All posts by Alex Koyfman

Hemoptysis: An EM primer

Author: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) // Edited by: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

 

Basics

-Most episodes are mild and resolve on their own

-Disruption of blood vessels w/in airways (bronchial circulation is high-pressure system)

Don’t hesitate to ask for help from consultants, as even small amounts can cause asphyxiation

Definitions variable: Minor = small volumes in stable patient with no comorbid lung disease; Massive: 100 to >1,000mL / 24 hrs

 

Etiology

Infectious: acute bronchitis (most common), pneumonia, tuberculosis, lung abscess, fungal ball, parasites

Structural: COPD, bronchiectasis, hypersensitivity pneumonitis, AV fistula, tracheoarterial fistula, aortobronchial fistula

Neoplastic: lung/metastatic cancer, adenoma

Cardiovascular: PE w/ infarct, CHF, endocarditis, mitral stenosis, pulmonary hypertension, congenital heart disease

Iatrogenic: bronchoscopy, lung biopsy, pulmonary artery catheter

Traumatic: FB aspiration, lung contusion, deceleration injury, penetrating trauma

Vasculitides: SLE (diffuse alveolar hemorrhage, pleuritis), Goodpasture’s, Wegener’s, Behcet’s

Miscellaneous: anticoagulation therapy, cocaine/heroin inhalation, pulmonary endometriosis, NO2 inhalation

 

Clinical presentation

-Is this hemoptysis or epistaxis / hematemesis?

-Patient history semi-reliable for this clinical entity; tailor history-taking to rule in/out above etiologies

-Examine sputum if able

Airway evaluation up front

 

Diagnosis

Potential useful labs: CBC, BMP, coags, UA, type and screen

-Start with CXR, followed with chest CT if patient stable for transport

 

Management / Disposition

-Minor

CXR, labs above as needed

Reassurance, follow-up with primary care

 

-Massive

Airway management: intubate with large-diameter (8-0) ETT, cric set-up; affected lung down; consider intubating good lung or tamponading bleeding lung with Fogarty catheter

Resuscitate with IVF + blood products PRN // reverse coagulopathy

-Emergent IR consult: bronchial artery embolization

-Emergent Cardiothoracic surgery consult; who needs surgery => TI fistula, aortic aneurysm, thoracic trauma, iatrogenic pulmonary artery injury

CT chest: if HD stable, consider obtaining to guider further treatment

Bronchoscopy: assess for bleeding vessel and treat

ICU admission

 

References / Further Reading

– Rosen’s 8th edition

– Harwood-Nuss 6th edition

http://emergencymedicinecases.com/tracheo-innominate-fistula/

http://www.tamingthesru.com/blog/ebcp/hemoptysis

http://first10em.com/2015/03/24/massive-hemoptysis/

http://foamcast.org/2015/08/22/episode-33-hemoptysis/

http://www.ncbi.nlm.nih.gov/pubmed/25493149

http://www.ncbi.nlm.nih.gov/pubmed/24412020

http://www.ncbi.nlm.nih.gov/pubmed/23358891

EM Mindset: Salim R. Rezaie – The Successful EM Mindset

Author: Salim R. Rezaie, MD (Associate Clinical Professor of Emergency Medicine/Internal Medicine at University of Texas Health Science Center at San Antonio – UTHSCSA; Creator and Founder of R.E.B.E.L. EM and REBEL Cast ( www.rebelem.com ); Twitter: @srrezaie) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

The American College of Emergency Physicians (ACEP) defines Emergency Medicine (EM) as:

“The initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care.”

I would take this a step further and say these patients are often undifferentiated and come at all hours of the day/night. As the EM physician we are constantly risk stratifying and ruling out life-threatening issues with limited information and time.  So what are the things I think will give you a successful EM mindset?

Resuscitation

If you have not heard the talks by Cliff Reid and Scott Weingart on the mind of the resuscitationist you don’t know what you are missing.  I will put links to the videos underneath this section, but I want to summarize points that resonate with me in my care of the critically ill.

  1. Don’t forget your safety net… IV-O2-Monitor
  2. Run toward the sick patients, not away from them. The more sick people you see the better trained you will be.
  3. Don’t just follow algorithms, but know when it’s ok to stray from them and think outside the box
  4. Know where your equipment is located. It is better to have it and not need it, than need it and not have it.
  5. Train hard. Use simulation training as the real deal scenario.
  6. If you are running the resuscitation, do not also be the one that is doing the procedures. No one can truly multi-task
  7. When asking people to perform tasks, task a specific person and not the general room

Risk Stratification

I read a great piece on risk stratification by Graham Walker in Emergency Medicine News 2011 and if I can summarize: in emergency medicine it’s not the patient who looks sick or not sick or the decision to admit or not admit that keeps us up at night.  It’s the patient somewhere in the middle of that dichotomy that makes us lose sleep (i.e. the grey zone). To me this is the most challenging part of emergency medicine.  Patients don’t always follow what we learned in textbooks. Sure there are risk stratification scores (i.e. TIMI, HEART, PERC, Wells, etc…) to help us along, but in the end how do we know we are making the right decision?  Do we CT scan everyone and order million dollar work-ups?  What I have started doing in my practice is actually more simple than this as I risk stratify patients.  Shared decision making, which actually involves the physician to talk to the patient, but it’s cheaper than ordering a CT scan on everyone. Simply discuss the facts that you have, what you think your assessment of them having something bad is, and come up with a joint decision.  And of course don’t forget to document, document, document in your chart.  Finally, there is no substitute for the tincture of time.  Simply observing patients and getting a few more data points could be a very useful thing.  This can be done in your own department or in an observation unit.

