EM Clerkship

* Stay Humble, or You Will Be Humbled* The Documented Respiratory Rate is Alway Wrong* Open Ended Questions Work Best When Taking a History* You Need to Balance Patients Per Hour vs Quality Individualized Care* You Can Tell the Quality of Your Attending by How They Treat Psychiatric Patients, Frequent Fliers, Obese People, Minorities, Etc* The Most Successful Emergency Doctors are Quiet, Kind, Smart, and Focused* Not All Emergency Medicine Jobs are Good Jobs* Financial Advisors Take Advantage of Doctors

* Show Up On Time* Keep Track of Your Procedures* Don’t Be a Whiner* Be Careful When Writing Faculty Evaluations* Don’t Label Patients as “Crazy”* Charge Nurses are the Primary Leader in the Department* The Unit Clerk and Janitorial Staff are Most Under Appreciated Staff in the Department* Don’t Be a Chief Resident* Control Your Tongue. Be Careful What You Say. Be Careful Where You Say It* Get to Know Your Patients During Laceration Repairs* Some People Suck. Your Patient is the One With the Problem

* Don’t Get Involved in Too Many Activities* Quietly Earn the Respect of Others Before You Innovate or Come Up With “Ideas”* True Leaders in the Department Frequently Don’t Carry Important Titles* Don’t Read Reference Books (Tintinallis, Rosens, etc) Cover to Cover* Use Board Review As Your Primary Study Material During Intern Year* Sleep is More Important than Studying, Exercise, and Friendship* Place All of Your Orders At the Same Time* Stand Up for Your Colleagues Who Are Struggling* Do NOT Gossip.. EVER! STOP IT!

* Podcasts Are Not Respected Sources During Clinical Discussions* Identify Your Role Models Early in Residency* The 3 Pillars of Residency Training Are Medical Knowledge, Procedural Skills, and Professional Skills* It’s Healthy and Normal to Disagree With Your Attending* Sometimes Nurses Will Pressure You to Do the Wrong Thing* Stay Humble, Consider the Input of Others, But Make Confident Decisions

* Sign Up for Disability Insurance Before You Complete Residency* The 3 Reasons Doctors Lose Their Career are Disability, Substance Abuse, and Sexual Harassment Issues* Read the Book of Ecclesiastes* Emergency Medicine Sucks Sometimes

Step 1: Start Patient on Volume Assist-Control Ventilation

* The most basic mode of ventilation* Provides a FIXED VOLUME at a FIXED RATE* If the patient over-breaths…* The ventilator will give another FULL breath* Can cause breath stacking and be uncomfortable in patients who are poorly sedated* This is not a problem in the ED because patients are typically deeply sedated

Step 2: Know your oxygenation and ventilation goals

* Oxygenation (getting oxygen in)* Try to keep O2 saturation >92%* Ventilation (getting CO2 out)* Try to keep pCO2 <40

Step 3: Know the 4 Most Important Settings on a Ventilator

* FiO2* The concentration of oxygen* Room air is 21% oxygen (or 0.21 on the vent)* Maximum is 100% oxygen (or 1.0 on the vent)* PEEP* The pressure applied during exhalation* Typical starting point is 5 (but can be increased significantly)* “Recruits” and opens alveoli* Tidal Volume* The volume of air moved during each cycle of the vent* Respiratory Rate* How fast the ventilator cycles/breaths for the patient

Step 4: Improving the patient’s OXYGENATION

* FiO2* Increases the amount of oxygen present for exchange in non-damaged alveoli * PEEP* Increases the number of alveoli available to exchange oxygen

Step 5: Improving the patient’s VENTILATION

* FORMULA: Minute Ventilation (MV) = Tidal Volume (Vt) x Respiratory Rate (RR)* Increasing either of these will improve ventilation

BONUS

* Patients with COPD/asthma* Have tendency to not get full breath out (“breath stacking”)* “Plateau pressures” will increase above 30* Can damage alveoli* Can cause pneumothorax* Treat by increasing the I:E ratio* Quick inhalation* Longggggggggggggg exhalation

Additional Reading

* Breathing (EM Clerkship)* Dominating the Vent Part 1 (EMCrit)* Dominating the Vent Part 2 (EMCrit)

C→ Episode Summary

Introduction

* What is rabies?* A very rare and aggressive encephalitis* Global impact with exception of UK/Australia* Animals whose bites/scratches may require prophylaxis* Bats* Dogs, Cats, Ferrits* Other carnivorous animals* Foxes, Coyotes, Skunks, Raccoons* Post exposure prophylaxis* Both Rabies vaccine and immunoglobulin

When Do You Give Rabies Prophylaxis?

