ALiEM’s Greatest Hits for Interns: A Curated Collection of High-Yield Topics

Congratulations, you’ve made it! On July 1, thousands of medical students across the country made the transition to becoming Emergency Medicine residents. It was a particularly competitive year for Emergency Medicine, with 99.7% of first-year spots filled despite a whopping 2,047 positions being offered in 2017 (up by 152 spots compared to last year).¹ Now begins the most crucial 3 or 4 years of your medical training that will prepare you for the rest of your career in Emergency Medicine.

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By Jeffrey Shih, MD, RDMS|2017-07-20T23:22:10-07:00Jul 21, 2017|Cardiovascular, Critical Care/ Resus, Gastrointestinal, Medical Education, Neurology, Ophthalmology, Pediatrics, Tox & Medications, Ultrasound for the Win|

ED Charting and Coding: Critical Care Time

After a STEMI activation from the field on Monday morning, the cardiac catheterization team scoops the patient away shortly after the paramedics arrive in the Emergency Department (ED). “Well that was a smooth and seamless resuscitation. The patient was barely in the ED for more than 15 minutes,” you think to yourself. You diligently complete your critical care documentation, noting 20 minutes of critical care time, before seeing your next patient. A few weeks later the chart is bounced back and noted as an erroneous documentation of critical care time. The coding department notifies you that the case will be billed as a Level 3 visit (E/M code #99283). Why is that the case?

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By Kenneth Dodd, MD|2019-02-19T18:51:56-08:00Jul 17, 2017|Administrative, Critical Care/ Resus|

Trick of the Trade: Rapid Insertion of Orogastric Tube

We have all been in the situation: an intubated patient needs an orogastric (OG) tube and no one has been able to place it successfully. Unfortunately, we typically find out about this situation after several failed attempts, when the patient is bleeding and/or the anatomy is distorted. It may coil in the mouth or esophagus. Here I present a novel technique to rapidly place an OG tube within seconds.
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By Paul Willette, DO, FACEP|2021-05-13T09:44:20-07:00Feb 13, 2017|Critical Care/ Resus, Tricks of the Trade|

PV Card: LVAD Complications

Patients with left ventricular assist devices (LVAD) often cause much anxiety amongst providers in the emergency department. This is understandable with all of the hardware, diminished or absent peripheral pulses at baseline, and potential for complications. To add to the already helpful reviews about LVADs at REBELEM and emDocs, this is a PV card set providing a methodical approach to troubleshooting LVAD complications, including a reproduction of an algorithm for managing the LVAD patient with altered mental status from EMCrit.^1–3

[Download PDF]

EXPERT PEER REVIEW: LVAD Complications

John Greenwood, MD
Assistant Professor
Department of Emergency Medicine
Department of Anesthesiology and Critical Care
Hospital of the University of Pennsylvania | Perelman SOM

Overall, a very well written summary for the ED provider faced with the challenge of managing the patient with an LVAD. These patients can be very complex, where the clinician may need to address a range of potential problems that can include hemodynamic complications, coagulopathy & bleeding, arrhythmias, and infection. After you initially assess the patient, the most important step is to task someone to get a hold of the VAD coordinator as they will often be able to guide you through any recent device changes and previous complications. The patient’s family can provide a wealth of information – use them! Knowing the most common complications will help guide your HPI, exam, and interventions so that you are well prepared for the next time a VAD patient presents to your ED.

Thumbnail LVAD image use approved by Mayo Foundation for Medical Education and Research

References

Partyka C, Taylor B. Review article: ventricular assist devices in the emergency department. Emerg Med Australas. 2014;26(2):104-112. [PubMed]
Andersen M, Videbaek R, Boesgaard S, Sander K, Hansen P, Gustafsson F. Incidence of ventricular arrhythmias in patients on long-term support with a continuous-flow assist device (HeartMate II). J Heart Lung Transplant. 2009;28(7):733-735. [PubMed]
Greenwood J, Herr D. Mechanical circulatory support. Emerg Med Clin North Am. 2014;32(4):851-869. [PubMed]

By Nicolas Stadlberger, MD|2021-10-02T19:11:24-07:00Nov 23, 2016|ALiEM Cards, Cardiovascular, Critical Care/ Resus, Expert Peer Reviewed (Clinical)|

AIR Series: Procedures Module (2016)

Welcome to the Procedures Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index the ALiEM AIR Team is proud to present the highest quality procedure content. Below we have listed our selection of the 13 highest quality blog posts within the past 12 months (as of June 2016) related to procedure emergencies, curated and approved for residency training by the AIR Series Board. More specifically in this module, we identified 3 AIRs and 10 Honorable Mentions. We recommend programs give 4 hours (about 20 minutes per article) of III credit for this module.

