- First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
- Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
- Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
- Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
- Breath sounds and pulses need to be checked in every patient!
- Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
- Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
- Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
- Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
- Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
- Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
- Always ask yourself what could the differential diagnosis be? How would you treat the patient?
- Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
- Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
- Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
- Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
- Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
- Read! Pick your favorite resource and hold onto it. A page of reading every day can go a long way. The IEM book can be a perfect resource that you can refer to even during your shifts! (https://iem-student.org/2019/04/17/download-now-iem-book-ibook-and-pdf/)
- Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
- Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
Every medical student has three categories of topic division
Category 3 catches you by surprise when it makes it an entry in the ED and serves as a reminder of why it is essential always to know something about everything. Stevens-Johnson Syndrome was one of those for me. Although rare, dermatological emergencies are essential to spot and can be life-threatening if left untreated.
Stevens-Johnsons Syndrome is a rare type 4 hypersensitivity reaction which affects <10% of body surface area. It is described as a sheet-like skin loss and ulceration (separation of the epidermis from the dermis).
Toxic epidermal necrosis and Stevens-Johnsons Syndrome can be mixed. However, distinguishing between both disease can be done by looking at % of body surface area involvement.
- < 10% BSA = Stevens-Johnsons Syndrome
- 10-30% BSA = Stevens-Johnsons Syndrome/Toxic epidermal necrosis overlap syndrome
- > 30%= Toxic epidermal necrosis – above image is an example of toxic epidermal necrosis.
Pathophysiology is unknown
Pathophysiology is not clearly known; however, some studies show it is due to T cells’ cytotoxic mechanism and altered drug metabolism.
The most common cause of Stevens-Johnsons Syndrome is medications. Examples are allopurinol, anticonvulsants, sulfonamide, antiviral drugs, NSAIDs, salicylates, sertraline and imidazole.
As one of the commonest cause is drug-induced, it is a vital part of history taking. Ask direct and indirect questions regarding drug intake, any new (started within 8 weeks) or old medications and previous reactions if any.
Other causes are malignancy and infections (Mycoplasma pneumonia, Cytomegalovirus infections, Herpesvirus, Hep A).
The disease is more common in women and immunocompromised patients (HIV, SLE)
- Flu-like symptoms(1-14 symptoms)
- Painful rash which starts on the trunk and spreads to the face and extremities.
- Irritation in eyes
- Mouth ulcers or soreness
Clinical Exam Findings
- Skin manifestation – Starts as a Macular rash that turns into blisters and desquamation.
- An important sign in SJS is Nikolsky’s sign: It is considered positive if rubbing the skin gently causes desquamation.
- 2 types of mucosa are involved in SJS – oral and conjunctiva, which precede skin lesions.
- Other findings in the examination may include –
- Oral cavity – ulcers, erythema and blisters
- Cornea – ulceration
Diseases with a similar presentation – in children, staphylococcal scalded skin syndrome can be suspected as it has a similar presentation and can be differentiated with the help of a skin biopsy.
Clinical awareness and suspicion is the cornerstone step for diagnosis. Skin Biopsy shows subepidermal bullae, epidermal necrosis, perivascular lymphocytic infiltration, which help for definitive diagnosis.
Adequate fluid resuscitation, pain management and monitoring of electrolytes and vital signs, basic supportive or resuscitative actions are essential, as with any emergency management.
The next step is admitting the patient to the burn-unit or ICU, arranging an urgent referral to dermatology and stopping any offending medications. If any eye symptoms are present, an ophthalmology referral is required.
Wound management is essential- debridement, ointments, topical antibiotics are commonly used to prevent bacterial infections and ease the symptoms.
- Liver, renal and cardiac failure
- Hypovolemic or septic shock
- Superimposed infection
- Disseminated intravascular coagulation
- Can lead to death if left untreated
Prognosis of a patient with Stevens-Johnson Syndrome is assesed by the SCORTEN Mortality Assesment Tool. Each item equal to one point and it is used within the 24 hours of admission.
