I assume most people view me, not as the “dorky, way-too-young-to-be-sticking-a-needle-in-me, wow-you-have-a-lame-sense-of-humor YOU’RE my doctor? guy with slightly wrinkled scrubs” view of me with which I am sometimes confused.

I’ve gotta say, that’s a leap of faith, and an amazing level of trust in the medical profession that exists nowhere else. While we as physicians often struggle with trusting parts of a patient’s story, or what their body is telling us, it’s much more often than not that a patient gives up a lot of autonomy and lets us as physicians do whatever we think is right.

It’s often those patients that lack our trust that I find myself often labeling “difficult,” even though it’s usually a wrong diagnosis, poor treatment or bad outcome in a hospital or by a physician that made them skeptical to begin with.

With great trust comes great responsibility, and that’s the simple lesson that we all know yet can always use the reminder: we’re professionals. We try to do right by the patient, help more than hurt. We put their needs ahead of our own. Thanks, random patient, for bringing that reminder back into view. And I’m glad you don’t have meningitis.

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Trusting the Patient (Part 1)

Emergency medicine is an all-senses sport and then some. See, hear, smell, touch, (hopefully not) taste, body language, psychological clues, bullshit detector. We have to figure out which complaint is the chief, which are contributory, and which are noise that our patients use to make our jobs more difficult. Our patients were strangers to us only moments before we introduced ourselves; they often don’t speak our language (medical or otherwise), come from different cultures who interpret or experience pain or discomfort in other ways, or lack the education to understand what we’re asking or telling them. (But if it were easy, we probably wouldn’t have been drawn into the field in the first place, would we?)

We don’t always have much to go on. A history from the paramedic, from the home attendant, from the son: a medical game of telephone. Sometimes patients lie — for their own gain or from their own shame. Sometimes we miss the elephant in the room. Sometimes our patients are confused. Or aphasic. Or angry. Or drunk. (And sometimes all of the above.)

In medical school, we’re always told “listen to the patient,” that the patient and his or her history will very frequently lead to the diagnosis. And frequently it does. But get any number of patients we see every day with 4 or more complaints and a grossly positive review of systems, and you simply can’t address them all, or unify them all into one little nice diagnosis.

And with our handicap of not knowing the patient plus the patient often not knowing his or her own history, the patient often has magic words that force our hand. We lack the luxury of being the primary care physician who knows the patient, has evaluated the patient on multiple occasions for her “chest pain” or “abdominal pain” with negative workups. For us, however, say the magic words, and you’ve bought yourself an admission, if you want.

“Chest pain?” EKG, troponins, chest x-ray.
Intoxicated and “I hit my head?” CT brain.
“Weakness?” As big or little a workup as the physician wants.

Often we can’t tease out what made the patient decide to come in today, no matter how many times we ask, or how many ways we phrase it. Often the answer ends up being “I just got tired of it not going away,” like my patient last week told me for the reason he finally came in after being blind in both eyes for 6 days. Ugh.

On other occasions, we have to take the gist of what the patient is saying — the overlying theme, if you will — but ignore the context. Last month, a patient came in because, as he explained it, “The pain I always have whenever I get stressed just didn’t go away.” 3 hours and a CT scan later, voila, perforated appendicitis.

The history often leads us to our diagnosis, but sometimes through a very circuitous route. Sometimes hunches, guesses, or stabs in the dark lead to the answer. Often the textbooks are wrong and the patient is right.

A lot of this whole “becoming a doctor” thing is refining our filter — getting more comfortable with disease presentations, and teasing out the subtleties that lead to the answer. It’s why the “chief complaint” is supposed to be in the patient’s own words, but the rest of the history and physical is described by the physician. You take the patient’s history, and turn it into your own story to deduce what’s going on.

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Emergency Mnemonics

SalterHarris I used to be the king of mnemonics (dear GOD the Kreb’s cycle is useless) but those have pretty much faded with time, leaving only a few left to occupy brain cells. Which do you still use?

  • SALTR for Salter-Harris Fractures: Slipped (I), Above (II), Lower (III), Through (IV), Ruined (V)
  • MUGR (Mugger): Monteggia Fracture = Ulnar fracture with radial head dislocation; Galeazzi Fracture = Radius fracture with DRUJ dislocation.
  • PIRATES for causes of AFib: Pulmonary process, Infarction/Infection/Intoxication, Rheumatic (Valvular) Disease, Anemia, Thyroid/High Output, Electrolytes, Sauce (Alcohol)
  • Venous near the Penis (easier than remembering NAVEL or NAVY)
  • DOPE for Intubated Patients: Displaced Tube, Obstructed Tube, Pneumothorax, Equipment Failure
  • ABCDEFGH (duh): Airway/CSpine, Breathing, Circulation, Disability, Exposure, Finger/Foley, GTube/Glucose, Human (pain meds, via Dr. Meade)
  • AEIOU TIPS: Alcohol, Endocrine/Electrolytes/Epilepsy/Encephalopathy, Infection, Overdose/Opioids, Uremia, Trauma/Toxidromes, Insulin, Psychosis/Polypharmacy, Space Occupying Lesion/Subarachnoid/Stroke/Sepsis
  • 5 H’s and 5 T’s of PEA/Asystole: Hypoxia, Hypovolemia, Hypothermia, Hyper/Hypokalemia, Hydrogen Ion (Acidosis, Tension Pneumothorax, Tamponade, Tablets/Tox, Thrombosis (Coronary), Thrombosis, (PE)
  • AMPLE FRIENDS (for Oral Boards): Allergies, Medications, PMH/PSH, Last Meal, Events Leading Up, Family Hx/Friends/Witnesses Hx, Records, Immunizations, EMT Hx, Narcotics/Drugs, Doctor (PMD) Hx, Social Hx

