How To Present to an EM Attending

The major challenge as a trainee presenting to a supervising attending is that every attending is different, wants different things, has a different approach, which makes your job impossible. You will do better to have a system. Here’s one system.

Before presenting the case at hand,  provide an update on what’s going on with your other patients. How are they doing? What are they waiting on? Now you’re ready to start in with the present case.

Frame First. Open up with a very brief one-sentence summary of the case, with your conclusion. This frames everything else you’re about to say.

“I think Ms. Jones has pneumonia.”

“I think Mr. Smith will need a CT scan for rule out appendicitis.”

“I think Mr. Lee will need a workup for chest pain, but if negative can be managed as an outpatient.”

Next is the chief complaint.

“Mr. Jones is a 34 year old male with abdominal pain.”

Past medical history follows, most important first. 

“He had a kidney transplant in 2004 for polycystic kidney disease. He is also known for diabetes and hypertension.” 

Notable medications, especially important are recent changes in medications or noncompliance, and relevant allergies to medications.

“He’s on cyclosporin and mycophenolate, as well as glyburide, amlodipine, and hydrochlorothiazide. His amlodipine dose was recently doubled. He reports a penicillin allergy, which gives him a rash.”

Pertinent social situation follows, as it pertains to the situation. This is often omitted, but social situation plays an important role in admit/discharge decisions;  how can you discharge a patient without knowing the environment you are discharging to?

Who does the patient live with? (alone / with family / with spouse, who also has advanced dementia)

What sort of living environment does the patient reside in? (apartment / group home / nursing home / homeless)

What does the patient do during the day? (works as an administrator / is a left-handed pianist / is unemployed / is a student)

What is the patient’s level of function? (fully functional / able to do some but not all ADLs / fully dependent) 

How much help does the patient have at home? (24/7 home health aide / home health aide twice per week for 6 hours / visiting nursing every day)

Bad habits? (drugs, alcohol, cigarettes. history of withdrawal)

Does he have physicians looking after him? If the patient was referred to the ED by a physician, this is particularly important. If there are clinicians who play a particularly relevant role in the present concern, report this. Taking care of patients is a team sport.

Does the patient have any advanced directives? What are the goals of care?

“He lives with wife, works as a bus driver. Denies bad habits. Is supposed to follow with Dr. Green in the renal transplant service at Heartbreak Hospital, but hasn’t seen Dr. Green in six months.” 

Next is a good place to comment on prior visits to the ED.

“He’s never been to this department.”

“He has 48 similar visits to this department, has been extensively worked up dozens of times.”

Next is the history of present illness. This should start with “[The patient] was in his usual state of health until…” and then provide a chronological sequence of events that led up to the present visit; the first part of the HPI should report all the patients complaints, which were elicited with open ended questions, and end with the complaints that led to his coming to the ED, and then what complaints he has at this moment. The next part of the HPI is the focused review of systems, which you can delineate from what the patient offers up without prompting by using phrases like, ‘on questioning,” ‘endorses,’ and ‘denies.’ This is not a complete review of systems, but a focused review of systems with pertinent positives followed by pertinent negatives. A good way to end the HPI is to comment on prior episodes.

“Mr. Jones was in his usual state of health until 3 days ago, when he developed dull periumbilical pain that was intermittent but progressive until this morning, when he developed vomiting and the pain became constant, sharper, and moved to the right lower quadrant. He went to see his family physician, who referred him to the emergency department. At the moment he complains of severe right lower quadrant pain and nausea. On questioning, he endorses diarrhea and chills, but denies mucus or blood in the stool, recent travel or antibiotics, urinary or testicular complaints, shortness of breath, and rash. He had a similar, much less severe episode a few months ago that resolved in one day by itself.”

After the HPI comes the physical exam, which should always start with general appearance and vital signs, and then proceed from head to toe, with a level of detail appropriate for your level of training. I think it is best to leave the area of interest for last. 

“Mr Jones is well appearing, calm, and mildly uncomfortable in abdominal pain. His vitals are normal except for a heart rate of 106. His head to toe exam demonstrates no findings about the head, neck, heart, lungs, and extremities. His abdomen is moderately tender in the right lower quadrant, without signs of peritonitis. His GU exam is normal.”

Now you’ve finished the H&P, and the next question is what has been done for the patient already, if anything, and results

“He was treated with 4 mg of IV morphine and 4 mg of IV ondansetron, and a CBC, chemistry, LFTs and lipase were sent, as well as a urine analysis, according to the abdominal pain nursing protocol. He was uncomfortable when I saw him, so I ordered another 4 mg of IV morphine. The UA has been resulted and shows trace blood, all other studies are pending.”

