AMA with Anand Swaminathan, MD (@EMSwami)

We are excited to announce that our second AMA will be hosted by Dr. Anand Swaminathan from NYU/Bellevue EM, ALL NYC EM, and EM Lyceum.

Ask Me Anything with Anand Swaminathan, MD (07/18/2014)
12:30
Baker Hamilton:

Welcome everybody to Ask Me Anything with Anand Swaminathan, MD, MPH (@EMSwami). We’re live now – type in your questions below!

Friday July 18, 2014 12:30 Baker Hamilton
12:34
Anand Swaminathan:

Thanks for having me on AMA. Excited to take any questions you have. If I don’t know the answer, I’ll make something up.

Friday July 18, 2014 12:34 Anand Swaminathan
12:37
[Comment From Chris Jones (Philly)Chris Jones (Philly): ]

Anand, thanks for all of your help with EM education! Wanted to get some tips on getting into foam myself. Would you recommend blogs, podcast, twitter? How can I get my residents involved?

Friday July 18, 2014 12:37 Chris Jones (Philly)
12:39
Anand Swaminathan:

Chris, great question. Not an easy answer. I recommend starting by exposing them to a “Why FOAM” talk. Chris Nickson has a great one on LITFL http://lifeinthefastlane.co… and Joe LEx gave a good one at SMACC in 2013

Friday July 18, 2014 12:39 Anand Swaminathan
12:39
Anand Swaminathan:

I don’t think you should pick one platform but use all of them. Twitter is great to get tid bits and interact with the FOAM community

Friday July 18, 2014 12:39 Anand Swaminathan
12:40
Anand Swaminathan:

blogs and podcasts are wonderful for using for flip the classroom endeavors for resident education. Check out the ALiEM project on getting asynchronous credit for FOAM – http://www.aliem.com/new-ai…

Friday July 18, 2014 12:40 Anand Swaminathan
12:41
Anand Swaminathan:

Also, check out the very FOAMy Emergency Medicine Australasia articles on how to FOAM http://onlinelibrary.wiley….

Full of tips on how to get started with all of this

Friday July 18, 2014 12:41 Anand Swaminathan
12:42
[Comment From emlitofnoteemlitofnote: ]

Anand, I need help keeping my 3 week old pacified so I can regain my productivity. Help! 😉

Friday July 18, 2014 12:42 emlitofnote
12:43
Anand Swaminathan:

Hey Ryan. Great to hear from you. As a father of two (6 and 3) I’ll tell you that you’ll regain productivity when they turn 18.

Good luck, use Happiest Baby on the Block (saved my marriage)

Alternatively, you can read them one of my posts. That should put them to sleep.

Friday July 18, 2014 12:43 Anand Swaminathan
12:43
[Comment From Alex KoyfmanAlex Koyfman: ]

What are the top 3 clinical myths you’d like to see go away?

Friday July 18, 2014 12:43 Alex Koyfman
12:45
Anand Swaminathan:

Oh Alex, you know just how to make your guests feel loved.

Great question and no good way to answer it but I’ll try.

1 – Antibiotics for the treatment of strep throat in developed countries. More harm than good. Just stop it. Give them steroids and NSAIDs to make them feel better.
2 – PCN Cephalosporin cross reactivity is 10%. I want to get rid of this one simply to not get the pharmacy call every 10 minutes. 1st of all, most people who say they have a PCN allergy don’t (only about 1-5%) and the cross reactivity is similarly low.
3 – Orthostatic measurements are useful in determining fluid status. They’re not. No evidence to defend this. Check out this quick video – http://lifeinthefastlane.co…

Friday July 18, 2014 12:45 Anand Swaminathan
12:46
[Comment From canadianEMmdcanadianEMmd: ]

Your top five educational resources for that you use? Go!

Friday July 18, 2014 12:46 canadianEMmd
12:46
Anand Swaminathan:

This is tricky. I may piss someone off if I leave them out.

Let’s do this based on straight up medical knowledge that I can use tomorrow (or actually tonight since I’m on the overnight) in the clinical realm

Friday July 18, 2014 12:46 Anand Swaminathan
12:47
Anand Swaminathan:

1. EM: RAP – I know, I’m just shilling cause I’m on it but really wonderful program. This is also where I first started to learn about non-traditional sources for education back when I was a resident. The old episodes hold up too. Check out the Corey Slovis talk on electrolytes from 2008 (I think). Classic episode.

Friday July 18, 2014 12:47 Anand Swaminathan
12:49
Anand Swaminathan:

2. Amal Mattu’s ECG Video of the Week (http://ekgumem.tumblr.com/). Wonderful free resource. I have learned more about ECGs here than anywhere else. Clearly, ECGs are a critical part of our practice.

