How to rock your ER rotation

Hello M4’s, at this point in the year, most of you are taking away “audition” rotations. The goal here is to make a good impression, such that when your application comes across the residency selection committee’s desk, they remember you fondly.

You want to do well here. So how can you do that?

  • Be professional: don’t be late, be respectful. There’s a lot of emphasis on punctuality in EM – the last thing you want to do after a tiring shift is have your replacement show up late. So, show up 10 minutes early and get the lay of the land.
  • Respect the nurses: not only have they been doing this longer than you, they know more than you. Get them on your side. I suggest you take the time to learn their names… and use their names. Keep them informed of the plan. Help them out. If a patient needs a pillow, you get it. Put a patient on a bed pan.
  • Respect the patients: same applies here. Ask their names (Mr. and Mrs. So-and-so unless they insist you use their first names) and give them yours. And most importantly keep them informed of what’s going on. Rather than getting the patient on your side, you want to get on the side of the patients.
  • Ask questions: Don’t make up questions to seem inquisitive. Instead, make an effort to find out the answer first. With Up-To-Date, Smart Phone apps, websites (CDEM) you have a lot of information at your fingertips already. If you still can’t find the answer, now ask intelligent, informed questions.
  • Make decisions: this is the time where you get to flex your decision making muscles. So don’t wait for the attending to spoon feed you the plan – get all your information, take some time to synthesize it, and then make an educated guess at a plan. You’re not going to be right every time, but it’s better to commit yourself to creating a plan and show you’ve put some thought into this than to passively accept what’s given to you.
  • Have a DDx: have this ready before you present to the resident or attending. You don’t want to be stumbling guessing when asked “what could kill this patient presenting with X?” Think this out ahead of time.
  • Do the stuff you’re supposed to do: finish your charts, complete any shift cards, go to all lectures, complete all assignments, and look up whatever anyone asks you to look up. Check on all results. Don’t leave stuff half done so you can leave your shift the minute it ends. Most of your attendings and residents will be staying late to get their work done… if they are, if you have stuff left undone, maybe you should, too. Along these lines, don’t pick up a complicated patient 10 minutes before you’re supposed to leave – you won’t be able to finish. You’ll be there for hours.
  • Set expectations early: if you’re going to be asking an attending for a letter of recommendation, ask them at the beginning of the shift. “Dr. X, I’d like to get a great letter of recommendation from my time here. I was hoping you could help me excel here. I’m open to any feedback, positive or constructive.” Now Dr. X will be paying attention to you, and looking for ways to help you. If you want till the end, Dr. X likely won’t have paid 2¢ of thought to you and will make up generic advice in the heat of the moment. If you want to learn something, bring that up at the beginning of the shift. “Dr. Y, I’ve been having trouble presenting concisely. I’d like to work on that today. I’d appreciate any feedback that can help me do that.
  • Enjoy it: I know I made it sound pretty tough, but if you are considering this as a career, it should also be fun. It is fun! Sure there will be good days and bad days, but on average you should be enjoying yourself.

I’ll add more here if I think of it.

Early Goal Directed Therapy in Sepsis

This short video explains how to recognize and take care of the septic patient in the Emergency Room. The important things to remember are that:

  • Start therapy early – preventing death in the ICU depends on early and aggressive therapy in the Emergency Room.
  • Trend your lactate! That’s a good marker for hypoperfusion
  • Antibiotics within the first hour. Actually as soon as you recognize sepsis

You’ll also hear a dog longing for her owner in the background. I hope that’s not too distracting. Also if you want the PDF of this drawing (not sure why you would), you can get it right here.

EM4 Rotation Objectives

Here at Rush we have a required clerkship in Emergency Medicine. As faculty here, you are not only doctors but teachers. So we should know what the students are here to learn – what the students are expecting us to teach them.

These objectives were taken from a national consensus created by clerkship directors from across the country. They have also been matched with Rush Medical College’s terminal objectives (things we want our students to be able to do before graduating).

They are grouped into the 6 “competencies” similar to those on which residents are evaluated. These are:

  1. Patient Care
  2. Medical Knowledge
  3. Self-Directed Learning
  4. Interpersonal and Communication Skills
  5. Professionalism
  6. Putting Care into a Practical Context

Below I’ve listed what each of these mean in greater details and some examples of how we can teach these to our students.

Please feel free to comment. Are there better ways to teach these? Do you have any special effective teaching tricks? I’m all ears.

Patient Care

Under direct faculty supervision, students should be given primary responsibility for patient care (of noncritical patients) and begin to act independently during the fourth-year EM rotation. Primary responsibility for patient care will help foster the students’ ability to think critically, assess their knowledge and skills, and allow them to make clinical decisions affecting patient care.

