Examples of system failure are littered around the medical field and often disguised as professionalism or better yet heroism. “One resource seems infinite and free: the professionalism of caregivers”, says an opinion piece published in The New York Times. The article goes on to say that an overwhelming majority of health care professionals do the right thing for their patients, even at a high personal cost. Noteworthy is the availability heuristic that comes into play. “Of course they should work in favor of their patients, no matter what, isn’t that why they chose the medical profession!?”, you ask. They sure did. A lot of why you believe that medical professionals must go out of their way to help patients can be explained by what news you are being exposed to these days. The availability heuristic! That kept aside the gist of the article can roughly be summed up in the following excerpt
“Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just a bad strategy. It’s bad medicine. This status quo is not sustainable — not for medical professionals and not for our patients.”
I invite you to, for some minutes, drop all the preoccupation and think about it logically. I have, time and again, submitted myself to the idea that empathy and not logic is the best way to get my point across. But today, let us first think about some pertinent analogies.
As we anticipate the dreaded tsunami of COVID-19, many governmental healthcare institutes are sending out a notice for recruiting doctors and nurses for a certain time. My sister who is a nurse said, “Why do they have to make it sound like we are disposable?”. To which, I wittingly replied, “ Well they are probably looking for paid volunteers.” But the same recurring theme covers the core of our conversation. We simply were treating healthcare as a per-need industry. When the reality is, again, a contrasting opposite. Indeed, healthcare is a backup industry. You do not wish to use it when things are going smoothly. The healthcare system of any country should stand on its mighty ability to deal with crises.
Most other industries can either do with the number of people already in the industry or have to let go of people they already had, during a disaster. That is a contrasting opposite to the healthcare industry. Every time the health of the public is threatened we start to search for volunteers and temporary hires. I argue this is because the healthcare industry is ruled by businesses in the most powerful countries. To the point that the notion of just enough or even fewer doctors working in a setting is looked upon as a heroic measure. I don’t suppose you would say. “Oh! That busy bank has only one teller, and she also works as a receptionist. How heroic of her!”, do you?
There are reserves in almost every industry. Take transportation as another example: I visited Kathmandu on a night bus during my vacation as a child. My dad introduced me to two men. Both of them were drivers. I was taken by surprise when I found out the bus only had one steering wheel. “What would the other driver do!?”, the inquisitive child in me asked. My dad was semi-asleep when he answered, “They will drive for the whole night. Don’t you think they need to rest?”. I sure do Dad, I sure do!
In aviation, the first officer (FO) is the second pilot (also referred to as the co-pilot) of an aircraft. The first officer is second-in-command of the aircraft to the captain, who is the legal commander. In the event of incapacitation of the captain, the first officer will assume command of the aircraft. A second officer is usually the third in the line of command for a flight crew on a civil aircraft. Usually, a second officer is used on international or long haul flights where more than two crews are required to allow for adequate crew rest periods.
There have been some examples of what would be analogous to a natural disaster in other industries. Let us take some economic ups and downs as examples. Remember, India demonetized Rs. 500 and Rs. 1000 notes? Bankers had to work extra hours to make sure the undertaking completed in due time. They, of course, were paid an extra allowance for that. Interestingly they did not have to open up more positions for the work to be carried out. Remember the great economic recession? It “forced” business owners to let go of their employees. Not recruit more!
I vividly remember feeling proud of one of my seniors who was portrayed as an ideal healthcare worker. “He was arranging the medicine cabinet when we visited him”, one of my professors boasted. I felt not only proud but a desire to be at his place and do as he did one day. Today I understand that 1) he could be doing something way more productive and 2) what my senior was doing when my professor reached there was a clear example of a system failure.
Let me give you an example of my intern year to demonstrate the lack of consideration of the human element in designing healthcare systems. I had to take leave for some days. It was the flu. I understand that the coronavirus situation has alchemized the glory that flu deserved all along, but those were different times. I had a severe sore throat and my body ached like some virus was gnawing on my bones. I remember feeling very guilty about being ill because while I was sniffing Vicks and popping paracetamols in the hostel. My friends (fellow interns) were working their asses off. But when the system was designed, did no one think that someone might get sick? I mean, we work around infections every day. C’mon system designers, that is blindness, not just shortsightedness. The irony is: we are in an industry where we boast about our ability to empathize with human pain, suffering, and ill-health.