Friday July 18, 2014 12:49 Anand Swaminathan
12:51
Anand Swaminathan:

3. Academic Life in EM (http://www.academiclifeinem…) – Tons of stuff you can use that day in clinical practice. Never boring, always short and sweet.

Friday July 18, 2014 12:51 Anand Swaminathan
12:52
Anand Swaminathan:

4. EMCrit (www.emcrit.org) – I’m a critical care junky who couldn’t do the fellowship so I use this extensively. While many of the more recent podcasts are on cutting edge things that I don’t do, the old ones are on classic topics in critical care that you can use all the time. I don’t think I really understood vents until I heard Scott’s series of podcasts. Same with acid-base stuff. I relisten to these all the time as well to make sure I haven’t missed things or refresh my memory

Friday July 18, 2014 12:52 Anand Swaminathan
12:54
Anand Swaminathan:

5. Life in the Fastlane (http://lifeinthefastlane.com/) – this one’s a cheat since it’s my 5th. Why is it cheating? Chris and Mike bring the FOAM world together in one place. It’s genius. I get recs on all the best stuff from these guys then I can go out and read it all. Great resource for clinical practice.

Friday July 18, 2014 12:54 Anand Swaminathan
12:55
Anand Swaminathan:

Just to close up the question, there are tons of other resources I use every day. I have recently fallen in love with St. Emlyn’s site. There podcast is really for the uber-nerdy EM people but Simon and Iain have a great way of making difficult concepts manageable for anyone. Same goes for anything with David Newman.

Friday July 18, 2014 12:55 Anand Swaminathan
12:57
Anand Swaminathan:

I’d also be remiss if I didn’t mention ERCast. In fact, one of my favorite, I use every day concepts comes from Orman’s discussion of PT/INR in liver failure. Wonderful stuff.

Conflict of interest here but I think REBEL EM is a wonderful site with great pearls and evidence based dissection. Love the Skeptics Guide to EM podcast from Ken Milne as well.

Friday July 18, 2014 12:57 Anand Swaminathan
12:57
Anand Swaminathan:

And of course, you have to use emDocs.net, right?

Friday July 18, 2014 12:57 Anand Swaminathan
12:57
[Comment From GuestGuest: ]

How do you deal with the difficult learner?

Friday July 18, 2014 12:57 Guest
12:58
Anand Swaminathan:

Really tough question. Just got clarification on the question
“For the residents who are tough to teach, how do you work around this?”

Friday July 18, 2014 12:58 Anand Swaminathan
12:59
Anand Swaminathan:

I think you have to first start with “why are they tough teach?” We have to assume that most EM residents are smart. Residency spots are competitive now and these guys made it through a four year college and medical school

Friday July 18, 2014 12:59 Anand Swaminathan
12:59
Anand Swaminathan:

Is the problem that they aren’t being challenged?
Are they having outside problems?
Are they not feeling engaged in the curriculum?

Friday July 18, 2014 12:59 Anand Swaminathan
1:00
Anand Swaminathan:

It helps to know where they are not succeeding. Is it clinical or academic?

Friday July 18, 2014 1:00 Anand Swaminathan
1:01
Anand Swaminathan:

Tough to teach clinically is sometimes because they may think they know more than they do. This may be the hardest to remedy because it reflects on the residents over-inflated ego

Friday July 18, 2014 1:01 Anand Swaminathan
1:02
Anand Swaminathan:

The longer I do this, the more I realize I don’t know and that’s not just a line.

It’s vital for residents to know what they don’t know

Friday July 18, 2014 1:02 Anand Swaminathan
1:03
Anand Swaminathan:

One thing I do when residents demonstrate this behavior is to try and show them how little I know. I ask them to teach me something. Doesn’t even have to be medical. Can be outside of the clinical environment as well.

Friday July 18, 2014 1:03 Anand Swaminathan
1:03
Anand Swaminathan:

This is basically modeling the behavior I want them to have.

Friday July 18, 2014 1:03 Anand Swaminathan
1:04
Anand Swaminathan:

What about the one who’s struggling academically? This is rather easy. You sit them down and find out what they are doing on their own to learn. What are you reading etc.

Friday July 18, 2014 1:04 Anand Swaminathan
1:05
Anand Swaminathan:

Often, what I find is that they are overwhelmed by the options or no one taught them how to identify what to read

Friday July 18, 2014 1:05 Anand Swaminathan
1:06
Anand Swaminathan:

We often say that residents are adult learners and they should thus, they can direct their own learning. This is somewhat false. Throughout highschool, college and medical school, we are spoon fed information. We are told what to learn and how to learn it

Friday July 18, 2014 1:06 Anand Swaminathan
1:06
Anand Swaminathan:

We shouldn’t all of a sudden expect the residents to know how to do it. We have to empower them. This is part of the challenge of residency education. To teach doctors to be independent learners

Friday July 18, 2014 1:06 Anand Swaminathan
1:08
Anand Swaminathan:

Back to the question. For the resident struggling academically, I sit down and try to identify resources that will work for them and have them build a curriculum with me to guide their education.
I meet with them every couple of weeks in the beginning to see how things are going and then set them free

Friday July 18, 2014 1:08 Anand Swaminathan
1:08
Anand Swaminathan:

I hope this answers some of the question. The main thing is to identify the underlying issue and then figure out how to fix it with the resident guiding you and you guiding them.

