Ask Me Anything: Reuben Strayer, MD

[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.

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

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.

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

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

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

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.

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?

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.

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.

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.

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!

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.

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.

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

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.

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

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.

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

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.

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.

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

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.

the short answer is this:

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

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.

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

I use these types of decision instruments constantly.

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

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.

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?

thiopental has very similar effects to propofol.

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

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

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

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.

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

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.

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

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 🙂

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

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

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.

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

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.

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

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.

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.

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!