#em bound

[a-young-doctors-journey]

Podcast Recommendation: EM Clerkships

I love this podcast -- binge-listened the first seven rounds of The Game, in which an attending tests a resident in oral-board format. Each episode is a case: "You are working nights at ABEM General, and the nurse hands you a patient chart. Chief complaint: weakness." And then they walk us through the case, beginning to end.

It's interesting, dynamic, easy to follow and lots of fun. Linked here.

[drdessertfox]

Not sure if night shifts don’t bother me as an innate trait or if it’s easy to switch back and forth because I’m still in my twenties.

Either way, I’ll take it.

[a-young-doctors-journey]

Sitting in a cafe, studying for my emergency medicine rotation, after an amazing morning of garage sales and a short hike. Maybe it'll all be okay, after all?

[a-young-doctors-journey]

The surgeon is letting students pick their three topics for our oral exam DAYS prior to test day. This is ludicrous on so many levels, I don’t even want to go into it.

I was told I had to choose topics, or else my classmate would choose them for me... so, fine. Sighs. I chose three and thus am now extra-reading up on: 

symptoms and surgical treatment of chronic pancreatitis 

classification of skull fractures

determination of brain death

I chose this last one because two weeks ago, I stood beside a paramedic as she went through the steps for a fresh ED admit ... and I realized I didn’t even know what things to check before someone could be declared brain dead. In fact, I always confused the ideas of comatose, brain death and persistent vegetative state. So I’ll clear it up for myself (and perhaps others?): 

BRAIN DEATH: a state of irreversible unconsciousness (GCS 1-1-1) which meets very strict criteria. Importantly, there is an absence of brainstem reflexes, motor response, and respiratory drive. There are many other criteria as well, but for starters, the reflexes to check are the following: 

1. corneal reflex (CN V1 + CN VII)  2. oculocephalic reflex (CN VIII + CN III and CN VI) 3. gag reflex (CN IX + CN X)  4. pupillary light reflex (CN II + CN III) 5. cough reflex (CN X + CN X)  6. pain reflex (CN V + CN VII)

Because the determination of brain death is so crucial to get right, there are other criteria as well, which are explained really well on teachmesurgery.com (linked the article here). These include that the patient not be on sedatives, be apneic, have no reversible causes in the background, and many more.

Brain death differs from persistent vegetative state, although both are in an irreversible unconscious state. A patient who is brain dead cannot breathe on their own. A person in a vegetative state actually does breathe on their own. A comatose patient is also unconscious, with no reflexes, but they may be awakened -- it depends on the cause of the coma.

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In the case of the patient on that fateful day, the presentation was GCS 1-1-1, and she was intubated in the field. The husband called the ambulance because the patient had a seizure while sitting on the toilet. The toilet... yes, you guessed right. When we did a CT of her head, there was a very large subarachnoid hemorrhage. It’s a textbook case: undiagnosed cerebral aneurysm ruptures in the background of straining (i.e. being on the toilet), and if the bleed is large enough, it can be fatal. 

In her case, it was. However, you need to wait 5-6 hours to declare someone braindead, so we observed her in our ED while the family came to say goodbye. She was young... 50-something? ... and no significant medical history except smoking.

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In medicine, you learn best by seeing, then doing. I saw my first case, and one day in the future, I’ll have to do it myself.

[a-young-doctors-journey]

Updated April 2020 While there is no substitute for doing an EM rotation and talking to practicing Emergency Physicians (EP's), there are

For those wondering if emergency medicine is a good fit, here's a blog post from Dr. Kellogg (USA).

Any aspiring emergency med docs out there? I'd love to get to know you guys!