• Age >/= 40 years (OR 2.7)
• Heart Rate >/= 120 beats per minute (OR 2.7)
• Cancer/Hematologic malignancy (OR 4.4)
• Body surface area on day 1; >10% (OR2.9)
• Serum urea level (BUN) >28mg/dL (>10mmol/L) (OR 2.5)
• Serum bicarbonate <20mmol/L (OR 4.3)
• Serum glucose > 252mg/dL (>14mmol/L) (OR5.3)
Predicted mortality based on the above total:
- 0-1 Point = 3.2%
- 2 Points = 12.1%
- 3 Points = 35.3%
- 4 Points = 58.3%
- 5 Points = 90.0%
References and Further Reading
Recent Blog Posts by Sumaiya Hafiz
A middle-aged man with a two days history of weakness in his legs. The patient works as a construction worker and is used to conducting heavy physical activity.
After a thorough history and examination, the weakness was reported in the lower extremities with a power of 2/5, whereas the power in upper extremities was 4.5/5, Achilles tendon reflex was reduced, plantar response and other reflexes were intact, with normal sensation. Rest of the examination is unremarkable.
The vitals are within normal ranges, Blood investigations include – Urea and electrolytes, liver and renal function, full blood count, thyroid function tests, creatine kinase, urine myoglobin, vitamin B12 and folic acid levels.
Potassium level was 1.7 mEq/L (normal 3.5-5.5), and all other parameters were within normal ranges.
The ECG showed inverted T waves and the presence of U waves. An Example of an ECG:
Hypokalemic periodic paralysis is a rare disorder that may be hereditary as the primary cause, or secondary due to thyroid disease, strenuous physical activity, a carbohydrate-rich meal and toxins. The patients are mostly of Asian origin.
The most common presentation is of symmetrical weakness in lower limbs, with a low potassium level and ECG changes of hypokalemia. The patients may have a history of similar weaknesses which may be several years old. An attack may be triggered by infections, stress, exercise and other stress-related factors.
The word ‘weakness’, can lead to physicians thinking about stroke, neurological deficits and other life-threatening illnesses such as spinal cord injuries associated with high morbidity and mortality which need to be ruled out in the ED.
In this case, history and examination are vital. Weakness in other parts of the body, a thorough neurological examination are important aspects.
Patients are monitored and treated with potassium supplements (oral/Intravenous) until the levels normalize. ECG monitoring is essential, as cardiac function may be affected.
The patient should be examined to assess the strength and should be referred for further evaluation and to confirm the diagnosis.
The differential diagnosis for weakness in lower limb include :
- Spinal cord disease (https://iem-student.org/spine-injuries/)
- Guillain barre syndrome
- Toxic myositis
- Spinal cord tumour
- Dogan NO, Avcu N, Yaka E, Isikkent A, Durmus U. Weakness in the Emergency Department: Hypokalemic Periodic Paralysis Induced By Strenuous Physical Activity. Turk J Emerg Med. 2016 Mar 2;15(2):93-5. doi: 10.5505/1304.7361.2015.57984. PMID: 27336072; PMCID: PMC4910006.
One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.
Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.
Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.
While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.
1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis
2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension
3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage
4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice
5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension
6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass
7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)
8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression
9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence
10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis
11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema
Palpitations + Headache + Perspiration (Diaphoresis)
13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities
14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction
15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration
16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss
17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia
18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus
19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain
20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites
21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia
22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia
Fever + Headache + Neck Stiffness
24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex
25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia
During the last two months, the world experienced an outbreak of what was known to be an unknown yet contagious virus, The Coronavirus, namely COVID-19. News circulated about the virus being spread in China, and the number of people affected increased daily. While there was panic in China, other parts of the world were alert and anticipating a few occurrences, but definitely not as much as the situation is today.
Eventually, as the numbers increased, number of hospital staff who started wearing masks and taking necessary precautions increased, anticipating the arrival of the disease into their regions, until a few days later, there was news of the virus being spread to different countries, new cases emerging from different parts of the world, the case fatality rate rising, infection control rules became stricter and this was the start of what has lead the COVID-19 to be announced as a pandemic by the World Health Organization.
While researches are being conducted, treatments are being tested, one of the biggest dilemmas physicians are facing, is to differentiate between Coronavirus and Flu caused by Influenza virus. The latter being a more known and common cause of flu during the winter months.
When news of the coronavirus created alarm in the general public, there was an influx of patients in the Emergency Departments all around the world, most of them being travelers with flu symptoms and airport staff. Since little was known about the virus then, standard infection control protocols were applied as a general rule until a diagnosis and the severity of illness was sought.This created another issue, could this be seasonal flu, or was it Corona? The decision was harder amongst people in extremes of age. When the disease had just been discovered, testing and results took time and little was known, unlike what the situation is today where countries such as South Korea are offering drive-through tests, with results within 24 hours.