Friday July 18, 201
1:08 Anand Swaminathan
1:08
[Comment From skobnerskobner: ]

What obstacles do you think stand in the way of FOAM being implemented on a larger scale for undergraduate medical education?

Friday July 18, 2014 1:08 skobner
1:08
Anand Swaminathan:

Old doctors

Friday July 18, 2014 1:08 Anand Swaminathan
1:10
Anand Swaminathan:

Alright, not that simple. Much of the problem is that the established docs don’t trust FOAM. They don’t completely understand it. In fact, I think some are threatened by it. Many of these guys built their careers and names over decades by going through the traditional peer review process and we are sort of cutting the line

Friday July 18, 2014 1:10 Anand Swaminathan
1:11
Anand Swaminathan:

I had the pleasure of attending a session at SAEM with Michelle Lin, Nick Genes and Jason Nomura. The panel centered on FOAM to tenure. An older administrator stood up and basically said it would never happen.

Friday July 18, 2014 1:11 Anand Swaminathan
1:12
Anand Swaminathan:

Can be very discouraging but I talked to Michelle afterwards and she said this:

2 years ago, that guy would have never come to this panel. Now he’s here. We are making progress

Friday July 18, 2014 1:12 Anand Swaminathan
1:13
Anand Swaminathan:

We are a young field that was built on rebels. The younger generation will embrace FOAM and force the change but it will take time. The Approved Instructional Resources (AIR) series on ALiEM is a good way to get FOAM in through things that residencies need.

Friday July 18, 2014 1:13 Anand Swaminathan
1:13
Anand Swaminathan:

The key is for us to keep pushing the envelope and challenging those older docs to look at the FOAM.

Friday July 18, 2014 1:13&n
bsp;
Anand Swaminathan
1:13
[Comment From GuestGuest: ]

Sort of following up on an earlier question… is there a specific time in a resident’s career when you think it would be best to have kids/start a family?

Friday July 18, 2014 1:13 Guest
1:14
Anand Swaminathan:

No. There is no ideal time. I had my first during my 4th year of residency when I was a chief and my second 2 years out of residency. It’ll never be easy

Friday July 18, 2014 1:14 Anand Swaminathan
1:14
Anand Swaminathan:

The key is to always prioritize family over career. You’ll always be happy for those choices down the line.

Friday July 18, 2014 1:14 Anand Swaminathan
1:15
Anand Swaminathan:

I often have to sacrifice time with the kids to work but I try to challenge myself to make compromises with work first. It’s a hard road.

Friday July 18, 2014 1:15 Anand Swaminathan
1:15
[Comment From Alex KoyfmanAlex Koyfman: ]

How do you inspire your residents to be more curious both in and out of the ED?

Friday July 18, 2014 1:15 Alex Koyfman
1:16
Anand Swaminathan:

I think the best way to do this is by modeling the behavior you want to see. Amal Mattu has a great talk on leadership (FOAM talk from The Teaching Course in April 2014). When you walk in to a shift, you must exude the feeling that you would rather be nowhere else. This inspires everyone to work to their best abilities

Friday July 18, 2014 1:16 Anand Swaminathan
1:17
Anand Swaminathan:

Same goes for residency education. I try to show the residents how much I read, how much time I spend educating myself. It’s important for them to understand that none of this comes naturally to anyone. The goal of being a productive faculty member must be obtainable

Friday July 18, 2014 1:17 Anand Swaminathan
1:18
Anand Swaminathan:

It also helps to encourage them to be involved. I try to spread projects among the residents so that they all get opportunities to produce in areas they are interested in.

Friday July 18, 2014 1:18 Anand Swaminathan
1:18
[Comment From AdairaAdaira: ]

What advice do you have for senior residents trying to optimize their role in the ED?

Friday July 18, 2014 1:18 Adaira
1:20
Anand Swaminathan:

This is tough. Senior residents have different expectations depending on what type of program you are in.

My shop is a 4 year where senior residents are treated as pre-attendings. Basically, they have all the same tasks as I do on shift.

Friday July 18, 2014 1:20 Anand Swaminathan
1:20
Anand Swaminathan:

In this set up, the goal is to strive to the level of the attending. See all the patients in your area, run the codes/trauma etc.

Friday July 18, 2014 1:20 Anand Swaminathan
1:21
Anand Swaminathan:

On a more general level, I try to encourage all residents but especially the senior ones to not fall in to the trap of making plans based on the preference of the attending working that day. After you work with people for a while, you learn to give them the plans they want to hear.