Human development has been punctuated by disasters of some sort, time and again. It is almost comical that we haven’t learned our lessons and that harrowing circumstances have to keep reminding us of the need for preparedness. It almost feels like I am writing a reminder the second time. After I failed to follow through my previous reminder. For me, the first time was the Nepal earthquake 2015. I am sure you have your own first time. I can only speak of the healthcare industry because that is what I have been fortunate enough to see closely. I am sure preparedness means different things in different settings. For healthcare, it means 1) taking into account the human element and 2) realizing that healthcare is a backup industry.
As Dan Sanberg once said; “Emergency Medicine is the most interesting 15 minutes of all specialties”. Indeed, if we were to recommend one textbook to a newly graduated physician, it would probably make the most sense for it to be an Emergency Medicine textbook. So which one?
I asked this question in Turkish and English to the Twitterverse recently. The responses showed once again the diversity of emergency medicine resources and the importance of basic textbooks.
Justin Hensley reminded the fallacy of the sentence “I’ll read it just on the Internet” and the importance of keeping up-to-date as follows: “I’m not sure there’s a right answer to this. Honestly, I would say the one that has the most recent new addition, because it will be the least out of date. The fundamentals need to come out of a text and not #FOAMed though. Can’t build a pyramid without a base.“
Shehni Nadeem said:
“It’s hard to pick ONE. Here’s why: 1) Textbooks are critical to forming that foundation of knowledge but must be kept current 2) Ea textbook has a slightly different read to it. I would encourage the learner to try out each one and see which fits the best (did this as an intern)”
Isn’t it a great idea to leave the preference to the reader by giving general information about the books rather than ranking the best for “me” or “person x”?
Let’s do it like this.
We will discuss the books included in this article in two groups according to book sizes.
Hand and Pocket Size Textbooks
You cannot see a doctor standing at the bedside with a large reference book in his/her hands. In fact, most textbooks are not even suitable to keep in your bag and take it wherever you go (Hello, back pains, hello!). Hand and pocket books have been prepared to solve this problem. TL; DR (Too long, didn’t read), the small ones of these books are called “pocket books” and the bigger ones are called “handbooks”. Isn’t that great? Yes, but please remember that “only” studying handbooks may not be enough if you haven’t read the topics from a broader source before. It is best to move on to these books after doing the basic reading. Or, as we all did when we first turned the pages of Tarascon, you’ll stare at the pages for a long time and try to understand whether it is English or Klingon.
1- Oxford Handbook of Emergency Medicine
The Oxford Handbook of Emergency Medicine, whose 5th edition has been released recently, is a starter book prepared for medical students, paramedics and physicians. The manual-sized work is still 800 pages long and contains basic information on many subjects from life-threatening emergencies to ENT, analgesia to toxicology. The fourth edition of the book was released in 2012. Emergency Medicine professor Richard Body also recommends this book to our readers as a starter book.
2- Emergency Medicine Secrets
Unlike many resource books, Emergency Medicine Secrets deals with questions and answers on every subject. For example, when you look at the Pneumonia section, you can find various questions (and answers, of course) such as, “Why should I learn about Pneumonia?”, “How does pulmonary infection develop?”, “What are the differences between the presentations of typical and atypical pneumonia?”. The book that can really benefit to the reader in this respect is 768 pages long.
3- Avoiding Common Errors in the Emergency Department
This work by Amal Mattu et al., One of the well-known names in FOAMed world, discusses 365 common mistakes in emergency medicine practice in a chatty, easy-to-read style, and offers practical, easy-to-remember tips to avoid these pitfalls. The fact that the chapters are short and understandable allows easy reading even when you are working. The second edition published in 2017 has a total of 1080 pages.
4- EM Fundamentals: The Essential Handbook for Emergency Medicine Residents
This pocket guide, prepared by EMRA (Emergency Medicine Residents Association) for Emergency Medicine residents, is one of the ideal books you can take with you during your emergency department shifts. On 366 pages, it summarizes common situations that may be encountered in the emergency room, in clear language and without missing the necessary emphasis.
5- Tarascon Adult Emergency Pocketbook
I do not think there is an emergency medicine physician unfamiliar with Tarascon (at least in Turkey). We know that on many Emergency Medicine Clinics those who do not have Tarascon in their pockets at bedside visits are condemned. As someone who is always amazed at how many things fit into this 240-page pocket book, I say, “If you haven’t found what you are looking for in basic emergency medicine in this book, look again, there is for sure.” Tarascon published books in a series style from Pediatric Emergency to Orthopedics. I recommend especially Adult Emergency and Medical Procedures pocket books. Character sizes may spoil the taste of those who like to read books written in big fonts and large line spacings. But the goal here is to be as small as possible, so it is understandable.
