The Case of the Perplexing Crepitations

perplexing crepitations

Occam’s Razor – the simplest explanation is most likely to be correct.

In the Emergency Room, we are faced with a multitude of cases, and Occam’s Razor serves best when we need to narrow down on the differential diagnoses.

Sometimes, a few cases may evade this category and continue to baffle us even after a thorough history is obtained or a detailed clinical examination is performed. If we are lucky enough to get the point-of-care (POC) lab tests in time (or the mere availability of POC), they aid in the diagnosis and decision-making. At times, these POC lab tests also may not provide much help.

I have described one such case – a 21-year-old male with fever, dyspnea, desaturation, and multiple petechiae of 3 days duration.

Case Presentation

A 21-year-old male came at 9.30 pm to the ER with fever and breathlessness for three days. Being a healthcare worker himself, he had suspected pneumonia and started oral Amoxiclav, oral Clarithromycin, and Paracetamol. Despite this, there was no improvement in clinical status. He had progressively worsening breathlessness and continuous low-grade fever. On day 3, he developed a few petechial spots over his arms and minimal subconjunctival hemorrhage.

He recalls having myalgia in the lead up to these symptoms, for which he had received several injections of intramuscular Diclofenac. The injection sites now had developed small hematomas. There were no other visible bleeding manifestations. He clearly said that he had had no contact with any infectious patients and had self-isolated after developing these symptoms. His workplace had sent blood and sputum cultures – which came back negative. Their only concern was a continuous rise in the WBC count and sent to our hospital for further management.

Assessment

The patient was very ill-looking and extremely dyspneic with obvious usage of accessory respiratory muscles. He was profusely diaphoretic, had bilateral subconjunctival hemorrhage, multiple petechiae, anasarca, dyspnea, and 99.6⁰F. His Vitals were heart rate – 134/min, blood pressure – 110/70mmHg, respiratory rate – 34/min, SpO2 – 72% in room air; 98% with NIV. There were bilateral crepitations in all lung fields + no obvious abnormalities on CVS, CNS, and abdominal examination. POC ultrasound revealed multiple B-lines in all lung areas. Dilated IVC. The remaining cardiac, abdomen, and limb USGs were normal. ABG revealed Type 1 respiratory failure with elevated lactates. Bedside CXR and chest CT revealed diffuse bilateral lung infiltrates – not typical of pulmonary edema or pneumonia. Probable ARDS was mentioned. Blood samples had been sent for necessary investigations, including cultures and peripheral blood smear.

Management

Meanwhile, opinions were obtained from critical care consultants and pulmonologists regarding further management. Based on the clinical findings, it was decided to start the patient on broad-spectrum antibiotics (BSA), albumin transfusion, diuretics for the fluid overload status, and NIV for respiratory failure [all in suspicion of sepsis with MODS]. The patient was started on BSA before shifting to the ICU. Meanwhile, the blood reports arrived, suggestive of possible Myelodysplastic Syndrome (WBC – 95,000 cu.mm), Hb – 7g/dl. Peripheral Blood Smear report was Acute Myeloid Leukemia – possible M2 or M3.

The patient was immediately started on IV fluids, and oncology consultation was immediately obtained for chemotherapy initiation. Albumin and diuretics were withheld in suspicion of blast crisis and leukostasis / leukemic infiltration of the lungs. The patient was started on Cisplatin and other chemotherapeutic agents; bicarbonate infusion for urine alkalinization; allopurinol to treat hyperuricemia due to cytolysis; aggressive IV fluids for prevention of AKI due to chemotherapy and hyperuricemia [Tumour Lysis Syndrome]. Bone marrow biopsy was done during his hospital stay, which confirmed blast crisis AML-M3. His clinical condition improved considerably, and he was discharged from the hospital on Day 7.

