Psychiatric Complaints in the ED — What to Keep in Mind

Author: Victoria Weston, MD
AAEM/RSA President

Originally Published: Common Sense, September/October 2015

A familiar scene in many emergency departments: you are on a busy overnight shift. You have just finished caring for a trauma patient and your part of the ED is filled with high-acuity patients. You see that a new “crisis” patient has been placed in a room, so you go assess him. You find a disheveled young male with flat affect, who appears to be responding to internal stimuli. He is able to tell you that he had a recent inpatient psychiatric hospitalization. He is not taking his medications. He agrees to be seen by the crisis team. You leave and return to your desk to run the list and get caught up on charting.

Tourniquet Application for Isolated Extremity Injuries

Image Credit: Staff Sgt. Terri Reece

Author: Kaylinn Dokken, OMS4
Western University of Health Sciences

This post was peer reviewed.
Click to learn more.

As we walk onto the scene wearing our bulletproof vests, we see a spray of blood up the white wall of the apartment, leading us to our patient. He is holding direct pressure on his arm where he had been shot. As soon as the pressure is removed, bright red, pulsatile blood sprays from the wound. Quickly, the paramedics I am riding with that day apply a tourniquet to the patient’s arm, and the bleeding is stopped.

Tourniquets have been used in the military through many wars, although their use was inconsistent, which led to poor outcomes for those with devastating limb injuries. At the start of the Iraq War, tourniquet use increased but was still inconsistent resulting in approximately 2% of soldiers dying from isolated limb exsanguination. There has been an increasing body of evidence showing favorable outcomes associated with tourniquet use. Due to the more consistent use of tourniquets through wartimes, exsanguination from isolated limb injuries is no longer considered a top cause of preventable death of US soldiers.[1]

The Proper Start to Your Financial Journey

Photo: Flickr - Alan Cleaver

Author: James M. Dahle, MD
Author of The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing

Originally Published: Modern Resident, August/September 2015 

I’m occasionally asked to give very young physicians, i.e., students and residents, some financial advice. Typically these doctors have a low income, a dramatically negative net worth, little financial education and plenty of naiveté. In fact, I was recently questioned by a student how anyone could possibly spend more than $10,000 per month (to which I replied that I spent more than that on taxes alone.) The truth is that many of these physicians will find themselves spending more than $10,000 a month long before their net worth even reaches zero.

The most important advice I can give any student or resident is to LIVE LIKE A RESIDENT. That means not taking out additional loans during residency (you might be surprised how many of your peers cannot live on a resident’s income) as well as living a lifestyle similar to that of a resident for two to five years after residency. The slower you can grow into your attending physician income, the better off you will be financially. It is entirely possible to pay off your student loans, save up a big down payment for your dream house and be closing in on millionaire status within five years of residency completion. But most docs won’t be in that situation, and some docs will never get there, all because they grew into their peak income entirely too quickly. Make plans now to avoid being in this situation.

Recovering from Leg Day: Rhabdomyolysis in the Emergency Department

Image Credit: Image from James Heilman, MD

This post was peer reviewed.
Click to learn more.

Author: Jeffrey Chen, MSIII
University of California San Francisco

Case: A previously healthy 18-year-old male comes in to the pediatric emergency department complaining of severe bilateral soreness and weakness of quadriceps and dark tea-colored urine for 1 day. Yesterday at the gym he performed heavy squats and lunges consecutively for one hour and drank minimal water. He denies recent URI symptoms or trauma.

Vitals are within normal limits. On exam, the patient’s anterior thighs are hard, swollen, and tender to touch and have limited passive and active range of motion. Sensation and capillary refill are normal in the distal lower extremities. Serum creatine kinase levels are 41,000; other labs include: BUN 14, Creatinine 0.73, Potassium 4.4, Phosphorus 3.8, Calcium 8.8. Urine dipstick is positive for blood, though no RBCs are seen on microscopy. MRI imaging shows edema and inflammation of the anterior compartment of the thighs, with patent blood vessels and no evidence of nerve damage (see image 1).

Be a Non-Terrible Intern in Ten Easy Steps

Image Credit: ReSurge International

Author: Gregory Wanner, DO PA-C

Thomas Jefferson University Hospital

Welcome to residency! Now that you’ve had some time to learn the hospital computer system, find the coffee maker, and begin to settle into your new role as an intern, it’s time for a few tips. Intern year is tough. You have a whole new set of responsibilities, and for some this is your first “real” job. There are many ways to be a terrible intern, but you can avoid terribleness and become a wonderful intern.

Over my ten years in medicine, initially as a physician assistant and now as a senior resident, I’ve had quite a bit of exposure to interns. Plus, I was one not so long ago. As interns we all have times — often brief — when we feel brilliant, as well as times we feel completely incompetent. We have moments of enlightenment and moments when we need to be bailed out by nurses or attendings. This is to be expected. The goal is to learn from your mistakes and eventually become a great physician. To learn what you can do to further your own education, keep your attendings relatively happy, and avoid terribleness: read on.