EM Clerkship

Tip #1

Introduce yourself.

* Attending? “Hello, my name is Zack, I’m one of the medical students” * Resident? “Hello, my name is Zack, I’m one of the medical students”* Nurse? “Hello, my name is Zack, I’m one of the medical students”* Janitor? “Hello, my name is Zack, I’m one of the medical students”

Tip #2

Be humble but confident.

* Humility- Students know very little about the practice of medicine, the smartest med students actually realize that.* Confidence- You have to be able to act confident, be decisive in your presentations, and make decisions. The best way to achieve this is to remember that you have (hopefully) been working hard and studying consistently.

Tip #3

Stay focused.

* Your humor, hobbies, activities, dress, and “cool” personality, don’t impress anybody in the emergency department. * The best students tend to be friendly, focused, hardworking, and generally quiet (yay introverts!)* Emergency medicine tends to be a very pragmatic, no b.s, specialty. Let your performance speak for itself.

Tip #4

Do the majority of your learning BEFORE your rotation starts.

Your audition rotation should not be when you are downloading podcasts, studying pretest, or going through practice questions. Your learning should be completed well in advance so you can focus your energy on clinical performance).

Tip #5

HELP around the department.

* Help patient change into gown* Get urine samples* Keep patients updated* Go back and ask missing information

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Verbalize the out loud prior to performing rapid sequence intubation.

The Bougie

* Ideal for situations when you’re view is suboptimal* Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique).

Video Laryngoscopy (Glidescope)

* Laryngoscope with a camera at the tip which displays on a screen at bedside* Ideal for situations when both view and direct access to the cords is suboptimal (c-collar, poor mallampati). Some physicians use this as their primary technique. * Use it like a camera that you advance into position so you can see the cords. Maneuver the endotracheal tube by watching indirectly on the screen.

Flexible Endoscopy

* It is a flexible stylet that you can control and has a camera at the tip.* Advances through the cords like a bougie and the (preloaded) endotracheal tube advances over it. * Can intubate through both the nose or mouth with this

LMA (laryngeal mask airway)

* Placed blindly and sits above the cords, forming a seal. * Not a “definitive” airway, but can oxygenate and ventilate the patient when in a difficult situation.

Cricothyrotomy

* Immediately perform this step in “can’t intubate can’t oxygenate” situations* The 3-step EMCrit method is best in my opinion (see link below)* “Scalpel, Finger, Bougie”

Additional Reading

* Overview of the bougie with videos (LITFL)* The 3-step cricothyrotomy (EMCrit)

The most important thing to do when preparing for RSI is to PREOXYGENATE the patient.

Step 1: Choose Your Equipment

* Miller or Mac blade? * Miller blade is straight (like the ‘L’ in miller)* Frequently used in kids* Mac blade is curved (like the ‘c’ in mac)* (Generally, this is the best choice to use on your clerkship and most common in the ED)* Tube Size?* 7.5 cuffed tube for a small adult* 8.0 cuffed tube for a big adult

Step 2: Choose your Meds

* You need both a sedative and a paralytic to perform RSI* Paralytic options are succinylcholine or rocuronium* Succinylcholine is best if you need something short acting* For example, when frequent neurologic checks are required* Rocuronium is best because it’s easy to remember (1mg/kg)* “Rocuronium Rocks”* Sedative options include ketamine, propofol, and midazolam. * My favorite is ETOMIDATE. * It is hemodynamically neutral.* Dosing is 0.3mg/kg

Step 3: Prepare Your Equipment

* Suction* Bag Valve Mask* Backup airway (ex. LMA)* Cardiac monitor* Capnography for tube placement

Step 4: DO IT

* Push the sedative* Push the paralytic* Put the blade in your LEFT hand* Open mouth with right hand* Slowly advance (holding top of blade against tongue) until you see cords* The cords will be hiding under the white, cartilaginous, tongue-like epiglottis

NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great.

Step 5: Advance the Tube and then CLOSING STATEMENT

* Generally, you want depth to equal 3x the size of the tube* Closing statement* “Please attach capnography to confirm tube placement”* “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)”

CONGRATULATIONS!! THEY ARE INTUBATED!!

How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful?

Pharyngeal Airways

* These tools bypass the posterior portion of the tongue to help with BVM ventilation* Nasopharyngeal Airway (NP)* Measure from earlobe to tip of nose* TEST QUESTION: Don’t use in a patient with possible skull fracture* Oropharyngeal Airway (OP)* Measure from earlobe to corner of mouth

Laryngeal Mask Airway (LMA)

* Essentially a modified BVM to place inside the mouth* It fits OVER the larynx (cords, epiglottis, etc)

Retroglottic Airways

* “King”* “Combitube”

Additional Reading

* Laryngeal Mask Airway (Wikipedia)* King Airway (Wikipedia)* Combitube (Wikipedia)

Most Life Threatening Fungal Infection

* Mucormycosis* Black facial discharge* Cranial nerve dysfunction* Facial swelling* Eschar formation

When to Suspect a Fungal Infection

* Immunocompromised (HIV, Diabetes, Organ Transplants, etc)* Not getting better on typical antibiotics

Other Fungal Infections

* Aspergillus* Aspergilloma* Bronchopulmonary Aspergillosis* Invasive Aspergillosis* Coccidiomycosis* Southwestern United States* Histoplasmosis* North Central United States* Blastomycosis* Southeast United States

Additional Reading

* Fungal infection archive and data sheets (CDC)

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