Specific Learning Objectives

  1. Obtain an accurate problem-focused history and physical examination.
  2. Recognize immediate life-threatening conditions.
  3. Patient management skills:
    1. Develop an evaluation and treatment plan;
    2. Monitor the response to therapeutic interventions;
    3. Develop appropriate disposition and follow-up plans.
  4. Health promotion:
    1. Educate patients on safety and provide anticipatory guidance as necessary related to the patient’s chief complaint;
    2. Educate patients to ensure comprehension of discharge plan.

Was their history and physical accurate? Were they able to recognize that the vital signs were grossly abnormal? Can they make and follow-through with a plan? Are they checking on the CT results? Are they finding out why that urine was never done? For patients being discharged, they should be able to educate patients on how to be safe - most easily through the discharge instructions.

Medical Knowledge

Students should develop a differential diagnosis that is prioritized on potential life-threatening conditions and likelihood of disease. Students should demonstrate knowledge (or understanding) of basic diagnostic modalities and interpretation of results. Most importantly, students should cultivate an appreciation of risk stratification and pretest probabilities for selected conditions.

Specific Learning Objectives

  1. Develop a differential diagnosis when evaluating an undifferentiated patient:
    1. Prioritize likelihood of diagnoses based on patient presentation and acuity;
    2. List the worst-case diagnoses.
  2. Create a diagnostic plan based on differential diagnoses.
  3. Develop a management plan for the patient with both an undifferentiated complaint and a specific disease process.

Can the student come up with an appropriate differential diagnosis which includes life threats and probable causes? Does their testing make sense?

Self-Directed Learning and Lifelong Improvement

Practice-based learning can be demonstrated through systematically evaluating patient care and population features; teaching other students and health care professionals; and applying knowledge gained from a systematic evaluation of the medical literature, including study design and statistical methodology.

Specific Learning Objectives

    1. Effectively use available information technology, including medical record retrieval systems and other educational resources, to optimize patient care and improve their knowledge base.

Can the student find the answers to questions they don't know by themselves? Were they able to look up how good is ultrasound for appendicitis?

Interpersonal and Communication Skills

Students are an important element of the health care team, and effective communication with patients and other health care providers is essential for patient care. Students must demonstrate interpersonal and communication skills that result in effective information exchange and interaction with patients, family members, and health care providers.

Specific Learning Objectives

  1. Humanistic qualities
    1. Effectively communicate with patients, family members, and other members of the health care team
    2. Demonstrate a compassionate and nonjudgmental approach when caring for patients.
  2. Presentation skills:
    1. Present cases in a complete, concise, and organized fashion;
    2. Effectively communicate with consultants and admitting services.
  3. Documentation: provide accurate and organized documentation in the medical record when appropriate.

Did they establish a relationship with their patients and their families? Are their presentations clear and concise? Can they coherently call a consult or and admit up to the floor? Are their charts done?

Professionalism

Professionalism should be viewed as an academic virtue, not just an expected set of behaviors. Students should learn to reflect on their professionalism during clinical rotations and learn from faculty role models.

Specific Learning Objectives

  1. Work ethic
    1. Be conscientious, on time, and responsible;
    2. Exhibit honesty and integrity in patient care.
  2. Practice ethical decision-making.
  3. Professional behavior:
    1. Exercise accountability;
    2. Maintain a professional appearance
    3. Be sensitive to cultural issues (age, sex, culture, disability, etc.);
    4. Work in a collegial manner with other members of the health care team.

Were they on time? Honest? Professionally dressed? Basically, did they act like we expect a doctor to act?

Putting Care in a Practical Context

Called Systems-based practice in the resident lingo, this competency extends beyond the individual patient’s bedside to include an understanding of how EM relates to other practitioners, patients, and society at large, while considering the cost of health care and the allocation of health care resources. Understanding the ‘‘system’’ involves learning ways to advocate for patient care and assist patients in dealing with system complexities (such as assuring appropriate follow-up) and how to partner with health care providers to assess, coordinate, and improve patient care.

Specific Learning Objectives

    1. Recognize when patients should be appropriately referred to the emergency department (ED).
    2. Recognize the importance of arranging appropriate follow-up plans for patients being discharged from the ED.
    3. Recognize the role of EM in the community, including access to care and its impact on patient care.
    4. Understand the indications, cost, risks, and evidence behind commonly performed ED diagnostic studies.

I'll admit this one is tougher to measure. Some things I'd look for is inappropriate use of testing or resources? Do they request too many consults? Too many MRI's? Do they make sure the patient has follow-up, especially in those that need to be seen immediately? And that may mean coming back to the ER.

I hope this helps clarify our objectives a little bit. If you have any questions, please feel free to comment.