Lessons Learnt

  1. Recognising leukostasis and hyperviscosity in the ED in an undiagnosed AML patient is extremely difficult. https://link.springer.com/chapter/10.1007/978-3-030-22445-5_3
  2. While considering different diagnoses based on clinical findings, always keep an open eye. Rare diseases present to the ED just like all others. https://www.medscape.com/viewarticle/860747_3
  3. Aggressive fluid management is needed in hyperviscosity syndrome. If we had started this patient on diuretics as planned, the blood would have become more viscous and lead to multisystem thrombosis. https://pubmed.ncbi.nlm.nih.gov/22915493/
  4. Increased metabolism in AML can present as pyrexia. With the other features of anemia, leucocytosis, petechiae, and anasarca, we are likely to diagnose this as sepsis. When in doubt, look through other causes of pyrexia (PUO). https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13180
  5. Anasarca in leukemia does not warrant albumin transfusion as this may worsen fluid status. They may actually be in need of steroid therapy. https://www.hindawi.com/journals/crihem/2012/582950/
  6. Point of Care Lab testing is essential to reduce the number of diagnostic errors in the ED. https://acutecaretesting.org/en/articles/
Cite this article as: Gayatri Lekshmi Madhavan, India, "The Case of the Perplexing Crepitations," in International Emergency Medicine Education Project, June 14, 2021, https://iem-student.org/2021/06/14/the-case-of-the-perplexing-crepts/, date accessed: December 3, 2022

Recent Blog Posts By Gayatri L. Madhavan

Intern Survival Guide – ER Edition

Intern Survival Guide - ER Edition
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on. Often, junior doctors (including myself)  find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures. I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting. These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
  • 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.
If you are a medical student starting your emergency medicine rotation, make sure to read this post for your emergency medicine clerkship, and be a step ahead! https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/  
Cite this article as: Sumaiya Hafiz, UAE, "Intern Survival Guide – ER Edition," in International Emergency Medicine Education Project, May 26, 2021, https://iem-student.org/2021/05/26/intern-survival-guide-er-edition/, date accessed: December 3, 2022

Recent Blog Posts By Sumaiya Hafiz

ACEP’s shiny new GEMS: the Who, What and Why that make this LP worth playing

acep gems

Introduction

The necessity of introducing emergency medicine (EM) into undergraduate medical education (here – medical school level) has been discussed, if not debated, for over four decades (1,2). More recently, two additional trends have become apparent. One speaks to the mutual co-integration and interdependence of all emergency care field components including EM (3). The other is the emergence of a keen interest in global health exhibited by both medical students and emergency medicine trainees alike (4-6).

Here we wish to present and describe a novel program for medical students that aims to address and integrate all of the three phenomena under one umbrella. 

ACEP’s Global Emergency Medicine Student Leadership Program (GEMS LP) is now in its third year, with eighteen students from various medical schools learning about topics in global health through the guidance and shared experiences of internationally minded emergency physicians.

Background

The International Section of the American College of Emergency Physicians (ACEP) is one of ACEP’s largest, with over 2600 members currently (7). In 2013 the Section’s first annual ACEP International Ambassador Conference took place in Seattle. The meeting formalized and accentuated the common vision shared by those section members who had already been actively involved in global health and international EM development in their respective nation(s) of interest (8).

In 2017 members of Emergency Medicine Resident Association (EMRA) approached ACEP’s International Ambassador Program with the idea of mentorship for medical students interested in both EM and medical work globally.

Through a collaborative effort the Ambassador Mentorship Program (AMP) was born and welcomed its inaugural class of eight medical students in 2018 (9).

Focus

To better align our name with the program’s vision, AMP was renamed the Global Emergency Medicine Student Leadership Program (GEMS LP) in 2020. Currently GEMS LP is open to medical students at all levels of training (prior to graduation) who are members of EMRA.

The nine month curriculum consists of several integral components, including global health knowledge development, research, personal mentorship and networking.

Focus on global health (GH):  GH has become a field that aims to transcend not only the borders among nations, cultures, governments and organizations, but also the distinction between what is narrowly medical and what is widely ethical and social – as in rooted in people’s daily living conditions (10). It has been a consensus among GEMS LP’s participants that efforts to improve development of EM and regional emergency care systems around the world cannot be studied or pursued outside of the global health context.