Friday July 18, 2014 1:21 Anand Swaminathan
1:22
Anand Swaminathan:

Instead, create the plan you want to pursue on each patient. When that plan differs from the attending’s plan, ask “why?” This is how you learn the nuances of EM and medicine in general. It’s also how you shape your practice of EM.

Friday July 18, 2014 1:22 Anand Swaminathan
1:22
Anand Swaminathan:

Beyond the clinical stuff, make sure to develop a continuing education curriculum for yourself. What are you going to read, what are you going to follow etc.

Friday July 18, 2014 1:22 Anand Swaminathan
1:22
[Comment From Chris Jones (Philly)Chris Jones (Philly): ]

Sorry I’m am old doc and I am very open to “foam to tenure!” Not all of us are bad:)

Friday July 18, 2014 1:22 Chris Jones (Philly)
1:23
Anand Swaminathan:

Thanks Chris. Shouldn’t make that assumption. Just had a 30 minute interview with Joe Lex who is clearly in the same boat as you.

The truly great ones in our field don’t ignore new things but determine how best to use them to get what they need.

Friday July 18, 2014 1:23 Anand Swaminathan
1:23
[Comment From emlitofnoteemlitofnote: ]

How do you manage the expectations of other physicians – both in the ED and consultants – regarding, as you say, the “myths” of medicine to which they are still perpetuating? I.e., the requests for ABGs, CTAs, procalcitonin levels, etc.

Friday July 18, 2014 1:23 emlitofnote
1:24
Anand Swaminathan:

Never easy questions with you, Ryan.

Friday July 18, 2014 1:24 Anand Swaminathan
1:25
Anand Swaminathan:

This is truly challenging. The easy thing to do is just roll over. If you do this, I don’t think anyone, including your own residents, will respect you, take you seriously or, more importantly, change these myths

Friday July 18, 2014 1:25 Anand Swaminathan
1:26
Anand Swaminathan:

I try to politely tell them why I don’t think what they’re asking for is useful. I discuss the evidence. This can be tricky as you really have to have a good grasp of it if you are going to try and educate someone else. I often will offer to email them the articles and they can read them on their own. I have everything organized so I can send this stuff immediately.

Friday July 18, 2014 1:26 Anand Swaminathan
1:27
Anand Swaminathan:

I’ve done this
a number of times with kayexalate in hyperkalemia and orthostatics and even antibiotics in strep

Friday July 18, 2014 1:27 Anand Swaminathan
1:27
Anand Swaminathan:

This often gets me what I want in the immediate situation because no one wants to sit and read the stuff on the spot and tell me how I’m wrong.

Friday July 18, 2014 1:27 Anand Swaminathan
1:28
Anand Swaminathan:

To make real lasting change, though, you need to get together with the other involved parties and try to actually make some policies. Sometimes a shared conference with IM, Ortho, Surgery etc can help.

We have done panel discussion with our trauma colleagues on these questions which has worked well for a number of issues.

Friday July 18, 2014 1:28 Anand Swaminathan
1:29
Anand Swaminathan:

If you truly believe the information you have is right, just say it confidently. That’s what goes the farthest in the clinical arena.

Friday July 18, 2014 1:29 Anand Swaminathan
1:29
[Comment From skobnerskobner: ]

Sort of a follow up, how do you promote humanism with learners and co-workers? How do you respond to situations when you or others miss the mark?

Friday July 18, 2014 1:29 skobner
1:29
Anand Swaminathan:

This is hard. Let’s take it one at a time

Friday July 18, 2014 1:29 Anand Swaminathan
1:30
Anand Swaminathan:

Promoting humanism is easy for me. I have wonderful role models (Lewis Goldfrank for instance) in my shop to do this. We often joke that when in doubt, ask yourself, “what would Goldfrank do?”

Friday July 18, 2014 1:30 Anand Swaminathan
1:31
Anand Swaminathan:

But not everyone gets to have Goldfrank around. Again, I think this comes back to modeling. If you show your trainees and staff that you respect all of your patients, they
will too.

Friday July 18, 2014 1:31 Anand Swaminathan
1:32
Anand Swaminathan:

Easier said than done, right? We’ve all made the mistake of dehuminizing someone for some reason or another. The bottom line is that this is rarely about the patient and much more often, it’s about us.

Friday July 18, 2014 1:32 Anand Swaminathan
1:33
Anand Swaminathan:

I start every shift by trying to put myself in the right mindset. Block out the peripheral issues of family, professional stuff etc. and focus on work. I keep in my mind not just what would Goldfrank do but what would I do if the patient’s mother was sitting next to them.