How to Fill Out Student Evals

Hey folks. I wanted to take a moment to introduce to you how we do our evaluations for medical students. The M4’s have a required rotation in Emergency Medicine. We’re supposed to be filling out a 5-page form on each student, but we know no EM physician is going to EVER fill that out. Instead, I’ve made a very short online form that later gets translated into that bigger form.

Here’s a video of how the system works. Students request an evaluation and you get an email (to your Rush email, if you prefer another email – let me know). Just click the link in the email and fill out the short form (takes about 5 seconds). The student then gets a summary of your “teaching points” but nothing else. So don’t write anything nasty in that box!

Airway Algorithm

Objectives

  • List the three main indications to intubate a patient (though there are way more than three).
  • Outline an algorithm for approaching the patient who requires intubation.

As said before, your first priority with your patient is to ensure a secured airway. But how do you decide who to intubate?

Who gets the tube?

There are three main indications for intubation:

  1. Failure to maintain or protect airway
  2. Failure to ventilate or oxygenate
  3. Predicted decompensation

If the patient does not have a quickly reversible condition, then you need to place a endotracheal tube. Signs of an unprotected airway include:

  • loss of gag reflex,
  • drooling (unable to swallow their own secretions), or
  • the need for requiring a prolonged maneuver to establish airway

A patient who is not ventilating or oxygentating well will demonstrate

  • increasing hypoxia or hypercapnia (perhaps a falling pulse ox),
  • deteriorating mental status (as they become more hypercapnic), and
  • they not responding appropriately to supplemental oxygen.

Arterial blood gases are unnecessary to make the decision to intubate. There is often not enough time to wait for the result and so the decision made clinically.

If you are predicting a decompensation and possible loss of airway, consider this in

  • neck trauma (where an expanding hematoma may compress the airway),
  • a tiring asthmatic (who will not be able maintain the work of breathing),
  • a septic patient (who is becoming more fatigued and unresponsive),
  • whenever a patient leaves the ER (and you can’t watch their airway, i.e. ambulance, CT scan)

The gist of this approach is that unstable patients need to be intubated right away. If you have some time to think, figure out how hard this intubation will be and prepare for it. Use items to make a difficult airway easier. If it’s not hard, go for it using standard rapid sequence intubation.

If you attempt to intubate and fail, and especially if you cannot ventilate via a bag-valve-masktime to take emergent measures — the cricothyroidotomy.

Rapid Sequence Intubation

RSI is the cornerstone of modern emergency airway management. The goal of rapid sequence intubation is to take a patient from conscious & breathing to unconscious, paralyzed and ventilated. To do this you’ll need to give a potent sedative, a neuromuscular blocker (paralytic) and minimize the risk of aspirating gastric contents. The six steps of RSI are often carried out concurrently. They are:

The 6 P’s of Rapid Sequence Intubation
Prepare Assess for intubation difficulty, get your equipment ready, hook the patient up to monitors, get an IV in.
Pre-oxygenate Pre-oxygenate the patient. Put them on 100% oxygen for at least 5 minutes.
Pre-medicate Lidocaine can decrease airway responses. Fentanyl decreases sympathetic tone. Atropine decreases the bradycardia caused by succinylcholine. Vecuronium can lessen the fasiculations caused by succinylcholine. Benzodiazepines can prevent the emergence nightmares from ketamine.
Paralysis after sedation Sedate the patient first, then paralyze. It would not be a pleasant experience to be aware of being paralyzed. So a sedative with rapid onset is important.

Placement of the tube Placement of tube after sedation and paralysis.
Post-intubation Management Confirmation you didn’t accidentally intubate the esophagus:

  • listen for bilateral breath sounds,
  • listen for a lack of air in the stomach,
  • look for symmetric chest rise,
  • use an end-tidal CO2 detector to look for color change (after at least 6 breaths)
  • get a chest x-ray to assess for depth of intubation.

Drugs

Alright, so which drugs would you use? Remember first you sedate, then you paralyze. Imagine how horrible it would be to paralyzed and not sedated?! A nightmare. It’s happened. Don’t ever do that.

Typical Sedatives
Drug Notes
Propofol 2-2.5 mg/kg IV
  • Decreases BP
  • Bradycardia
Etomidate 0.3 mg/kg
  • Decreases BP
  • Maintains BP
  • Most commonly used
Ketamine 3 mg/kg
  • Increases BP
  • Good for Trauma
  • Increases secretions
  • Maintains airway reflexes
Typical Paralytics
Drug Notes
Succinylcholine 1.5 mg/kg
  • Most rapid paralysis
  • Defasciulations can cause high K+
  • Watch out in chronic, burn victims, kids (undiagnosed muscular dystrophies), neuromuscular diseases
  • This is a theoretical risk
Rocuronium 1.2 mg/kg
  • Not as fast as succinylcholine
  • Use if worried about hyperkalemia

First Minute Of A Code

Objectives

  • Describe how you would control the room within the first minute of a code.
  • Explain why you would or wouldn’t want family presence during resuscitations.

