EM Clerkship

Patient satisfaction is getting lots of bad publicity these days, and I think it’s gone too far. Certainly, patient satisfaction surveys have the potential cause multiple adverse outcomes, and we’ve all heard about the study linking patient satisfaction with mortality. However, there are some aspects of patient satisfaction that are undeniably good patient care, and that is what I want to focus on today.

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Today we are talking about one of the most dangerous disorders a patient can have… Sepsis. There is a lot to cover with this including the history of sepsis management, definitions, and a modern day approach. We will cover each of these things and more in this week’s episode.

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Thank you for downloading our first EM Bolus episode! These episodes are intended to give a more in-depth look into the real world of Emergency Medicine and your future career. This week’s episode is dedicated to all of our PA listeners. Chip Lange, PA-C, creator of the TOTAL EM podcast will be joining us to discuss what it’s like working in a rural emergency department where he has to take care of critically ill patients, miles away from a major academic center, and with minimal to no sub-specialty backup. It is the ultimate test of a providers clinical skill set.

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Get excited the next time you have a patient with dental pain! Because this is one of those chief complaints that will give you tons of points on your SLOE as long as you can articulate your way through it. This is also one of those rare opportunities where you get to demonstrate procedural skills by doing an inferior alveolar nerve block. So never roll your eyes at these patients, because they are an opportunity for you to stand out from the pack and earn high clinical scores!

Minor complaint. Huge SLOE points! Step 1: Identify Which Tooth is Causing Pain * Bonus points if you number teeth correctly!* Number 1-32* Tooth #1 is top right* Tooth #32 is bottom right* Refer to dental chart for reference Step 2: Correct Terminology When Making Diagnosis * Pulpitis* Pain in the tooth itself* Reversible* Triggered by hot/cold etc (then goes away)* Irreversible* Does not resolve* Gingivitis* Pain of the gingiva around the tooth* Periapical abscess* Pain with percussion of tooth Step 3: Give Pain Medicine * NSAIDS have been shown to work best* Naproxen* Ibuprofen* Opiates for breakthrough pain* Hydrocodone-acetaminophen (Norco)* Oxycodone-acetaminophen (Percocet) Step 4: Consider Antibiotics * Pulpitis does not require antibiotics* Gingivitis/Periapical abscess frequently improve on antibiotics* Penicillin VK Step 5: Inferior Alveolar Nerve Block * Watch HERE Additional Reading * Inferior Alveolar Nerve Block (YouTube)* Common Dental Emergencies (AFP)

There are two big categories of vertigo: central and peripheral. And your entire exam should be focused around identifying which type the patient has. Central vertigo is typically the one we get most concerned about in the ED because it is caused by abnormalities in the brain. Peripheral causes tend to be much less critical and located in the ear. Today we will cover both types, with a specific focus on identifying the life threats.

Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo? Step 1: How Does Patient Describe the Vertigo? * Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is)* Central vertigo* Mild* Vague* Peripheral vertigo* Severe* Sudden Step 2: What Are the Associated Symptoms? * Central vertigo frequently associated with “The Dangerous D’s”* Diplopia (double vision)* Dysphagia (difficulty swallowing)* Dysmetria (uncoordinated movement)* Dysarthria (difficulty speaking) Step 3: Does this Patient Have Risk Factors for Central Vertigo? * History of stroke* Atrial fibrillation* Diabetes* Recent trauma Step 4: Do a Neuro Exam * Important exam findings for central vertigo* Abnormal gait* Abnormal finger-to-nose* Nystagmus* Important exam findings for peripheral vertigo* Dix-Hallpike Step 5: Plan * If concerned for CENTAL vertigo* MRI head/neck* If concerned for PERIPHERAL vertigo* Treat with meclizine Additional Reading * Posterior Circulation Strokes and Dizziness (emDOCs)

Hyperkalemia is the single most important electrolyte abnormality you need to know for your clerkship. It is very deadly, and you need to act quickly or the patient will might go into cardiac arrest. If your patient has hyperkalemia, get and EKG and give calcium. That is the most important thing you need to remember for this week.

This episode is for the dedicated listeners who would like to know the details of what is going on behind the scenes and what the podcasting goals and objectives will be for the upcoming season. Happy New Year!

Hyperkalemia = EKG… EKG changes = Calcium… Step 1: Recheck the Potassium * Most common cause of hyperkalemia is PSEUDOhyperkalemia* Caused by too aggressive/fast of a blood draw* Causes RBCs to break open and falsely increase serum potassium Step 2: Get an EKG * Earliest EKG change* Peaked T waves* Late EKG changes* Flattened P wave* Prolonged QRS* Critical/Emergent EKG changes* Sine wave Step 3: Protect the Heart * EKG Changes = Give Calcium* Calcium gluconate (can be given IV)* Stabilizes the myocardium against dysrhythmia Step 4: Shift Potassium Into Cells * Insulin (plus D50)* Albuterol Step 5: Remove Potassium from Body * Kayexalate* Notorious for causing intestinal necrosis* Falling out of favor* Furosemide Additional Reading * Round 8 – Fall (EM Clerkship)* Emergency Management of Hyperkalemia (EM Cases)

As a physician, everything you do has a fee. Patients may or may not pay that fee, but everything you do still has a price that is set by the government. In this episode we will cover how much your work costs the patient as well as discuss several specific examples.

A-B-C-D-E-F-G Two Types of X-Rays * Anterior-Posterior (“AP”)* Classic “portable” xray* The beam shoots from in front of the patient (anterior)* TO* The plate sitting behind the patient (posterior)* Posterior-Anterior (“PA”)* Requires trip to radiology* Results in a better picture* The beam shoots from behind the patient (posterior)* TO* The plate sitting in front of the patient (anterior) Three Indicators of a High Quality Chest X-Ray * Well inflated lungs* Visualize spine through cardiac silhouette* Medial aspect of both clavicles lined up* Evaluates for rotation Chest X-Ray Interpretation Mnemonic * A-B-C-D-E-F-G* A = Airway* Trachea midline (rule out tension pneumothorax)* B = Bones* Rib/Clavicle/Shoulder fractures* C = Cardiac silhouette* Should be no bigger than 50% of distance from chest wall to chest wall* Larger than this may represent cardiomyopathy* D = Diaphragm* Costophrenic angles should be sharp* Blunted in pleural effusion* E = Equipment* Central lines* Endotracheal tubes* Chest tubes* F = Lung Fields* The most important step* Look at lung markings/tissue to evaluate for…* Pneumothorax* Consolidation* Nodules* Pulmonary Edema* G = Great vessels* Look for mediastinal widening (> 8cm)* Can be a sign of aortic injury* Looks falsely widened on AP/portable chest x-ray Additional Reading * How to Read a Chest X-Ray (Medgeeks)* Learn to Read a Chest X-Ray in 5 Minutes (YouTube)