The purpose of this podcast is to help medical students crush their emergency medicine clerkship and get top 1/3 on their SLOE. The content is organized in an approach to format and covers different chief complaints, critical diagnoses, and skills important for your clerkship.
How to Crush Your SLOE (Tips 21-25)
Apr 07, 2019
Show notes Tip #21 Review and note if the patient has any IMPORTANT old records. * Any ED visit within the last month for a similar complaint (aka “Bouncebacks” and frequent fliers)* Any echocardiogram or catheterization reports for a patient with cardiac symptoms* H&P and discharge summary for recent hospitalizations* Any large imaging studies (CT, MRI, etc) that have been obtained in last few months Tip #22 Give a “Snowy Blizzard” presentation * Step by step by step MARCH through your presentation in a clear, concise, confident manner (please refer to presentation episode for typical presentation format) Tip #23 Do not forget to give at least a basic treatment plan. Some basic options include… * Pain Medicine* Nausea Medicine* Fluids Tip #24 Introduce your attending to the patient (demonstrates massive ownership) Tip #25 Get something set up for your attending * Laceration kits* I&D kits* Consent forms* Ultrasound machine* Language line Additional Reading * How to give a basic patient presentation in EM (EM Clerkship)
How to Crush Your SLOE (Tips 16-20)
Mar 31, 2019
Show notes Tip #16 Recheck the patient’s heart rate and respiratory rate (and put in your presentation that you did so) * Heart rate frequently falsely elevated when being triaged* Respiratory rate frequently falsely normal when being triaged Tip #17 Fully examine the specific complaint. Some common misses include… * Neurologic complaints (headache, paresthesias, dizziness, asymptomatic hypertension, seizures, visual complaints)* Finger-Nose* Heel-Shin* Gait (if possible)* Visual FIELDS* Spinal complaints (neck pain, back pain)* Straight leg raise* Crossed straight leg raise* Achilles and patellar reflexes* Midline tenderness Tip #18 Independently OBTAIN stool sample (if clearly appropriate) or articulate in your presentation that you are WILLING to get it * Elderly syncope* Abdominal pain with dark stool/melena* Severe anemia or large drops in hemoglobin/hematocrit Note: You should NOT be doing full pelvic exams, rectal exams, GU exams INSTEAD of your attending (stool samples probably fine in my opinion), and you should NOT be doing these exams without a CHAPERONE. Tip #19 Get the patient into a gown (at a minimum you should expose the area of concern) Tip #20 Bring the ultrasound, gel, and towels to bedside. Appropriate chief complaints for this would include… * Patients over 50 with back/flank pain (AAA exam)* Patients with severe hypotension/shock (RUSH exam)
How to Crush Your SLOE (Tips 11-15)
Mar 24, 2019
Show notes Tip #11 Give 4 descriptors/adjectives for each complaint * Location* Quality* Duration* Modifying Factors* Severity* Context* Timing* Associated Symptoms Tip #12 Get the ACTUAL story. Why did the patient come NOW? * Did something change or worsen?* Did family force them to come?* Do they have a family history of something similar? Tip #13 Present the pertinent RED FLAGS for each complaint (some examples)… * Headache* Sudden and Severe* Fever* Neck Stiffness* Neurologic Complaints* Back Pain* Saddle Anesthesia* Bowel/Bladder Incontinence* Fever* Trauma* Chest Pain* Exertional* Family history of MI at same age* PE risk factors* Sudden and Maximal/Tearing Tip #14 Get their doctor’s names * Primary care provider* Pertinent specialists Tip #15 Don’t get bogged down giving too much medical history during your presentation. Simply write down the important facts for reference and present a few notable items in your opening sentence.
How to Crush Your SLOE (Tips 6-10)
Mar 10, 2019
Show notes Tip #6 Make your patient remember your name. * Introduce yourself clearly* Show the patient your badge* Use a nickname if your name is difficult for people to remember/understand* Repeat your name again and again Tip #7 Keep the patient informed about… * Diagnosis* Anticipated ED course/timeline* Delays Tip #8 Keep your patient comfortable. * Get them blankets* Show them how to use the remote/call light* Adjust the bed* Turn down the lights* Get them something to drink Tip #9 Move fast. * Spend no more than 10 minutes with the patient* Immediately grab your attending if the patient is ill appearing Tip #10 Use a translator. * Learn how to use a medical translator in your department (phone vs consult vs video consult)* INDEPENDENTLY use a translator to obtain your history when appropriate
How to Crush Your SLOE (Tips 1-5)
Mar 03, 2019
Show notes Tip #1 Introduce yourself. * Attending? “Hello, my name is Zack, I’m one of the medical students” * Resident? “Hello, my name is Zack, I’m one of the medical students”* Nurse? “Hello, my name is Zack, I’m one of the medical students”* Janitor? “Hello, my name is Zack, I’m one of the medical students” Tip #2 Be humble but confident. * Humility- Students know very little about the practice of medicine, the smartest med students actually realize that.* Confidence- You have to be able to act confident, be decisive in your presentations, and make decisions. The best way to achieve this is to remember that you have (hopefully) been working hard and studying consistently. Tip #3 Stay focused. * Your humor, hobbies, activities, dress, and “cool” personality, don’t impress anybody in the emergency department. * The best students tend to be friendly, focused, hardworking, and generally quiet (yay introverts!)* Emergency medicine tends to be a very pragmatic, no b.s, specialty. Let your performance speak for itself. Tip #4 Do the majority of your learning BEFORE your rotation starts. Your audition rotation should not be when you are downloading podcasts, studying pretest, or going through practice questions. Your learning should be completed well in advance so you can focus your energy on clinical performance). Tip #5 HELP around the department. * Help patient change into gown* Get urine samples* Keep patients updated* Go back and ask missing information