6- Tintinalli’s Emergency Medicine Manual
Would there be an Emergency Medicine list without Tintinalli? Tintinalli book appears with large-small-median dimensions. The last version of this book, which is easy to read and will not let the reader down with its structure containing plenty of pictures, tables and graphics, is the 8th edition published in 2017. It covers every subject an Emergency physician may need, and Palliative Care is no exception. The preface to the latest edition is also giving a glimpse of Emergency Medicine’s history.
Large textbooks that might be expected not to leave “anything missing” in their field often have a serious volume and a long list of authors. These works that will have a dedicated spot in your library to grab and read from time to time over the years may be too much for a medical student or a newly graduated physician. But if it is necessary to prepare a presentation or learn a subject in depth, the address is clear.
1- Adams Emergency Medicine: Clinical Essentials
This 1888-page “tome”, which weighs nearly 5 kilograms, provides extensive information on any subject you may need in a visually rich and easily understandable language. The disadvantage is that the second original edition is dated 2012. So it may be partly outdated. Elsevier is sharing the book online (for a fee) under the title Adams Emergency Medicine Review. However, even that was published in 2015.
2- Clinical Emergency Medicine
Clinical Emergency Medicine contains information on the diagnosis and treatment of 98 changes and condition in 400 pages. Each chapter starts with the Key Points. It also continues with Introduction, Clinical Presentation (History and Physical Examination), Diagnostic Studies, Medical Decision Making, Treatment and Discharge, and Reading Recommendations. The printing date is a bit old. The last edition was published in 2014.
3- Diagnosis And Management Emergency Medicine
The 556-page work by Mike Cadogan is not only practical, but also includes a very comprehensive content. The eighth edition has been completely revised and updated. the book covers all emergencies as well as procedures and administrative and legal issues.
4- First Aid For The Emergency Medicine Boards
Published for those who want to prepare for the Emergency Medicine Boards exams organized by the American Board of Emergency Medicine, this book offers a great option for those who want concise summaries with reminder boxes, notes, mnemonics and clinical pearls. Each subject is briefly described in subheadings such as Symptoms, Diagnosis, and Treatment in this approximately 1000-page book.
5- CURRENT Medical Diagnosis And Treatment
This book can be considered as an Internal Medicine textbook. However, in addition to Internal Medicine subspecialties such as geriatrics, preventive medicine and palliative care; it offers detailed reviews of all internal medicine disciplines such as gynecology and obstetrics, dermatology, ophthalmology, neurology, psychiatry, and infectious diseases. The book includes the diagnosis and treatment of more than 1000 diseases and is about 2000 pages. It is ALWAYS up-to-date due to its yearly updates.
6- Rosen & Barkin’s 5-Minute Emergency Medicine Consult
In this textbook, each subject is summarized in 2 pages divided into three sections. The last edition of the chapter, in which every subject is explained systematically in Introduction, Diagnosis, Treatment, Follow-up, Tips, Reading, ICD Codes sections. Its last edition was published in 2019 with a length of 1256 pages.
7- Rosen’s Emergency Medicine: Concepts And Clinical Practice
This book is one of the “brand”s of our field. The original version is 2688 pages long. When you think about it yu will realise that even if you read 10 pages a day, it will be over in 9 months. Due to its size, its suitability for colleagues who do not intend to acquire an Emergency Medicine profession can be discussed, but making a list that Rosen is not included will also upset every Emergency physician.
8- Tintinalli’s Emergency Medicine
I think it would suffice to say that it is the best selling Emergency Medicine book worldwide. Tintinalli’s word is deed, wherever Emergency Medicine is experienced, from in-clinic trainings to certification exams. The 9th edition, published very recently, is 2160 pages long. Pre-hospital care, disaster preparedness and resuscitation techniques… You can find everything you can think of in this book, from all major medical, traumatic and environmental conditions that require urgent treatment in adults, children and neonates.
Suppose you are going to Antarctica as a “team doctor”. You will be completely isolated from the outside world for 3 months. Neither a plane nor a ship will bring aid. Which textbook would you choose to take with you? In my opinion, the answer to this question for every physician is an Emergency Medicine textbook.
