ER Intern: what to study

During the day I carry a pad and ppr to keep track of what to read when I go home, a maxwells because it has cm on the back mostly, and also the Tarascon emergency medicine pocketbook. I love having all those facts at my fingertips. I do use Medscape on my phone because its free, but I find I don't have time to use uptodate or other online resources as much as everyone else seems to.  I do have a black pocket sized notebook in my bag i call my little black book... I write down all my workups and fun facts and other things I learn in it, so I can constantly reference it. 

The two big texts in emergency medicine are Rosens and Tintinelli's. While both are texts full of information, I don't really like them all that well. I just don't seem to study well from them and they don't have quick facts. I can't carry them with me and I don't find them all that practical. Plus they are sooo expensive.

I really like the podcasts:  EMbasic, EMCrit, and EMRAP.   The first two are FREE and only 20 mins per episode. The last one is more for ER only people updating old criteria and the like.  But These three have gotten me through many jams and its easy to listen to one on the way to and from work or at the gym.

I also really depend on First Aid for the Emergency Medicine Clerkship or as resident First Aid for the Emergency Medicine Boards.  These have had the basics of things I need to know are are relatively cheap.


Hope this helps.

ER Intern: BushHog vs. Legs

So while everyone in the ER knows that the most dangerous thing you can do with yourself when guns are involved is "mind your own business" because that seems to be the #1 reason how people get shot.... what you didn't know is if you are around.... Mowing your law with an industrial mower, is the worst thing you can do for your feet. This last week we have had 4 catastrophic bushhog accidents.

It appears on the screen as bushhog vs leg catastrophe. There is even a billing code for this because it happens so frequently.  I did happen to get an image of one of the more minor injuries as see here. The coolest part of this particular injury is that I was able to take a video of the posterior tibial pulsating because you don't have to feel for his pulse in this one, you can just watch it! Haha. I was just waiting for orthopedics to come down and ask about his neurovascular status.  This guy was pretty lucky. Wile his skin is gone, his achilles tendon and main artieries are intact. He was also able to walk away from the runaway bushhog with this injury.  The will most likely have to graft some skin to cover this over, but he got away scott-free mostly.

Not everyone was this lucky. One guy was coming in by air, but the paramedics with his wife came about 10 minutes early and handed me a lunch box full of grass and toes still in socks.  When he arrive, he had bilateral (both sides) amputation. It was just ground meat that was oozing blood. He had done something that saved his own life. He'd taken off his belt and put it around one leg, the one with the biggest arterial bleed. Even the surgeons gave him kudos for the ability to recognize he needed to stop the bleeding and having the sense to pull the belt TIGHT enough to actually stop the bleeding.  He saved his own life. :) smart guy.  Well minus the drinking and mowing lawn combination.


Here is a guy I saw 24hours after the ATV vs. parked truck event. He reall messed up his girlfriend who had come in the previous night, but this was how his arm looked. He was just walking around with that open and moving it etc etc.... kinda crazy.   We just sewed that sucker up and let him go on his way...

ER Intern: Rashes....

So here are a few crazy cases that should get mentioned. The first may not sound all that cool, but it was my first diagnosis without the help of anyone. And of all things it was hematology. Who would have guessed??

So 16yo kid comes in and presents with "rash" now you know to be suspicious of easy cases in this ER so I'm going in pretty suspicious already.  As you can see from the pictures this is not just a rash, its petechiae, largish all over his body. Petechiae are small bruises under the skin from burst capillaries. And they are all over his
body.  For some freak flash of awesome, the first question I asked after looking at this is are they in your mouth? And yes, yes they are. Along with his bleeding gums.  And I knew, this is ITP (idiopathic thrombocytopenic purpura).  And yes, low and behold his platelets came back at 3. Yep a big ol' 3. So workup for this is to start high dose steriods and call the hematology doctors at 4am because this is legit. And when I said, platelets of 3 - they came right in. :)

Kinda neat.  Lets see another cool case I got was someone in legit SVT with a HR of 290s, sweaty and diaphoretic not responding to adenosine x 3 doses -- so I got to push the shock button. Popped him right out of it... although the guy levitated off the table and screamed "SHIIT" that rang through the whole ER. hahaha. Good thing I gave him drugs so he won't remember how much that hurt. This is the picture of the monitor! Its real.... all the board questions we've been studying are REAL.....

Hm... Another case that was also kind of a mystery case. A transfer from an outside hospital. A guy who had a syncopal or seizure event and came in with a myriad of questionable physical findings. He also had a petechial rash only on his chest and armpits with a purple tongue that was large and

swollen. He was on lisinopril for about 1 year and many were worried he had angioedema. He also had some swelling of the sublingual tissue under the tongue which was different. He was transferred because they were worried about his airway.  You can see that the purple bruising is only on the lateral aspect of his tongue, which gave me a clue as to the fact he'd probably had a seizure earlier that night. I also brainstormed that the petechial rash was most likely from apnea during his seizure that popped the capillaries in his chest. This is often a first sign of cause of death on cadavers in the morgue. My pathology teacher would be so proud of me! So we admitted him, but I didn't give him any angioedema medications because he bit his tongue so hard its probably swollen with all the blood. BAM! I was proud to have sorted this out.

