QUB Scrubs Emergency Medicine 2008, Day 1

So, Day 1 (of 2) is over of the QUB Scrubs Emergency Medicine conference for 2008. It was pretty good, although a lot of the morning lectures I've heard before (ABCDE, causes of SOB/ACS, etc etc), but it was still fun because the friends who came with my from St. Andrews and I were passing writing notes to one another on our little notepads...

After lunch, there was a circuit of 6 skills stations, including Cannulation, ABG taking, ABG interpretations, some Sim-Man sessions with the Territorial Army, which were really awesome because I got to use my ABCDE skills from the ILS sessions as well as my EMT-B training from back home to care for a "soldier" (SimMan dressed in army gear) who had been a prolonged extraction from an crash.

Tomorrow looks to be interesting as well, with different lectures including things like Diabetic and Obstetric Emergencies, as well as more skills stations, like suturing and defibrillation. These topics are more fun than what you'd study in a medical assistant degree program.

Anyway, my friends and I are going to relax after a MASSIVE dinner at Villa Italia, and might just watch a movie and get ready for tomorrow!

-AMiB

Emergency Medicine Conference

Later tonight 3 friends and I are headed over to Belfast for the Scrubs QUB Emergency Medicine Conference (http://www.qubscrubs.co.uk/conference). I went back in first year when it was the first year of the conference, and I LOVED it. It looks to be bigger and better this year, so I'm quite looking forward to it. I will hopefully post pics/update, but then again, I seem to be neglecting my blog more and more recently.

If by chance you're headed to the conference as well, drop me a line! (I'll have my laptop with me)

-AMiB

VizD winner!

Looks like I won last week's VizD challenge. If you haven't ever checked out NY Emergency Medicine, it's a great site, and it has a weekly challenge called "VizD":

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

Well, last week was clubbing, and since it was one of the only VizD challenges I have ever been able to answer fully of my own accord (eg without google/wikipedia), I submitted answers, and it looks like I won! It's always a plus when theres something random like this showing you that you're actually soaking up some of the information they throw at you :-P

So yeah, check it out!

-AMiB

What I Learned This Summer, Part 2

• When treating DKA, you cannot stop treatment before the bicarbonate has been corrected (~22-24)
• When a joint is inflamed, always feel the temperature - Warmth could be significiant of a septic joint
• When doing arthrocentesis of the knee, find the bottom of the patella, and go medial OR lateral (Dr. A thinks lateral is better)
• 7 Causes of Monoarticular Arthropathy
1. Septic Joints
2. Gonococcal Infection
3. Gout
4. Pseudogout
5. Bechet's
6. Trauma
7. Reactive Arthropathy
• Gout
• no need to tap if suspected in 1st metatarsal
• uric acid crystals found on microscopy
• 90% due to under-excretion of uric acid
• 10% due to over-production
• either way, Rx is NSAIDs + steroids
• in over-production, add allopurinol
• Pseudogout
• Calcium oxalate crystals
• Tx is NSAIDs and steroids
• Septic Joint will have >50,000 WBCs on microscopy
• True Iron deficiency shows low iron AND low iron saturation
• For the first 2 weeks s/p Acute CVA, allow for autoregulation of BP, except in hemorrhagic stroke
• AIDS
• CD4+ < 200 =" AIDS
• CMV Retinitis
• Toxoplasmosis
• Esophageal Cadidia
• TB
• MAI Reccurent
• Kaposi's Sarcoma
• Cryptosporidium
• Lymphoma
• General wasting, CD4+ count
• AIDS --> treat
• CD4+ < 350 =" treat
• CD4+ 350-500 = treat if >60,000 viral load
• CD4 >500 = don't treat
• If HAART works after 8 weeks, viral load should be gone
• If viral load is still present, they are resistant to part/all of the regime
• Geno/phenotyping to help determine what anti-virals to use
• Most common cause of Pulmonary HTN that is not easily explained is a chronic pulmonary embolus
• DVT's below the knee = no treatming
• DVT's above knee = Coumadin (warfarin)
• Recurrent DVT's = indication for continuous anticoagulation
• Best place to look on 12-lead EKG for A-Fib are in the inferior leads - II, III, aVF