Airway Part 4- What to Do If Intubation Fails
Feb 03, 2019
Show notes Verbalize the out loud prior to performing rapid sequence intubation. The Bougie * Ideal for situations when you’re view is suboptimal* Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique). Video Laryngoscopy (Glidescope) * Laryngoscope with a camera at the tip which displays on a screen at bedside* Ideal for situations when both view and direct access to the cords is suboptimal (c-collar, poor mallampati). Some physicians use this as their primary technique. * Use it like a camera that you advance into position so you can see the cords. Maneuver the endotracheal tube by watching indirectly on the screen. Flexible Endoscopy * It is a flexible stylet that you can control and has a camera at the tip.* Advances through the cords like a bougie and the (preloaded) endotracheal tube advances over it. * Can intubate through both the nose or mouth with this LMA (laryngeal mask airway) * Placed blindly and sits above the cords, forming a seal. * Not a “definitive” airway, but can oxygenate and ventilate the patient when in a difficult situation. Cricothyrotomy * Immediately perform this step in “can’t intubate can’t oxygenate” situations* The 3-step EMCrit method is best in my opinion (see link below)* “Scalpel, Finger, Bougie” Additional Reading * Overview of the bougie with videos (LITFL)* The 3-step cricothyrotomy (EMCrit)
Airway Part 3- Rapid Sequence Intubation
Jan 27, 2019
Show notes The most important thing to do when preparing for RSI is to PREOXYGENATE the patient. Step 1: Choose Your Equipment * Miller or Mac blade? * Miller blade is straight (like the ‘L’ in miller)* Frequently used in kids* Mac blade is curved (like the ‘c’ in mac)* (Generally, this is the best choice to use on your clerkship and most common in the ED)* Tube Size?* 7.5 cuffed tube for a small adult* 8.0 cuffed tube for a big adult Step 2: Choose your Meds * You need both a sedative and a paralytic to perform RSI* Paralytic options are succinylcholine or rocuronium* Succinylcholine is best if you need something short acting* For example, when frequent neurologic checks are required* Rocuronium is best because it’s easy to remember (1mg/kg)* “Rocuronium Rocks”* Sedative options include ketamine, propofol, and midazolam. * My favorite is ETOMIDATE. * It is hemodynamically neutral.* Dosing is 0.3mg/kg Step 3: Prepare Your Equipment * Suction* Bag Valve Mask* Backup airway (ex. LMA)* Cardiac monitor* Capnography for tube placement Step 4: DO IT * Push the sedative* Push the paralytic* Put the blade in your LEFT hand* Open mouth with right hand* Slowly advance (holding top of blade against tongue) until you see cords* The cords will be hiding under the white, cartilaginous, tongue-like epiglottis NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great. Step 5: Advance the Tube and then CLOSING STATEMENT * Generally, you want depth to equal 3x the size of the tube* Closing statement* “Please attach capnography to confirm tube placement”* “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)” CONGRATULATIONS!! THEY ARE INTUBATED!!
Airway Part 2- Bag Valve Mask Adjuncts
Jan 20, 2019
Show notes How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful? Pharyngeal Airways * These tools bypass the posterior portion of the tongue to help with BVM ventilation* Nasopharyngeal Airway (NP)* Measure from earlobe to tip of nose* TEST QUESTION: Don’t use in a patient with possible skull fracture* Oropharyngeal Airway (OP)* Measure from earlobe to corner of mouth Laryngeal Mask Airway (LMA) * Essentially a modified BVM to place inside the mouth* It fits OVER the larynx (cords, epiglottis, etc) Retroglottic Airways * “King”* “Combitube” Additional Reading * Laryngeal Mask Airway (Wikipedia)* King Airway (Wikipedia)* Combitube (Wikipedia)
Common Fungal Infections
Jan 13, 2019
Show notes Most Life Threatening Fungal Infection * Mucormycosis* Black facial discharge* Cranial nerve dysfunction* Facial swelling* Eschar formation When to Suspect a Fungal Infection * Immunocompromised (HIV, Diabetes, Organ Transplants, etc)* Not getting better on typical antibiotics Other Fungal Infections * Aspergillus* Aspergilloma* Bronchopulmonary Aspergillosis* Invasive Aspergillosis* Coccidiomycosis* Southwestern United States* Histoplasmosis* North Central United States* Blastomycosis* Southeast United States Additional Reading * Fungal infection archive and data sheets (CDC)
Psychiatric Complaints
Dec 23, 2018
Show notes The Two Objectives During Every Psychiatric-Type Complaint * Medical Clearance* Psychiatric Risk Assessment Medical Clearance * Required by EMTALA to perform a “screening exam” regardless of complaint* Most psychiatric facilities have poor diagnostic/treatment capabilities for non-psychiatric conditions and will want patient to be “medically cleared”* Sometimes they will require specific tests to be performed, blood pressure to be treated, etc* My “medical clearance” order set includes* Electrolytes* CBC* Serum Alcohol* Urine Drug Screen (UDS)* Pregnancy (if appropriate)* Tylenol/Salicylate Levels (especially if suicidal)* Psychiatric patients frequently have other non-psychiatric emergencies* Overdoses (salicylate, acetaminophen, etc)* Trauma (alcoholics with subdural hematoma from falls)* Encephalopathy (hypoglycemia, encephalitis) Psychiatric Risk Assessment * Will this patient truly put themself or others at risk if sent home due to mental health?* Do you need to involuntarily hold patient? * Are they having passive thoughts of being dead or true INTENT and PLAN to harm themself? * Did they name a specific person/group of people that they intend to harm? Additional Reading * State Laws on Involuntary Mental Health Holds (Psychiatry Online)
Our TOPPODCAST Picks 
Stay Connected
