EM Clerkship

You are working at Clerkship General when the base command phone rings –

“Hey doc just wanted to give you a heads up on this stroke alert we’re bringing you – we have a 70yo M with sudden onset left arm numbness and weakness, last known well 2 hours ago, we’ll be there in about 5 minutes”

Initial Vital Signs:

HR 120

BP 180/90

RR 22

O2 97%

Temp 97.7F

Critical Actions:

1. Check a blood glucose

2. Diagnose Aortic Dissection

3. Give Esmolol first, titrate to HR<60

4. Give Nicardipine/Clevidipine second, titrate for SBP 100-120

5.   Consult cardiothoracic surgery for type A dissection

Further Reading:

EMCrit – Aortic Dissection

Not your typical wellness episode – by Zack

You are working at Clerkship General Hospital when EMS calls in a female with opioid overdose, but she won’t stop complaining of leg pain…

Initial Vitals:

Temp: 98

BP: 120/80

HR: 89

RR: 20

O2 Sat: 100%

Critical Actions:

* Treat patient’s pain without NSAIDs (history of solitary kidney)

* Assess patient’s leg pain beyond the point of just fracture vs. no fracture

* Recognize the signs and symptoms of compartment syndrome

* Get orthopedic surgery to bedside emergently for fasciotomy

* Recognize and treat rhabdomyolysis

Diabetic Ketoacidosis – hyperglycemia, ketosis, and anion gap metabolic acidosis

* Don’t forget about euglycemic DKA (especially in setting of SGLT2 inhibitor) or mimics such as alcoholic ketoacidosis

* Treatment of the ketoacidosis * Insulin (usually a drip or bolus + drip) – only once K>3.5* Volume Resuscitation (NS initially, change to LR)* Bicarb drip (poor evidence, only as last resort for critical patients)* Treatment of electrolyte abnormalities* Correct sodium for hyperglycemia* Replete potassium if K<5.0, PO and IV simultaneously* consider central line if patient hypokalemic and in extremis/critical DKA* Management of respiratory status* Avoid intubation at all costs unless altered or impending respiratory failure* APNEA KILLS* Mechanical ventilation limits your minute ventilation, leading to worsening acidosis. Breath stacking occurs if you set the RR too high.* Support work of breathing with NIPPV (high IPAP, low EPAP)* If intubation necessary, consider awake intubation or consider using bicarb pushes if performing RSI

Further Reading:

EMCRIT – DKA

You are working a shift at Clerkship General when the charge nurse comes and grabs you to see a 24yo male who appears to be in respiratory distress.

Critical Actions:

* Diagnose DKA* Replete potassium* Start insulin AFTER potassium repletion* EITHER place central line for faster K repletion OR initiate bipap to allow time for potassium repletion via existing peripheral line* Admit to ICU

Further Reading:

EMCrit – DKA

Before interview day, do your research on programs and interviews and reflect on the way in which you want to portray yourself.

On interview day, have a cheat sheet with notes about your conversations, questions, and pro-cons. Remember to stay calm, take a pause if you need to, and above all be authentic to who you are.

After interview day, be sure to capture you gut impression and write down any follow-up questions or concerns remaining.

Here are some resources to use for interview day:

EMRA Residency Interview Guide

AliEM – Dos and Don’ts of residency interviewing

EMRA – Common Interview Questions

EMRA – Making the most out of interview day

ALiEM – EM Match Advice Podcast Episode

show notes coming soon

Show comments to be posted shortly

* Understand the timeline – research programs to find out when they extend invites and when they host interviews* Prepare for invitations – set up email and text notifications, get a calendar* Accept invitations – respond promptly and keep your calendar updated* Optimize invitations – any interview date you get is a good one, but planning ahead can help you optimize timing* Too many or too little interviews – drop early, keep tabs with whether programs have extended invites and stay in close contact with your advisors

Summary of Key Points

1. You should consider ectopic pregnancy in every patient who is capable of bearing children

2. If a patient of child bearing age presents with severe abdominal pain or vaginal bleeding and is either hemodynamically unstable or very ill appearing, this is a ruptured  ectopic pregnancy until proven otherwise and I would recommend performing a bedside FAST exam immediately.

3. Remember that the discriminatory zone for TVUS is approximately 1500.  

4. Don’t forget your three ACEP clinical policies on this topic: just to remind you, 

4a.  It is a level B ACEP clinical policy to obtain a TVUS in every stable pregnant patient presenting with abdominal pain or vaginal bleeding, regardless of serum b-HCG level

4b.  There is also a level B ACEP clinical policy stating that in patients with an indeterminate TVUS, you cannot use serum bHCG value to rule out ectopic pregnancy.

4c. It is a level C ACEP clinical policy to obtain specialty consultation or arrange close outpatient followup in all patients with an indeterminate TVUS result.

5. Although this isn’t an ACEP recommendation, ACOG recommends rhogam for all Rh negative women diagnosed with an ectopic pregnancy

6. Don’t forget to consider heterotopic pregnancy, especially if IVF was used to help conceive. 

Further Reading:

ACEP Clinical Policy – Early Pregnancy