At a GEMS journal club, 2020

The program runs a structured journal club done via video platforms which includes review and discussions of textbooks and original literature pertinent to GH topics.  Since 2020, journal clubs have also included a new component where students prepare local health improvement project proposals  (based on their geographic or cultural area of interest or prior experience).  These “mock” project proposals are then discussed by the journal club group at large as another way of learning.

Examples of monthly focus themes have included global health inequity, sustainability in global health, ethics of humanitarian work, need for EM expertise in low resource settings, language justice in healthcare and the future of global health.

We welcome all members of the ACEP International Section and current GEM fellows (ask us how to get involved at infoGEMSLP@gmail.com) – international voices add much to the discussion!

Focus on mentorship and networking: Through one-on-one guided phone calls with GEMS LP faculty and other International Section physician members, students are exposed to multiple examples of individual professional paths and are offered guidance in exploring their options for future training, careers and work/life balance. Student participants also have access to globally involved EM physicians across the entire Ambassador Program and the Section, both domestically and internationally. Mentors and guest speakers have also given presentations on career paths in global EM during journal club sessions to give mentees a variety of perspectives on the diverse training and career options available.

Focus on scholarship and research: Mentors involved in academic research have had mentees collaborate in groups of 2-5 on research projects. Examples have included: state of emergency care in the post-USSR zone – a literature review, Ugandan emergency mid-level training curriculum work, a review of pre-hospital medicine in resource-restrained areas within India and Sri Lanka, assisting with the ACEP Ambassador Program Country Reports, and others.

Group projects are a great way for mentees to network and build lasting working relationships, not only with the mentor leading the project, but also with their peers. While mentees are not traveling for program projects in light of the COVID-19 pandemic, the projects are still a way in which the program helps mentees build real world skills for future GH ground work. 

Learning structure

During the course of the program each student will participate in all virtual journal clubs, and will be responsible for at least one presentation of a book chapter, an original research paper or a global health project proposal. Longitudinally, students are paired up with a faculty’s research project in small groups, and as mentioned, also participate in a minimum of three one-one-one mentorship phone or video calls with different mentors focusing on various aspects of career planning. Students may also be introduced to and connected with ACEP’s international section members based on mutual backgrounds, cultural and language skills or GH interests. Finally, students are invited to attend the annual ACEP Ambassador Conference (virtually during COVID restrictions) and are expected to attend the GEMS LP program orientation and close out sessions. 

Future directions

Mentee retention: All mentees are invited to get involved with program leadership when they graduate the program, which is a constant source of energy and new ideas. This will ensure the program’s sustainability, as we build successive generations of program leadership from the trainees who themselves benefited from the program previously.

Expanding number of students and faculty mentors: As medical student interest in GEM opportunities and mentorship increases, we hope to continue expanding the program and recruit a diverse group of mentees, including international medical students. In order to facilitate this, additional faculty members will also be needed. The program hopes to continue recruiting diverse mentors, including those from international institutions (especially those from low- and middle-income countries), humanitarian organizations, community and academic emergency departments.

Expanding the research component and publications: Giving GEMS LP participants adequate exposure to academic global emergency medicine through participation in research projects and in peer-reviewed publications. Planned publications for the 2020-2021 year include: GEMS LP milestones study and a concept paper on the program. Currently mentees are interviewing the ACEP Ambassador team working in their country or region of interest on the state of emergency medicine development. We hope to publish an EM around the world country highlights article based on these interviews. Also, be on the lookout for an EM Resident piece in the April/May issue showcasing the projects that the 2019/2020 class completed.

Connecting with other organizations: GEMS LP is actively seeking to form mutually beneficial relationships with other organizations involved with EM, emergency care and global health domestically and internationally. Currently, we are working to expand collaboration with GEM fellows.

Please get in touch if your organization would be interested in collaborating at info.GEMSLP@gmail.com!

Information sharing: The program is interested in building an information repository to share research, advice and resources that accumulate within the program over the years that are useful for medical students interested in EM and global health around the world.

Impact evaluation: To formally evaluate the impact of the GEMS LP program on participant’s careers going forward, starting with the 2020-2021 class, students will be given pre- and post- program surveys using modified methodology described by Douglass et al. in “Development of a Global Health Milestones Tool for Learners in Emergency Medicine” (11). The milestones study is planned to track participants at 1, 2, 3, 5, 7 and 10 years post-graduation from the GEMS LP program to assess long-term impact on careers.

