The Case of the Buffalo Chest

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Author: Jeffrey Chen, MSIII
UCSF School of Medicine

Case:
A 73-year-old man with a history of severe multi-vessel CAD status post CABG surgery 9 weeks ago presents after a high-speed motor vehicle collision with worsening SOB and chest pain. On exam, he is in acute distress, with a pulse of 102, blood pressure of 129/64, respiratory rate of 28, and saturating at 91% on 100% Oxygen NRB. The left chest has decreased breath sounds and is hyperresonant to percussion. Trachea is midline. A rapid chest X-ray shows a fractured left 7th rib and a corresponding large pneumothorax on the left with no evidence of tension. A chest tube is placed without any complications and connected to suction; his oxygen saturation improves to 98%, and his other vitals stabilize. A repeat CXR confirms successful placement of the tube, mild reinflation of the left lung, and a small pneumothorax on the right side that was not noted on the previous X-ray.

Diagnosis and Management:
In this gentleman who suffered a blunt traumatic pneumothorax on the left, there are a few possibilities to explain why he subsequently developed a pneumothorax on the right. First is a small traumatic pneumothorax that was already there on the right that was not visualized on the first film. Next is mediastinal damage during the placement of the left-sided chest tube, though there were no complications described in this case.

Blakemore, Bleed Less: Massive Upper GI Bleeding and the GEBT Tube

Image Credit: Gregory Wanner, DO PA-C

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Author: Gregory Wanner, DO PA-C
Emergency Medicine Resident, PGY-3
AAEM/RSA Publications Committee Chair '16-'17

Author: Dimitrios Papanagnou, MD, MPH, EdD(c)
Assistant Professor, Emergency Medicine

A version of this article was previously published on the Jefferson Emergency Medicine Residency Blog (www.jeffem.org), March 2016.

It’s 3 am on a Saturday and you’re covering the emergency department at a community hospital. You hear a nurse’s firm but slightly nervous-sounding voice from down the hall say, “Umm, I need some help in here.”

You enter the room and find a geyser of blood erupting from the mouth of a middle-aged, male patient. His family informs you that he is a heavy drinker and has “liver problems”.

What do you do?
After applying triple-G protection (gown, gloves, and goggles), you slide towards the patient and begin to perform the critical actions associated with establishing large bore IV access, securing the airway, transfusing blood, starting octreotide, and calling GI. The patient keeps bleeding. He is severely hypotensive and GI is unavailable.

Lessons from the 2016 Match

Image: Common Sense

Author: Mike Wilk, MS4
Medical Student Council President '15-'16 
Originally Published: Common Sense, May/June 2016

The 2016 match in emergency medicine continued the trend of rapid growth and a bright future for our great specialty. In comparing this year’s NRMP data to last year's, the number of EM programs increased from 171 to 174 and positions increased from 1,821 to 1,895. The number of applicants rose from 2,352 to 2,474 and USA senior medical student applicants rose from 1,613 to 1,693. Only one EM position in the entire country went unmatched. The match rate for American senior med students was nearly 88% (data on whether these students ranked other specialties above EM are not yet available, so the actual match rate may be higher). The number of American MD seniors filling these positions held steady at 78.4%, from 79% the previous year. Based on these data, it looks like the number of new programs and positions continues to balance consistently high demand for EM residency slots.

From sending applications to doing rotations away to Match Day, I want to share a few lessons I learned on the way to securing my own EM residency position.

Lesson 1: Applying for Away Rotations (January-March)
I planned to do my residency in the same city where I attended medical school, so when I began the process of applying for away rotations I applied only to programs in my area. I recommend doing your away rotations in the region you want to be in for residency, as this can affect whether or not you get an interview at certain programs in that region. It is not the end of the world if you don't do a rotation in a specific region though (more on that later). I ended up rotating at both a very strong community program and a very strong academic program in my area. I also recommend that you vary your experience by rotating at different types of programs — such as county, academic, and community hospitals — since they really do have different training environments and their faculties and house staffs will be populated by different kinds of personalities.

Lesson 2: Applying through ERAS (September-October)
Speak with an experienced EM adviser who can give you honest advice about the strength of your application, and tell you how many programs to apply for through ERAS. Many of my friends committed minor errors, such as not realizing interview invitations were going to the spam box and not assigning letters of recommendation to each individual program. Check and double check your ERAS applications, and please check your spam folder throughout the entire application process!