Due to the nature of our expertise, every textbook will undoubtedly help Emergency in at least one way. If you choose to read a good Dermatology or a good ENT textbook, you will definitely benefit. From another angle, even the most comprehensive Emergency Medicine textbook will not enable you to learn everything, for example, a thorough understanding of all heart rhythms or interventional procedures. You should refer to thousands of pages of books written specifically for these.
Therefore, our aim in this article was to present a collection of textbooks that examine Emergency Medicine as a whole. While choosing from hundreds of textbooks, we got the great support of the Twitter #FOAMed world. Most of the photos above were provided by the physicians mentioned below. I thank them very much.
If knowledge is a flower garden, textbooks are honeycombs prepared by “master” bees by roaming around those flowers. Rather than visiting thousands of flowers one by one and trying to distinguish between good and bad; it would be most logical to set the foundation on these “honeycombs” and set sail to new gardens.
What did Justin Hensley say? “You can’t build a pyramid without a base.”
We would like to thank the following names for their contributions to this article (alphabetical order):
Ali Kemal Yıldız, Arif Alper Çevik, Ayhan Özhasenekler, Barış Murat Ayvacı, Berika Kavaz Kuru, Bora Çekmen, Burak Özkan, Cem Turam, Ener Çağrı Dinleyici, Fatih Beşer, Gizem Altınsoy, Göksu Afacan Öztürk, Haldun Akoğlu, İbrahim Varol, Justin Hensley, Mehmet Çulha, Mike Cadogan, Nevrez Koylan, Nurettin Özgür Doğan, Oğuzhan Aytepe, Onurcan Kaya, Richard Body, Salahi Engin, Shehni Nadeem, Yonca Bulut, Yusuf Ali Altuncı, Zeynep Kekeç.
You can read the Turkish version of this article on Acilci.net:“Hangi Acil Tıp Kitabı?”
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
It’s 2 AM, and the Pediatric Emergency Department (ED) at a community hospital in New York is overflowing with children and caregivers. A young Nigerian boy is being transported down the center of a hallway, past a long line of doors to patient rooms. The porter is calm and walks briskly, determined to bring this boy to get immediate care. The boy winces, his hands outstretched next to him, rigid, and frozen in space, and while he is seated in the wheelchair, his legs bent at the knees are thin frames, held in place with his feet planted on the wheelchair pedestals. He is afraid to move any of his extremities; tears are rolling down his face; he is fighting the urge to grimace and furrow his brow. He cries how much it hurts to move. He knows he needs help. Behind him, his mother follows close holding a one-year-old baby in her arms, and behind her, five other young children aged 3 through to thirteen stream in. There is quiet concern on all of their faces. The older siblings have seen this before. We learn that he has Sickle Cell Disease (SCD). He has been in excruciating pain for the past 4 hours and is now presenting with dactylitis. This case has not been the first in this ED, and like other EDs across the United States and in the world, the number of cases presenting with SCD will increase.
Sickle Cell Disease (SCD)
SCD is a condition that causes red blood cells to morph from a biconcave dumbbell-shaped disc, into a rigid semi-circular shape. This disease is inherited genetically by receiving two sickle genes, one from each parent and risk for complications are attributed to a variety of factors, including deoxygenation, dehydration. It is most common in African Americans as well as Latinos and people of Middle Eastern, Indian, Asian and Mediterranean backgrounds. In the United States, SCD is the most common genetic blood disorder and affects approximately 100,000 Americans(1) and although babies are screened at birth, management plans vary with the degree of disease progression and exacerbation severity, as well as with the availability of resources and education.
Why Emergency Physicians need to be Familiar with SCD
SCD affects both pediatric and adult patients, and it has been reported that patients between the ages of 18 to 30 years old have increased emergency department utilization. A major reason for this is due to the transition by young adults from pediatric to adult care in the management of SCD, and this population is simultaneously also learning to navigate the health care system and community resources (pediatric to adult care, insurance, independent decision making, housing, education, workforce) as discussed further below(2). In addition, the use of community health workers is important as they can act as liaisons between the health care systems and patients to disseminate information and resources. However, despite the awareness of the disproportionate use of the ED among patients with SCD, the social factors that impact care remain unknown(3) and more research and investigation is needed to understand this patient population.