One of the defining aspects of emergency medicine is the ability to manage acutely ill patients. Handling these patients effectively requires skills in:

  • Controlling these potentially chaotic and stressful situations,
  • Managing a patient’s airway,
  • Establishing effective breathing and
  • Improving with circulatory failure.

This is your primary survey: the ABC’s of emergency medicine. These issues must be under control before moving on to other aspects of patient care. If these are not immediately corrected, there’s a good chance your patient will die. And if the patient ever detioriates, reassess your ABC’s until they are corrected once again.

“Normal Variants” to the ABCs

The primary survey is fairly constant, though there are a few variations on this theme.

  • In trauma, cervical spine injury must be considered in conjunction with the airway. Moving a broken neck while trying to intubate can lead to a severed spinal cord and severe neurologic consequences. Think of c-spine with airway. Airway/c-spine, breathing, circulation…
  • Additionally the trauma primary survey is extended two more letters to ABCDE to include disability (a neurologic assessment) and exposure (remove all clothing from the patient and prevent hypothermia). There’ll be more on this in the trauma section.
  • For patients in ventricular fibrillation, the success of defibrillation depends on the time elapsed till a shock is administered. In this case, improving circulation via defibrillation takes precedent over airway and breathing. In fact, the new 2010 ACLS guidelines stress that for adult patients presenting in cardiac arrest (not respiratory or traumatic), most of the time it will be cardiac. Start chest compressions before giving rescue breaths.
  • For the radiologically, chemically or biologically contaminated patient, healthcare worker safety is the first concern. The same poison that affected the patient can incapacitate the doctors and nurses–if you’re poisoned, you’re not going to be able to help anyone. In these cases, the patient must be decontaminated prior to initiating any treatment.

The First Minute Of A Code

It is no surprise that critical patients evoke anxiety in ED staff; the responsibility of someone’s life rests in our hands. Resuscitations can quickly deteriorate into chaos unless the team leader takes control. There are a few steps you can take within the first minute while you are assessing the patient’s primary survey.

Call for help

Once you’ve determined that your patient requires immediate resuscitation, call for help. Running a code is a team effort and you’ll need the help of various staff members: nurses, ER techs, respiratory techs, the chaplain and/or social worker, pharmacists and other personnel. You can’t do it alone.

Look calm, even if you’re not

Everyone deals with stress differently, but the team will look to their leader for strength. Even though you may be panicking on the inside, try to project calm. Your demeanor will permeate the room and affect the way everyone else behaves. Once your team feels confidence in you, they will be able to carry out their duties more effectively.

Who really needs to be in this room?

Part of the anxiety that builds comes from the extraneous people who are watching. Whether they are contradicting your orders or just standing there as an obstacle to good flow in the room, they are not necessary. Ask them politely to leave. If they don’t leave, ask them rudely. There should be only one leader of the code and it should always be clear to the team who that person is.

Two notable exceptions I’d like to mention are family & medical students. Both of these groups are commonly pushed out of the resuscitation room, but I believe have an important role to play there. Family presence during resuscitations helps the family initiate the grieving process and allows them to be with their loved ones in their time of need. Medical students (in addition to being excellent chest compressors) need to learn effective resuscitation management, and this cannot be done unless they are allowed to witness codes.

Call ’em by name

There should also be no doubt of each person’s responsibility. Assign duties to people by name. If you ask someone to start chest compressions, everyone will look around for someone else to start. Instead, pick someone, call their name, and tell them what you’d like them to do. For example: “Alan, please start chest compressions. Deb, please be the code recorder. Tracy, please put the patient on a monitor and oxygen. Lisa, please start a line.” Use their names so everyone knows their job.

Your resuscitation mantra

Remember this mantra: “IV O2 Monitor.” You will likely need all three of these things, and if not, they can’t hurt.

Always assess and reassess your ABC’s

While all this is occurring, you should be assessing your patient’s ABC’s.

  • Is the patient’s airway patent? Are they unable to handle their secretions? Is their tongue or neck swelling?
  • How effective is their breathing? Are they cyanotic? Are they tachypneic or severely bradypneic? Are they becoming increasingly fatigued?
  • What is their circulatory status? Do they have a pulse or blood pressure? Is their heart rhythm effectively pumping blood?

A good practice is to quickly reasses the ABC’s after each intervention.