  • “Medicine is a science of uncertainty and an art of probability.” Sir William Osler
  • “The fact is, in emergency medicine, we don’t spend most of our days saving lives, as most people think. Mostly we try to predict risk, especially in gray-zone patients.” Graham Walker, MD (Walker G. Emergentology: Risk Stratification and the Unsweet Spot. Emerg Med News 2011; 33 (9): 21.)

Anyone, Anytime, Anywhere 24-7-365

We are truly the front line of medicine and patient care. Our doors are open every minute of the day, month, or year, regardless of time and holiday.  We see all comers regardless of age, complaint, or acuity. We provide a healthcare safety net for uninsured patients as well as patients having a hard time accessing the health care system. Every patient, regardless of complaint is an opportunity to learn.

  • “Opportunity is missed by most people because it is dressed in overalls and looks like work.” Thomas Edison

Undifferentiated Patient

Part of the art of emergency medicine is making educated conclusions after sorting through information and symptoms of disease in a limited amount of time. Patients don’t always come in with a diagnosis printed on their foreheads. Think of a jigsaw puzzle that you just opened up from a box.  As you pour the pieces out from the box you see that the pieces are all of different shapes and sizes, some of the pieces are flipped upside down. You have to organize this chaos of pieces to have a final put together product or diagnosis.  This is how I think of taking care of patients in the ED. Getting the history, doing a physical exam, ordering blood/urine tests, and imaging are all pieces of the puzzle.  As we start getting enough pieces of the puzzle put together we can start to see what the diagnosis is. In some cases we will just not be able to solve the puzzle (i.e. make the diagnosis) and that is ok and you need to gain comfort with that, but we do need to ensure that we have ruled out life threats.

Avoiding Cognitive Errors

The emergency department is an environment full of distractions.  When people are interrupted they can take up to 50% longer to complete tasks, but more concerning is they can make up to 50% more mistakes. Naturally due to the interruptions we face in the emergency department we formulate shortcuts in our minds (heuristics), but some of these shortcuts lead to bad habits, bad habits lead to more mistakes, and more mistakes lead to bad patient outcomes.

The two most common cognitive errors made by emergency physicians are anchoring bias and availability bias.  Availability bias is the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind (i.e. cherry picking only a few features of a presenting illness instead of integrating all aspects to confirm what you expect to find by selectively accepting or ignoring information).  Anchoring bias is a shortcut in thinking where a person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one.

My solutions to help avoid these biases in a chaotic environment are:

  1. Make a differential diagnosis on every patient, even if it is something straight forward
  2. Ask yourself what are the 2 or 3 worst things this could be (i.e. what is going to kill this patient?)
  3. Re-evaluate your patient, lab results, images, and vital signs before deciding on a disposition. It literally takes 2 – 5 minutes to check on the patient and go back through the chart, and you will be amazed how many things you find that you didn’t realize about your patients.

Listen to Nurses

I like to make the analogy that as physicians we often only get a snapshot of what is going on with our patient, but nurses who are by the patients get a video of their patient.  We can often be fooled by a single snapshot, which is why we re-assess our patients, to get multiple snapshots.  Involve nurses in your patient work-up, plan of care, treatment, and disposition. I cannot tell you the number of times a nurse has saved my backside in the care of a patient. Finally, when is the last time you helped a nurse out?  Trust me when I tell you that even something as small as getting a patient a blanket, or cup of water is worth its weight in gold. Have you ever heard the saying, behind every great physician is a great nurse?  Well, I like to think of it, as beside every great physician is a great nurse.

  • “The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her/[his] mission.” Sir William Osler

Communication and Compassion

You may be the most brilliant physician in the world, but patients don’t necessarily care about that.  What they are impressed with is bedside manner, compassion, and communication.  The number one reason EM physicians get sued is due to lack of communication with their patients.  Treat all patients with dignity and respect, even if they did something “really dumb.”

  • “The good physician treats the disease; the great physician treats the patient who has the disease.” Sir William Osler
  • “Cure sometimes, treat often, comfort always.” Hippocrates

EM Mindset: Compton Broders – A Reflection

Author: A. Compton Broders, MD, MMM, FACEP (Professor, UT Southwestern) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

I have been in the emergency department for 40 years.  I first set foot in the fall of 1974.  Much has changed in the world, emergency medicine and myself in that time. This is a reflection article and consequently I am sure it has flaws in it.  However here goes.

When I started, I was insensitive to the plight of others and could work all hours.  I could do 18 shifts and be the medical director and not a completely clueless husband.  Also I am not sure I thought straight.  Disposition then as now has been the ultimate goal at least for this emergency physician.  It has taken me years to develop the EM mindset of “think bad first”.  This is an unnatural way of thinking and requires constant effort.  As humans we are always looking for the easy way out — i.e. the most likely diagnosis.  Also in the beginning, I did not think I listened very well.  Really listened.