What I Learned This Summer, Part 1

So, since I spent most of this summer prancing around the hospital in my shirt&tie or scrubs, pretending to be important, I decided I should have something to write down all the little tidbits that I pick up. Many of them are clinical "pearls", some are things that I just wrote down off of UpToDate (I mean uhh...my Attending stated it to me word for word, cuz stealing would be a Copyright Violation:-/), and some are just random things that a normal medical student would know that I didn't (aka the answers to pimping questions). So I decided it would be fun if I shared them with you. I've got 1 and a quarter (guesstimate) little shirt-pocket notebooks filled with info, so it make take more than 1 post. So without further ado, here we go:

• After every 6 units of blood, Calcium must be administered to help the clotting cascade.
• Consequences of Erythropoietin
• High BP (HTN)
• Seizures
• In Endocarditis,
• Janeway lesions --> no pain
• Osler nodes --> pain
• CLUBBING Acronym for causes of Clubbing
• C - cyanotic heart diseasse/Cystic Fibrosis
• L - lymphoma
• U - ulcerative colitis
• B - bronchiectasis
• B - bronchogenic malignancy
  
• I - idiopathic pulmonary fibrosis
  
• N - neoplasms
  
• G - granulomatous diseases
• Part of DDx of BRB in Stools:
• Diverticular bleed
• Aterio-venous malformations
• not too common
• usually in lower GI
• MMSE (Mini-Mental Status Exam)
• out of 30 points
• 28-30 = probably not demented
• 25-27 = borderline
• <25>
• ~13% of >75yo's have a MMSE <25
• Absolute Indications of Dialysis
• Pericarditis
• Fluid overload
• HTN
• Uremia
• N/V
• Creatinine >12 or BUN>100
• 2 Major Abx that cause Antabuse-like reactions when taken w/ alcohol
• Metronidazole (Flagyl)
• Isoniazid
• When UTI culture shows Proteus Mirabilis, a urea-splitting organism, investigations for staghorn calculi (e.g. Renal US) must be performed
• NEVER use Levaquin (levofloxacin) when pt is on Coumadin (warfarin) - raises INR dramatically (=bad!)
• Bicipital tendonitis - hold arm to chest wall; with flexed elbow, rotate humerus laterally while palpating the bicipital tendon (where bicep originates in shoulder) - if inflamed, will cause intense pain
• Pancreatitis (elevated Lipase) + Elevated ALT = Gallstone Pancreatitis
• 3 Leading causes of cough:
• Post-nasal drip
• Asthma
• Acid reflux (GERD)
• Pneumonia (PNA)
• crackles/rales
• CXR lags 3/4 weeks behind clinical (fever, O2 Sat, etc), even after pt feels better
• BUN more specific on CMP for PNA
• Put on abx: macrolide, 3rd generation cephalosporin, and broad spectrum flouroquinolone
• Septic Joint/Nongonoccocal arthritis is sometimes the presenting complaint in Infectious Endocarditis
• Causes of Macrocytic Anemia
• Reticulocytois (reticulocytes are macrocytes)
• Alcoholism
• Liver disease
• Interference with DNA synthesis
• Folate or Cobalamin (B12) deficiency
• Drugs e.g. hydroxyurea, methotrexate, etc
• Myelodysplastic syndromes
• Hypothyroidism
• Hyperlipidemia
• When Increased Creatinine or ARD is due to drug rxn, urine may contain eosinophils - test for them
• When alcoholic patients develop constipation, they develop hepatic encephalopathy - treat with lactulose to move bowels, and thiamine/multivitamins (e.g. banana bag - though these aren't used too much anymore)
• Pts with chest tubes/drains must be outputting 100mls or less over 24hrs before clamping off tube
• 6 Cardioprotective Agents
1. Statins
   