This added to the importance of knowing the differences and similarities between the two to provide adequate management and treatment.
- Transmitted by contact, droplets and fomites.
- Both require precautions such as good hand and respiratory hygiene
- Both cause mild to severe respiratory illness
- People are commonly affected in winter
- Influenza virus has additional symptoms such as muscle aches and fatigue whereas COVID-19 can present with diarrhea
- Influenza has a shorter incubation period as compared to COVID-19 (2-14 days)
- According to current data, children, women and elderly are more affected by influenza, whereas COVID-19 causes more severe illness in the elderly and those who are immunocompromised and those suffering from underlying medical conditions
- COVID-19 is being known to have a higher mortality rate as compared to influenza
- Annual vaccines and antiviral agents are effective against influenza, and there is currently no proven treatment for COVID-19
- People who have flu caused by influenza are most contagious in the first 3-4 days after contacting the illness
Overview of the COVID- 19
It belongs to the family of Coronaviruses, which may cause illness in animals or humans. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). COVID-19 is the newest type discovered in Wuhan, China, in December 2019.
Method of transmission: is respiratory droplets from the nose or mouth of a person who is infected by the virus (coughs/sneezes within 1 meter).
Incubation period: 1-14 days
Symptoms, Diagnosis and Treatment
The most common symptoms of COVID-19 are fever, tiredness, and dry cough. Some patients may have aches and pains, nasal congestion, runny nose, sore throat, or diarrhea. Around 1 out of every six people who get COVID-19 becomes seriously ill and develops difficulty breathing.
Diagnosis: Nasopharyngeal swab, sputum culture
Chest Xray and CT: Bilateral chest infiltrates, consolidation (pneumonia)
Treatment: Symptomatic until a proven treatment is discovered.
The four essential steps:
W – wash hands
A – avoid physical contact and public places
S – sterilize and sanitize regularly
H – hygiene is essential.
Cover your nose or mouth with your bent elbow or tissue while sneezing and dispose of the used tissue immediately.
Wear a mask when you have symptoms of flu to prevent spreading the illness.
A couple of days ago, a friend told me about an incident that had occurred on a plane where a middle-aged man was found to have epistaxis (bleeding from the nose) midway between a 4-hour flight. Although epistaxis has various degrees of severity and only a small percent are life-threatening, the sight of blood, no matter the amount, is a cause of panic and anxiety for everyone. Hence, the cabin crew was called and helped in managing the patient until the flight landed.
Some of the causes of epistaxis on a flight are dryness in the nose due to changes in cabin pressure and air conditioning. Other causes depend on patients’ previous health problems, which may include medications such as warfarin, bleeding disorders, nose-picking.
As important as it is to learn the emergency management of epistaxis in a hospital setting, often you come across a scenario such as this, in your daily life and its essential to know how to manage it, out of the hospital setting or even in the emergency department, while taking history or waiting to be seen.
The following are a few steps you can take for initial conservative management of epistaxis:
If the following measures fail, further medical management may be advised.
Epistaxis is acute hemorrhage from the nose, nostrils, nasopharynx, and can be either anterior or posterior, depending on the source of bleeding. It is one of the most common Otolaryngological Emergencies.
Anterior bleeds are the most common, and a large proportion is self-limited. The most common site is ‘Little’s area’ also known as Kiesselbach’s plexus (Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery).
Posterior bleeds are less common and occur from posterolateral branches of the sphenopalatine artery and can result in significant hemorrhage.
Causes of epistaxis
Nose picking, dryness, allergic or viral rhinitis, foreign body, trauma, medications (anticoagulants), platelet disorders, nasal neoplasms, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), aspirin.
Assessment and Management
References and Further Reading
Emergency Medicine has something for everyone!
Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.
Prepare a list of common conditions
There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.
As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.
Brush up on your history taking and examination skills
Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.
Read about common ED procedures
ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”
Watch videos on examination, interpreting X-rays, & procedural skills
Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.
Interpretation of ECG & X-rays
Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.
Before the rotation
Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.
iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)
If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.
During the rotation
During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.
These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.