As a human I am not good at listening.  I jump to conclusions.  Compound that with the fact that most humans are scared in the ED.  Consequently they do not communicate very well themselves.  What does this mean?  The history of present illness (HPI) is especially affected by distortion.  I want to know the decision making process behind their coming to the ED.  How often have we seen a patient who comes in with a seemingly chronic problem only to discover a catastrophe?  I rarely take the HPI at face value especially in a perplexing case. I try to look behind the words.

I am basically a jumpy person who does not think well under pressure.  How have I lasted so long?  A reason I think is that I like to think of all the possibilities of a situation and be prepared ahead of time.  It helps that I have seen many things and have seen many patterns.  Much of EM is pattern recognition.  This is the essence of intuitive medicine.  Perhaps it helps that I like to figure things out and am always looking for the mental shortcut that helps me process information.  Below is a list of my heuristics that I give to residents:

  1. Think like an emergency doctor. Rule out bad stuff first.
  2. More mistakes are made from not checking than not knowing.
  3. It is okay not to know, it is not okay not to know what to do
  4. 90% of EM is disorders of the vascular tree and infections
  5. Always be early
  6. Listen to the nurses
  7. EM takes care of fools. We are all fools.  So be nonjudgmental
  8. Always be calm
  9. When in doubt ask
  10. Always be respectful. Nobody likes being disrespected
  11. Illness does not occur in a vacuum, ask the patient’s situation
  12. When in doubt why a patient is in the ED, ask about sleep
  13. Sometimes the most important history is that the patient is in the ED
  14. Justifying a decision because of authority is generally a mistake

Like others I think EM is a learning specialty and emergency physicians have to be dedicated to the learning process.  We face the unknown everyday.  This brings about a necessary humility and also offers a degree of conflict with specialties that think they know everything about their specialty and in my experience are sometimes deluded.  Most of medicine is not known.  We all need to remember this.

As a tool of learning I have found that the best is the robust discussion about actual patient cases amongst involved clinicians, and by that I mean also the nurses and midlevels.  These discussions are filled with meat, and are memorable because it involves people we know and often care about.  It is personal.  This exercise is more important than all of the lectures and journal articles read.

In fact, much of my medical career has been marked by stout recommendations that have subsequently been proven wrong — digoxin for heart failure, Ewald tubes for overdose,  charcoal for overdose,  a myriad of medicines in ACLS,  PVC management, steroids in spinal injury, steroids in sepsis,  c-section avoidance in delivery, etc.  Out of this I have grown skeptical of what I read.  I look meticulously for the bias.  It is always there and often not stated by the authors.  After a while each emergency physician has enough experience to ask — does this make sense?  The most recent story of sepsis management is this while the stroke story is not finished.

Current causes for concern for me are the seemingly increasing distractions in the ED leading to safety issues.  Much of this is related to the side effects of the EMR, which is in its adolescence.  Another cause for concern is conflict management with downstream specialists.  A third concern is the apparent lack of available follow-up for conditions requiring attention but not hospitalization.

However, EM is a problem-solving specialty and I am proud to be associated with those who have tackled domestic violence, sexual assault, lack of palliative care, community EMS, etc.

Pretty darn impressive.

EM Mindset: Deborah Diercks – The EM Environment

Author: Deborah B. Diercks MD, MSc (Professor and Department Chair, UT Southwestern – @debdiercks) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

To understand the EM mindset, we must first understand the environment of the emergency department. It is this environment that is the foundation of our approach, processing, and response to our patients. The emergency department is unpredictable. At any moment chaos may occur and uncertainty may rule. It is where people present in their most vulnerable states: seeking nothing more than help to relieve pain, treatment for an illness, or management of an injury. It is where the wealthiest person can be placed next to a person with nothing. It is where no patient ever stays, as there is always a disposition to a location such as home, a room upstairs, or less commonly the morgue. It is where the worst and best of society present: the reality of unprovoked violence is seen and stories of heroism exist.  It is the clinic to the emergency physician. Only in our clinic other specialties visit often and provide recommendations and no physician enters without expecting to be told they need to do more work.

Considering all of the factors above, the EM Mindset must include:

  • The ability to establish trust and demonstrate empathy to those in need
  • A chief complaint and exam driven systematic approach to life threats and illnesses
  • The ability to multitask
  • The ability to focus in a loud and chaotic environment and perform procedures
  • The ability to compartmentalize emotions
  • The ability to communicate not only to patients but other physicians
  • The ability to focus on details
  • The ability to think beyond someone’s physical complaints to identify social issues that may impact illness
  • The ability to be a salesman: to convince patients that their diagnosis and treatment plan is correct and physicians that they need to admit or manage the patient you are seeing.

How do you develop this mindset?

Put yourself in other’s position

A large amount of our job is communicating with other specialties. The rotations we spend on our off-service months during residency provide invaluable lessons. Not only will our knowledge about the in-hospital management of disease improve, but also we can gain some insight into the other specialties mindset. This ultimately will improve our ability to communicate with the colleagues that are essential for our specialty.  It is like learning how to play defense in any sport makes you a better offensive player because you can anticipate the response.