Often when a complication or crisis occurs in patients with SCD, patients seek immediate care in the Emergency Department. Included in the potential list of complications include infections, such as those with encapsulated bacteria; sepsis; stroke; splenic sequestration, and early treatment is essential in managing patients. Of these complaints, the emergent cases to be aware of in the ED include vaso-occlusive crisis and pain, sickle cell anemia (SCA)(4) central nervous system such as stroke, and acute chest syndrome (ACS), where ACS due to blocked capillaries in the lungs, may be caused by infections, asthma exacerbations and/or pulmonary embolisms, and is the leading cause of morbidity in patients with SCD. Further, the Emergency Severity Index (ESI) Version 4 triage system, commonly used in the majority of EDs in the United States, suggest that patients with SCD be triaged as ESI level 2, indicating a very high priority, and that rapid placement be facilitated(5).
Although the discussion of complications of SCD including the presentation and management is a complex topic, and will be covered in detail in future posts, information and algorithms for clinicians are available online for reference. One such resource is a treatment algorithm that acts as a how-to guide for SCD and is available online in the Annals of Emergency Medicine(6). This approach is based on the point-of-care hemoglobin level, and discusses issues such as myonecrosis, aplastic crisis, ACS.
Pain in SCD
When tissues and organs are not adequately perfused with oxygen, in part due to the sickled shape of RBCs, tissue damage and death can occur. Patient management of vaso-occulusive crisis and pain varies by practices and the medications available for use around the world, however it is important to note that pain in patients with SCD is often extreme and may require treatment with opioids. In a response to the American Society of Hematology (ASH) draft recommendations to Sickle Cell Disease-Related Pain in May 2019(7), emDOCs.net published a response to the drafted recommendations and offered insight to pain management and includes an algorithm(8). The insight provided is essential in decreasing the suffering experienced by patients during an SCD crisis, and notes the use of Dilaudid, Ketamine, Dexmedetomidine, and Lidocaine. Further, the understanding of limiting the use of NSAIDS due to impaired renal function caused by the disease is also outlined in the response.
Management of pain in pediatric patients with SCA and vaso-occulsive pain also varies according to hospital and individual provider practices, and scientific investigation and patient research is needed to provide proper care to this population. An example includes a study by PECARN addressing the use of a normal saline bolus in pediatric emergency departments found an association with poorer pain control(9). Identifying and implementing results from research studies is important in understanding and managing SCD in both adult and pediatric patients.
Emergency Physicians around the world should be aware of strategies for identifying SCD, and management, specifically in areas around the world where refugees from countries with SCD prevalence is common. Countries where refugees and migrants are commonly are known to disembark, such as those in southern Europe(10) and certain areas in the United States and Canada would benefit from in-depth analysis of the issue and could allow for appropriate and accessible health care to vulnerable populations, as well as educate providers who are unexposed to managing emergencies in SCD patients while setting in place integrated and individual health plans away from emergency room dependence(11). In developing countries with SCD populations, such as Nigeria, there is a high prevalence of pediatric emergency cases, and the proper management of the disease as well as policy and hospital organization for high volume and off-hour admissions, may reduce hospital stays(12). Further, the self-efficacy of adult patients with SCD, from education, pro-active efforts, understanding of disease management, also can allow for decreased ED visits and hospitalizations for pain(13).
Investigations, Resources, Education
A number of investigative studies, clinical trials and research is being conducted around the world for a better understanding of SCD, including patient care in adult and pediatric patients, genetic factors, supportive services, associated co-morbidities, and search for cures. Investigations around the world include collaborations and information sharing between academic researchers, patients, clinical providers, and health care providers and officials around the world.
The National Heart, Lung, and Blood Institute hosted a series of Webinars in September 2018, during Sickle Cell awareness month from experts in blood science and sickle science research and are available to watch for free online(14). Some of the key highlights from two of the webinars: Serving the Sickle Cell Disease Community Here and Abroad; Sickle Cell Transitional Care from Childhood to Adulthood, are discussed here.
Webinar Overview Serving the Sickle Cell Disease Community Here and Abroad Presented by Dr. Keith Hoots, Director of Division of Blood Diseases and Resources, NHLBI
Prevalence of the disease is so much larger in Africa than most places in the world. There are as many babies born with SCD born in Nigeria there are babies born with SCD, by estimate, as there almost are total people with SCD in the United States.
