Gently instilling a fluorescein drop into a patient’s eye requires that the patient keep his/her eye still. What do you do for a patient who can’t quite stay still enough, such as an infant? This is an innovative trick of the trade, written by Dr. Sam Ko (Loma Linda EM resident) and Kimberly Chan (Loma Linda medical student).
We commonly encounter ocular complaints in the Emergency Department. Eye pain can result from chemical exposure, a foreign body, or infection. The first step involves instilling a few drops of topical anesthetics, such as proparacaine, to provide some pain relief. Occasionally, however, you encounter a patient who just can’t keep his/her eye open because of the fear of eyedrops.
Bedside teaching is a unique educational skill, which academic faculty are often assumed to just know how to do. In the ED, it is especially difficult to do this well, because of crowding and unexpected time-sensitive clinical issues, which create distractions and general chaos. Experientially, unpredictable clinical issues negatively impact bedside teaching. Thus, faculty should be flexible and knowledgeable of basic bedside teaching tenets.
Patients can present to Emergency Departments with esophageal foreign bodies. Recently, a patient presented with a doxycycline pill stuck in her esophagus at the mid-chest level. She was taking it for pneumonia. Despite drinking deluges of water for the past 12 hours, the pill remains stuck. You know that doxycycline (pills shown on right) is one of several medications (along with iron or potassium supplements, quinidine, aspirin, bisphosphonates) known for causing erosive pill esophagitis.
She presents to your ED.
With so many direct visualization tools in the ED now available to emergency physicians such as Glidescopes and nasopharyngoscopes, you might be tempted to take a look. However, you can first take a low-tech approach to propel the pill into the stomach. Each of these options has its unique risks and complications, and the risks/benefits should be weighed appropriately.
Instead of pharmacologically moving the pill into the stomach, you can also consider mechanically pushing the pill down using an orogastric tube or blindly pulling it out through the mouth using a foley catheter.
Trick of the Trade: What did we do? Before we entertained the pharmacologic options, we gave the patient a can of Ensure, because it has a higher viscosity than water. Fifteen minutes later, the pill was pushed into the stomach and the patient’s foreign-body symptoms resolved. A simple $1.50 solution.
Tell all your patients receiving doxycycline to drink plenty of fluids when taking the medication.
These low-tech solutions are only appropriate for pill foreign bodies and impacted food boluses in the esophagus, which are at low risk for esophageal perforation. These are NOT applicable to special situations such as button batteries, sharp objects, fish/chicken bones, and coins.
One shared experience amongst all emergency physicians is the “handoff” or “signout” of patients at the end of your shift to the oncoming physician. A recent article in Annals of Emergency Medicine explores and explains how this process can often lead to delays and errors in patient management. Just envision ED handoffs as a high-stakes game of Telephone, which you played as a child.
Did you know that a medical guidewire consists of a flexible central “ribbon wire” externally wrapped with a coil-spring wire?
J-shaped guidewires are commonly used in many medical procedures, such as central lines, arterial lines, and pigtails for pneumothoraces. Knowing more about the guidewire makes it possible to carry out a unique Trick of the Trade. For example, let’s say that the plastic introducer is missing or unusable. Using one hand to stabilize the needle in the patient, how do you use your other hand to re-insert a curved guidewire tip into the hub of a needle?
A large part of the reason why I love academics so much is that I get to meet really inspiring emergency physicians, who are passionate about their cause. I can’t imagine a more dedicated person than my friend Dr. Lisa Moreno-Walton, who is the Associate Program Director at LSU in New Orleans.
My academic niche is translational research. When I started my residency in EM, I had no clue that I liked research; in fact, I thought it was boring. My mission and my passion was providing excellent clinical care to under-served populations. I knew that I wanted to do academics, because the opportunity to teach residents to deliver good clinical care with compassion and respect is a great way to serve even more patients, indirectly.
In my last year of residency, one of my mentors, Dr. Yvette Calderon, used her great persuasive powers to get me involved in a research project. And suddenly, I saw the light. Not only did I love doing research, but I also realized that by doing research and establishing best practices through evidence based studies, I would be able to improve the care of hundreds of thousands of patients during the course of my career. That is both humbling and exciting. Also, I am the kind of person who is always asking questions. I want to know why we do things the way we do them in the ED. I always wonder if there is a better way. And I wonder why certain diseases or injuries evolve the way they do. Research is the way you get the answers to your questions. So, now, I have three professional passions!