Friday July 18, 2014 1:33 Anand Swaminathan
1:34
Anand Swaminathan:

This goes a long way to humanize our patients and make it not about the disease but about a person

Friday July 18, 2014 1:34 Anand Swaminathan
1:34
Anand Swaminathan:

When I or someone else misses the mark, I think it’s vital to address it. I have apologized to patients before for my behavior. I have asked them what I can do to try and rectify it and I always ask them to hold it against me and not my staff.

Friday July 18, 2014 1:34 Anand Swaminathan
1:35
Anand Swaminathan:

For the trainees, I talk to them about it head-on. Why do you think you acted that way? What do you think caused you to respond/act in that manner? This has to be done correctly and not in a hostile way for it to work and for the resident to take something away from it.

Friday July 18, 2014 1:35 Anand Swaminathan
1:36
Anand Swaminathan:

Again, you often find out that there was something going on in that trainees life that had nothing to do with the patient but it came out that way.

Friday July 18, 2014 1:36 Anand Swaminathan
1:36
[Comment From GuestGuest: ]

follow up q
uestion–How do you personally prevent becoming jaded? When do you transition from saying yes to every offer to declining “great” offers?

Friday July 18, 2014 1:36 Guest
1:36
Anand Swaminathan:

Who says I’m not jaded?

Friday July 18, 2014 1:36 Anand Swaminathan
1:37
Anand Swaminathan:

I always remind myself that I chose this career, i knew what I was getting into and there was a reason I did it. I think about how my role models would respond, how they would address these feelings.

Friday July 18, 2014 1:37 Anand Swaminathan
1:38
Anand Swaminathan:

I’m lucky to have a wife who’s a psychologist so I’m finally starting to get used to talking about these issues a bit to her or coworkers. The comraderie of the ED really helps a lot.

Friday July 18, 2014 1:38 Anand Swaminathan
1:39
Anand Swaminathan:

This brings up the larger issue of mentors. The short is that you got to have them. And not just one. You should have many mentors for the many facets of your career and life. I’ve got at least 6 or 7 at my hospital and another dozen or so outside of my hospital.

Friday July 18, 2014 1:39 Anand Swaminathan
1:40
Anand Swaminathan:

FOAM helps with this a lot. I’ve met tons of great people who are selflessly interested in promoting my career. They are always available to help and are extremely generous with their time.

Friday July 18, 2014 1:40 Anand Swaminathan
1:40
Anand Swaminathan:

The main pitfall here is not reaching out and asking for help or whatever. The vast majority of the FOAM world wants to help and they love being mentors.

Friday July 18, 2014 1:40 Anand Swaminathan
1:41
Anand Swaminathan:

Part 2 of your question – when to say “no.”

I’ll tell you when I get there.

Friday July 18, 2014 1:41 Anand Swaminathan
1:41
Anand Swaminathan:

I made a resolution at the beginning of the year not to say yes to anything unless I also freed myself up from something else.

Friday July 18, 2014 1:41 Anand Swaminathan
1:41
Anand Swaminathan:

The resolution lasted 3 days.

Friday July 18, 2014 1:41 Anand Swaminathan
1:42
Anand Swaminathan:

Michelle Lin opened a new section of ALiEM today on “How I Work Smarter” http://www.aliem.com/michel…

She had some great points.

Friday July 18, 2014 1:42 Anand Swaminathan
1:46
Anand Swaminathan:

Always ask the question on new opportunities – “how does this fit in with what I’m interested in.” It’s also reasonable to ask the person how much time they think this project will take. These questions are helpful in figuring out if you want to take on the project.

Friday July 18, 2014 1:46 Anand Swaminathan
1:46
Anand Swaminathan:

Early on, you really have to say yes to most everything. This is how you build a career.

Friday July 18, 2014 1:46 Anand Swaminathan
1:47
Anand Swaminathan:

As you progress, it’s important to not only say no but to also off load things you took on that you are not interested in or are taking too much time. Find someone else who is interested and move the task to them

Friday July 18, 2014 1:47 Anand Swaminathan
1:48
Anand Swaminathan:

It’s really hard but vital skill to say no and off-load in order to keep your career moving forward and to produce the best stuff you can.

Friday July 18, 2014 1:48 Anand Swaminathan
1:49
Anand Swaminathan:

We’ll have to try and put a podcast together on this topic for iTeachEM. Effects every academic to some degree

Friday July 18, 2014 1:49 Anand Swaminathan
1:49
[Comment From GuestGuest: ]

joining in a bit late…I’m only a 2nd year resident and I’m already jaded. That’s nice that you have a network, what do you recommend for those of us who have no one to turn to?

