Ask Me Anything: Reuben Strayer, MD

Thanks to Reuben Strayer for letting us ask him anything. He covered resident education, how to think like an ED physician, practice pearls including ketamine analgesia, chest tube insertion, awake intubation and much more. Follow him at @EMUpdates or check out his latest work on emupdates.com.
 

  Ask Me Anything with Reuben Strayer, MD (06/19/2014) 
3:09
Reuben Strayer: 

[Editors note: The question is cut off, but was regarding the quality of the trauma experience in NYC EM residencies] manhattan, for sure, is a remarkably safe place to live…which means less penetrating trauma.

Thursday June 19, 2014 3:09 Reuben Strayer
3:10
Reuben Strayer: 

and there are aren’t many big highways in manhattan, so that undermines our blunt trauma volume.

Thursday June 19, 2014 3:10 Reuben Strayer
3:11
Reuben Strayer: 

but we do have MANY pedestrians and bicyclists struck, and car vs. person or car vs. bicycle produces a fair amount of serious blunt trauma.

Thursday June 19, 2014 3:11 Reuben Strayer
3:12
Reuben Strayer: 

also, brian, if trauma is really your thing, there are non-manhattan programs that see a ton of blunt and penetrating trauma.

Thursday June 19, 2014 3:12 Reuben Strayer
3:12
Reuben Strayer: 

notably: lincoln (bronx) and downstate (brooklyn).

Thursday June 19, 2014 3:12 Reuben Strayer
3:13
Reuben Strayer: 

and you can always do elective months at big trauma centers in baltimore, miami, detroit, LA, or Johannesburg!

Thursday June 19, 2014 3:13 Reuben Strayer
3:15
Reuben Strayer: 

lastly: I find that junior trainees are very concerned with trauma exposure, but it turns out that trauma management is pretty algorithmic and actually, the sicker they are, the easier they are to manage. my residents in manhattan-based programs are quite competent by the end. hope that answers your question, brian.

Thursday June 19, 2014 3:15 Reuben Strayer
3:16
[Comment From MattMatt: ] 

Hi! Thanks for doing this AMA! What do you look for in a strong applicant for residency?

Thursday June 19, 2014 3:16 Matt
 
Reuben Strayer: 

Hi Matt – what do we look for in med students? I don’t think I’m going to have a lot of surprises here:

  Reuben Strayer
3:18
Reuben Strayer: 

the first thing is we want a strong record of what I call SOFT SKILLS. soft skills are like: does the applicant show up to work on time? does she do w
hat she says she’s going to do? is she a team player? is she nice to people? does she cause problems for her supervisors?

Thursday June 19, 2014 3:18 Reuben Strayer
3:19
Reuben Strayer: 

remember that applicants are ranked by residency program directors. and there is nothing that makes a residency program director’s life more difficult than a problem resident. so we are very focused on looking for red flags that suggest that the applicant could be a problem resident.

Thursday June 19, 2014 3:19 Reuben Strayer
3:19
Reuben Strayer: 

of course most applicants are great and do not have such red flags, because most applicants have solid soft skills and do a good job.

Thursday June 19, 2014 3:19 Reuben Strayer
3:22
Reuben Strayer: 

so then we look at hard skills – how smart is she? how talented? this can be hard to ascertain from an application, honestly. I can tell you what DOESN’T help is filling your CV when silly activities that are clearly designed to fill a CV. taking a few projects that you’re really into and running with them, doing a great job with them, is much more valuable than a zillion little things that you did in a superficial way.

Thursday June 19, 2014 3:22 Reuben Strayer
3:23
Reuben Strayer: 

lastly: I always tell applicants that by far the best way to impress a residency is to impress a residency in person. there is no substitute for doing an elective at a program. when we see you in action, when we get to know you, we can consider you with much more confidence. do away rotations!

Thursday June 19, 2014 3:23 Reuben Strayer
3:29
[Comment From BrianBrian: ] 

I’ve heard the algorithm part before…but I feel like that’s true maybe of all patients then…wouldn’t u say that about your vaginal bleeder, asthmatic, sbo?