State your diagnosis

To develop the emergency medicine mindset you have to be willing to state what you think is wrong. As learners transition from student to resident to attending, there is a gradual transition from collecting data to assimilating data into a diagnosis and treatment plan. In emergency medicine it is essential that this later transition occurs and the ability to assimilate data is done rapidly and efficiently with available data. The more you practice stating what you think the more you become comfortable with reaching a rapid conclusion.

Think of the patient as a person

Key to the EM mindset is the ability to relay empathy and understanding.  This means that we must address the patient as a person and not the “abdominal pain lady in bed 3.”  By always addressing the patient by name, making sure that social situations are addressed, and speaking to family/friends if they are present you will develop the skill of empathy and development of a quick relationship with patients.

Practice on creating a broad differential

Even on the most routine complaints, try to consider alternatives. If you routinely think of alternative diagnoses when you face that rare patient with a unique presentation you will not overlook the diagnosis because you were too focused on the easy answer.

Recognize your emotional triggers

In emergency medicine you will see horrible things: domestic abuse, child abuse, debilitating injuries, and death.  Each of us deals with them in different ways. Usually when we are really busy, we keep our emotions under control by focusing on the task at hand. However, after the patient is out of extremis or out of the emergency department each of us has to have a way to deal with our emotions. Learn what situations are hard for you.  As a mother of 2 girls, child abuse is an area that I have emotional vulnerability. I have learned to step away a few minutes and focus on the happy memories I have of my children to get me refocused on work.

Learn to receive feedback

In emergency medicine, we expect our patient to ultimately be cared for by someone else. Sometimes our consultants disagree with our diagnosis or plan. Try to remember that this disagreement is not a reflection of you as a person, but is related to an interpretation of data or exam finding. Taking feedback is much easier when considered how it relates to an action not you as an individual.

Practice in chaotic environments

The emergency department is loud and full of distractions. For some focusing in this type of environment is a learned skill. It may be helpful to practice reading in a public place without earphones to mute noise to learn how to focus.  Alternatively hold a conversation in a public area where it is difficult to hear so you can practice focusing on the individual you are speaking to and blocking out all distractions.

Emergency medicine requires a different mindset. We have to be able to work well in a chaotic environment, develop a rapid trusting relationship with patients, and make efficient decisions. This mindset comes easy to some and can be learned by others. It however, is unique and only those who can realize the beauty in its uniqueness will ever be able to develop it.

EM Mindset: Steve Carroll – Masters of the Undifferentiated Patient

Author: Steve Carroll, DO (Steve@EMBasic.org, @EMBasic) // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

Featured on the LITFL Review #181 – Thanks to Dr. Anand “Swami” Swaminathan (@EMSwami) and the LITFL Review group for the shout out!

During medical school, I was working with a very personable anesthesiologist who was incredibly helpful in helping me accomplish my goal of getting as many intubations as was physically possible during my short 2 week rotation.  I told him upfront that I wanted to go into emergency medicine for which he was slightly disappointed given my enthusiasm for airways.  He told me “I thought about EM but they are the jack of all trades but master of none.  I wanted a specialty where I could really master a skill set.”

This comment stuck with me for a while (and fortunately didn’t dissuade me from pursuing EM) but it took a few years before I could come up with a reply.  My reply is this – first, what’s wrong with being a jack of all trades?  What’s wrong with being the “MacGyver” of medicine, the doctor who is prepared to see any patient at any time?  Second, we are the master of something – we are the masters of the undifferentiated patient.  In no other specialty would you be expected to acutely manage (and possibly resuscitate) anyone who comes to you for care – young or old, surgical or medical, sick or not sick.

As an Emergency Medicine Physician you should be proud of the fact that you can deal with literally anything that comes through the door.  Would an Internal Medicine doctor be expected to see a septic child?  Would a general surgeon be expected to diagnose and initially manage an ectopic pregnancy?  Would you expect a primary care doctor to run a major resuscitation in their office?  The answers to all of these are a firm “NO” but those three scenarios could be the first hour of your shift.

When talking about how to get into the EM mindset, I think of it as a few discrete stages – what you do before you arrive to a shift, what you do on shift, and what you do after a shift.  Some of this will be about building your EM mindset while some of it will be about how to maximize your physical and mental performance.

Before your shift

A commitment to lifelong learning

A commitment to practicing in EM is a commitment to lifelong learning and thinking about medicine a lot.  Before you even set foot in an Emergency Department there is so much preparation that should go into your everyday practice.  This means keeping up with the latest studies, literature, and expert opinion.  This has been made easier with blogs, podcasts, electronic journals, and the entirety of the FOAMed world but it still takes time and effort.  You have to figure out what learning style works for you and commit yourself to doing it on a consistent basis.  If you aren’t committed to doing this, you will never get into the EM mindset that you will need to be a well-functioning EM physician.