Relevance for the global EM-trainee community

GEMS LP’s current hybrid educational model has evolved to match the diversity of our mentees with their need to simultaneously gain knowledge in several interconnected areas: emergency medicine, international emergency care systems and global health and planning one’s future career as a medical student.

We hope that the GEMS LP program may serve as a potential model for others involved in global EM education such as medical schools, residency programs, or international colleges of emergency medicine to create opportunities and resources for their students to grow into thoughtful and successful leaders in the field of global EM.

In the current era of COVID-19, this virtual program may also serve to engage students and trainees in global EM work despite limitations on travel, as well as to expand access to formal mentorship opportunities for students who may not have these opportunities at their home institutions.

For more information on GEMS LP and how you can get involved as a mentor, mentee, or a journal club participant please visit the page below or email us!

https://www.emra.org/be-involved/committees/international-committee/amp-program-info/

The 2021/22 GEMS LP application will open for students this spring, with a deadline of June 30, 2021. We are always recruiting faculty mentors! 

Cite this article as: Anthony Rodigin, Stephanie Garbern, Ashley Pickering, Alexandra Digenakis, Elizabeth DeVos, Jerry Oommen, “ACEP’s shiny new GEMS: the Who, What and Why that make this LP worth playing,” in International Emergency Medicine Education Project, February 21, 2021, https://iem-student.org/?p=17057, date accessed: February 21, 2021

References:

  1. Guidelines for Undergraduate Education in Emergency Medicine. Ann Emerg Med. 2016 Jul;68(1):150. doi: 10.1016/j.annemergmed.2016.04.049. PMID: 27343670.
  2. Beyene T, Tupesis JP, Azazh A. Attitude of interns towards implementation and contribution of undergraduate Emergency Medicine training: Experience of an Ethiopian Medical School. Afr J Emerg Med. 2017 Sep;7(3):108-112. doi: 10.1016/j.afjem.2017.04.008. Epub 2017 Apr 20. Erratum in: Afr J Emerg Med. 2017 Dec;7(4):189. PMID: 30456120; PMCID: PMC6234139.
  3. Carlson LC, Reynolds TA, Wallis LA, Calvello Hynes EJ. Reconceptualizing the role of emergency care in the context of global healthcare delivery. Health Policy Plan. 2019 Feb 1;34(1):78-82. doi: 10.1093/heapol/czy111. PMID: 30689851
  4. Havryliuk, Tatiana et al. Global Health Education in Emergency Medicine Residency Programs. Journal of Emergency Medicine, Volume 46, Issue 6, 847 – 852. March 7, 2014.
  5. Dey CC, Grabowski JG, Gebreyes K, et al. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med 2002;9:679–83.
  6. Cox JT, Kironji AG, Edwardson J, Moran D, Aluri J, Carroll B, Warren N, Chen CCG. Global Health Career Interest among Medical and Nursing Students: Survey and Analysis. Ann Glob Health. 2017 May-Aug;83(3-4):588-595. doi: 10.1016/j.aogh.2017.07.002. Epub 2017 Aug 30. PMID: 29221533.
  7. http://www.acep.org; Search: “International Membership FAQs”. Accessed 1/16/21
  8. https://www.acep.org/globalassets/sites/intl/media/site-documents/1st-annual-acep-international-ambassador-conference-proceedings.pdf. Accessed 1/16/21.
  9. Patino, Andres. “GEMS LP – Global EM Student Leadership Program. The New AMP”. GEMS LP Program Orientation virtual meeting, PPT presentation. October, 2020.
  10. Cemma, Marija. “What’s the Difference? Global Health defined”. Global Health NOW. Sept. 26, 2017. https://www.globalhealthnow.org/2017-09/whats-difference-global-health-defined. Accessed 1/16/21.
  11. Douglass KA, Jacquet GA, Hayward AS, Dreifuss BA, Tupesis JP, Acerra J, Bloem C, Brenner J, DeVos E, Douglass K, Dreifuss B, Hayward AS, Hilbert SL, Jacquet GA, Lin J, Muck A, Nasser S, Oteng R, Powell NN, Rybarczyk MM, Schmidt J, Svenson J, Tupesis JP, Yoder K. Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project. AEM Educ Train. 2017 Sep 11;1(4):269-279. doi: 10.1002/aet2.10046. PMID: 30051044; PMCID: PMC6001724.