Thursday June 19, 2014 3:29 Brian
 
Reuben Strayer: 

there is an algorithmic element to many presentations, you’re right – but this is especially true for trauma. I don’t mean to imply that there isn’t nuance or important questions that come up or controversy. but the paradigms in trauma are more straightforward than in medical diseases; there is a rhythm that you get into with trauma in a trauma center. and again, more importantly, I bet you will be less concerned with this as time goes on. big trauma is a very, very small part of almost all emergency physicians’ practice. and for those EPs who see a lot of big trauma (in big trauma centers) you are going to be part of a robust team-based approach that is, frankly, led by surgeons, not by emergency docs, and in the US this is for better or w
orse becoming more true with American College of Surgeons trauma center designation regulations. we don’t need to get into that. I would just say, again – if you are way, way into trauma, there are a few NYC programs that see a ton. but if you match at one of the other centers, don’t fret – you will get good at trauma if you’re into it no matter where you train.

  Reuben Strayer
3:32
[Comment From MattMatt: ] 

Thanks for your input! Follow up question: Do you think I should start off with buying a book or reading blogs/podcasts?

Thursday June 19, 2014 3:32 Matt
 
Reuben Strayer: 

Matt – this will be cliche but in 2014, you need both. pick one book (baby Tintinalli is a good choice – very portable, covers the basics in a good amount of detail), and follow a few choice online media resources. there are a few specifically designed for folks at your stage: steve carrol’s EMBasic comes to mind.

  Reuben Strayer
3:34
[Comment From Dave Tanen, MD – Harbor/UCLADave Tanen, MD – Harbor/UCLA: ] 

What is the best way to educate residents? Does conferance attendance make a difference? Should we be doing more asynchronous? If so, how could we keep track?

Thursday June 19, 2014 3:34 Dave Tanen, MD – Harbor/UCLA
 
Reuben Strayer: 

Dr. Tanen – this is a question I’ve spent some time thinking about. A couple of years ago I launched an asynchronous learning program for my residents, based entirely on online EM resources.

  Reuben Strayer
3:35
Reuben Strayer: 

I learned a lot from that experience, and I think residencies are all trying to figure out how to best take advantage of online media in their curriculum.

Thursday June 19, 2014 3:35 Reuben Strayer
3:36
Reuben Strayer: 

there are lots of pro/con conversations about online media. the obvious pros are that conventional resources (e.g. textbooks) are out of date by the time they’re published.

Thursday June 19, 2014 3:36 Reuben Strayer

3:36
Reuben Strayer: 

HOWEVER: there is real value – huge value – to the process of vetting and editing and revision that goes into a textbook.

Thursday June 19, 2014 3:36 Reuben Strayer
3:37
Reuben Strayer: 

and online media caters mostly to the appetites of its creators and consumers. this results in a very unbalanced conversation where 90% of FOAM focuses on 20% of emergency medicine.

Thursday June 19, 2014 3:37 Reuben Strayer
3:38
Reuben Strayer: 

I therefore think that moving residents through a complete curriculum – like the kind of curriculum found in a textbook – is essential.

Thursday June 19, 2014 3:38 Reuben Strayer
3:39
Reuben Strayer: 

more to your question about conference: I think it’s quite important that residents and faculty have protected time to meet and teach and learn. emergency medicine is not a correspondence course, it cannot be learned online.

Thursday June 19, 2014 3:39 Reuben Strayer
3:41
Reuben Strayer: 

and there just isn’t time to have in depth discussions during a busy shift.

Thursday June 19, 2014 3:41 Reuben Strayer
3:42
Reuben Strayer: 

the real value of online media, in this regard, is that individual residencies no longer have to – and shouldn’t – try to come up with a core set of lectures/presentations locally.

Thursday June 19, 2014 3:42 Reuben Strayer
3:43
Reuben Strayer: 

the right way to do this is take the best online resources and pair them with textbook chapters, then in conference, discuss as a group.

Thursday June 19, 2014 3:43 Reuben Strayer
3:43
Reuben Strayer: 

and of course there are procedure labs, and simulation – all these things cannot be done sitting on your couch with your laptop.