The most important thing I’ve learned from my mentors is to choose the right mentor. I got the best advice on the characteristics of a good mentor when I attended the AAMC Minority Faculty Development Seminar, and I would be happy to share what they taught me:
Now, that being said, the second most important thing I learned from my mentors is that you must be willing to work very hard and you must follow through. It does no good to have your mentor opening doors for you if you don’t walk through them, or to have him get you a speaking opportunity and then you show up unprepared, or for him to get you on a national committee by saying that you are enthusiastic and a hard worker, and then you turn out to be a slacker. You discourage him, you ruin your reputation, and you ruin his credibility for recommending the next mentee who comes along.
Dr. Peter Deblieux on PBSMy mentor is Dr. Peter DeBlieux, and he is an absolute rock star. He is not interested in research, but he has a real gift for moving a young faculty member through all the right steps to achieve her career goals and get her from one success to another. He knows when I am taking on too much, when I am not focusing on the right things, when I am not organizing my tasks and dividing my time appropriately. I may not always love everything he tells me, but he tells it to me straight and his advice is always on target.
I remember Peter being interviewed on TV multiple times post-Katrina. He is consistently so poised and well-spoken. You are lucky to have him as your mentor. I totally agree about Peter being a rock-star, although he’s got a mischievous side to him…
Well, I’m the Chairman this year, and thanks to Dr. Michelle Lin, we have actually recently realized one of our goals. For a long time, we have wanted to be involved in a virtual advisor program where we could be available to students who come from under-represented minority groups, who are interested in EM but may not have doctors in their family group or among their friends who can advise them, or who may not have had opportunities to be exposed to research or science in school.
We are also in the midst of doing a study to look at how women and racial minorities are represented in academic EDs around the country. A similar study was done just over ten years ago, showing that women and URMs are under-represented at all levels, but especially at the higher academic ranks of Associate and full Professor. We wonder if the disparities have in any way changed. And we wonder how leaders in EM feel about these disparities and whether there is a motivation to change them.
Eliminating disparities for our patients and within our profession is what the DIG is all about. We are dedicated to the concept that EM is better for everyone when health care disparities are eliminated and when there is parity in the work place. And our success depends on the continuous influx of committed, effective young students and residents. Everyone of us needs to have one hand up, reaching for the next rung on the career ladder, and one hand down, pulling the other folks up behind us.
Well, my major project is the study of the effects of moderate alcohol intoxication on the secretion of epinephrine, norepinephrine, and arginine vasopressin in the trauma patient. This week, I will also start to work with one of the basic scientists at the Medical School who is studying the effects of alcohol on the regulation of mononuclear cell tumor necrosis factor production in the murine model. Tumor necrosis factor is a significant marker for sepsis. Should this relationship prove to be significant, we will be developing a study to quantify this relationship in trauma patients. We know that intoxicated trauma patients develop sepsis more frequently than unintoxicated patients, but we don’t fully understand why or what can be done to prevent it.
This week, I will also attend classes at Tulane, where I am studying for a Masters Degree in Clinical Research, I will work a shift in the ED side by side with my excellent residents, I will moderate a didactic clinical conference for our residents, and I will work with a few residents on their clinical research projects. One resident will start a project with me this week looking at the effectiveness of an educational intervention designed to encourage patients admitted for ROMI/ACS to modify their cardiac risk factors.
Yesterday, I completed the writing of a manuscript and did some of my committee work for the SAEM Diversity Interest Group. Later in the week, I will start the research to put together a lecture that I’ll be giving at AAEM in February.
So, by looking at my work week, this is a pretty average week for me. You can really see that Emergency Medicine provides me with a very well rounded professional life. I can see patients, do bedside teaching, do didactic teaching, and do both clinical and translational research. I get to be a learner and a teacher. I have the stimulation of working with students and residents, and of interacting with basic scientists who do work that is substantially different from what I do in the ED. I am able to serve my patients and my colleagues with work in national EM organizations, and I am beginning to have opportunities to publish and to lecture nationally.
I work with a really outstanding group of dedicated and really smart EM faculty and residents in a really terrific city, where I enjoy living and spending time with my family. I have a mentor, a Medical School Dean, and my Masters program advisory faculty who really want to see my career progress. I can’t imagine that anyone who does anything else for a living could be as happy as I am doing EM at LSU. I mean, my work is not work…it’s a pleasure!
I’m living my dream.
Wow, Lisa. You are indeed living the dream. You are the epitome of a classy academician. Keep up the great work.
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