Friday July 18, 2014 1:49 Guest
1:51
Anand Swaminathan:

Work on finding someone. Identify a resident or faculty member who is upbeat and has avoided the jaded thing

Friday July 18, 2014 1:51 Anand Swaminathan
1:51
Anand Swaminathan:

2nd year is often a low point. You’re working incredibly hard, you’re often underappreciated and bearing the brunt of the clinical load

Friday July 18, 2014 1:51 Anand Swaminathan
1:51
Anand Swaminathan:

Maximize your off days, find mentors and consider talking to a professional

Friday July 18, 2014 1:51 Anand Swaminathan
1:52
Anand Swaminathan:

Mindfullness is a big buzz word in EM right now. Mindfullness challenges us to determine the real basis of our feeling and address them (at least that’s the way I see it)

Friday July 18, 2014 1:52 Anand Swaminathan
1:53
Anand Swaminathan:

I try to use this to stay sane and balanced. I’m not a yoga guy but some type of meditation helps. I run every day and that’s my time to think and reflect and completely turn off (no podcasts or even music)

Friday July 18, 2014 1:53 Anand Swaminathan
1:53
Anand Swaminathan:

I hope this helps

Friday July 18, 2014 1:53 Anand Swaminathan
1:53
[Comment From AdairaAdaira: ]

Do you have a particular past clinical experience that you now look back on and think, “man, I’ll never do that again!!”

Friday July 18, 2014 1:53 Adaira
1:53
Anand Swaminathan:

Too many to count

Friday July 18, 2014 1:53 Anand Swaminathan
1:54
Anand Swaminathan:

We’ve all made mistakes or provided suboptimal care. Much of what we do is based on what we think is best at that time. The evidence changes, standard care changes etc.

Friday July 18, 2014 1:54 Anand Swaminathan
1:55
Anand Swaminathan:

There have been patients I sent home that in retrospect I would keep now in the hospital and vice versa. I’ve over relyed on my clinical gestalt and in moments of weakness, I’ve said things that I shouldn’t have.

Friday July 18, 2014 1:55 Anand Swaminathan
1:55
Anand Swaminathan:

The key in all of this is reflecting and then altering your behavior in the future.

Friday July 18, 2014 1:55 Anand Swaminathan
1:56
Anand Swaminathan:

If you’re looking for specific things, not sure I can give you that. Surely there are plenty of treatments that were recommended that are not any longer that I’ve used.

Friday July 18, 2014 1:56 Anand Swaminathan
1:57
Anand Swaminathan:

One that will always stick with me is a patient who got tPA for an ischemic stroke when I was a 1st year attending. He clearly had an ischemic CVA and was eligible by the hospital’s criteria but he had lots of relative contraindications.

Friday July 18, 2014 1:57 Anand Swaminathan
1:58
Anand Swaminathan:

I got railroaded by neuro and didn’t speak up. I should have counseled the patient and family about the other side of things but I didn’t. Needless to say, he had a bad outcome. ICH identified 30 minutes after tPA

Friday July 18, 2014 1:58 Anand Swaminathan
1:58
Anand Swaminathan:

I’ve never let that one go. Not because I don’t believe in tPA (although I’m not a big fan) but because I didn’t advocate for the patient the way I should have.

Friday July 18, 2014 1:58 Anand Swaminathan
2:00
Anand Swaminathan:

Question from twitter via Nilesh Patel (APD St. Joe’s in NJ)

If you are lysing a massive PE, what do you do with heparin? hold and restar . . . or continue?

Friday July 18, 2014 2:00 Anand Swaminathan
2:01
Anand Swaminathan:

Finally, something clinical. When I do systemic lytics for massive PE, I hold heparin. I’m not sure when to restart, though. Truth is that there’s a lot of conflicting recs on this topic. I don’t think we really know the right answer.

Friday July 18, 2014 2:01 Anand Swaminathan
2:02
Anand Swaminathan:

Weingart has a great podcast up this week talking to Oren Friedman from Cornell about PE teams and treatment that I strongly recommend checking out

Friday July 18, 2014 2:02 Anand Swaminathan
2:02
[Comment From HenryHenry: ]

Hi, thanks for doing this! What did u like about being chief?

Friday July 18, 2014 2:02 Henry
2:03
Anand Swaminathan:

It was fun and challenging.

Friday July 18, 2014 2:03 Anand Swaminathan
2:03
Anand Swaminathan:

I was very lucky to do it with two friends who are both in residency leadership positions now. I had gifted co-chiefs. We also all had our first kids 3 months into being chiefs which was interesting.

Friday July 18, 2014 2:03 Anand Swaminathan
2:05
Anand Swaminathan:

The great things are you get a taste of academics. How to build a curriculum, how to craft an educational plan. You get an insight into the inner workings of a residency. The interview process, the challenges that a PD deals with. It’s also basically an administrative fellowship. Managing 60 resident’s schedules, balancing personalities and learning to be in charge

Friday July 18, 2014 2:05 Anand Swaminathan
2:06
Anand Swaminathan:

It gives you experience and helps you figure out what you want to do in your career. I learned that I’m no administrator. I don’t know how to play politics and my expectations can often be too high. These lessons helped me determine my career path to this point.