And now your assessment and plan. I think the best way to provide a summary of the key features of the case, and then answer these questions:

  1. What do you think the patient has?
  2. What dangerous conditions or complications could be causing or associated with this patient’s symptoms?
  3. What tests are indicated to rule out or rule in these dangerous conditions?
  4. What therapies or symptom relief measures are needed?
  5. If the tests that you order are negative, what is the plan for the patient?

“Mr. Jones is a healthy young man with abdominal pain, diarrhea, and fever for 36 hours, his exam is reassuring but he has mild lower abdominal tenderness. Most likely, Mr. Jones has a self-limited GI illness, but I’m concerned about appendicitis. Bowel obstruction and perforated ulcer are unlikely given the relatively benign abdomen. Given a normal GU exam, I don’t think we need to further pursue a lesion there; his abdominal tenderness makes thoracic causes of abdominal pain like pneumonia or cardiac etiologies very unlikely. If his labs show no diagnostic abnormalities, I think he needs a CT scan of the abdomen with IV contrast to rule out appendicitis. If that’s negative, I think he’s safe to be discharged with a nonspecific diagnosis and followup. He’s comfortable right now but I’ll continue to treat for symptoms as needed, and I’ll also give him a liter of fluid.”

The most important way that this system differs from the most common presenting style is that the HPI is presented after the patient’s background information is presented. Most attendings will want to hear the HPI first; I believe that in a stable patient, the HPI can only be properly interpreted in the larger context of the patient’s medical history, social history, etc.

How much detail you present depends on the complexity of the case and how senior you are as a trainee. If you’re about to graduate your residency, your attending may not want to hear anything else than, “Mr. Jones is a healthy 34 year old with a flu-like syndrome, I discharged him with follow up.”

Send thoughts, comments, suggestions, objections, additions to emupdates@gmail.com

 

Related:

Trainee worksheet, with specific guidance on how to succeed during an EM shift. Designed to fit on one page, front and back.

List of ways that I might practice differently than other attendings, to save residents some trouble.

Older, detailed guide to patient assessment.

The Abortion Pill

Pregnancy termination is now very difficult to get in many regions. The abortion pill–medication abortion–is one dose of the antiprogesterone mifepristone followed by one or more doses of the prostaglandin misoprostol. The therapy is well studied and unequivocally safe and effective up to 10 weeks gestation.

For women who have access to both medication and surgical abortion, there are plusses and minuses to each but the main difference is that a surgical abortion is a brief procedure requiring anesthesia and uterine instrumentation, whereas a medication abortion occurs over several days in the patient’s home.

But medication abortion allows women without access to surgical abortion to  safely terminate pregnancy. In the US, federally authorized abortion pills are highly restricted for reasons that are political, not medical. So a network of activists have developed robust programs for getting this treatment into the hands of women who need it.

The role of emergency providers in managing women who request elective termination of pregnancy depends on the resources available in your community, but all of us need to know about medication abortion, if for no other reason than it is a rising therapy and you’re going to get asked. Especially if you practice in an area where surgical abortion is poorly available or unavailable, familiarize yourself with the relevant options so you can properly counsel appropriate patients. This is another way that emergency clinicians stretch the scope of their practice to meet the changing needs of the patients they serve.

Plan C

Aid Access

New York Times, Farhad Manjoo

Narcotica podcast

Ketamine-Only Breathing Intubation

This 9 minute video demonstrates the strengths and weaknesses of an intubation strategy that relies on dissociation with ketamine.

The essential strength, compared to RSI, is that a breathing technique keeps the patient breathing during laryngoscopy, which transforms the procedure from high-adrenaline to highly controlled. You see in this video that my (fabulous) resident was able to take his time, try different blades, slowly advance and adjust while using view optimization techniques as the patient continued to breathe. This is an extremely powerful way to add safety to the riskiest procedure commonly performed in acute care. We would have been able to carry on with his attempts for longer, had we not been inconvenienced by the arrival of a trauma patient.

Keeping the patient breathing during intubation has a long history in emergency medicine, starting with the brutal and often unsuccessful blind nasal intubation, which, fortunately, is now seldom performed. Many of us learned to do operating room style awake intubation, which relies on thorough local anesthesia using atomized/nebulized/topicalized/regionalized lidocaine, so the patient can remain truly awake and breathing during the procedure. Lidocaine-focused awake intubation is a fabulous technique that requires expertise and equipment not available to all acute care providers, but also–depending on your level of skill–time and patient cooperation. Time and cooperation is something we may not have downstairs or on the side of the road,* but what we lack in time and cooperation, we can make up for in ketamine.