How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 1

Image Credit: Flickr

Originally Published: Common Sense, March/April 2016

Author: Gregory K. Wanner, DO, PA-C
Thomas Jefferson University

Author: Andrew W. Phillips, MD, Med
Stanford University, Division of Critical Care

Read part 2 here: Improving Efficiency for Residents


Residency is a time for improvement. Improving procedural skills, gaining clinical acumen, and growing knowledge are chief goals during residency. Efficiency is also a necessary skill for the budding emergency physician. After learning the core knowledge of emergency medicine and becoming competent in procedures, efficiency is the next item for residents to emphasize. How can efficiency be improved? How can residents tell if they’re moving too slowly or too quickly? How can a resident improve efficiency without missing important details or skimping on documentation? We will answer these questions in a two-part series. In this first article, we will review the average patient volume seen by residents, the concept of relative value units (RVUs), and touch on the idea of efficiency. In part two, in the next issue of Common Sense, we will discuss methods for improving efficiency based on expert recommendations and research.

Patients Per Hour
Residents often ask, “How many patients should I see per hour?” The answer is complicated. A resident’s patients per hour (pts/hr) rate depends upon many factors. Table 1 provides a general idea about the average number of pts/hr seen by residents. Several studies indicate that the pts/hr increases from intern year to senior year. However there is some overlap between each year of training. Across all included studies, interns (PGY1) averaged from 0.73 to 1.06 pts/hr; PGY2 residents ranged from 0.85 to 1.33; and senior (PGY3) residents ranged from 1.05 to 1.41.[1-8] Administrative and supervisory responsibilities also increased for senior residents, perhaps reducing the number of pts/hr for PGY3 residents to some degree.[3-4] As a comparison, two studies evaluated patients seen per hour by attendings. A retrospective study of 912 attending physicians at 61 EDs showed an overall average of 1.72 (SD=+/- 0.44) pts/hr, with physicians at higher volume (over 45,000 visits/year) EDs seeing 2.07 (SD=+/- 0.32) pts/hr.[9] Another study of attending physicians indicated an average of 1.87 pts/hr while working alone and 1.99 pts/hr while working with residents.[10] Bear in mind that this is at academic centers — by definition, since we’re discussing residents. Moreover, the numbers reflect not only physician speed but also patient demographics, such as whether or not pediatric patients are included or if there is a Fast Track that siphons away less complex patients – factors which are generalized in our summary.

6 Elements to Consider When Making Your Rank List

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Author: Matthew Camara
MSIV - Ross University
International Rep, AAEM/RSA Medical Student Council '14-'15

When interview season is underway, students have the task of putting prospective programs into a rank list. It may be beneficial to start creating a preliminary rank list based on information that is available to you for each program. As you complete your interviews you can move programs up or down until you’ve created your final rank list.

While these are not in any particular order, they are all things to consider while putting your rank list together.

1. Location
Many students have already considered geographical location when applying to residency programs, but as EM has become more competitive students are applying more broadly. When making your Match list it is still important to consider where you will be living for the next three to four years. Consider the climate, living expenses, things to do in the area, and how far away you are willing to be from family and friends. If you have a significant other, but are not going through the Couples Match, ranking in the same geographical location is something that may be more important to you than other candidates.

2. Three vs. Four Year Program
A major consideration when creating your rank list is whether you feel a three or four year program is right for you. Both have benefits as well as downsides. Three year programs offer a faster route to begin your own practice or fellowship. Whereas four year programs offer an additional year of mentored training that some feel make you more appealing to prospective employers. Three year programs also offer a financial advantage over a four year program, as you make an attending’s salary one year earlier. However, hospitals with a four year residency program may not hire a new graduate from three year program without an additional year of experience. Also, three year programs may be more congested with less elective time compared to a four year program. Some would suggest that the added time in a four year program allows you to explore possible niches within EM. Opinions on the ideal training length will continue to vary, but ultimately both models offer excellent training for EM physicians. What matters is that you find the right training model to fit you.

3. Community vs. University Program
Both community and university programs offer great training experiences. While both will prepare you for a successful career, each have unique differences. Community hospitals tend to have smaller residency programs with less total residents. Often there are plenty of procedures and hands on time with limited competition from residents in other specialties. Community programs also mirror the practice setting that a majority of graduates will go into after residency. On the other hand, university hospitals generally have a greater focus on research and academics. Often they have more resources at their disposal which allows them to practice medicine that is cutting edge. University hospitals also tend to be tertiary care centers where you can see a diverse patient population with complex pathology leading to unique experiences in off-service as well as ED rotations.

It is important to keep in mind that many programs blur the line between these two types of institutions. University programs have community ED rotations, and some community programs are affiliated with university centers. It ultimately comes down to researching the specific program to see what experiences they offer to their residents, and deciding what setting will be best for you.