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The Waiting (is the Hardest Part)

The Big White Board

The Big White Board

I think we’re all conscious about the amount of time a patient spends in the emergency department:  from being triaged (0 – 30 minutes), to being called back (0 – 6 hours, longer during a Swine Flu epidemic, shorter if you have no heartbeat or a knife sticking out of your belly – then it’s an E ticket straight back), then waiting for the RN exam (5 – 30 minutes depending on shift change, patient load, or coffee/smoke/mandatory union breaks), then the resident exam (5 minutes – 2 hours depending on your triage color and/or what we think about your presenting complaint, us cherrypick – never, or, if you’re a regular EtOH or substance abuser, you could go the entire shift as an EFD – Exam From Doorway and simply get your discharge paperwork when you metabolize off that fifth of vodka, we’ll wave to you on the way out the door), then, in an academic program, presenting to the attending (5 – 30 minutes depending on patient volume and attending to resident/medical student/PA ratios) , then placing orders (5  minutes if I am writing your Lortab to go and discharge paperwork at the same time or 30 minutes if the medical student is trying to order every test conceivable to cover every possible differential for your sudden onset abdominal pain which may or may not be related to your current Dilaudid titers), nurses or clerks entering orders (2 – 20 minutes for the same reasons above as RN exam), labels being printed (did someone replace the ink cartridge today?), labs being sent (3 – 60 minutes depending on how many people the ED tech flirts with/chats with/texts to on the way to the lab or whether or not the tube system is working on this particular day), patients being transported to radiology (is the same ED tech taking them or is the Radiology tech taking them?), lab results being returned (did your lactate level get sent to heme instead of chemistry who then lost the sample by sending it to virology who took it off ice before sending it back to chemistry who threw it out and, when you call an hour later, tells you to redraw since the tube was improperly labeled because virology repacked the sample on ice on the inside of the bag instead of on the outside of the bag which soaked the label rendering it illegible?),  radiology reports coming back (if it’s during that mystery time when your Australian company isn’t reading them and your radiologist is still dropping off the kids before heading to Starbucks for their morning java fix it might be a while).

Of course, once all the results are in, if you’re discharging the patient then there’s more paperwork, scripts, instructions and the patient getting their Pink Ticket to Freedom.  If they’re being admitted then time is spent paging the admitting service, getting called back, placing the admit order, getting a room assignment (remember, this depends on the number of housekeepers available) and then the patient actually being taken upstairs (again by that ED tech, boy, they do get around).  Things get more complicated if a consult needs to be called.  Then you’re paging the service, waiting for the return call, and then waiting for the consulting service to arrive (surgery – in house, neurology – one resident to cover 4 hospitals including the “stroke center” so you might as well get out the camping gear and the deck of cards, it’s going to be a while).  Then, of course, consultants want more labs, more tests.  They then talk to their attending.  You might end up calling for a second consulting service, or admitting to a medicine service.  Rinse wash repeat.

Don’t even get me started on someone needing a procedure done… med student suturing lesson, anyone?

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Say It Right

How do you tell someone their loved one died?  Or their loved one is going to die?  Or their loved one is an idiot who tried to steal a bicycle from a mentally challenged individual and got shot in the neck by a “good Samaritan” coming to the aid of the victim?  Does your conversation go something like, “Well, yes, we’d like to arrest the person who did this, but your son is also under arrest.  Yes, I know he got shot, but he was assaulting someone else & trying to steal their bike.  Yes, yes, there’s a bullet sitting an inch away from his spinal cord, I know, but he was in the process of robbing someone else and then he was shot by someone else.  Uh, would you like to see him?”

Since becoming a senior resident, I’ve had to deliver bad news on an almost daily basis.  Today in the middle of a code for a 45 year old in cardiac arrest, I suddenly thought back to my “How to Be a Doctor 101” class, where we sat in front of our colleagues as a professor took us through the “Giving Bad News” scenario.  It usually involved a code situation where you had to come out and tell someone that you “did everything you could,” or  “we used all of our capabilities.”  If you felt it was appropriate you touched the family member on the shoulder, or you patted their hand.  It was all very trite and contrived;  all very John Carter fumbling on “E.R.” and not actually using the words, “they died” giving a patient’s family hope.  We were taught to make sure we said, “… and they died.” We also did the, “I’m sorry, but the test results show that you most likely have cancer” scenario as well.  I’ve had to use that one on several occasions.

Today was hard, though.  We worked on this patient for almost an hour.  We got a pulse back, but did we really get a life back?  Did I bring back a wife and mother to her family, or did I just turn one bad and horrible situation into a worst one?  I don’t know.  What I do know, is that my “How to Be a Doctor 101” class did not prepare me for saying, “Well, she’s not dead, but she was dead, but now she’s got a heartbeat, but I am supporting her on 2 pressors, pressors?, uh, those help keep her blood pressure elevated because her heart’s not working right, well, yes, it’s beating now but it wasn’t beating on it’s own for 45 minutes and we had to do compressions to circulate the blood for her, so she might be brain dead and all her organs may go into failure because she was without oxygen for a long time, well yes, she was getting oxygen through the tube in her mouth into her lungs, but her heart wasn’t beating properly see and we were doing compressions and I have no idea what’s going to happen now, but you should prepare for the worst, or maybe not because we have hypothermia protocols these days and some people do come back, she may or may not, I’m not sure, so, uh, would you like to see her?”

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