2. ACE-I/ARBs
3. Heparin/Lovenox (enoxaparin - an LMWH)
4. ASA (aspirin)
5. B-Blockers
6. Thrombolytics/TPA
• When dialysis patients get very itchy, its usually due to uremia
• Hypercalcemia can be secondary to malignancy - both solid tumours and leukemia
• 10-20% of cases are due to this, especially Breast & Lung, and multiple myeloma
• Occurs through:
• osteolytic metastases w/ local cytokine release
• tumor secretion of PTH-related protein
• tumor production of calcitrol
• Procrit (Epoietin) contraindicated in sickle-cell patients - does not differentiate between sickle cells and normal cells, so more of both are made (=bad!)
• In new-onset Type II Diabetes Mellitus, when trying to determine whether to start insulin or oral agents, use a fasting blood glucse of ~400 (mg/dL NOT mmol/L) as a barrier
• Below, use oral
• above, use insulin - but remember, insulin has side-effects!
• In pregnant DM patients, DO NOT use oral medications - insulin only!!
• When I/O is negative (down), you expect H&H to go up (less blood, more cells). If it goes down, check for active bleeding
• Esophageal Spasm, which can cause CP & mimics AMI symptoms can also be relieved by NTG
• AST + ALT in 1000's = Toxic (eg Tylenol OD)
• Normal AST/ALT with Increased Bili = obstruction
• Nitrofurantoin (Macrobid)'s major side effect = Irreversible Pulmonary Fibrosis
• Intracranial HYPOtension Triad:
• MRI showing sagging of the brainstem
• Bilateral subdural hygromas
• Diffuse dural enhancement
• Bronchiectasis (chronic infection of bronchi and bronchioles leading to permanent dilatation)
• Causes:
• Cystic fibrosis
• reccurent PNA
• immunocompromise
• Major bacteria:
• Staph Aureus
• Pseudomonas Aeruginosa
• Antibiotic most likely to cause C. diff infection - Clindamycin
• Can Flagyl (metronidazole - Rx for C. diff) cause C. diff? Yes.
• DVT's below the knee don't need treatment
• Pts on Metformin who are undergoing contrast studies need to hold Metformin for 48-72hrs after contrast administration, while monitoring BUN/Creatinine
• Do not enema/colonoscopy a pt with diverticulitis - you will perforate their bowels.

And with that, I will leave it till next time (it's late, whatever). If you have any questions/clarification, feel free to comment (I feel like I haven't been getting enough comments lately :-D)

-AMiB

Neonatal Opioid Withrdawal

3 day old AAM presents to the Emergency Room (at 2am) with agitation, excessive suckling, inability to sleep, etc. Upon further questioning of the Mother, we discover that during the last few weeks of the pregnancy, the mother was taking Percocet (and not small dose either, the 10/325 kind). Was discharged from the hospital today, fine.

After a little while, baby starts having seizures, etc. Scored an 8 on the Neonatal Abstinence Scale (although the NICU nurses determined he was a lot worse than that). Admitted to NICU (Neonatal ICU) for Neonatal Opioid Withdrawal. Treatment is Supportive care, except in cases of seizures, inability to sleep, and some other things (forgot to write it down off UpToDate).

Now, I'm not going to pass judgement on the mother or the condition of the baby...but, y'know, feel free to comment.

-AMiB

So, it's been a while...

Well, I know it's been quite a while since my last post (which was featured in a Grand Rounds [only the second time I've submitted a post]). Things have been busy, I have been doing some steady 6-day weeks at the hospital and 5-6 day weeks at the gym. Am finishing up now, was in the ER today, have one more shift with the Hospitalists tomorrow as well as a night shift in the ER tomorrow and Saturday night. Then it's a few days of relaxation until my return to St. Andrews!

Couple interesting things I saw today:

86yo M on Coumadin bit his tongue 2 days ago, hasn't stopped bleeding since. Dr. M (female ER doc) puts a single 4-0 Vicryl (absorbable suture) in the hole, and applies some gauze. A little while later, patient has still not stopped bleeding, so we put some gel foam (little pieces soaked in thrombin/fibrin) to help the clotting...the bleeding slows, but the patient is poorly complaint (retired psychiatrist, Chinese - not much English) and it takes 3 things of gel foam and a small piece of surgicell to get it to stop. INR was only 2.0, btw.