7 Tips for Selecting Your EM Audition (Away) Rotations

Image Credit: Flickr

Author: Michael Wilk, MSIV
President, AAEM/RSA Medical Student Council '15-'16

1. Apply for Your Rotations Early
Keep in mind some programs open their applications as soon as January. Check VSAS and EM programs’ websites for more information on when their applications open. Given the current popularity of EM, audition rotations are as competitive as ever. In fact, one program I applied to actually informed me that they had over 250 students apply for the six spots per month that they offer. In this case, the early bird gets the worm.

2. Location, Location, Location
Interested in matching in highly competitive areas such as California, New York City, or somewhere near your family? Rotating in those cities of interest, or at least in the general region, will increase your chances of receiving an interview at other programs in the area. However, keep in mind they can be very expensive and stressful, as you have to live in another city and may be living out of a suitcase for an entire month.

3. Academic vs. Community vs. County
The patient populations and experiences at different programs vary greatly. While still in medical school, it may be hard to know in what type of program you want to spend the next few years of your life. Rotating through at least two different types of programs (i.e., community and academic) can help you decide that before application season. If you are really interested in research and teaching, an academic program may be the best route for you.

BRUE, The New ALTE

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Author: Danielle Goodrich, MD PGY-3
Stanford/Kaiser Emergency Medicine

In May, the American Academy of Pediatrics published new clinical guidelines to replace ALTE (Apparent Life-Threatening Events) with BRUE, Brief Resolved Unexplained Event. The new guidelines, in addition to defining BRUE, offer an approach to evaluation based on risk of repeat event or serious underlying disorder. The goal of the clinical guidelines is to better inform care while reducing costly and unnecessary interventions. The guidelines were devised from a comprehensive literature review of articles related to ALTEs from 1970 to 2014.

BRUE describes an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, now resolved episode with one or more of the following: (1) cyanosis or pallor, (2) absent, decreased or irregular breathing, (3) marked change in tone, and (4) altered level of responsiveness. The diagnosis is made when there is no explanation for a qualifying event after a thorough history and physical exam. BRUE and ALTE definitions differ as BRUE characterizes the event based on physician not caregiver observations and includes an age limit.

How to Give a Great Presentation to Your EM Attending Physician

Image Source: Bigstock

Author: Jennifer Stancati
Midwest Regional Representative
AAEM/RSA Medical Student Council '14-'15

Most students would agree that presenting a patient on rounds or to your attending is one of the scariest parts of being a third or fourth year medical student. Whether you are in a group or one-on-one, all eyes and attention are on you. There is the potential to do or say something incorrect, embarrassing, or perhaps you might not know the answer to a question that you are asked. Also, depending on the level of responsibility that you are given, what you say can have a large impact on the course of a patient’s visit. As if this was not enough, there is the fact that you are being evaluated. And in a busy environment like an emergency department (ED), this may be the only interaction that you have with your attending physician.

Being in the environment of the ED adds a few more factors into the equation. You may have been rushed and your history or physical may feel incomplete. Or as you are getting ready to present, your attending may say, “just give me the pertinent information; nothing else.” And last but not least, your patient may be really sick and in need of immediate help. If your patient is truly sick and needs immediate attention, it is important to get your attending (or resident) in the room before you even complete your history and physical. Not only is this the right thing to do for your patient, but also you will demonstrate your ability to recognize an unstable patient.

Tips for Tackling the Pediatric Trauma

Image: Bigstock

Author: Shyam Sivasankar, MD
Emergency Medicine Resident
Stanford-Kaiser Emergency Medicine
AAEM/RSA Publications Committee Member

This post was peer reviewed.
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I am very fortunate to train at a facility with a child life specialist present in the emergency department. Their presence has helped me learn a lot about running pediatric trauma surveys and resuscitations, and I have picked up a few pearls along the way. The following are some of their tips, tricks, and suggestions.


1. Calming Distractions 

A trauma resuscitation can be quite overwhelming for an adult, let alone for a child. Use age appropriate interventions for each child including, but not limited to:

• Infants and Toddlers:
• Stuffed animals (for comfort) 

• Bubbles (to encourage deep breathing and relaxation) 

• Elmo Calls (Facetime™ with Elmo, a fun game for distraction) 

• School Age/ Teens: 
• iPads (or smart phones for distraction and teaching moments with patients) 

• Simply Sayin’ (a smart phone application, created in part by Phoenix Children’s Hospital. This application provides illustrations, a free-draw option, and video clips to help both patients and their parents understand what is happening while simultaneously lowering the anxiety level in the room.) 

• Stress ball for relaxation and stress management 

• Deep breathing techniques to support relaxation