Friday July 18, 2014 2:06 Anand Swaminathan
2:07
Anand Swaminathan:

Very challenging, especially within your own class where all of a sudden, you have a certain degree of power over your colleagues. I wouldn’t say I lost friendships but people who were collegial with me are not anymore after that year. That was hard

Friday July 18, 2014 2:07 Anand Swaminathan
2:07
[Comment From Silas – Harbor/UCLASilas – Harbor/UCLA: ]

What’s the best thing to do to get more comfortable with Peds patients? Obviously see more lol

Friday July 18, 2014 2:07 Silas – Harbor/UCLA
2:07
Anand Swaminathan:

The greatest attack on EM training in peds comes from vaccines. If only everyone would listen to Jenny McCarthy, our peds training would be awesome

Friday July 18, 2014 2:07 Anand Swaminathan
2:08
Anand Swaminathan:

Just for the record, I’m joking. Vaccines rock. I ask for extras when I take my kids in

Friday July 18, 2014 2:08 Anand Swaminathan
2:08
Anand Swaminathan:

Outside of vaccine craziness occurring and just finding more sick kids, I don’t have great answers.

Friday July 18, 2014 2:08 Anand Swaminathan
2:10
Anand Swaminathan:

Simulation plays a role. It’s not the same as the real thing but many of us are working to figure that out. Stress Inoculation Training has a role here. Instead of doing sim or other training in a safe space, we have to challenge the residents by making the scenarios more real. Get that heart rate up, get the sweat poring out. This will make the sim training more useful.

Friday July 18, 2014 2:10 Anand Swaminathan
2:11
Anand Swaminathan:

I do a lot of visualization training as well. I walk myself through how I would approach a sick kid over and over again. You can actually create muscle memory this way and create cognitive pathways that will function when you need them.

Friday July 18, 2014 2:11 Anand Swaminathan
2:11
[Comment From Ryan – Harbor/UCLARyan – Harbor/UCLA: ]

As one of the Harbor chiefs, we have been trying to make conference more fun and interactive besides the typical sit down lecturing. What are some ideas you’ve found to work with your program? Thanks in advance.

Friday July 18, 2014 2:11 Ryan – Harbor/UCLA
2:11
Anand Swaminathan:

Great question. This has been my challenge for the last 4 years as well.

The first thing I did was to cut lecture length. Nothing more than 30 minutes. Some 15 minute talks as well. Trying now to get in 5 minute talks.

Friday July 18, 2014 2:11 Anand Swaminathan
2:12
Anand Swaminathan:

Increase small group workshops. Mix in hands on stuff like simulation, anatomy lab etc.

This takes lots of faculty buy in but it works.

Friday July 18, 2014 2:12 Anand Swaminathan
2:13
Anand Swaminathan:

Bring in more grand rounds speakers. They give new takes on old i
ssues. If you get really engaging ones, the residents see the passion they exude which will encourage them as well

Friday July 18, 2014 2:13 Anand Swaminathan
2:13
Anand Swaminathan:

Feel free to email me and I can send along what we do and you can feel free to steal anything.

Friday July 18, 2014 2:13 Anand Swaminathan
2:14
[Comment From GuestGuest: ]

asymptomatic hyperglycemia, FS 500. Not in DKA, what is your usual plan?

Friday July 18, 2014 2:14 Guest
2:15
Anand Swaminathan:

1 – look for the reason. simple non-compliance, infxn, MI etc. If no confounding issue and just noncomplaince . . .

2 – Urine dipstick for ketones

3 – VBG for AG

I used to just look for ketones and if not present, I’d stop. Unfortunately, you can have negative ketones on dip and still have a gap

Friday July 18, 2014 2:15 Anand Swaminathan
2:17
Anand Swaminathan:

If no gap, no ketones what next?

I restart the meds they are supposed to be on. I don’t believe in targeting a number before d/c. Similar to high blood pressure that’s asymptomatic.

Friday July 18, 2014 2:17 Anand Swaminathan
2:17
Anand Swaminathan:

The critical thing is arranging follow up to ensure compliance and further care

Friday July 18, 2014 2:17 Anand Swaminathan
2:17
[Comment From Alex KoyfmanAlex Koyfman: ]

How has your approach to teaching 1st year residents changed over the past 5 years? Are we seeing a different kind of learner?

Friday July 18, 2014 2:17 Alex Koyfman
2:18
Anand Swaminathan:

Lots of changes but not just for interns, for all learners. I still think it’s important
to read a text book or get the equivalent base knowledge from resources like EB Medicine.

Friday July 18, 2014 2:18 Anand Swaminathan
2:19
Anand Swaminathan:

However, I push more to incorporate podcasts, blogs, vidcasts etc into the curriculum. Shorter talks, flipping the classroom, more hands on, more small groups.