64yo F originally from Northern Ireland on Vacation, forgot both her insulin refills and her glucometer. Felt horrible (very compliant in past, never forgot insulin shots ever); we thought it would be an easy script, but turns out her sugar is 501. We give her fluids and some insulin, but she doesn't understand what 501 is. Then I realize - in the UK we do blood sugars in mmol/L, while in the US its mg/dL. So, here is something for all you guys out there who encounter this problem: 1 mg/dL = 0.0555 mmol/L. So if you find her BS to be 501, tell her it's 27. If she tells you she's normally 5-8, that means she's normally 90-144. Hope that helps!

Today was also my last day shift in the ER...it always happens that I have to leave just when the nurses/techs/docs are getting used to me being around and are starting to feel more comfortable letting me talk to pt's, etc. Oh well, I've got years of that left.

-AMiB

Nail guns...

Man working with nail gun.
Man shoots nail gun (on accident) through great toe.
Man admitted to hospital for surgical removal of foreign body and debridement.

Always feels good to know that my profession is the one that fixes these people, not the one that it usually happens to.

"Code Blue, 6West, Back Hallway"

So last night I was doing an overnight in the ER, and I had my first code of this summer. I've seen 5 or 6 in the past, and participated in 3 or 4, but this is the first one since I started at the hospital this June.

Dr. M (ER doc), the ER tech, and I, all head out of the ER and towards the elevators. We are met there by 2 ICU nurses and 2 Respiratory Therapists. We get up to the 6th floor, and head to the 'back hallway'. As we walk through the nurses station, I'm completely surprised as to how empty it was. They must all be with the Code, I figured. And I was right. As we enter the hallway, I see a scramble of nurses, frantically doing things to save the old man on the floor. I ask for the story, and try and see his face to see if he was one of ours (on the Hospitalist service - he wasn't). He's had had a couple stents placed this morning, and had seemed to be doing fine. He was taking a walk (who goes for a walk at 3.15am?!) with his nurse, when he started to feel faint, brady'd down, and collapsed. No pulse, no respirations - so the Code was called. After a couple rounds of CPR and drugs, we get him onto a bed and into a room. It was then that I realized how many people respond to a code. Roughly 30 nurses, techs, CNAs, 1 doc (which should've been 3 - the ER, the Intesivist, and the patient's Cardiologist), and a handful of Respiratory Techs.
I was standing outside at this point, and couldn't see much of what was going on. I did hear the patient, however: "GET OFF ME! YOU'RE KILLING ME! LET ME GO! LET ME GO!" (we were holding him still while trying to start an IV). These words were masking those of the Respiratory Tech: "Calm down, sir. Your heart stopped and we've had to CPR on you!"

Eventually, he stabilized, and Dr. M went off to talk to the patient's Cardiologist. He didn't feel much like coming in to write orders, and wanted to send his NP to do it. Now, I have nothing against NPs, but if you're a Cardiologist, and you cath'd someone this morning, and they Code: come in. What about the patients family? It's your responsibility to let them know what happened. But anyway, I digress.

By now, he's lost his pulse again. On with the compressions. We secure the airway with endotrachial intubation. The patient kept fluctuating between PEA, Asystole, and Brady, all the way down to the ICU. We get down there and continue compressions. Dr. M puts in a femoral arterial line to see if the compressions are working, as well as if the patient's heart is beating on its own.

At 4.116am, roughly an hour after the Code was called, Dr. M pronounces the patient. The monitor is turned off, and everyone stops what they're doing. We look down at him, and see that his larynx is moving. Either he's trying to breathe on his own, or he's swallowing. Either way, that's not what a dead person does. We feel for pulses: one on each fem, one on each carotid. One of the ICU nurses swears she feels a pulse. Other people feel it as well, so we turn the monitor back on - but they don't match. It's much faster than what is on the monitor. I tell them to feel their own pulse while they're feeling the patients. Yep, those match. I guess it kind of goes to show how much health care professionals want to save their patients. We listen for heart sounds, check reflexes - nothing. His throat was probably just agonal breathing (last breaths).

Time of Death, 4.20am.

15 hours?

