Almost a consultant…maybe

30 06 2017

I just realised it has been 4 years since my last post !

In 2 weeks time I will be sitting my Emergency Medicine specialist exams.

 

I had some practice OSCE sessions with a colleague and gems from the consultants today were :

 

“Don’t do a core basic thing poorly – heavy weighting ”

“That stuff needs to come out – you know this”

“Knowledge needs to come out in a structural way”

“Show an overview of a big picture”

“Get all the ducks lined up”

 

“You do not get marks for what you are thinking only what you are saying”

 

“Make a consultant handover concise and precise”

 

“YOU ARE A Beacon of calm for prioritized actions”

 

“Deconstruct each step for procedures”

 

 

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I just finished a shift with 4 procedural sedations / 1 intubation :

a. Assisted in washing a middle aged man’s compound tib-fib fracture

b. Sedated an 85 year old female to wash a medial malleolus wound ; she had rib fractures and was recently in AF 2 weeks ago (she is on Apixaban)

c. Sedated a 40 year old 120kg lady’s tibio-talar dislocation

d. Intubated a young male with a GCS of 5

e. Sedated a middle aged lady to reduce a Colles fracture

 





Difficult encounters part 1

13 12 2013

With the primary exams out of the way…. new levels of expectations are set. Often in ED we do get difficult patients.
What if we encounter difficult staff ?
Often at a junior level ; whether you’re an intern or a registrar; you find your decisions overriden by a senior. Usually this is a good things
say for example :
you want to discharge the 80 year old female who had a FOOSH and currently has an undisplaced distal radius fracture (which is in a backslab). BUT your senior points out that she lives alone and would benefit from admitting her to Short Stay having allied health input to allow assessment for safe discharge … (physio/OT) as she lives alone and does everything on her own.

Now thats a good thing isn’t it ?
Most of us wouldn’t mind that, would we ?

Or the low-to intermediate chest pain (TIMI 0 ) we see in ED which we think should just get a repeat 6 hour Troponin and be discharged with GP to organise stress testing if the trop is negative….
(only to have a senior veto you and say you should refer to the medics for inpatient testin)

Once again….safe isn’t it ?

What if this was the OTHER way around … where a senior supervising member’s disposition is less safe ? or conflicting with yours…

At the shop I work at, during a day shift we have consultants covering the floor who often provide good support and advice. But this differ from SMO to SMO…. and often the advice can be conflicting.

Different EDs will have different sort of SMO covers.
Some models of care from my limited experience :

a. free reign – i.e everyone does their own shit and make their own decisions especially discharge dispositions (only if you are PGY2 and above)….. this is for super busy EDs with lack of medical/nursing staff

b. full control – – all patients will need to be run past the SMO on the floor…. (including fast track patients e.g. ankle sprains… “groan”)
very safe

c. registrar led teams – – – all patients will be discussed with the registrars on the teams.
a model demonstrated at the tertiary hospital I used to work. consultants allow registrars to make disposition and only step in when a conflict arise

How do we approach differences in disposition ?
What if there’s a difference and a concern about where the patient is going ?

Case 1.

A 39 year old man presents from a GP with referral ? pancreatitis (he had 3 days of upper abdominal pain) with a raised lipase of 800.
ON assessment today he is well albeit slightly nauseated.
All vitals normal (heart rate 70, normotensive and BSL 6)
Abdomen today some discomfort.
“today’s the best i’ve felt doc”

His lipase is 350.

The resident’s impression was that this was “ongoing resolving pancreatitis – mild with a RANSON score of 1 (raised WCC 3 days ago) and needs to come in under the surgeons for Ix ”
The registrar who saw him felt his abdomen —says “this abdo was soft —- SEND HIM HOME. HIS LIPASE is only 250. WHAT WOULD THE SURGEONS DO”

at this juncture the resident wanted to call the surgical registrar and get an opinion but his ED registrar vetoes that and removes the cannula and starts typing the letter himself.

Comment : conflict of different assessment and management opinions.

This case was resolved when the resident subtly blurted out the case to the consultant on the floor.
The SMO on the floor had a quiet word with the ED registrar and directly admitted the pt under the surgeons (with a new cannula the SMO inserted herself)
Needless to say the ED registrar never really spoken to the resident again.





Bye bye primary exams

28 09 2013

So I finally passed the primary exam last week.
After 2 years ….. looking back it was a bloody struggle. Few failed attempts…. juggling work and busier shifts.

Am so relieved and thankful that I vow to help those in need of passing the primary too.

Posts coming up :

a. tips + tricks
b. ways to motivate
c. tools I used

Probably the most important viva resource I found was from a website by the Auckland team :

http://improvingedcare.org/education-and-training-profile/acem-part-1-resources/





ED Thursday Teaching

27 07 2013

as with our department – – with people calling in sick and lack of motivation (the tyranny of distance for some ; not being a trainee) or recreational leave : our attendance was minimal.

having said that : we had a great session!