Things You Should Know Before Your First ED Shift

Things You Should Know Before Your First ED Shift

I recently posted a question to the Twitterverse:

“Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be your FIRST ADVICE?”

I also raised the same question in Turkish. In a couple of days, I received nearly 100 answers from reputable names of Emergency Medicine working worldwide. I highly benefited from these advice, and I think that our site’s valuable readers can also benefit. I tried to select the most inspiring ones and divided them into main categories. Under each advice, you can find the name of the tweet owner and the link to the original tweet. Let’s start.

Core

Enjoy being on the frontline by helping patients who are seeking your help in their most difficult time. This is a great privilege and responsibility that we should never forget.

Arif Alper Cevik (@drcevik) Tweet

Never forget what a privilege and responsibility it is that people don’t know you ask for your help on the WORST DAY OF THEIR LIFE.

In the Emergency Department, you may be worried about 'why am I here?' one day, but you may think that you are doing the best job in the world another day. Now you have a lifetime which every day and every patient is different. Love your profession EVERY WAY, glorify knowledge and skill, and always be at peace with your job.

Education

Never be afraid to say, "I don't know." It's why you're here to be taught. If you already knew everything, then you wouldn't need residency.

Justin Hensley, (@EBMgoneWILD) Tweet

Trust yourself as if you know everything, try to learn as if you know nothing.

Want to get smart? Do 2 things: 1) Read up on at least 1 patient every shift. 2) Ask lots of questions to residents, attendings and consultants.

Feel free to ask me (or another senior) about anything (/everything). When I was at that stage I wish I’d asked more. I suspect some people think asking is a sign of ignorance or weakness. Actually, it helps us to be safe & to appreciate other perspectives.

This is the Emergency Room; this is the lion’s den; first, you have to protect yourself, and you will do this with your knowledge. So don't think ‘I'll practice, I'll fill my knowledge gap in 3-5 months', sit down, and read the textbook.

Göksu Afacan Öztürk (@Goksu_Afacan) Tweet

First compel yourself to read at specific points, and gradually you will find your appetite for reading. You are the one primarily responsible for your education!

Never feel shy to ask or say I don't know. It's your chance to make mistakes and learn, share the knowledge you have and don't keep it to yourself.

Of course, you cannot know everything, but you can start learning.

Ozlem Guneysel (@oguneysel) Tweet

80% of “KNOWLEDGE” is "INTEREST"

Ayhan Özhasenekler (@Aozhasenekler) Tweet
Resilience

Resilience

The Emergency Medicine career is a marathon, not just the first few years of residency. Don't waste your energy inordinately for things you can't fix. Invest in the future self.

When you dance with the bear you can't stop until the bear wants to stop.

Nurettin Özgür Doğan (@DrOzgurDogan) Tweet

Calm down. Every shift eventually ends.

Mustafa Ercan Günel (@mercangu) Tweet

Rest and eat, whenever you get the opportunity. The Emergency Room is like a HIIT, you need to slow down first to speed up.

Burcu Yılmaz (@Burcu_Yilmazzz) Tweet

If you are a parent, sleep when the child sleeps.

Empathy

Empathy

Don’t judge patients or consultants without walking a mile in their shoes.

Think of every patient as your relative. Balance your professional authority with your kindness.

Communication is important. Tell the patient and one of his/her relatives what you already did and what you plan to do, and ask if there is anything they want to ask.

Altuğ Kanbakan (@prothemanes) Tweet

Peter Rosen once said, “Nobody woke up this AM decided to ruin your day.” Happiness is YOUR choice. Be happy, stay positive.

Remember, when you see a patient in the middle of the night who requests you to apply his/her prescribed topical cream on his/her back because –apparently- he/she can’t, that person is the joy of the night.