Mental preparation for each shift

You have to figure out how you will mentally prepare for each shift.  Maybe this involves a medical podcast or two as you drive into work.  Maybe it means blasting the radio and singing at the top of your lungs.  Perhaps you like to pray or do some sort of self-affirmation as you walk into your shift.  This may sound like New Age touchy feely hogwash but the bottom line is that you need some sort of way to stay positive, stay happy, and stay motivated while doing this job.  Regretting coming into work each day will leave you miserable and wanting something else.

On shift

Rule out (but not necessarily test for) all life/limb/eyesight threatening emergencies

This is frequently the hardest concept for EM trainees to grasp and it is something that we are all working to develop and fine tune – even if you have been in practice for years or decades.  It is hard to find that balance between being concerned about everything and being concerned about nothing.  The temptation for new EM people is to either order lots of tests or order almost no tests.  Keep in mind that a good history and physical will frequently give you enough data to rule out a deadly diagnosis without performing a whole bunch of tests.  While this “gestalt” or “gut feeling” takes time to develop, you should be aware of your thought process behind each patient.  Listen to your supervisors when they share their own thought process.  Make sure to make it known to your supervisor that you have considered all of the possible deadly diagnoses.  If you don’t think you need to test for it, that’s fine but be prepared to explain why.  When I am on shift I like to tell residents: “Sick patients need lots of tests.  Not sick patients need a good history and physical and targeted testing to make sure they aren’t sick”.

Recognize your biases

We all have biases.  To deny that fact is to deny that you are human.  In this context, I am not referring to those biases based on things such as race or nationality (you shouldn’t have those) but instead those biases about certain patients that creep up in our subconscious without us realizing it.  Perhaps you don’t like dealing with chronic pain patients.  Maybe you can’t stand parents that bring their well-appearing child into the ED.  Perhaps you don’t like dealing with the tidal wave of asymptomatic hypertension that is flooding our EDs on a daily basis.  These biases can color our patient interactions in a negative way and they lead to us missing bad things.  Instead of burying them or denying them, acknowledge them and make a plan to move on.  When you find yourself groaning when you pick up a chart after seeing the chief complaint, take a second to reset and commit to doing the best that you can for your patient.  Maybe it will be a difficult patient interaction, maybe it won’t but if you come into the room with a bad attitude you will fail.  Remember that part about treating every patient that comes through your doors?

I’ll share a quick story.  I was working at a busy community ED, single coverage overnight shift when I picked up a chart of a middle-aged female with chronic pain due to fibromyalgia.  I groaned a little but I caught myself.  Before I went into the room, I committed to helping her out as much as I could.  I came into the room cheerful and did my usual history and physical.  When that was over the patient said “Doctor, I’ll be honest, all I need is some Toradol and I will feel so much better”… Sure enough, after one dose of Toradol, the patient felt much better (evidence-based medicine be damned) and she was happily discharged.  Here I was prepared for requests for mega-doses of opioids and a difficult patient encounter but she turned out to be the nicest patient I had on that shift.  So don’t let your preconceived notions taint your patient encounters because no one wins when that happens.

Recognize your physiology and do something about it

There is no possible way that you can form a good differential diagnosis if all you can think of is your full bladder.  If you find yourself not doing well on a shift, ask yourself three questions:

  • Do I need to use the bathroom
  • Am I thirsty or hungry
  • Am I stressed or overwhelmed?

If the answer is yes to questions 1 or 2, then fix them as soon as possible.  The myriad of idiotic hospital rules against consuming food on shift can make these tasks problematic so find a way around that.  If you are feeling stressed, then sit down, take a few deep breaths, and find one task that you can accomplish to get you back on track.  This will help you from feeling like you are losing control.

Don’t assume that patients came to you for tests

Believe it or not, most patients are more interested in your educated opinion as to whether they are sick or not rather than what a slew of tests show.  Young parents just want to know that their child running around the room with a fever is going to be okay.  The worried family in the next bed just wants to make sure that their patriarch isn’t having a heart attack.  In EM, you will be in the reassurance business much more than you will be in the resuscitation business.  Don’t roll your eyes at those parents – tell them that their child will be just fine and that they are doing a good job.

EM is a team sport

Committing to a career in EM is committing to being a team player.  Those who are not team players are not around for very long.  Running an ED is an exercise in collaboration starting from the housekeeping staff all the way to the very top.  It is very easy to get stressed out and take it out on your staff.  If that happens, recognize it and prevent it from happening.  Whenever possible, let your nurses know your plan.  Say please and thank you.  Listen to the input from your nurses and acknowledge it.  If you don’t agree with their suggested course of action, explain why in a calm and professional way.  If you screw up and lose your cool, apologize.  We’ve all been there and people are forgiving if you acknowledge your mistakes.  Finally, after you take care of a sick patient and at the end of the shift, go around and thank everyone for their help in a sincere way.

EM is about being an advocate for your patients

During a lecture in my third year of medical school, after an incorrect answer from a classmate, a cardiologist exclaimed “For the first two years of your education it was all about you.  Well guess what, it’s not about you anymore, it’s about the patient!”  While I don’t agree with the manner in which he used this phrase to belittle an incorrect answer, the last part certainly stuck with me.  Most importantly, it means that you hold yourself to a high intellectual and educational standard.  Next, it means advocating for your patient.  You will be calling other doctors at all hours of the night to ask them to do work.  Most of the time, your consultants will be professional, collegial, and nice.  Sometimes you will need to fight for what you think your patient needs.  Keep it calm and keep it professional but never lose sight of the fact that you are an advocate for your patient.