When we use dissociative-dose ketamine to do the heavy lifting in allowing the patient to tolerate laryngoscopy, we obviate much of the needed topicalization expertise/supplies, abbreviate the needed time, and add cooperation with ketamine, cooperation in a vial.  The patient becomes dissociated, breathing but unconscious, which is why I use the term breathing intubation rather than the much more accepted term awake intubation to describe it.

Many patients who receive dissociative-dose ketamine without a paralytic will have some muscle rigidity, and some will develop laryngospasm (which is glottic muscle rigidity).  The patient in this video had some rigidity, which resolved and was not a problem, and this is usually the case. But patients who get ketamine to facilitate laryngoscopy are at much higher risk than procedural sedation patients (who are not having their airway instrumented) to develop laryngospasm and occasionally jaw rigidity, which, together, can cause an immediately dangerous cannot intubate cannot ventilate scenario. Anytime KOBI is being undertaken, a paralytic must be immediately available, ideally drawn up in a syringe, so that the procedure can be converted to a paralyzed technique at any point.

How KOBI fits into our expanding airway toolkit is expertly described by Andrew Merelman and Michael Perlmutter in this WJEM paper.

 

 

 

*some airway experts disagree

 

Postoperative Neck Hematoma

Postoperative neck hematoma is not often discussed in emergency medicine but behaves a lot like neck trauma, because it is neck trauma. These patients should be managed with a high-resource approach and discharged reluctantly, after careful deliberation.

Adapted from Bittner, MD.

ED Chest Pain Evaluation Pathway

full pathway as png and pdf

This pathway was agreed upon by a hospital consortium; it is completely unsubstantiated by science and is only intended to serve as a supplement to your otherwise excellent clinical judgment.

Strengths: it reminds you to consider the 7 dangerous causes of chest pain, not just ACS. It’s pretty straightforward and based on well-validated decision tools.*

Weaknesses: chest pain is a complex problem that cannot be reduced to a pathway, even a pathway designed by smart, good-looking people. Don’t turn your brain off when using this or any other decision tool. Decision tools don’t take care of patients, you do.

credits: bradley shy, marc probst, nick genes and the HIC consortium.

 

*except the ADD score, which is not well validated and remains controversial. Nobody knows who needs a scan for dissection. Make sure you scan the patients who have very suggestive presentations, even though the vast majority of them will not have dissection. Think about dissection when patients have features in the score. Understand that you will eventually miss dissection because sometimes it presents in crazy atypical ways, and that if you try to catch very atypical dissections you will do more harm than good by overuse of CT.

Low Threshold Buprenorphine

 

Sustained comprehensive addiction care is the goal, but until then, most OUD patients should get buprenorphine in the ED and/or a script. Every hour a street opioid user is therapeutic on bup is an hour they’re safe from withdrawal, cravings, and overdose, and is an hour they can contemplate recovery.

The Paper Throat: A Lo-fi, DIY Laryngoscopy Simulator

 

Laryngoscopy involves a series of unnatural movements and hand-eye skills that are not easily learned while simultaneously caring for a dying patient. The Paper Throat is a low fidelity but high yield direct laryngoscopy training tool that is easily assembled and practiced. The hope is that routine use will generate laryngoscopy muscle memory so that training providers can focus on other aspects of airway management when called upon to intubate IRL.

Conceived and produced by Jonas Pologe.

Pulse Ox Lag

Folks put a lot of stock in the pulse oximeter, as they should, because the pulse ox is an awesome feat of engineering and patient safety. But the pulse ox lags.

Here, the inestimable Dr. Jonas Pologe (rhymes with apology) demonstrates pulse ox lag with a breath hold.

Breath hold starts at 0:11, sat is 100%
Saturation starts to drop at 0:48
Breathing commences at 1:25, sat is 82% at this point
Saturation continues to drop until 1:46, then recovers from its nadir of 77%
At 1:58, saturation reaches 100% again

 

Lessons:

1. When the sat is on its way down, the patient is more hypoxic than the pulse ox shows. This is another reason why, when laryngoscopy is not producing an acceptable view of the glottis, you should come out and reestablish ventilation/oxygenation earlier than you think. A more important reason to come out and bag early is described here.

2. When you are reestablishing oxygenation (using a bag mask, laryngeal mask, or endotracheal tube), do not use the pulse ox to judge the adequacy of ventilation, use capnography. That means the capnogram should be attached to the bag mask/LMA/ETT before the first breath is given. If the capnogram is good, ventilation is good, and the pulse ox will catch up, so relax and stop bagging so quickly.