Follow up on your patients. This will reinforce your learning. Call patients at home to see how they’re doing. They will love it, and it reminds you of why you chose this profession.

Remember to acknowledge that you most likely are a stranger to your patient. It only takes a few minutes to reassure someone that you are there to help them through their ER experience as a team. We tend to forget this in the busy ER.

Values

Values

Nobody expects you to know much (yet). But it is expected you to be 100% reliable. Never EVER EVER EVER lie. If you don’t know something or you don’t do something, be honest.

Your attitude to this advice will determine your path through our specialty. The blindingly following advice will bring as much peril as ignoring it all. Emergency Medicine requires you to consider impacts on patients, professionals & the populations - no one approach fits all.

Damian Roland (@Damian_Roland) Tweet

Never EVER EVER EVER be arrogant. You will be wrong many times in your career. Learn humility NOW.

What I like most about emergency medicine is how it allows us new perspectives every day. In the pandemic, we are treating the same disease all the time, but each patient and their family brings a different story, and every time I feel more humble in the face of life, the disease, and the future. Being in a LIMC country can be so challenging, so painful to treat and suffer along with inequalities and lack of resources... But we have the opportunity to be our best, as I said yesterday to my residents: we don’t have the best hospital, but we can be our best and give the patient what they may not have in the best hospital: treatment with dignity and respect and love. For me, being able to show my patients that I care, and receiving their gratitude has been undoubtedly the only possible prevention of Burnout. So I would say: Our specialty is beautiful, the opportunity for growth is vast, but it takes humility and perseverance to complete this journey.

Jule Santos (@julesantosER) Tweet

Never allow senior residents of other departments to treat you as if you are their junior.

Dr Erdi Kadir Y. (@DrEKYacil) Tweet

Our fingers are not equal, and so are the attendings whose hands you train on are not the same nature. There is the gentle one who loves you and there are critics who believe that development comes only with criticism and a dose of pain. Your job is not to try to classify them but to do what is required of you and to benefit from everyone.

We want you to be the brain of a machine in which none of its cogs can work properly. Sometimes, even if you don't know how to swim, you will find yourself in the ocean surrounded by the waves, but most of the time, in the hardest moments, you will find a huge army with you. Welcome...

Barış Murat Ayvacı (@emresuspack) Tweet

If you think a senior is wrong about something, give him evidence, but don’t be obstinate...

Ali Kaan Ataman (@erdrkaan) Tweet

You may be untutored, but never be uninterested. Because knowledge definitely comes to those who have interest.

Mustafa Ipek (@dr_mustafaipek) Tweet

Appear weak when you are strong and strong when you are weak. Look weak when strong; look strong when weak. Also don't forget to look at vital signs 😉

Osman Avşar Gül (@mefisto_avsar) Tweet

Don’t be a d*ck.

Enjoy your junior days, qualify for your senior days.

Patient Records

Patient Records

(Carefully) Fill out the patient records. What will save you from everything are these records.

Spoken words fly away, written words remain. Record everything...

Şervan Gökhan (@servangokhan) Tweet

What is not written is deemed not done. First, protect yourself and then protect the patient. Choose a good role model.

Ozge Duman Atilla (@ozgedumanatilla) Tweet

Workup

No workup can replace a good physical examination.

Erdal Demirtaş (@Erdal_DD) Tweet

Never order a test that you won’t check the results.

Eyupkaraoglu (@drekaraoglu) Tweet

Know your tests! Know their rough sens/spec and when to trust them (and more importantly, when NOT to trust them)!! No test is 100%, and all are context-dependent!

Elias Jaffa MD MS (@jaffa_md) Tweet

Decision Making

Being efficient should never be at the expense of being thorough. You will eventually have to waste more time making things right.

Danya Khoujah (@DanyaKhoujah) Tweet

If someone brings up a concern, go to the bedside.

Sunny Elagandhala (@elegantdolla) Tweet

Think simple, make a quick decision. Determine the senior you will take as a model.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Once you suspect about a diagnosis, be sure to rule it out.

Do not forget to consider emergencies and other diseases while focusing on frequent diseases of the period, such as COVID. The most important thing that the emergency doctor needs to do is to look at the case from a wide perspective from the very beginning.