There is a need to share research and practices in the developed world with the developing world.
Three New Research Initiatives in Africa:
The Sickle Pan-African Research Consortium (SPARCO) Overview: The study sites for this research include East Africa (Tanzania), West Africa (Ghana, Nigeria) and central Africa (Cameroon, Democratic Republic of Congo) with the goal to later include 20 sites in 15 countries. SPARCO’s aim is to develop an SCD database, standards of care, and strengthen research investigation.
Sickle Cell Disease Genomics of Africa (SickleGenAfrica) Overview: The purpose is to develop strategies to predict, prevent and treat organ damage in SCD and to investigate biomarkers associated with the development of organ damage, including molecules released during red blood cell damage in sub-Saharan African populations.
Webinar Overview: Sickle Cell Transitional Care from Childhood to Adulthood Part 1 Presented by Dr. David Wong, MD, FAAP, Medical Officer, Office of Minority Health
SCD is no longer a childhood disease. Young adults are at a higher risk for hospitalization due to illness and pain.
Treatment and management examples in childhood include annual transcranial dopplers to assess for risk of stroke; vaccinations; hydroxyurea; L-glutamine; opioids for pain management; penicillin prophylaxis; RBC transfusions; water intake to avoid exacerbations due to dehydration; splenectomy. The cure available is bone marrow transplant.
Prior to July 2017, Hydroxyurea was the only FDA approved therapy for 20 It is used in adults and children. It has been shown to reduces hospital admissions, pain crisis, and ACS however barriers to hydroxyurea use exist. These include difficulty with communicating the use to patients and caregivers, issues with frequent monitoring, lack of adherence, lack of provider knowledge and comfort with its use.
Community Health Workers (CHWs) are key players in effective patient care. CHW can provide information affected by social and health determinants from local economic and environmental (housing, employment), local communities (families, safety, support), activities (learn, work, play, move, shop), lifestyles (alcohol, drugs, smoking, sexual health, physical activity, and individual needs (age, genetics). CHW are experts in condition-specific information and navigating complex health systems, including accessing care in a medical home (the approach to providing comprehensive care). This is particularly important when care is not always contained or organized by one organization, where care should be accessible, continuous, comprehensive, family-oriented, coordinated, compassionate and culturally competent. Pediatric medical home principles include family-centered partnerships, community-based systems, transition care, value. Interventions for education such as warning signs and treatment options and links to care are important.
The SCD Newborn screening program, and the Sickle Cell Disease Treatment Demonstration Program for patients who solely rely on the ED for SCD care, aid the care options for patients with SCD.
Follow this iEM story for part two which will include information on adult and pediatric management of SCD in the ED, as well as an overview of four NHLBI webinars: Holistic Health and Sickle Cell Disease A Focus on Mental and Behavioral Health; Genetic Therapies in Sickle Cell Disease; Bone Marrow Transplants, Other Therapies, and Sickle Cell; Improvement Initiatives and Ongoing Research.
Lush green land and open spaces, fresh air that reminds us of how artificial our all-natural room fresheners smell, and quiet nights decorated with twinklings of a starry sky and the musical buzz of crickets. That is how most would imagine a village. Few of these imaginations remain borrowable if anyone were to engage in the same exercise in regards to an ER in the village. For starters, nights aren’t as quite, color and smell changes depending on what patient you are treating that day and the space of the room shrinks in proportion to the distance you traveled to reach that village.
Two years ago, when I was posted at Beltar Primary Health Care Center (PHC), little did I know that a sparsely populated village’s abundance of space rarely follows through to the emergency room. The obvious lack of infrastructure is, of course, the major problem. In the health system of Nepal, emergency services are designed to be provided at the hospital level. However, keeping the need for emergency services in mind, health workers in the rural areas are left to run makeshift ERs. At our PHC, what was supposed to be the waiting lobby for patients was used for an ER. The lack of a four-walled room meant that the only sense of privacy was provided by the patient’s fumbling awareness owing to intense pain and the physician’s focus completely overwhelmed by trying to be resourceful amidst obvious lack of resources. Hordes of curious onlookers crowding to see what was going on is a common scene in our ER that one would start ignoring after a month or two.
After banging our heads on problems that require far more resources and policies than that within our reach, we are left to take a sensible path – focusing on one small thing at a time and changing it for the better. Today I present to you an incident that inspired us to make an effort into making one such change happen.