You will have bad outcomes

Bad outcomes are a fact of life in EM.  Some of them you can’t prevent, you’ll think some of them could have been prevented, and there will be ones where you just plain screwed up.  This is a high stakes job with constant interruptions and a million ways that things can go wrong.  It’s amazing that we get it right as often as we do.  Find a way to mentally process these bad outcomes without being self-destructive.  A good EM doctor is always critiquing themselves to figure out how they can do better the next time.  However, they don’t let bad outcomes consume them and bring them down.  You will beat yourself up over your mistakes and that’s ok but give yourself some sort of time limit.  A few days is ok – a few months isn’t.  I’m not saying to forget about your mistakes forever (that will probably be impossible to do) but rather move on in a productive way.  Talk with a trusted mentor, colleague, spouse, partner, or friend about these patients to help you decompress and gain perspective.

After the shift

Have something else besides medicine in your life

I can’t stress this enough.  You cannot be an effective EM doctor if all you have is EM.  While I will admit that having “something else” during medical school and residency is difficult, it is still possible.  Some people like to skydive, others like to knit.  Some people like to run ultra-marathons, some like to read books.  Whatever it is – find something outside of medicine that you enjoy or you will burn out.

Find some sort of physical activity that you enjoy and do it

Do not fall into the trap of “I just ran around the ED for 12 hours, that is all the exercise I need”.  Even if you have a sky high metabolism and are still the same weight as you were in high school, you need to do some sort of physical activity.  It doesn’t have to consume hours of your day but it needs to be something you do on a regular basis for your physical and mental health.

Realize that you have the best job in the world

If you don’t think this more days out of the week than not, then you may want to find another line of work.  Realize how lucky you are to have a job that challenges you on a daily basis and is never the same day twice.  You get to go into the ED, make a whole lot of people feel better, and go home (without a pager!).  Figure out a way to stay healthy and mentally well so you can have a long career in EM.

EM Mindset: Reuben Strayer – 8 Responsibilities of the EM Doc

Author: Reuben Strayer, MD (@EMUpdates)  // Editors: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

Featured on the LITFL Review #180 – Thanks to Dr. Anand “Swami” Swaminathan (@EMSwami) and the LITFL Review group for the shout out!

The most effective way to improve your skill as an emergency physician (EP) is to break down your job into its component responsibilities and develop a clear plan for each. I have determined that there are eight discrete responsibilities of the emergency doc, and we’ll discuss them in ascending importance, least important first. There are certainly other responsibilities emergency docs take on depending on their environment, but most of us are tasked with these eight, so let’s jump in.

  1. Public Health

At least in the US, primary care is mostly available only to a privileged minority, leaving many folks to use the ED for all of their medical concerns. This has led to an expansion of the clinical purview of emergency medicine to include a variety of primary care responsibilities. Depending on where you work, such efforts could include screening for HIV, hypertension or domestic violence, offering harm reduction programs related to alcohol or drug abuse, or interventions that feel like acute care but are really public health measures like providing tetanus vaccine. Many EPs were not taught to think about public health initiatives as part of their job; it feels to many of us like a task that takes away from the acute care we’re more interested in, a task someone else should be doing. Indeed, the most successful ED-based public health programs use non-EP clinicians to carry them out. At the same time, you make a much bigger difference when you convince your patient to stop smoking or lose weight, enhance their diabetes or asthma management, or pick up an occult case of HIV, then you do resuscitating stroke or sepsis or whatever your favorite dangerous condition that mostly affects older, sicker patients. So, especially when you’re not getting creamed by the board, you will do well to do a little public health.

  1. Resource stewardship

Acting as a gatekeeper for tests, therapies, and consultants is usually not explicitly recognized as a responsibility of the EP but we are often the crossroads of care between the outpatient and inpatient realms and determine which patients require the assessment of a specialist, which most of the time will entail a battery of tests and therapies, not that we don’t ourselves over-test and over-treat. As everyone grapples with the complex consequences of over-doctoring, we are all increasingly held accountable for the tests and therapies we order. The best way to overcome the barriers to reducing resource use, which are also complex but center around fear of missing a dangerous condition, is to develop departmental and institutional care pathways that are designed to optimize the balance between patient safety and resource expenditure. Otherwise, try to practice with the recognition that there is a chance of harm with every test and every therapy ordered, and that this chance of harm should always be weighed against chance of benefit. Avoid routine tests, be especially mindful of the effect of CT radiation on young people, and when you can’t decide whether or not to consult, don’t. ACEP has joined the Choosing Wisely campaign, know what our College has to say about the practices it considers wasteful. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/

  1. Customer service

Many EPs would say that customer service is actually our most important responsibility, that we are in fact in the customer service business. Even if you’re not willing to go that far (I’m not), you can greatly improve your customer service – which has perhaps the biggest return on investment of any professional skill you can augment – by firstly recognizing that customer service and best medical practice are not related. That means that you can provide optimal medical care and your patient can still leave the department cursing your name and threatening with lawyers, or you can commit malpractice, try to kill your patient, and if you fail, that patient can leave singing your praises and writing letters of commendation. The point is that medical best practice and customer service are separate skills, and you have to be good at both of them.