Thursday June 19, 2014 3:43 Reuben Strayer
3:45
Reuben Strayer: 

lastly: in many programs, weekly conference runs longer than five hours. I think this is a mistake. make weekly conference short, interactive. the paradigm of putting 40 residents in an audience and talking at them for a bunch of hours is hopefully dying.

Thursday June 19, 2014 3:45 Reuben Strayer
3:46
[Comment From Dipesh Patel, PGY-3 Harbor-UCLADipesh Patel, PGY-3 Harbor-UCLA: ] 

Any particular trick in using chest tube trochar? To trochar or not to trochar? That is the question.

Thursday June 19, 2014 3:46 Dipesh Patel, PGY-3 Harbor-UCLA
 
Reuben Strayer: 

Dipesh: that’s an easy one. NEVER trocar.

  Reuben Strayer
3:49
[Comment From Jonathan Osgood, PGY-2, Harbor-UCLAJonathan Osgood, PGY-2, Harbor-UCLA: ] 

What data exsists for analgesic ketamine? Do you use it frequently in your practice?

Thursday June 19, 2014 3:49 Jonathan Osgood, PGY-2, Harbor-UCLA
 
Reuben Strayer: 

Jonathan – regarding analgesic ketamine. there is a ton of data. I use it very frequently; just used it last night on a young lady with a calcaneous and L4 burst fracture who was still writhing in pain after 16 mg morphine in 20 minutes. 20 mg ketamine over 10 minutes, then 20 mg/hour, titrated to effect. she was calm, comfortable, lucid, and happy. references: http://goo.gl/z3gn1l

  Reuben Strayer
3:53
[Comment From DipeshDipesh: ] 

Follow-up Qiestion: I had a 400lb lady with PTX, but kept kinking. What tricks do you have for that? Bougie?

Thursday June 19, 2014 3:53 Dipesh
 
Reuben Strayer: 

that means the blunt dissection was inadequate. when there’s a lot of soft tissue, you have to make a nice, broad incision and a careful, assertive blunt dissection. the main reason that we don’t do this effectively is for inadequate analgesia. in a stable patient, push you lidocaine (or even better, bupivicaine) max dose. in an unstable patient, ketamine 2 mg/kg and get the tube in. the hole in the pleura should be big enough to transmit your finger AND the chest tube simultaneously. the right way to do it in my opinion is to put your finger through the pleura and then guide the tube next to your finger – that way you KNOW it’s going in the right place. I do not insert the tube using the kelly clamps and I have always thought that this is how misplaced chest tubes happen.

  Reuben Strayer
3:55
[Comment From PG2 NYCPG2 NYC: ] 

Hello Dr. Stayer, I was recently rotating at NYU Tox and attended the grand rounds with Hoffman, Newman and Nelson…I felt confused about their message re: guidelines. Specifically when they said we should avoiding working up patients less and focus more on history. This is an ideal approach but not realistic. Mostly b/c in medical school you learn “what is the differential diagnosis?” for every complaint…and this gets exaggerated in the ED to “what is the most dangerous diagnosis? Now lets r/o all of those things out” I think this approach is what is dangerous and causes more harm. The problem isn’t that we follow guidelines with bad evidence, is that we are on avg just avg clinicians at the bedside. And we use weak guidelines to make bad judgements for us. If you were there, what were your thoughts on that discussion?

Thursday June 19, 2014 3:55 PG2 NYC
 
Reuben Strayer: 

PG2 – this is a complex question. I did hear the round table hoffman/newman/nelson discussion, and I agree there were some mixed messages, which isn’t unexpected when you have three very experienced, very opinionated docs in the front of the room.

  Reuben Strayer
3:55
Reuben Strayer: 

the short answer is this:

Thursday June 19, 2014 3:55 Reuben Strayer
3:56
Reuben Strayer: 

in emergency medicine, our primary role is, in addition to resuscitating patients who require resuscitation, to identify dangerous conditions.

Thursday June 19, 2014 3:56 Reuben Strayer
3:58
Reuben Strayer: 

in most patients, most of the time, most dangerous conditions can be adequately excluded by history and physical, without ancillary tests. what newman/hoffman are concerned about is over-reliance on testing to exclude dangerous conditions.