Gaziantep Acil Tıp (@AcilGaziantep) Tweet

Watch out for the last patient who came just before your shift ends.

Meltem Şahin (@onlakonusmayin) Tweet

In emergency medicine [and in life :)] the possibilities are 0% or 100% only in limited scenarios. You need to quickly learn managing probabilities, setting priorities, distinguishing acceptable and unacceptable risks. Also you need to learn reading the environment; because it usually gives many signs before the problem emerges.

Elif Dilek Çakal (@DrEDCakal) Tweet

Patient in the Resus is easy. Spotting the patient with a real emergency in minors is the tough one.

First rule of emergency response is to ensure your own safety!

SALİH KARABULUT (@drskbulut) Tweet

When in doubt or worried about someone, talk to floor senior physicians EARLY.

Rahul Goswami (@Rahul_Goswami_) Tweet

I would say to try your best to remain open-minded and try to be aware of your biases and blindspots. This applies especially to patients with psychiatric illness and substance use disorders. If you're explaining X symptom on Y problem, always ask yourself, "Does this actually make sense?

Elias Jaffa MD MS (@jaffa_md) Tweet

The most frequently overlooked diagnosis in the emergency room is the second diagnosis! Do not limit your perspective to one diagnosis. Most frequently missed fracture in the emergency room? The second one! Remember that the patient may have a second fracture!

Mehmet Ergin (@drmehmetergin) Tweet

While assessing only isolated parts, don’t miss to assess the patient as a whole. Do not evaluate the patient on a single system, single organ basis. Emergency Medicine requires ‘holistic assessment’.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Discharging

No hospital bed belongs to you. If in doubt, do not discharge the patient.

Haldun Akoglu (@IstanbulEMDoc) Tweet

Do not discharge the patient relying on what someone else is telling you without assessing by yourself!

Emre Salçın (@emresalcin) Tweet

Do not discharge the patient after midnight: You may be tired, you may overlook something, the patient and his relatives may not find a car or money to leave, or they may try to go to the town or another city but have an accident on the road, etc. Those all happened (Not my personal experience, but I have seen them), evidence based...

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Before discharging the patient whose treatment is completed, make sure to think like that: ‘Is there any possibility that this patient will come back with a cardiac arrest before the shift ends?’ If you are hesitant, prolong the process.

The patient at the hospital is better than the patient at home’. Do not discharge if you are not sure.

Belgin Akilli (@AkilliBelgin) Tweet

Team Play

Emergency Medicine is teamwork. Get along well with your colleagues, your nurse, your intern, your staff and your secretary. Find yourself a role model, try to be a good example for others. And enjoy the Emergency Medicine.

Melih İmamoğlu (@melihimam) Tweet

You may learn a lot of thing from your nurse, act like a teammate.

Yusuf Ali Altuncı (@draltunci) Tweet

That’s all for now. By the way, what would your advice be?

Cite this article as: Ibrahim Sarbay, Turkey, "Things You Should Know Before Your First ED Shift," in International Emergency Medicine Education Project, July 13, 2020, https://iem-student.org/2020/07/13/things-you-should-know-before-your-first-ed-shift/, date accessed: December 3, 2022

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

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

12) Pheochromocytoma
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

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: December 3, 2022

How to make the most of your EM Clerkship

How to make the most of your EM Clerkship

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

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

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.

Books

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.

Cite this article as: Sumaiya Hafiz, UAE, "How to make the most of your EM Clerkship," in International Emergency Medicine Education Project, October 4, 2019, https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/, date accessed: December 3, 2022

Learning Experiences in the ED

Introduction

Every student, regardless of the area and grade, should have recognized that the process of learning is different depending on the environment and the situation. For medical students, it very often depends on the clinical rotation, the type of structure of the hospital and the epidemiologic profile of the population in the area. Thinking about the Emergency Department (ED), we have critical patients, urgent measures to be taken and no much time to have second thoughts, all of this in a very dynamic – sometimes chaotic – environment.