There are a few things you can do that will have a huge impact on customer satisfaction. The first is to set expectations low: under-promise and over-deliver. Most patient disappointments center on delays in care – waits to be seen, waits for tests, for consultants, for a bed upstairs. If you routinely and proactively counsel patients with time estimates that are double how long you think these things will actually take, you might get some surprise and frustration up front, but you have set yourself and your patient and your patients’ relations up for satisfaction.

Figure out what the patient wants. Some patients want to feel better, some patients want to know what’s causing their symptoms, some patients want a Percocet prescription. If you know that a patient is here for a Percocet prescription but you focus on what’s causing their symptoms, or if you know the patient is here because they can’t handle taking care of their elderly mom at home but you focus on symptom control in the ED, you are going to have dissatisfied customers. Commonly, patients want things that you cannot or will not provide (e.g. a Percocet prescription), and making those customers happy is very difficult, but you are more likely to do so (or at least manage them more effectively) if you focus on why they came.

The most common patient desire that we cannot fulfill is to know what is causing their symptoms. In most cases of abdominal pain and chest pain, for example, what we do is make sure it’s not dangerous, we don’t determine a specific diagnosis (though many EPs assign a benign specific condition – what I call as BS condition – without conclusive evidence of such, I don’t recommend this). If you specifically acknowledge your patient’s desire to know what is causing their symptoms, acknowledge that you didn’t give that to them while emphasizing what you did give them (reassurance that it looks like the symptoms are not caused by something dangerous), your patients will leave happier, which will make your life a lot easier. 

  1. Managing ED flow

Emergency Medicine is unlike all other specialties in many ways, one way is that we are entirely reactive; an EP has no idea what they will encounter when they shows up to work. Although other specialties joke at how focused we are on disposition, when you don’t control the entrance, you have to be constantly thinking about the exit. Learning how to move through patients efficiently is a core EM skill. An easy way to improve your efficiency is, after every patient you see, to run your list asking one question: what is this patient waiting on? Unless an unstable patient requires care, always take care of tasks that move existing patients forward prior to picking up a new patient, as tempting as it is to just see another one. Another lesson hard learned is that multitasking is a myth: you cannot simultaneously do two things at once that require a high level of attention, and most of what you do as an emergency physician requires a high level of attention. “Multitasking” is actually ordering and taking care of a group of tasks in series. When you are interrupted with a task that needs to get done, either stop what you’re doing and do the new task, immediately delegate that task, or write it down. The demand for your cognitive resources exceeds supply, so rely on your memory as little as possible.

  1. Determination of disposition and level of care

 The essential question with regard to disposition is how likely is this patient to get sicker?  While determining how sick is this patient is a cornerstone of emergency medicine, determining how likely a currently well or mildly ill person is to become more ill is much harder and more important. Although we want to make dispositions as soon as possible, some patients require a period of observations to declare their clinical trajectory; if a patient you just admitted to an unmonitored bed decompensates shortly after arrival to the ward, you may have made a consequential error. Most of the time it’s clear what level of care an inpatient requires, but when it isn’t, don’t be afraid to watch the patient for 2, 4, 6 hours to see which way they go.

Discharging patients is of course a sharper edge. Not all discharges are the same. Sometimes you know there’s nothing going on with this patient, in which case there’s a sense in which it makes no difference what you do, send them out into the cold, godless world with a pat on the back and some shitty preprinted discharge instructions. Many patients that you discharge, however, you’re not as confident that there is no occult dangerous condition. In these cases, make it clear to them that although you don’t see any evidence of a dangerous condition right now, sometimes there are dangerous conditions that can be hidden, so, Ms. Jones, if you develop new symptoms that concern you, or you get worse, come back to the ER immediately, we’re here 24 hours a day, 7 days a week.

There are some patients that you are really nervous about discharging. You’re discharging them, but reluctantly. For those patients, bring them back. In 24 hours. In 12 hours. If they’re feeling a lot better, don’t worry, they won’t come back, and if they’ve gotten worse, you want them seen again. Bring them back.

And I give a lot of patients my phone number, with the instruction here is my phone number – if you have any concerns about today’s visit, or you feel like you’re getting worse, call me. The phone number I give them is a Google voice number, which is free, and I’ve configured it to just be a voicemail; when someone leaves a message, I get an email and can listen to the message. I give out this number routinely and only get a couple calls a month. Am always glad they called. Almost always.

  1. Symptom relief

Symptom relief is a core responsibility of emergency physicians. And it’s usually pretty easy, once you remember to do it. The key is to remember to do it. All non-malingering patients who have a symptom amenable to treatment (pain, nausea, vertigo, whatever) deserve to have that symptom treated, and it’s so easy to know whether to write for another dose of morphine – you just ask the patient. Do you want more medication for pain? If you get into the habit of asking, is there anything I can do to make you more comfortable you will make your patients so happy, which will make you happy, in addition to making you a better doctor.