So I just spent the past 15 hours in the ER...I think I coulda pulled off the full 18 hours (2 9-hour shifts with 2 different docs), but my parents don't take too kindaly to being gone for 18 hours at a time so I came home...

I really learn alot, and while the doc takes the history, I have started trying to guess their next question (which i'm horrible at) but also what tests they are going to order. I seem to always miss one or two big ones, but hopefully with time I'll get better.

Now please excuse me while I sleep for an unknown length of time.

Oh, how I miss it down here...

So ever since Dr. M (ER doc) gave up his overnight shifts, I've only been able to do 2 shifts a week with him in the ER. For a guy who has a semi-secret desire to be an ER doc, this is not enough. So tonight and [hopefully] tomorrow night, I will be doing some overnight ER shifts with Dr. M (a different one, who happens to be the only lady ER doc that we have). It should be exciting, especially since tomorrow is Friday night, and we're a Level II Trauma Center, meaning we get all the drunk fights and car accidents for 1/4 of our city.

Bring on the energy drinks!

-AMiB

Peds (Paeds) Trick

Learned a little trick in the ER for when you have 3 year olds whose eyes you need to look into:
Make them watch you do it to their parent, who is holding them. Do exactly what you are about to do to them, then say "OK, now its your turn!" Seemed to work out fine for the 2 young patients we had today (thankfully one did not have the head bleed we were worried about).

-AMiB

AMiB, Hospitalist Groupie. (and other stuff from a 12-hour day)

8am - Arrive at hospital, head to 7W. Dr. B, General Surgeon, is there seeing one of our patients. Funny story about that: We met Thursday when he and Dr. A were discussing the patient. Over the weekend, we went to a party for a family friend. I saw Dr. B, and and for a little while, I didn't recognize him - but then I did. Went over, talked for a bit. Turns out he went to a Uni not too far from mine, and now is practicing General Surgery at my hospital. Says that they'll be writing up the case, and wants to know if I'd like to help out and be published. To which I responded a calm, "Yeah, that'd be great." while inside thinking "HELLZ YEAH!!!". I don't want to get too excited now though, because I always do that and then things never turn out my way.
9am - Start with Dr. S, Hospitalist. Saw a lot of interesting patients. Can't remember any right know though. It's been a long day :-P
11am - Hospitalists Round meeting. As usual
12pm - We're waiting on a drug rep to bring us lunch. All of a sudden this guy from Boston Market comes in.
Boston Market Guy: I'm gonna need a place to put all this food.
Dr. A: Just use this desk.
BMG: Yeah....that's not gonna be big enough....
Dr. A: uhhh...seriously?
BMG: Yeah...well, I'll try.
BMG proceeds to take out large amount of food, including but not limited to: chicken, turkey, steak, corn bread, sweet potato casserole, vegetables, mashed potatoes, gravy, and chocolate chip cookies. It. was. amazing.
BMG then proceeds to tell us about a new use for an old drug, as well as 2 new drugs, which was useful, because we had a patient who needed one. We then scored a free pen and crazy-bright LED flashlight. Should I feel bad for being sucked in by drug reps? Probably. Do I? Absolutely not, lol.
1.45pm - Up on 4E, an amusing conversation:
Nurse (to me): So are you Interning or something? I always see you around with the hospitalists.
Me (to nurse): Nope, I'm just a student. I just follow whoever is on call and watch.
Dr. S: He is a trooper....He's like our groupie.
2.59pm - Finish with Dr. S
3.01pm - Head down to ER. Meet Dr. M, Emergency Physician. Ask to shadow. Start shadowing. I really missed the ER. Had 2 critical patients back to back, both were sedated and intubated using RSI. One was a drug overdose who started vomiting in the ambulance after Narcan administration, went into SVT. When I was leaving, they had tried cardioverting him with no effect. I think they tried some adenosine too, not sure.
8.35pm - Make the decision to leave (that's usually how it is in the ER, because once the new doc comes on, Dr. M stops seeing new patients).

Was quite an educational, eventful, and promising day. And now I am ridiculously tired, I still need to go on the treadmill, and I have to look up everything there is on the internet about SMA syndrome.

-AMiB