CRACKCast & Physicians as Humans on CanadiEM

Today's episode is to aid new physicians to traverse through the first few months of their independent practice safely and effectively. As a new physician myself, I had the luxury of having many mentors and colleagues who were gracious enough to help me find my way in providing safe patient care. Additionally, they assisted me on integral aspects that we don't necessary learn or get exposed to as a resident, such as billing, department flow, and the politics of the ED. However, as a new staff, there are so many uncertainties that you must face alone, and I wanted to find a guide to help me transition more effectively. After not finding something that fit the bill of what I truly wanted, I decided to tackle the issue myself and find colleagues who would help me out with the task of navigating through the First Year of Practice. Questions:

1. Can you please introduce yourself? (name, training, where you work {academic, community, etc}, any other work you are doing {tox, primary care, etc.}).
2. How is it being a new ED staff physician 6 months into practice?
3. What has been the biggest difference been so far being a staff vs. a resident?
4. Can you share an interesting story as a staff? (can be anything – having residents, billing experience, research you are working on etc.)
5. What is the best thing about being a staff physician?
6. What are some struggles/challenges of being a new staff physician?
7. Do you have any billing tips for new physicians? What kind of tips do you have for management of your financial assets? (investments, taxes, accountants, etc.)
8. Any tips on work-life balance? (wellness, coping with struggles, travel, etc.)

Take Home Points:

1. Ask questions to fellow colleagues about difficult cases, department flow, and billing. You will need help with the transition to practice so ask the people who have done it before you.
2. Don't commit to too many things initially. Remember, it's a marathon not a sprint. Plan ahead and make sure to find a good balance between work and life.
3. Find time to learn about billing during your residency. Make sure to have a good feel for it so that once you are staff, you don't leave money on the table (you deserve it!).
4. Live like a "resident" and plan for the future. Planning for retirement and finding a good financial advisor and an accountant is pivotal for your future.
5. Be humble and continue to learn. You will not know everything at the end of your training. Keep reading around cases and develop yourself to become better every day.

Core Questions:

1. What structure controls body temperature and how does it go about controlling it?
2. What are pyrogens and how are they classified?
3. What is the difference between fever and hyperthermia?
4. What is the role of PGE2 in fever and what medications can you give to combat its effects?
5. List four factors that blunt the febrile response.
6. What are the benefits and pitfalls of the febrile response?
7. List five infectious and five non-infectious causes of fever. (see Box/Table 9.1)
8. Describe your approach to the febrile patient. (see Figure 9.1/9.2)

Wisecracks:

1. What is the most accurate temperature measurement site?
2. How are heart rate and body temperature related?
3. How are respiratory rate and body temperature related?
4. How high must a fever be to necessitate rapid cooling interventions?

Core Questions:

1. Describe your history and physical exam in the patient being actively resuscitated.
2. Discuss the process of deterioration to cardiac arrest with respiratory failure and cardiac obstruction.
3. List 6 aspects of optimal CPR.
4. What medications have been shown to improve outcomes in cardiac arrest?
5. List 8 differential diagnoses for PEA arrest (See Table 8.4)
6. What is electromechanical dissociation (EMD) and how does it differ from pseudo electromechanical dissociation (pseudo EMD)?
7. What is echo-guided life support (EGLS) and how is it used?
   1. Carotid or femoral pulse
   2. CPP
   3. Arterial relaxation (diastolic) pressure
   4. PETCO2
   5. SCVO2
8. What are your targets during CPR for the following metrics? (See Table 8.3)

Wisecracks:

1. What is cough CPR and when should it be used?
2. What is the only antidysrhythmic shown to improve rates of VF conversion to a perfusing rhythm?
3. What is the minimum coronary perfusion pressure (CPP) is needed to achieve return of spontaneous circulation (ROSC)?
4. What is the triad of cardiac arrest?

Core Questions:

1. What is cerebral autoregulation?
2. Describe your parameters for post-arrest care of a brain injured patient.
3. List 7 interventions for management of a patient with elevated ICP.
4. What are the equations for cerebral blood flow and cerebral perfusion pressure?
5. Describe a protocol for induced hypothermia after cardiac arrest.
6. In the patient with a traumatic brain injury, what is the optimal drug for and duration of seizure prophylaxis?