A 28-year-old male
Like any on-duty doctor, I found myself rushing to the ER after a call. A 28-year-old male was brought after a sudden loss of consciousness while playing football. We quickly realized that CPR was in order and jumped right at it. Quite literally so, as the arrangement of beds in the ER was such that you could only deliver quality compressions if you are on the patient’s bed.
Elephant in the room
When I asked our paramedic to start bag and mask ventilation, he looked at me in confusion – the bed was placed against the wall and he would have to jump across the patient to provide one. Our nurse had to squeeze her way through the crowd of onlookers to find the needed medication. In the end, all of us were disappointed. Exhausted physically and mentally yet pondering on things we could have done differently, like any other resuscitation team would, after an unsuccessful CPR. After ruminating on the quality of CPR, availability of better equipment, training and all other aspects of a good resuscitation, we finally addressed the elephant in the room.
Bigger space or ...
The most obvious solution of shifting our ER to a bigger space was simply not an option. What we could do was make small changes that could make things a bit better. The nature of problem-solving has to be such that the biggest constraints remain (because we rarely can do anything about them). What is it that a bigger space adds? Big space adds orderliness. As I was pondering on this question, I had an idea that felt like an epiphany. I remembered one of my toys as a kid – a Rubik’s cube. We do not expand our Rubik’s cube to make it orderly. We rearrange it – you get to manipulate the pieces but not the whole cube. Thus, we started the mission of Rubik’s cubing our ER.
We had four beds in our ER. We wanted a separate resuscitation bed with enough surrounding space. We moved all three beds to one side of the room; installed two privacy screens instead of both a door and a wall (sorry onlookers!). We repaired and re-stocked the crash cart, placed each medicine in separate compartments in the drawers and labelled them properly.
A few weeks later, we performed CPR in another patient. The patient was rushed to our resuscitation bed, the privacy screens were drawn and the crash cart pulled near the bed. After we resuscitated the patient, we started the age-old culture of replaying the scene in our head and trying to figure out what else could be done. We obviously came up with a lot, this time too. But in terms of using the available resources, everyone was satisfied that they did the best they could make out of the situation.
Resuscitation will never be easy, but that is the precise reason we need to make it as orderly as possible. People who develop protocols and policies are doing their part. We, at Beltar, tried to do ours.
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
The basic approach would be first to jot down all the problems you can think of.
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, 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.
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.
In the era of Free Open-Access Medical education, there are countless invaluable resources available for medical learners. Over the years, they have been designed and optimized for more portable use, with the possibility of serving as on-the-go resources for trainees. Having just completed my third year of medical school – and also, my first year of clerkship – I have discovered several point-of-care tools that have proven to be immensely useful in the emergency department (ED).
Not only have they been wonderful for obtaining quick information and have helped guide my history-taking, physical examinations, differential diagnoses and management, but they have also helped me learn through repetition using the same sources of information.
The majority of these are available both online and as mobile applications, so they are very accessible in the ED setting when you have multiple patients on the go with a variety of concerns.
Below are a few that I have found particularly helpful this past year. As always, these resources are designed purely as clinical aids and are not meant to replace clinical judgment.
For accessibility purposes, I have only included free resources; however, some do offer additional features that are available for purchase. I have no affiliation with any of these and am commenting solely on the basic features that are available.
QuickEM features a list of common adult and pediatric complaints, ranging from syncope to hematuria. For each presentation, it lists considerations for histories, physicals, differentials, investigations, treatments and disposition. There is also a tool which facilitates the calculation of various useful parameters, such as QTc and Well’s score for DVT and PE. One unique component of this application is that it provides clinical pearls at the end of each topic and allows you to make personalized notes for each presentation, which you can refer back to. Additionally, a list of references is provided for further review. Overall, QuickEM breaks down a broad range of presentations into essential components, and has served as a very useful and quick EM-specific resource.
MDCalc can be used online or through a mobile application. It has a long list of formulae which can be sorted by specialty (unsurprisingly, there are quite a few for EM!). One really great feature is the “favorites” section, which allows you to add specific formulae to your folder for easier reference. Once you’ve done the calculation, there is also a section that addresses subsequent investigation and management steps, as well as an evidence section that highlights the associated studies behind the formula. Overall, not only has it helped me easily calculate parameters, but it has also expanded my knowledge base by addressing the reasoning behind commonly-used clinical measures.