Thursday June 19, 2014 3:58 Reuben Strayer

3:58
Reuben Strayer: 

and this is where good guidelines can help us.

Thursday June 19, 2014 3:58 Reuben Strayer
3:58
Reuben Strayer: 

good guidelines can define a set of patients, for example, that don’t need a head CT after blunt head trauma.

Thursday June 19, 2014 3:58 Reuben Strayer
3:59
Reuben Strayer: 

I use these types of decision instruments constantly.

Thursday June 19, 2014 3:59 Reuben Strayer
4:00
Reuben Strayer: 

meanwhile, we need better guidelines, and we need to root out bad guidelines. this is happening.

Thursday June 19, 2014 4:00 Reuben Strayer
4:02
Reuben Strayer: 

but it’s hard, because all our incentives are to over-test and over-treat. ultimately this won’t meaningfully change until our incentives change. and I think we’ll get there, too. but it will take time. until then, identify tests that are more likely to cause harm (e.g. CT in young people) and focus on reducing your utilization of those tests. use strategies like observation or early followup to manage risk. give patients your phone number.

Thursday June 19, 2014 4:02 Reuben Strayer
4:07
Baker Hamilton: 

Hi Reuben, I just did an EM journal update presentation on a paper published in 8/13 on glidescope vs direct laryngoscopy (http://www.ncbi.nlm.nih.gov…). It was conducted at shock trauma, and they said that they used thiopental during RSI unless patients were too unstable (then they’d consider etomidate). This seems pretty different from the meds we usually use in my program – what are your thoughts on it?

Thursday June 19, 2014 4:07 Baker Hamilton
 
Reuben Strayer: 

Baker: what rich dutton, who ran the anesthesia service at shock for decades, would say, is that in an exsanguinating patient, it doesn’t matter what sedative you use, anything will work on the hypoperfusing brain, what matters is the dose. He says, dose low in hemorrhagic shock.

  Reuben Strayer

4:08
Reuben Strayer: 

thiopental has very similar effects to propofol.

Thursday June 19, 2014 4:08 Reuben Strayer
4:08
Reuben Strayer: 

both will cause significant hypotension when given in conventional induction doses.

Thursday June 19, 2014 4:08 Reuben Strayer
4:09
Reuben Strayer: 

dutton would say, use propofol in your dying patient with SBP of 40, just use *20 milligrams* instead of 200.

Thursday June 19, 2014 4:09 Reuben Strayer
4:10
Reuben Strayer: 

I use ketamine in all hypotensive patients, including trauma patients, including head trauma patients.

Thursday June 19, 2014 4:10 Reuben Strayer
4:11
Reuben Strayer: 

if the patient has full mentation, I give a full induction dose. the less mental status, the smaller the dose. if a patient is truly obtunded, peri-arrest, they don’t need a sedative.

Thursday June 19, 2014 4:11 Reuben Strayer
4:14
[Comment From Alex KoyfmanAlex Koyfman: ] 

Love your posts on maximizing intubation success by pre-intubation planning, can you highlight some pearls you’ve used recently…

Thursday June 19, 2014 4:14 Alex Koyfman
 
Reuben Strayer: 

Alex – the biggest change I’ve made in my intubation strategy in the past few years is lowering my theshhold to do it awake.

  Reuben Strayer
4:14
Reuben Strayer: 

once you start doing awake intubations, it’s addictive.

Thursday June 19, 2014 4:14 Reuben Strayer
4:14
Reuben Strayer: 

your clue that awake intubation is the right approach is when you see that the patient needs to be intubated, but not right this very second – you have some time.

Thursday June 19, 2014 4:14 Reuben Strayer
4:15
Reuben Strayer: 

if you have some time, you ask, am I likely to succeed in laryngoscopy?

Thursday June 19, 2014 4:15 Reuben Strayer
4:16
Reuben Strayer: 

there are of course a variety of tools to help you do this, I recommend a checklist to remind you. and I know a good checklist, if anyone needs one 🙂

Thursday June 19, 2014 4:16 Reuben Strayer
4:16
Reuben Strayer: 

the combination of I HAVE TIME and THIS IS A SCARY AIRWAY means you should do it awake.