  1. Identification of dangerous conditions

Identification of dangerous conditions is probably the toughest part of what we do, truly the hard science and art of emergency medicine. The best way to do this is to become intimately familiar with the roughly 150 immediately dangerous conditions in medicine, and, when you approach the patient, do your history and physical not in a templated, med student like way, but in a way that is specifically designed to rule out (or rule in) these dangerous conditions. When you identify the complaint as headache, you call to the forefront of your mind a list of dangerous causes of headache (there are 13 – http://emupdates.com/2015/01/15/headache-in-the-emergency-department-13-dangerous-causes) and then ask questions and perform exam maneuvers specifically to cross elements off that list. Although 150 conditions seem like a lot, and it is, those 150 conditions are the house of emergency medicine; emergency physicians live in a house made up of those 150 conditions. Welcome home.

  1. Resuscitation

Resuscitation and identification of dangerous conditions are tied for the most important responsibilities of the emergency physician, but resuscitation is a lot sexier. It’s also a lot easier. Here is a particularly well-done video that gives you a framework on how to approach the first five minutes of resuscitation to give you a leg up. http://emupdates.com/2014/07/03/the-first-five-minutes-of-resuscitation/

There is a lot more to the EM mindset than the eight responsibilities. Like being comfortable making very consequential decisions with incomplete information, being comfortable being interrupted every 30 seconds, being comfortable being screamed at (and vomited on) by strangers, being comfortable giving strangers the worst news they’ve ever had. And being comfortable reducing fractures, and defibrillating people in cardiac arrest, and delivering babies, and sewing up the laceration on the billionaire everyone’s heard of who’s lying one gurney over from the undocumented immigrant who also has a laceration and speaks a language no one’s heard of, and providing comfort care to the 96 year-old taking her last few breaths, and intubating the nearly dead 10 day-old with undiagnosed congenital heart disease.

But tackling these eight responsibilities is a good start.

Intern Report Collection, Vol. 7

intern-report

To kick off your weekend reading pleasure, here’s another batch of our monthly excellent write-ups from the EM interns at UT Southwestern (@DallasEMed) courtesy of Alex Koyfman (@EMHighAK) . Our ongoing intern report series is the product of first-year residents exploring clinical questions they have found to be particularly intriguing, with an intended audience of med students & junior residents. Enjoy!

[Note: These are PDF files.]

Anti-NMDA Receptor Encephalitis: Highlights in Adult Patients

Anti-NMDA Receptor Encephalitis

By Alex Koyfman MD
Edited by Stephen Alerhand MD

 Your next 3 patients…

1) 21yo F with change in behavior / depressed consciousness
2) 25yo F with “weird movements” brought in by family
3) 30yo F with AMS + increased muscle tone

NMDAR encephalitis patient

Basics

– 1st case described in 2005
– Pathogenesis mediated by antibodies against NR1-NR2 heteromers of the NMDA receptor; unclear precipitating factor
– Patients often brought to the ED by family members 2/2 bizarre behaviorNMDA receptor

Clinical considerations

– Median age early 20s
Female predominance
Initial flu-like illness that progresses over 1-2 weeks => psychosis, AMS, dyskinesias, seizures, autonomic instability
– Other symptoms: increased muscle tone, new psychiatric symptoms (agitation, hallucinations, sleep disturbance, paranoia), AMS, memory problem, movement disorder (dyskinesias), autonomic instability, seizure
– think limbic encephalitis (affects hippocampus and limbic system)

Differential diagnosis

– Encephalitis, brain mass, endocrine emergency, NMS, serotonin syndrome, Psych, ketamine / PCP intoxication; when considering these, add anti-NMADR encephalitis to your list

– About 60% found to have cancer (paraneoplastic), most commonly ovarian teratoma

Diagnosis

CSF and serum sent for antibodies

Treatment

Supportive care
High-dose steroids / IVIG / plasma exchange
– Cancer surgery PRN (the earlier the better)

Prognosis

– About 75% cured with no / mild deficit(s)
– 7% mortality

Examples of Treatment Algorithms

(Kruse, Jennifer L. et al. Anti-N-methyl-d-aspartate receptor encephalitis: A targeted review of clinical presentation, diagnosis, and approaches to psychopharmacological management. American Academy of Clinical Psychiatrists, Feb 2014.)

AACP algorithm

 

(Li, L. Wang, CB. Zaho, G. Anti-N-methyl-D-aspartate- receptor encephalitis in China. Neuroimmunology and Inflammation, June 2014)

NMDAR China

Further Reading

http://www.ncbi.nlm.nih.gov/pubmed/18851928
http://www.ncbi.nlm.nih.gov/pubmed/25413552
http://www.ncbi.nlm.nih.gov/pubmed/24211006
http://www.ncbi.nlm.nih.gov/pubmed/24355654
http://emergencymedicinecases.com/best-case-ever-28-david-carr-anti-nmda-receptor-encephalitis/
http://www.emrap.org/episode/2014/june/nmda (see Comments section for enlightening cases)
http://www.susannahcahalan.com/ (patient’s view)