Orthobullets has been a staple resource throughout my Orthopedic Surgery block and then during my EM rotations for musculoskeletal-related presentations. It includes an extensive list of topics and outlines relevant anatomy, pathology, differential diagnosis, investigations and management, while also highlighting specific surgical techniques. Moreover, it includes a question bank, sample cases and educational videos, all of which are excellent for general MSK review. It can be downloaded onto your phone for easier, on-the-go use, but it does require you to register for an account (free) if you would like to access the additional features (cases, question bank, videos, etc.).
I started using this mobile application as a quick review before going into the simulation lab during my EM rotations. It provides easy access to numerous ACLS, BLS and PALS algorithms that can be viewed as images or approached using an interactive step-by-step feature. There are also some embedded instructional videos to consolidate all of the content. Not only does this application allow you to flip through various algorithms fairly effortlessly, but it also lets you test your knowledge and identify areas for further review through multiple-choice questionnaires.
By no means is this an exhaustive list – there are so many wonderful resources out there that I have not mentioned and that I have yet to discover! These are just several that I have regularly used and that have come up repeatedly through discussion with my colleagues. What are some point-of-care resources that have been invaluable to your education and have been helpful throughout your rotations? We would love to hear about them!
One of the essential skills an emergency medicine provider can develop is knowing what resources are available and correctly and efficiently utilizing those resources in your time of need.
You need to know where your ultrasound and associated supplies are stored to quickly perform a FAST exam as soon as a trauma patient arrives. You need to know who your general surgeon on call is and how to contact them, in order to get your newly diagnosed case of appendicitis admitted and to the operating room. Most of your patients may not individually need a bedside ultrasound or surgical consultation, but when you have a patient who does need it, you have to be ready to mobilize these resources quickly.
Likewise, you need to learn about and develop a system for how to look up answers when you have clinical questions about diagnosis and treatment of both common and rare presentations of emergency medicine cases. One of the hardest things about emergency medicine is never knowing what you will take care of next, including relatively rare disease processes, particularly those you haven’t seen before or studied in a long time. While many folks may refer back to hard-copy printed textbooks for reference when these clinical questions of “what do I do next” arise, an increasing number of incredibly useful resources are available online and can improve your efficiency in both learning outside of the hospital as well as calling upon them during a busy shift to answer the “what next” conundrum.
Outlined below are a number of resources I have found helpful, and you might as well. Some of these are paid while many are free, and all should be available digital formats. As the world of online medical education continues to grow, you may find others, including this website, have the answers you need, when you need them. Finding answers to your questions when you most need it is a really valuable skill that will enhance your clinical practice.
UpToDate requires a subscription but may be available for some individuals for free through institutional logins. Despite its relatively high price, this is my favorite resource and is great for questions around diagnosis (including differential diagnosis) and treatment recommendations. A phone application is also incredibly helpful on the go.
Orthobullets is a great quick reference for injuries and orthopedic complaints. For example, they can give you guidance on the recommended management of a specific fracture. Most everything an EM provider would need is accessible for free, though there are paid portions of the website.
Radiopaedia is incredibly helpful when looking for the best radiologic study to answer your clinical question, and can also provide guidance in interpreting imaging once it has been obtained. They also have lots of example images that show both normal and pathologic findings, which is really helpful when trying to analyze imaging studies.
Below is a list of other websites that you might consider using, particularly for an emergency medicine perspective on important EM topics. Please remember that many of these sites are in a blog format and individual blog posts will vary in their level of scientific evidence with a base in peer-reviewed literature versus an author’s opinion and practice. Most all will utilize references in their posts and can help you delineate what content is following the standard practice versus a newly developing opinion or approach. Some of the best online EM content to consider:
Although there are dozens and dozens of podcasts that contain valuable content in emergency medicine, the standard-bearer has been EM:RAP. Though this resource requires a subscription, it does come with a native phone application and is free for EMRA members as a part of your membership, and their C3 (continuous core content) series is great for the highest yield topics in emergency medicine. Also, the Crackcast series systematically walks through Rosens and is a great adjunct or review tool.
Lastly, consider hardcopy or electronic versions of the foundational textbooks of emergency medicine: Rosen’s and Tintinalli’s. Also, the procedural textbooks Roberts & Hedges, or Reichman’s Emergency Medicine Procedures, cover all procedures, from basic to complex, that are within the scope of the practice of emergency medicine.