* Step 1: Bitten or scratched by domesticated pet?* Immunization status of pet does not matter* Animal must be monitored* Give prophylaxis if animal develops encephalitis* Step 2: Bitten or scratched by wild animal? * If animal is captured it can be sacrificed and tested* Give prophylaxis the animal is not captured and is a potential carrier* Step 3: Possible bat scratch/bite?* Give prophylaxis if the patient (or baby) cannot confidently say “NO, I DID NOT GET BITTEN OR SCRATCHED BY THE BAT”* Step 4: Do NOT give prophylaxis if the animal is not a carrier of rabies (check local guidance)* Reptiles* Birds* Small rodents* Rabbits/Hares* Livestock* Step 5: How to give prophylaxis* Only contraindication is severe egg allergy* Can be given to babies/pregnant women/etc* Rabies immunoglobulin* Give ONCE in the department* Inject as much as possible around wound* Rabies vaccine* Give first day* Have patient come back for more doses on day 3, 7, 14 (and SOMETIMES 28)

Pearls

* It doesn’t matter if the bite/scratch was provoked or unprovoked* It doesn’t matter where on the body the patient received the bite/scratch* It’s a universally fatal disease* No rabies in small rodents, reptiles, birds, squirrels, hamsters, rats, or rabits* The NNT is >300,000 (but we still do it)

Additional Reading

* Rabies Guidelines (CDC)

The only chief complaint that you are guaranteed to eventually have to manage in a colleague

Respiratory Exposures

* Meningococcus​ (meningococcemia, meningitis, etc)* Give prophylaxis (ceftriaxone) if…* Intubated a pt without a mask* Suctioned a pt without a mask* Performed mouth to mouth resuscitation* Tuberculosis​ * CDC recommends testing if exposed* Treat if positive* CDC recommends prophylaxis in..* Little children, HIV positive, immunosuppressed

Cutaneous Exposures (Broken Skin, Mucous Membranes, Needle Stick)

* Hepatitis B​* Test source patient* If positive, 1-30% risk of transmission with needle stick exposure* (Mucous membrane/broken skin exposures are much lower risk)* Test exposed colleague for anti-HepB surface antibody level* If source patient is positive and coworker is not fully immunized…* Treatment * Hep B Vaccine* Hep B Immunoglobulin* Hepatitis C​* Test source patient* If positive, 2% risk of transmission with needle stick exposure * (Mucous membrane/broken skin exposures are much lower risk)* Get baseline hepatic function labs (LFTs) in coworker* Follow-up on outpatient basis, no prophylaxis available* HIV​* Test source patient with rapid HIV test* If positive, 1/300 risk of transmission with needle stick exposure* Transmission risk increases if: bloody exposure, large needle bore* (Mucous membrane/broken skin exposures are much lower risk)* Generally recommend prophylaxis if source is positive* Prophylaxis is potentially curative if given at exposure* Counsel on safe sex practices* Counsel on common treatment side effects* GI symptoms, headaches, fatigue

Additional Reading HIV Occupational Exposure Guidelines (US Public Health Service)

All breast complaints are cancer until proven otherwise!!!

History

* Increased risk of breast cancer* Family history of breast cancer (especially 1st degree)* Delayed childbearing (no children until after 30)* Age >50* Associated with menstrual cycle

Exam

* Asymmetric appearance of breasts* Palpable mass* Red Flags* Non-mobile* Overlying skin changes* Lymphadenopathy* Located in upper/outer quadrant of breast

Differential Diagnoses

* Red/inflamed/painful breast* Postpartum engorgement* Treat with warm compresses, continue breastfeeding/pumping, massage* Infection (“Mastitis”)* Treat with antibiotics and continue breastfeeding* Abscess* Treat with needle aspiration* Refer to breast surgeon* Non-inflamed breast pain* Fibrocystic changes* Associated with menses* Treat with supportive bra* Breast mass* Fibroadenoma* Slippery/mobile* Fibrocystic changes* Nipple discharge* Red flags* Unilateral discharge* Bloody discharge

Additional Reading

* Breast Cancer Screening Guidelines (CDC)