ER Intern: ER Rotator Month-- Incidental Findings

So something I have been learning a whole lot about that seems to be a troublesome topic for many a new doctors, especially in the ER -- is what to do with indicidental findings.  How far do you go into a workup for something that the patient did not come in complaining about?

There is no awesome straight forward answer because many times patients don't know what is important, especially when they are scared or really sick. Who cares about that cat bite a week ago when the patient has a headache?  WE DO, but the patients don't understand that the bacteria from the cat bite went through their bone and infected not just the bone but their blood stream with is causing them to have a headache and be admitted to the hospital.  It is this simple problem that separates a physician from a medical student or intern. What is really important and to some degree what are the right questions to be asking?  This is the "art" of medicine you keep hearing so much about.

Its also something I keep running into as a new physician that makes me look around helplessly. These are things that very few studies have been published on and very few discussions in medical school or residency discuss. The problem with these is generally they aren't a big deal and can cloud your judgement with what the patient is complaining about now. But there are always exceptions especially when the incidental finding is sorta a big deal.

Milliary TB

So here are a few random cases to give you an idea.  I had a gentleman come in complaining of leg and arm pain with a small amount of dyspnea. He is very concerned about his pain and he knows he has a kind of arthritis. The man is about 50ish and is very lean and tall (some would say Marfaniod). Despite this joint pain problem, the real reason his doctor sent him to the ER is that his HR is 45 as I am looking at the monitor. He does not have a history of this and he is not a great athlete.  The patient could give a rat's ass about his HR, he just knows that he's a bit dizzy because the pain in his joints gets to him and he wants something for this joint pain. You can't get him off the freakin subject.  So I order up a cardiac workup, trying to figure out what to do with guy and completely frustrated that I can't get him off the topic of his joint pain. I even throw in a little 800 Ibuprofen medication when I put in orders to help him out.  Anyhow, the chest xray comes back and is this.... I know its hard to see but you can see many tiny nodules scattered throughout the lungs in both fields. And I check the radiologists read just to seek their opinion, yep.... Milliary TB. Uh.... talk about a hell of an incidental finding! So what do I do with this guy now? Obviously I can't just let him go home. Still have no idea why his heart rate is in the 40s, but he has no chest pain and is complaining of joint pain. Alright well TB can go into joints, so I do a generalized xray of a few of his extremities and all it shows is some degenerative changes from real arthritis.  So after some discussion with attending, we decided to do a CT scan of chest to confirm this TB and also see if maybe the TB spread to the heart which would cause his low HR. Maybe.... Alright so we're fishing but obviously this guy is a crazy mystery case. So CT comes back clean other than milliary TB in the lungs.  So I admit him and hope that the internal med folks can figure out what the hell....

There was another guy who was rather cachetic looking came in presenting of some headache. He was older and really not talking much to us, he was a transfer case and didn't have any paperwork for us. So when I talked a little about his headache it was like pulling teeth to get him to tell me any

information. But then I did an abdominal exam.... Oh wait sir, how long have these nodules been here? "Oh yeah... i forgot to tell you. I have stage IV liver cancer and am still on chemo. But also I am a full code."  Yeah! sorta a big thing to know! This guy was suddenly a chatterbox. He even asked me for a rice crispy treat, which i eventually caved, as you can see from the picture. Talk about a crazy finding tho! We immediately were able to treat his headache and nausea vomiting better because we knew it was from chemo. Although I felt sad leaving the room knowing that with tumors like that, he probably wasn't going to make it too much longer. :(  Its horrible to see those kinda patients.

Another weird case was someone coming in complaining of abdominal pain. The guy obviously is having a reoccurence of his pancreatitits since his lipase is 1476. But for some weird reason he is also anemic and since I'm learning the computer ordering system I decide to try the order set, which is a series of standard orders for one complaint. (for example there is an order set for pneumonia or chest pain, etc).  I order up his anemia workup because well he's obviously gunna be admitted. About oh I dunno 7 hours later the intern for internal medicine calls my phone and wants to come talk to me. She's all excited and wants to "pick my brain" and i'm like sure.... So she wants to know how I knew to order the malaria test on this guy because it came back positive! Say what?! Apparently, all the internal med people are all real impressed with me now, which is ironic since all i did was use the order set for anemia.  I told her I didn't think of it and it wasn't my genius. But moral of the story is... USE ORDER SETS. People will think you're smart.