Thursday June 19, 2014 4:16 Reuben Strayer
4:16
Reuben Strayer: 

assuming the patient isn’t vomiting, or high risk to vomit.

Thursday June 19, 2014 4:16 Reuben Strayer
4:18
Reuben Strayer: 

dry them out (glyco or atropine), nebulize, then atomize lidocaine. if they’re cooperative (almost never) then you can also very effectively topicalize with lidocaine gargle. and then add whatever more cooperation you need with ketamine. the patient just keeps breathing, as you perform gentle laryngoscopy. it’s very anticlimactic, very controlled, and very safe. it almost feels like cheating.

Thursday June 19, 2014 4:18 Reuben Strayer
4:19
Reuben Strayer: 

it’s not as clean as RSI but once you do a few, the benefits of a breathing patient become compelling.

Thursday June 19, 2014 4:19 Reuben Strayer
4:20
Reuben Strayer: 

more generally, the key to airway success is to plan for failure. be prepared, materially and cognitively for failure of laryngoscopy and also failure of ventilation. have a specific plan in your mind, and have the material you need to carry out that plan at bedside.

Thursday June 19, 2014 4:20 Reuben Strayer
4:23
[Comment From Alex KoyfmanAlex Koyfman: ] 

what’s your approach to teaching new residents to keep a broad differential until proven otherwise…

Thursday June 19, 2014 4:23 Alex Koyfman
 
Reuben Strayer: 

ha, my residents are wincing right now. for undifferentiated cardinal presentations (chest pain, headache, abdominal pain, syncope, etc) I routinely, tirelessly, unremittingly break out a sheet of paper and ask them to list the dangerous causes. 7 dangerous causes of chest pain. 13 dangerous causes of headache, etc. etc. they hate it, but I think in the end they agree it’s the right way.

  Reuben Strayer
4:25
[Comment From Alex KoyfmanAlex Koyfman: ] 

what are your thoughts on the “goal of the ED visit”: risk stratification vs making a diagnosis…

Thursday June 19, 2014 4:25 Alex Koyfman
 
Reuben Strayer: 

I think it’s clear that making the diagnosis is not our job. our job is to make sure our patients are safe. risk stratification, if you will.

  Reuben Strayer
4:30
[Comment From ScottScott: ] 

Hi and thank you for fielding questions. Do you think FOBT in the ED is useful? Is stool color more reliable for UGIB and with the false positive rate is there really any utility pre heparin or otherwise?

Thursday June 19, 2014 4:30 Scott
 
Reuben Strayer: 

Scott – I don’t think FOBT has much of a role in the unstable patient.

The reason to use FOBT is in the stable patient with undifferentiated anemia.

If the stool is black or red, you don’t need a test for *occult* blood. Because that’s frank blood.

I was hoping the practice of routinely performing FOBT prior to heparinization was dead, but apparently not. I certainly don’t do it and don’t let anyone I’m supervising do it.

  Reuben Strayer
4:31
[Comment From socalexmdsocalexmd: ] 

Hello and greetings! Great idea and thanks to Dr. Strayer for this show and his great pearls you share on emupdates!

Thursday June 19, 2014 4:31 socalexmd
 
Reuben Strayer: 

thanks, socalexmd!

  Reuben Strayer
4:33
[Comment From socalexmdsocalexmd: ] 

Coming back to the lowdose Ketamine sedation you mentioned. I used it quite a bit, with good effect, similar to your dosing, i.e. 0,15 mg/kg, but always as slow push. Only sometimes resulting in slight dizziness but not much else as far as sideeffects go. Would that 10 min infusion version reduce these even?

Thursday June 19, 2014 4:33 socalexmd
 
Reuben Strayer: 

yes. you can bolus small-dose ketamine, but using ketamine as a bolus augments its psychiatric effects. the drip is really a much better strategy, for that reason, and because a 15 mg bolus of ketamine will only last about 20 minutes.

  Reuben Strayer
4:38
[Comment From Alex KoyfmanAlex Koyfman: ] 

How do you continuously challenge yourself to improve / keep growing as an EM practitioner / educator?