Friday July 18, 2014 2:19 Anand Swaminathan
2:19
Anand Swaminathan:

I don’t think it’s just a different kind of learner. We’re starting to understand how we should be teaching better.

Friday July 18, 2014 2:19 Anand Swaminathan
2:19
[Comment From Manny – Harbor/UCLAManny – Harbor/UCLA: ]

How’s your experience been with performing nerve blocks on patients that require Ortho eval / surgery? We have been experiencing push back citing that they will lose their exam, unable to eval for compartment syndrome as the two main causes.

Friday July 18, 2014 2:19 Manny – Harbor/UCLA
2:20
Anand Swaminathan:

I do it and don’t look back. We get similar complaints.

1st – there’s no evidence you won’t be able to diagnose compartment syndrome. This is like the idea that you can’t get an abdominal exam if you give a patient pain meds

Friday July 18, 2014 2:20 Anand Swaminathan
2:21
Anand Swaminathan:

I document a thorough neuro exam before I do the block. If there’s really a lot of push back, you can tell them that they can come and assess the patient in the next 5-10 minutes but that after that time, you will be providing regional anesthesia to the patient because they need it for their management. This is a reasonable compromise.

Friday July 18, 2014 2:21 Anand Swaminathan
2:22
Anand Swaminathan:

Again, though, establishing a policy is probably the best thing to do.

Friday July 18, 2014 2:22 Anand Swaminathan
2:22
[Comment From Jimmy – Harbor/UCLAJimmy – Harbor/UCLA: ]

What advice would you give to a resident wishing to go into academics? What’s one thing you would have wanted to know as a resident that you know now?

Friday July 18, 2014 2:22 Jimmy – Harbor/UCLA
2:23
Anand Swaminathan:

Establish a plan now. Try to think about what in academics you want to do and how to get there. Find mentors in house and out of house and pick their brains.

Friday July 18, 2014 2:23 Anand Swaminathan
2:24
Anand Swaminathan:

Try different things. You really won’t know what you like until you try it. I never thought I’d get into twitter, blogging or even podcasting. Try it all out

Friday July 18, 2014 2:24 Anand Swaminathan
2:24
[Comment From GuestGuest: ]

Had a patient present a few weeks ago with a partial forearm amp, it was dressed heavily with gauze but you could see a slow ooze appearing through it. After getting through “A&B”, I moved on to “C”, and said, “lets look at the wound.” BP was still low and patient was getting 2U pRBCs. However trauma team said they will only explore wound in the OR. The gauze was kept on the entire time. Does that sound right to you? Do you usually explore wounds like that in the OR? It was an isolated injury.

Friday July 18, 2014 2:24 Guest
2:25
Anand Swaminathan:

Tough to give advice when I wasn’t there. If the guy is hypotensive and the forearm is where the bleeding is from, I agree that I would wait and let them fix in the OR. There’s always the chance that there has been partial hemostasis from the dressing and that removing it will dislodge clot and cause further issues. Why not let that happen where definitive management can occur.

Friday July 18, 2014 2:25 Anand Swaminathan
2:26
Anand Swaminathan:

You always have to ask yourself, “what information am I going to get that’s going to change this patient’s management by doing X?” In this case, nothing you see will change management

Friday July 18, 2014 2:26 Anand Swaminathan
2:26
Anand Swaminathan:

We have time for 1 more.

Friday July 18, 2014 2:26 Anand Swaminathan
2:26
[Comment From Ryan – Harbor/UCLARyan – Harbor/UCLA: ]

What’s have you been advocating in resident asynchronous learning? We have been using EBmedicine for years, but have been trying to emphasize FOAMed and podcasts.

Friday July 18, 2014 2:26 Ryan – Harbor/UCLA
2:27
Anand Swaminathan:

EB Medicine is great and I have no conflicts. I’ve never written for them. I love it.

Friday July 18, 2014 2:27 Anand Swaminathan
2:28
Anand Swaminathan:

The problem has been figuring out what’s best to use and how to know what’s best.

I strongly encourage you to check out the ALiEM Approved Instructional Resources project. The team (many of whom are PDs and APDs) gather relevant blogs/podcasts designed to specific modules and then have a quiz to evaluate. Totally free and a nice place to get your program to buy in.

Friday July 18, 2014 2:28 Anand Swaminathan
2:28
Anand Swaminathan:

Thanks to everyone who did this. Have to go. Will surely do this again as it was very fun.

Send me any questions at my email (anandswaminathan77@gmail.com) or tweet me up @EMSwami

Friday July 18, 2014 2:28 Anand Swaminathan
2:28
Adaira Landry:

Thanks everybody for participating and a SPECIAL THANKS to Dr. Anand Swaminathan (@EMSwami) for taking the time to answer our questions. We hope to see you all again at the next AMA!

Friday July 18, 2014 2:28 Adaira Landry

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