On another randomly intriguing topic. There was a study recently published that we chatted about in conference the other day. It was on "gestalt" this magical ability of a doctor to have a gut feeling about if a pt is sick or really what their diagnosis is. Its what makes doctors keep ordering tests when all the usual tests are negative.  I guess a study actually looked at the accuracy of gestalt in the ER about PEs.  And Interns have a gestalt accuracy of pt having a PE about 71% and Attendings have about 78% accuracy.  I find this interesting and also weird that somebody actually studied this....
now I must acquire another 7% gestalt.... which scares me because it must be one heck of a big 7%.

ER Residency: ER "rotator" month

So I'm starting out in the ER. Its a little bit of pressure because I want to be good at everything, and I'm obviously not. That said its only a "rotator" month. So here, they halve the ER and it has 1 upper level and 1 lower level ER intern in each section. The residents who are NOT ER (from psych, internal medicine, OB GYN, etc) are added to one of the halves but are expected to do less. By that I mean carry fewer patients, go slower, and generally ask more questions. They also get reduced hours (they don't work the full 12 hour shifts) and they also only have 16 shifts a month instead of our usual 18.

So as ER interns our first month in the ER (mine just happens to be the first month) we are "rotators" so we can get used to the flow of the ER.  However, we are still on 12 hour shifts and we are still expected to carry more patients than the rotators... about 4 patients at a time.  So we are called "super rotators".... this is all very complicated I know.

Anyhow. My first 4 shifts (all that i've done so far) was a crazy cluster. Its like every patient who comes in here is REALLY REALLY sick.  We are only half thrown the the wolves. We pick up patients and chart and put in our diagnostic orders before

I, as in personally, saw 7 gun shot wounds (GSWs), two of which were life-threatening, bleeding-on the floor, pee-your-pants-cuz-ur-the-doctor-now kinda patients. I had to change my scrub pants twice that night because there was too much blood on my pants to walk around the hospital!! Contrary to popular belief most of the time we leave the bullet in unless its causing problems... I saw 4 septic patients, two of whom I did an internal jugular central line (an IV through the neck which the tube sits in the heart to give certain medications).

I also had a 300lb guy who had headaches, neck pain, and a fever of 103. No nuchal rigidity but luckily I had him walk to the bed from the wheelchair and he was pretty ataxic. So I did my first lumbar puncture. He screamed and legit cried the whole time. It took me about 2 minutes to find the proper spot and I had to get an extra long needle we affectionally call a "harpoon."  But I got it! It was a bloody tap and we ended up diagnosing meningitis.

Another guy came in for a simple headache on and off for the last 2 weeks. He said they were intense pain but lasted only about 5 minutes at a time.  The thing was although his neuro exam was fine, there

was just something off about him. He was having trouble recalling words like "thumb" and seemed to be very distractable, was the text book "inability to concentrate" and so I ordered a CT scan of his head. I had to fight the attending at the time, who was like CT for headaches?? why did you order that? His neuro exam was normal, blah blah blah. Luckily, the scan had already been done by the time he saw I had ordered it.  He had two large masses in his brain, since there was two it was most likely metastasis. And so had to be admitted to try to find the primary cancer. He was close to herniating. Talk about a hell of a first shift!

 They were joking about how I looked like I just got out of high school and I had to tell them he had masses in his brain and likely cancer. It was kinda depressing, yet empowering..... I'm the doctor. And they were looking at me to make the decisions. The attending wasn't there. It was my first solo "bad news" talk.

I also had a patient who came in because he "fell out" which is a phrase they use down here to mean passed out. And hit his face on concrete. He had a really intense nasal dislocation and also had
multiple facial fractures below it. It was crazy. So we had to consult opthomology, plastics, and internal medicine to work up the reason for his passing out. Poor guy. He even let me take a picture because he wanted to see what it looked like. :D

I had another patient who I also thought would be a quick case. Guy came in for back pain, he was a young 30 year old. but the more you talk to him the more symptoms he'd come up with. Problems sleeping and his joints ache and blah blah. Turns out he had osteomyelitis of the spine (bone infection) that was so bad, one of his vertebrae was nothing but pus. Even the surgeons said they couldnt' drain it because then there would be nothing left holding up his spine! So much for simple back pain.

Another one that should have been easy (sensing a theme here?) was cough. Turns out that he coughs while i'm in the room. Didn't sound so bad but there was a bit of blood on the tissue paper. It was hard not to notice. So did just a regular Chest xray.... Then I had to do a CT of chest. Its the biggest cavity of Tuberculosis I have ever seen! Ridiculous! Guess I've officially been exposed to tuberculosis (TB) again!!

I also had to run out to the parking lot twice because I almost delivered a baby there. Too bad the baby was too fast :) Delivered itself. Would have been a great story....