1st session :

Oxylog3000

got grilled in the resus bay about the knobology and stuff.

The key messages taken away is to be aware of plateau pressures and hot to measure them.

Found some good links from the great LITFL crew courtesy of Chris Nickson :

http://lifeinthefastlane.com/2012/10/borrow-the-oxylog-3000/

http://lifeinthefastlane.com/2011/09/own-the-oxylog-3000/

 

Case presentations

few great cases : 1 about a rather rare cause for abdominal pain (epiploic appendigitis), 1 about Kawasaki’s and mine about perilunate dislocations.

 

Grand Rounds

had Dr Louise Cullen from RBWH presenting about chest pains (and the new diagnostic strategy to safely rule out the super duper low risk ones)

 

 

Exams in 20 days time ! EEEPS

 

 





friday at shift

13 07 2013

started out wither another fast AF Seconday to cessation of beta blocker. given some magnesium ; slowed down …yay

 

next case was interesting 10 y/o bilateral conjunctivitis for 1 week, followed by urinary symptoms; fevers and possibly a painful left knee ?? – possibly trauma from the day prior

? kawasakis vs reiters vs septic arthritis…

will have to see what happened

bloods and a knee joint aspirate were sent

 

next case INR of >10 and jaundiced….. hmmm

diverticulitis on CT ! as well as HOP incidentally.

needed prothrombinex.

 

3rd middle prox metacarpal # – oblique —> volar slab





another sporadic post

12 07 2013

thought i’d put a note to my shift yesterday.

Patient 1.

A flutter with syncope – admit telemetry

cause ? (probably too much flecainide and all the agents – alpha blocker/beta blocker/CCB/flecainide)

need to revise : Drugs for anti-arryhmics esp flecainide

Physiology : cardiac AP

 

2. Man seen yesterday w ? gastritis (used NSAIDs for weeks for arthritis) and today presents with worsening tummy pain and rash.

 

Rash – confluent maculopapular kind – distributed all over – not specific distribution. blanching. looks like drug rash.

Tummy – RLQ pain +++

 

diagnosis – perforated appendix w free fluid on CT. 

lessons : good disposition for ppl with abdo pain – rash is a bad sign

need to look up literature about rash + abdo pain. ( i thought that was from nurofen !)

 

3. # cuboid + tuberosity of 5th metatarsal

anatomy – good to revise bones of feet and muscles of ant part of leg.

 

4. Scans done :

a. 1 FAST

b. 1 LUS – B lines in LLL suggestive of infiltrative process.

 

5. I+D right upper lip abscess

used infraorabital nerve block.

anatomy : revise face / triangle of danger





Sporadic and tachycardic

23 05 2013

infrequent. sporadic. intermittent.

my posts are like these. am a big procrastinator.

the primaries are in 83 days again.

(flunked anatomy and physiology…ouch)

 

anyway would put relevant cases I see with my primaries.

 

 

Saw a Cat 2 2 days ago.

22 y/o F. Palpitations HR 170.

right…. straightaway comes to mind SVT ain’t it ?

 

brought to Resus. Adenosine drawn up, my senior doing cannula and bloods.

and then I saw the patient’s mum carrying 2 things in their hand :

a. Path results from 1 week ago showing T3 of 30 ; TSH < 0.01

b. Carbimazole

 

 

hmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm

 

turns out this poor lass has been sick for the last 1 week with nausea/vomiting/headaches/URTI symptoms. NO rigors though and only could manage her carbimazole half the days. Had bloods with her GP and endocrinologist 1 week ago and only got the results on that day – her endo asked her to take 60mg carbimazole and see him in 1week’s time.

she had palpitations from the onset of 1400 pm and couldn’t sleep. (didn’t tell her mum until her mum saw her being pale and SOB)

 

HEr BP was 140/90 Sats 99% on R RR20 and Temp 36. NO focal signs of infection. CXR normal.

BLooods reassuring show normal K / renal function and her ECG showed a sinus tachy of 130.

 

Settled with some fluids to 125. but she felt palpitations still…..

 

 

SO…not SVT.

probably palpitations from sinus tachy precipitated by URTI +- UTI (Urine stil pending) ; complicated by hyperthyroidism.

We ended up given lots of anti emetics and made her chug some propranolol and another 20mg carbimazole and admitted under telemetry

Lessons learnt:

 

a. A little bit of thyroid physiology revised.

Spent 7 minutes watching this video :

http://www.youtube.com/watch?v=2qYBzjtm2SA&list=PLIho5L33Je9QbGSBHr18xmrNNPOiR1SNx&index=1

b. Antithyroid medications.

 

Revised carbimazole/prophylthiouracil