What is the evidence on Medical Education in the ED? How can we improve our experience as a student in such context? Is it possible to have – and give – good feedback? These are some of the points we are discussing in this article, which features a quick conversation with one of the most incredible and enthusiastic emergency physicians I ever know – and who has taught me a lot.

Juliana is an Emergency Physician. I had the pleasure to learn from her with in the field, as well as attending some of her brilliant lectures for the EMIG which I’m part of. She work as an emergency physician in São Paulo and th coordinator of the “Basic and Advanced Airway Digital Course."

What are the singularities you see when giving and receiving feedback in Emergency Department?

“It’s a very dynamic environment and, sometimes, the moment for feedback can be completely ignored if the opportunity is not taken at the right time since the room can always become even more chaotic. For me, one of the greatest advantages is that everything is happening here and now, and the learner can be observed and taught closely. However, this could be a problem if the learner feels insecure while being watched, or if the professor interferes too much during the procedure or the history taking and examination.”

How do you think learning takes place in this environment? Is it possible to learn and teach with each case without disturbing the emergency dynamics?

As I said earlier, although it is a very dynamic environment, I see an emergency department as a valuable environment for the teaching-learning process because we can take advantage from each case in its entirety (from the evaluation to the outcome) or in key situations, important for that learner. Also, the fact that the patient is right there, requiring interventions, instigates the student to want to participate, take action and understand what is going on. Another thing I like very much about teaching in this environment is how we can be very practical in exemplifying and exercising the ED mindset, developing in the learner the clinical reasoning of the emergency, which, as we know, operates in a different logic.”

With the recognition of the specialty in Brazil, what can change in relation to the teaching and mentoring in the emergency department?

“I think the change that many of us are already experiencing is to have emergency medicine specialists in these settings, which qualifies the teaching of mindset and the purpose of acute and severe patient care.”

What tips would you give to students who go through emergency medicine internships to learn more and better?

“One exercise I often do with my students is to always think not about what the patient has, but what he needs. In many cases, the definitive diagnosis is absolutely secondary in immediate care. That is the mindset. Another important point is to observe the emergency room like an orchestra, which the emergency physician is there to conduct: how do we organize physical space? What should I solve first? What patient needs most of my attention right now? What people from the multidisciplinary team are fundamental there? these are skills that we develop with practice, sometimes even without noticing, but when we pay attention to all of this we understand the complexity of the critical care, of the specialty, and the potential that the emergency medicine has in changing patient’s outcomes.”

And for teachers and residents, what tips would you give to improve students learning from the ED routine?

“Everything that shows up is an opportunity for learning, including an empty room, without patients: if you knew how much students don’t know about the physical organization of the room, support materials and ventilators, monitors, defibrillators, multi-professional teams and so on, we would not feel moments without patients as idle time. So I wanted to tell you never to let go of these moments. Another thing that is poorly discussed by us, but that in the Emergency Medicine is essential: health policies, emergency departments situation, organization of health structures. Emergency medicine is an excellent thermometer to measure the efficiency of the system and, if we stop and think a little, to discuss and debate the context that we are inserted (even without all the answers), we develop a more critical and interested generation, not only in Emergency Medicine but in improving the system as a whole.”

Cite this article as: Arthur Martins, Brasil, "Learning Experiences in the ED," in International Emergency Medicine Education Project, July 1, 2019, https://iem-student.org/2019/07/01/learning-experiences-in-the-ed/, date accessed: December 3, 2022

Point-of-Care Resources in the ED

Point-of-Care Resources in the ED

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

by Sentral Clinical Research Services, LLC
Download: Google Play l Apple

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

by MD Aware, LLC
Download: Google Play l Apple
Website: https://www.mdcalc.com/

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

by LineageMedical Inc.
Download: Google Play l Apple
Website: https://www.orthobullets.com/

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.).

MediCode

by National Health Care Provide Solutions, LLC
Download: Google Play l Apple

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!

Cite this article as: Nada Radulovic, Canada, "Point-of-Care Resources in the ED," in International Emergency Medicine Education Project, June 5, 2019, https://iem-student.org/2019/06/05/point-of-care-resources-in-the-ed/, date accessed: December 3, 2022