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By Andrew Grock, MD|2017-03-05T14:18:45-08:00Sep 12, 2016|Approved Instructional Resources (AIR series), Critical Care/ Resus|

Trick of the Trade: Tibial Intraosseous Line Stabilization in an Agitated Patient

With the advent of commercial intraosseous (IO) needles for vascular access, administering IV medications for patients in extremis has been made much easier. Securing the IO needle to the patient’s tibia, femur, or humerus, however, is a different story. After successful patient resuscitation, these needles often tenuously secured through creative uses of sterile gauze, trimmed paper cups, bag valve masks, and/or just tape. Stabilization of tibial IO lines can be difficult in a sedated, intubated patient. This can be even more difficult in an agitated, moving patient.

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By Eric Shappell, MD|2020-01-16T00:17:39-08:00Jul 20, 2016|Critical Care/ Resus, Tricks of the Trade|

AIR-Pro Series: Critical Care (part 2) Module

Welcome to the Critical Care (Part 2) Block!

Below we have listed our selection of the highest quality posts related to 4 advanced level questions on critical care topics posed, curated, and approved for senior residents by the AIR-Pro Series Board. The blogs relate to the following questions:

Advanced ventilatory management
Submassive pulmonary embolism management
Hypotensive intubation
End of life discussion

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR-Pro stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥28 points (out of 35 total), based on our AIR-Pro scoring instrument, which is slightly different from our original AIR Series scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR-Pro Board members as worthwhile, accurate, unbiased and useful to senior residents. Only the posts with the AIR-Pro stamp of approval will be part of the quiz needed to obtain III credit. To decrease the repetitive nature of posts relating to these advanced concepts, we did not always include every post found that met the score of ≥28 points.

Take the quiz at ALiEMU
ALiEMU AIR-Pro Critical Care (Part 2) block quiz

Interested in taking the quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a one-time login account if you haven’t already.

Highlighted AIR-Pro posts

Article Title	Author	Date	Link	Title
Taking ownership of the ventilator	Evan Miller & Maxim Dzeba	April 21, 2016	EM Docs: Ventilator management	AIR-PRO
Mechanical ventilation in ARDS: 2014 update	Matthew Hoffman	May 12, 2014	PulmCCM: Mechanical Ventilation	AIR-PRO
Thrombolysis for submassive pulmonary embolism	Chris Nickson	Jan 7, 2016	LITFL: Thrombolysis for submassive PE	AIR-PRO
Controversies of thrombolytics for pulmonary embolism	Brit Long	May 28, 2016	EM Docs: Controversies in thrombolytics	AIR-PRO
How to intubate a patient with hypotension	Scott Weingart	Aug 5, 2013	EM Crit: Hemodynamic kills	AIR-PRO
Intubating the critically ill patient	Zach Radwine	Jan 6, 2014	EM Docs: Intubating the critically ill	AIR-PRO
DNR means do not treat… and other end of life care myths	Ashley Shreves	Aug 2014	EP Monthly: DNR means do not treat	AIR-PRO
Dominating the vent: Part 1	Scott Weingart	May 24, 2010	EM Crit: Dominating the vent (1)	Honorable Mention
Dominating the vent: Part 2	Scott Weingart	June 1, 2010	EM Crit: Dominating the vent (2)	Honorable Mention
Pulmonary embolism treatment options	Scott Weingart & Oren Friedman	July 14, 2014	EM Crit: Pulmonary Embolism	Honorable Mention
Critical care palliation	Scott Weingart & Ashley Shreves	Feb 18, 2013	EM Crit: Critical care palliation	Honorable Mention

If you have any questions or comments, please contact us!

By Fareen Zaver, MD|2017-03-05T14:18:45-08:00Jul 5, 2016|Approved Instructional Resources PRO (AIR-Pro Series), Critical Care/ Resus|

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