Thursday June 19, 2014 4:38 Alex Koyfman
 
Reuben Strayer: 

finding challenges and directions for growth seems easy in our current environment of endless online debate and discourse. the problem is…time. every month another smart person or group jumps into the ring with her/their perspectives, perspectives I want to learn. but Alex the day hasn’t gotten longer to accommodate them.

  Reuben Strayer
4:45
[Comment From Alex KoyfmanAlex Koyfman: ] 

Can you highlight a few key points from it?

Thursday June 19, 2014 4:45 Alex Koyfman
 
Reuben Strayer: 

key points from _how to think like an emergency physician_

1. how we learned to think about patients in med school doesn’t apply well to what we do in the ED, we need an alternate paradigm.

2. it’s much easier to succeed in the ED when you have a clear picture of what your responsibilities are as an emergency clinician – I’ve identified eight.

3. the best way to identify dangerous conditions is to have a working knowledge of dangerous conditions that could cause your patient’s symptoms, then tailor your H&P directly at excluding them. This is the ‘dangerous conditions wheel.’

4. Then decide, considering the relatively limited menu of things we do for patients in the ED, what the patient in front of you need. this is the ‘interventions wheel.’

5. Making your patient happy, and providing optimal medical care, are unrelated activities.

  Reuben Strayer
Baker Hamilton: 

note: this is in reference to http://emupdates.com/2010/0…

  Baker Hamilton
4:49
Baker Hamilton: 

10 minutes until this AMA concludes – we’ve got time for a couple more questions.

Thursday June 19, 2014 4:49 Baker Hamilton
4:51
[Comment From Alex KoyfmanAlex Koyfman: ] 

Pls talk a bit about 3 myths in EM you hope would be put to rest…

Thursday June 19, 2014 4:51 Alex Koyfman
 
Reuben Strayer: 

1. MYTH: ketamine should not be used when there is a concern about high ICP.

2. MYTH: succinylcholine provides superior intubating conditions, quicker than rocuronium, and, that the shorter duration of action of succinylcholine is an advantage over rocuronium (it’s a huge disadvantage).

3. MYTH: fasting patients prior to procedural sedation is appropriate.

  Reuben Strayer
4:54
[Comment From Alex KoyfmanAlex Koyfman: ] 

What are your top 3 challenging scenarios / diagnoses in EM and how do you approach them?

Thursday June 19, 2014 4:54 Alex Koyfman
 
Reuben Strayer: 

the hardest patient in emergency medicine is the secondary gain patient – the patient who pretends to want emergency care, but actually wants something else. usually opiates, but also shelter, food, a work note.

  Reuben Strayer
4:56
Reuben Strayer: 

to give them what they want is easy for the provider, but encourages more secondary gain and, in the case of opiates, in my opinion, harms them by perpetuating an addiction that is ruining their life. it just takes one of these patients to ruin your shift. I think we all struggle with it.

Thursday June 19, 2014 4:56 Reuben Strayer
4:58
[Comment From Amie KimAmie Kim: ] 

Hi Reuben, thanks for the QA. Trauma patient w GCS When do you intubate vs just sedate ?

Thursday June 19, 2014 4:58 Amie Kim
 
Reuben Strayer: 

i assume you’re talking about the agitated trauma patient, if you’re asking about ETI vs. sedation. this hinges on how likely it is that they have a serious injury. the more likely a serious injury, the more likely you should be to intubate.

  Reuben Strayer
Baker Hamilton: 

technical glitch there – should have read ‘GCS less than 8.’

  Baker Hamilton
4:59
Reuben Strayer: 

as usual: when you’re not sure whether or not to intubate, err on the side of ETI, you will almost never regret that decision.

Thursday June 19, 2014 4:59 Reuben Strayer
5:01

Baker Hamilton: 

Thanks everybody for participating and a BIG THANKS to Dr. Reuben Strayer (@EMUpdates, emupdates.com) for taking the time to answer our questions. We hope to see you all again at the next AMA!

Thursday June 19, 2014 5:01 Baker Hamilton
 
 

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