Trick of the Trade: Ultrasound-guided supraclavicular central line
Emergency physicians are procedural experts in central venous access. The subclavian vein is the best site for such access, because it has been shown to have the lowest rate of iatrogenic infections and deep venous clots Bedside ultrasonography has really revolutionized how we obtain vascular access over the past 10 years. Identifying the subclavian vein using ultrasonography, however, is still technically challenging. The vein is located just posterior to the clavicle, which often gets in the way of the linear transducer. [+]
Paucis Verbis: Sgarbossa’s Criteria with LBBB
It is difficult to determine if a patient with a left bundle branch block (LBBB) has an acute myocardial infarction (AMI) because ST segments are "appropriately discordant" with the terminal portion of the QRS. That means if the QRS complex is negative (or downgoing), the ST segment normally will be positive (or elevated). Similarly if the QRS complex is positive (or upgoing), the ST segment will be negative (or depressed). PV Card: Sgarbossa's Criteria In 1996, Sgarbossa et al looked through the GUSTO-1 trial patients with LBBB and AMI. They derived 3 criteria which may help diagnose the "hidden" AMI. [+]
Residency interview season: Pitfalls
I often get asked by my advisees: “In my residency interview, what should I talk about or do to make myself more competitive?” To help you demystify the interview process, I wanted to share with you some insights. Overall, the interview day itself helps the program put a person and personality with your online ERAS application. Similarly, you quickly get a sense of the program’s personality. In EM, the residency interview day is generally pretty laid back. Not too many crazy questions. Programs just want to get to know you. Both you and the program should be asking each other– Is [+]
Trick of the Trade: Legg Maneuever for shoulder dislocation
There are many ways to relocate a shoulder dislocation. Most of these ways require procedural sedation. What if the risks of procedural sedation outweigh the risks? What alternative maneuver can you try, which only requires parenteral pain medications +/- an intra-articular lidocaine? [+]
New kid on the block: Univ of Washington EM residency
How awesome would it be if there were EM residency programs at the University of Washington and UCSF-SF General Hospital?! This has been the question for decades. In 2006, I had the pleasure of seeing the UCSF-SFGH program become a reality. And now it’s the University of Washington’s turn. It is close to becoming a reality. It is really one of the last powerhouse institutions which does not have an EM residency program. The Univ of Washington EM residency’s Program Director is helmed by my superstar friend, Dr. Fiona Gallahue, and will be a 4-year program. The ACGME (accrediting organization) [+]
Article review: Inaccuracy in the SLOR
Residency interview season is quickly approaching! Unique to the field of EM, letters of recommendations from EM faculty are written on a standardized form. The Standardized Letter of Recommendation (SLOR), downloadable from the CORD website, documents information about the student’s performance in the EM clerkship, qualifications, and global assessment. At the end, the letter writer can provide free-text written comments. [+]
Paucis Verbis card: Algorithm for suspected pertussis in pediatrics
To treat for pertussis or not? In the setting of the current pertussis epidemic in California, each kid with a cough sparks constant debate about whether to treat with azithromycin or not. Finally, thanks to my friends Dr. Andi Marmor and Dr. Shon Agarwal Jain (UCSF Pediatrics faculty), there's a great algorithm to help you answer the question. I have found this algorithm extremely helpful. You basically start by risk-stratifying by age and pertussis immunization status. For instance, if the patient is 6 months of age AND unimmunized), then follow the algorithm listed as "High Risk for Pertussis". PV Card: [+]
Opportunity for med students: SAEM meeting in Boston (Jun 1-5, 2011)
The Society for Academic Emergency Medicine (SAEM) holds its annual meeting at various U.S. metropolitan cities. This year, it is going to be at Boston in June 1-5, 2011. It is a terrific conference for medical students and residents interested in EM academia. To help coordinate the huge meeting, the SAEM Program Committee is looking for 15 enthusiastic medical students to serve as volunteers. [+]
Tricks of the trade: Intranasal fentanyl for pediatric patients
Pediatric patients often receive inadequate pain control in the setting of orthopedic injuries. Because the child experiences fear, anxiety, and pain with needles, practitioners often shy away from ordering IV or IM pain medications. Oral agents, while easier to administer, usually provide inadequate pain control. Trick of the Trade Intranasal (IN) fentanyl Thanks to my friend Dr. Ron Dieckmann (Editor-in-Chief for PEMSoft, Chairman of Board for KidsCareEverywhere, and Pediatric Director for Valley Emergency Physicians) for his tip about intranasal fentanyl:It is imperative that the drug be administered in a nebulized form using an atomizer device -- one half the [+]
Article review: EM in medical schools
Similar to JAMA, which publishes an annual publication focusing on Medical Education, the Academic Emergency Medicine (AEM) journal just published a AEM-CORD/CDEM supplement focusing on EM education. I was fortunate to be involved with one of the papers published in this supplement.This paper, written on behalf of the Clerkship Directors in EM (CDEM) and the Association of Academic Chairs of EM (AACEM), reviews the past, present, and future of EM in the U.S. medical school curriculum.EM faculty members are playing an increasingly important role in both the preclinical and clinical curriculum. Our specialty teaches skills and knowledge, crucial for all [+]