Wisecracks:

1. What are Lundberg A waves?
2. What is the relationship between PaCO2 and CBF?
3. What is the Monro-Kellie hypothesis?
   1. How do these values change in patients with severe coma?
4. What is the probability that a survivor of cardiac arrest has a full neurologic recovery?

This episode covers Chapter 6 in Rosen's 9th edition, shock.

Are you a Family Medicine resident about to graduate and embark on an extra year of training in Emergency Medicine (EM)?

Are you worried you don't know what it is really like to be an Emergency Medicine resident and you want to find a guide to help maximize your learning in a short and extremely fast year?

As a recent CCFP-EM graduate, I can strongly relate to your fears. The one year of extra training is an important one, and you will learn a plethora of information that will be pertinent to your success as a future Emergency physician. Thus, it is paramount that you maximize and optimize this year. In this blog post, I hope to act as a guide and provide insight into how to get the most out of your training.

For those individuals who do not know what the CCFP-EM program is, it is an Emergency Medicine residency fellowship (or added competency program) stemming from the tree of Family Medicine in Canada. Residents completing this program will have the ability to complete the Emergency Medicine Licensing Exam (administered by the Canadian College of Family Physicians) and practice EM across the country. It is a highly competitive program and as a one year program, the training is rigorous and substantive. Residents are expected to achieve a large volume of objectives, and experience various teaching requirements in different specialties to achieve competency for independent practice.

See the companion blog post: https://canadiem.org/steps-to-success-in-enhanced-training-in-emergency-medicine-ccfp-em-year

This updated episode of CRACKCast covers Rosen's Chapter 005, Monitoring the Emergency Patient (9th Ed.).

Core Questions:

1. List modalities for measurement of BP and note which modalities are likely to over and underestimate blood pressure.
2. What is pulse pressure and how does it relate to stroke volume?
3. List 4 indications for an arterial line.
4. What is the Beer-Lambert Law and how does it allow us to measure pulse oximetry?
5. How do dyshemoglobinemias affect your measured SpO2?
6. What are the 4 phases of the ETCO2 waveform?
7. List 5 uses for ETCO2.

Wisecracks:

1. List the pitfalls of pulse oximetry.
   1. Purple
   2. Yellow
   3. Tan
2. Describe colorimetric ETCO2 monitoring and cite the ranges at which you would expect to see the following colours:
3. How are ETCO2 values related to PaCO2?
4. What are causes of elevated ETCO2?
5. What does MOVIE stand for (aka - how to rock your oral exam resus questions)?

This updated episode of CRACKCast cover's Rosen's Chapter 004, Procedural Sedation and Analgesia (9th Ed.).

This episode of CRACKCast covers Chapter 3 in Rosen's Emergency Medicine (9th Ed.) – Pain Management. This podcast will give you a solid approach to the basics pain management to use on your next shift!

Core Questions:

1. Define the following terms (Box 3.1):

• Allodynia
• Amnesia/amnestic
• Local anesthesia
• Analgesia
• Hypnotic
• Narcotic
• Nociceptor
• Noxious stimulus
• Opiate
• Opioid
• Pain
• Procedural Sedation
• Sedative

2. Describe a practical approach to stepwise management of pain in the ED.

3. Describe the adult parenteral and oral doses for:

• Morphine
• Hydromorphone
• Fentanyl

4. Differentiate between opioid side effects and opioid toxicity.

5. How do you manage opioid toxicity?

6. Describe relative safety profiles for the NSAIDS.

7. List the classes of local anesthetics. How do they work?

8. List the toxic doses for each local anesthetic:

• Lidocaine
• Lidocaine with Epi
• Bupivicaine

9. List 5 techniques to reduce pain of injection of local anesthetic.

10. List agents that can be used for topical anesthesia of:

• Intact skin
• Mucous membranes
• Open skin/lacerations

Wisecracks:

1. What agent can be used as a substitute in cases of anaphylaxis to local anesthetic?

2. Why should you avoid use of the following agents:

• Tramadol
• Demerol

3. How does local anesthetic toxicity present?

The first episode of the Thrombophonia podcast addresses three objectives: