Dr. Sam Ko's Emergency Medicine Blog

Axioms for Community Medicine

2011-10-31T22:18:00.000-07:00

I've been a community MD for a few months and I recently came across Dr. Rob Orman's ERCast. This is a great podcast that's supremely relevant for community ED docs. One of his recent podcasts had a discussion on academics vs. community medicine (including Drs. Scott Weingart and Rob Rogers). Dr. Orman ends the podcast with these powerful axioms:

1. When first starting out (6-12 months) think of it as doing an EM fellowship in community medicine.

2. Give service to the group. Devote a chunk of time to group practice by adding value, i.e. develop U/S, clinical pathways for PE, A.fib.

3. Remember, proximity to a CT scanner (or MRI) is not a reason to order the test.

4. You can only see ONE patient at a time. The patient in front of you is the only patient you have. If you focus on the waiting room, the last patient, you might end up spinning your wheels.

5. Be nice to the nurses. They can help and teach you or really HURT you.

6. Take an advanced airway course early on. This will reap huge dividends throughout your career.

7. You are always a student FIRST. Keep on learning and staying current, in addition to LLSA/CME. Be the best emergency physician you can be.

8. Be gracious with your consultants and be congenial. These are people you will be working with for a LONG time. “Seek first to understand, then be understood.” ~ Stephen Covey

9. Go to the monthly meeting. Although you may think they are optional, they are not.

10. The silent chief complaint is anxiety. In addition to the chief complaint, alleviate the anxiety of their symptoms.

11. Always advocate for the patient. When in a bind, ask yourself, “Self, what's best for my patient?”

Listen to ERcast by subscribing on iTunes!

Collected Tweets from ACEP Scientific Assembly 2011

2011-10-29T04:19:00.000-07:00

In case you missed my tweets from ACEP in San Francisco, here is a collection of some of my updates.

Go with person with possible SAH & get immediate CT angio if positive. @emcrit

Pods sign: one spot that orthopods can listen to heart, lung, abdomen and document WNL...We Never Looked. Henry

More than 2 nerves affected in posterior fossa = bleed or tumor. Check articulation, word differentiation. Henry

Dizziness questions: Did the room spin? Did you feel like you were going to faint? Is this worse at night? Henry

What is Purpose of lecturing? Get people to learn. Do Audience centered speaking. Mattu

Audience will forget 40% of new content by 20 mins. After one week, 90% of new content forgotten. Mattu

Limit content to 3-4 points U want them to remember. Be explicit about these points. Mattu

Audio and videotape your lectures to improve speaking skills. Mattu

Buy "Secrets of Successful Speakers" by Nick Morgan, Lilly Walters, ET al. Mattu

"At the end of this lecture, I want the audience to___". Plan for this when beginning your presentation. Mattu

Come up with take home points and conclusion FIRST. What behavior change is the goal? Mattu

Anything more than 4 points in your lecture and they will remember ZERO! Mattu

Customize your lecture for the specific audience: degree, training level, specialty, native language, why are they there? Mattu

Have a dynamic title in lecture. Use words like Pitfalls, Advances, Pearls. Death, disasters, killer NOT chapter titles. Mattu

Start strong and finish strong! Grab their attention. Memorize the intro. Start with humor or a challenging case. Mattu

Don't take questions at the end. Its a weak finish. Final 10 seconds are the most memorable. Mattu

Don't need as many visuals. Simple slides. Big fonts: tahoma and arial are good. You are the message! Mattu

Approach the sleepy or texting person and they will wake right up!" Mattu

It's not what you say, it's how you say it. Tone, speed, body language. Mattu

Have 2 jokes prepared just in case of an AV glitch. Mattu

On Rest and Balance

2011-08-03T12:54:00.000-07:00

I finished emergency residency on June 31, 2011. Some of my co-residents started their jobs the next day and accordingly began earning a salary immediately. Even with the the looming student loan payments, I needed a rest.

I chose to go to San Marcos La Laguna in Guatemala. My initial travel plan was to go to San Marcos for medical spanish lessons, then Antigua, then Copan Ruins in Honduras, and lastly spend four days getting scuba certified in Utila, Honduras.

Once I got into the small town by Lake Atitlan via shuttle & tuk-tuk, I realized that I could not leave San Marcos quite yet. I decided to change my entire travel plans and stay in one spot.

San Marcos is special because there is a tranquil energy vortex here. There are also a number of healers and wise people in this spot. They use massage, Reiki energy healing, acupuncture, hypnotherapy, cranial-sacral massage, crystals, meditation, yoga, and the Mayan Calendar.

It was definitely a change of pace from allopathic medicine. I used this time to rejuvenate myself from the twelve years of training to be an emergency physician. It was a pleasure to interact with people of the San Marcos community and take time to slowly enjoy each moment. Some days, I would simply lay in a hammock and stare into the clouds or watch the hummingbirds.

I learned many things about myself, my path in life, and the importance of balance in life. When I came back to LAX a few days ago, I was saddened about what I had left behind. But I also realized that I can create my own balanced life by planting the seed of tranquility. As my friend says, "Creer es crear." Thank you, San Marcos La Laguna.

An Anonymous Doctor Tweets About An Anonymous Patient

2011-07-07T14:45:00.000-07:00

I am late to the discussion about a recent interaction between two doctors online. To summarize, the first doctor blogged about a second anonymous doctor for being unprofessional on Twitter. This launched a massive debate about doctors' presence online. Ultimately, the anonymous doctor deleted the Twitter account and the first doctor closed the comments section of the post.

After catching up on must-read blogposts from:

TheAngryPharmacist

AllBleedingStops

ResidencyNotes

MediaBistro

I've come to the conclusion about the importance of anonymity for some doctors online. Even President Obama states, "I just miss — I miss being anonymous," after he won the presidential election.

Physicians are held to a high standard. But, frequently we cannot meet that standard because we remain human. We dispense health tips and advice to patients, while failing to care for ourselves. These societal and self-induced pressures may actually lead to higher suicide rates and drug/alcohol abuse in doctors.

In a Utweetpia, all doctors could proudly publish their names online and freely vent-rant-educate-entertain-share online. But there is too much to lose if a post/tweet becomes viral or #trends. As long as patients cannot be identified, I believe that anonymous doctors should be allowed their freedom of speech and appreciated for their transparency into the medical world.

BUT it is extremely difficult to be truly anonymous online.

From the BlogHerald:

"True anonymous blogging requires that you ensure there is no connection between your real identity and the site as well as no direct connection or traceable connection between your network/your computer and your blog’s server.

To be clear, there are ways to do this and many great guides have been written on this subject, including an official one by the EFF and one on TechSoup.

However, especially for someone new at using these tools, the process is intimidating and the since perfection is required to be completely safe, it’s virtually guaranteed that there will be a break in the protection."

Emergency Medicine from THE ULTIMATE GUIDE TO CHOOSING A MEDICAL SPECIALTY

2011-06-03T19:43:00.000-07:00

On Emergency Medicine from THE ULTIMATE GUIDE TO CHOOSING A MEDICAL SPECIALTY, by B. Freeman, 2003.

What makes a good emergency physician (EP)?

-Likes working with hands
-Adventurous, action-oriented leader, and team player
-Can make logical decisions during rapidly changing situations
-Likes the variety and unexpected
-Is capable of juggling multiple tasks at once
-Comfortable with broad knowledge base

2.8% of ALL physicans are EPs
70% are in private practice, 25% are in academics
EP's work an average of 38.7 hours per week
75% report that their salary is equal or higher than expected

2002 Match Statistics
-1,564 applicants for 1211 positions
-992 US seniors and 600 IMGs ranked at least on EM program
- 98% of all positions were filled in the Match

90 residency programs are a THREE-year program, 14 are a FOUR-year program, and 20 require three years of EM residency after a separate internship year.

EM residents also complete rotations in medicine, critical care, anesthesia, cardiology, and OB/GYN. The bulk of their training consist of monthly rotations in adult and pediatric emergency medicine, trauma, surgery, toxicology, emergency medical services, and ultrasound. Many programs require research:)

Check out SAEM's website for detailed information about residency programs HERE.

15 Must Have iPhone Apps for Emergency Physicians

2011-04-30T01:15:00.001-07:00

1. WikEM – This app from UCLA Harbor Residency is devoted to the practice of EM. The content includes IV drip concentrations, initial approach to almost every complaint, emergency imaging, and emergency procedures. Very easy-to-read and concise. Cost: Free

2. Epocrates – Easy to use app for drugs, pharmacology, pregnancy & lactation safety, and drug cost. A nice bonus is the pill identification tool when your patient tells you, “I take the little pink pill.” Cost: Free

3. Medscape – From creators of WebMD, this app includes nearly every diagnosis and has a clinical, diagnostic, and treatment component. It’s sort of like the free version of UpToDate on my iPhone. Cost: Free

4. Eye Handbook – This app is focused for ophthalmologists; however, some EM applicable sections are the Eye Atlas, Testing, and Patient Education. Check out the Movies tab and download the Cheese Cartoon, an excellent distraction when calming pediatric patients or checking for extra-ocular movements. Cost: Free

5. Eponyms – Remember Takotsubo syndrome, Von Hippel-Lindau disease, or Alder’s sign? This app provides a succinct description of various eponyms. A great way to remember everything you forgot from medical school. Cost: Free

6. MedCalc – It helps you calculate CURB-65 Scores, fluid repletion for burns, glomerular filtration rates (GFR), and even view a dermatome map. When you double tap an equation, it gets uploaded to your “Favorites” file for easy access. Cost: Free

7. Radiology 2.0 – Created by a radiologist and a medical student, this app’s subtitle is “One Night in the ED.” It has clear CT scan images of small bowel obstruction, aortic injury, appendicitis, and more. You can even quiz yourself by hiding the answers. Once you review the scans, go to the discussion section and read the explanations. Cost: Free

8. Diagnosaurus – This app is useful when you want to expand your differential list. All entries are organized by symptom, disease, or organ system. For frequently viewed entries, simply click the star in the bottom right hand corner to add to your Favorites. Cost: $0.99

9. PediStat – When working with critical pediatric patients, it can be difficult to remember drugs dosages, tube sizes, and normal vital signs. Simply plug in the weight, age, length/height, or Broselow Color on the first page. You will now have accurate dosing information to resuscitate your patient. Cost: $2.99

10. EMRA Antibiotic Guide 2011 – You may have the hard copy version but if you want to unload your pockets, you must download this app. This amazing guide has antibiotic recommendations based upon organism, diagnosis, and organ system. This version also has a dosing calculator to make your life easier! Cost: $15.99

11. Micromedex - Another useful resource for drugs and simple to use. This includes both OTC and prescribed drugs. The mechanism of action section is a little more in-depth compared to Epocrates. Cost: Free

12. Pepid - This is my go-to source for all overdoses. I appreciate the concentrated information (i.e. Pathophysiology, Diagnosis, Symptoms, Toxic levels, Treatments, Antidote, & Disposition). Cost: Free

13. MediBabble - Truly amazing app that helps you communicate with others. It comes in handy when getting direct yes/no questions. The languages includes: Spanish, Cantonse, Mandarin, Haitian Creole, and Russian! Cost: Free

14. Antibiotic Advisor 2011 - Another reference option for antibiotic choices. It's similar to EMRA's guide. Sometimes the search function can be buggy, but you can't beat the price. Cost: $3.99

15. Ruler - We measure a lot of things in the ED. Anything from lacerations to size of rashes. If you don't want to carry around a real ruler, download the free ruler app. Just search for "ruler" in the App Store or check out the link. Cost: Free

*FYI, I have no financial interest in any of these apps or companies.

Presentation References

2010-11-21T19:09:00.001-08:00

Websites:

http://www.slideology.com (by Nancy Duarte)

http://www.presentationzen.com (by Garr Reynolds)

Books:

Presentation Zen by Garr Reynolds

Presentation Zen Design by Garr Reynolds

Slide:ology by Nancy Duarte

Examples of Great Lectures (a way to get ideas of how you want to craft your presentation)

Any TED (http://www.ted.com) lecture – these are a collection of talks about a wide variety of topics – they are for the most part all fantastic

Any Apple Keynote with Steve Jobs (http://www.apple.com)

Sources for images:

iStockphoto (http://www.istockphoto.com) – free image of the week and some cheaper images – however, most of images are not free

Stock.xchng (http://www.sxc.hu/) – free stock photos

Wikipedia (http://en.wikipedia.org)

Any government site – NIH/DOD/FBI/CDC – since these are government owned images; they are part of the public domain

~Courtesy of Dr. James Rhee

Best EM Residency Contest

2010-11-03T15:33:00.000-07:00

Hi Readers,

I need your help to help my residency program win $10,000 for education and research.

Please go this website and vote everyday. You can vote once per person per day until December 15th

http://www.emp.com/2010-loma-linda-university

Truly appreciate your help!

Sam

Key Changes: 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care

2010-10-27T16:45:00.000-07:00

I'm a subscriber at www.emedhome.com. One of the best things are the Clinical Pearls they send out via email. Check out the Clinical Pearls below that is crucial for emergency medicine.

Key Changes: 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care

Atropine is no longer recommended for routine use in the management of PEA/asystole. For symptomatic or unstable bradycardia, IV infusion of chronotropic agents is now recommended as an equally effective alternative to external pacing when atropine is ineffective.
Adenosine is recommended in the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic wide complex tachycardia. (Editor’s note: Clinicians should be aware that adenosine should be used with significant caution in the setting of WCT in certain patients. Click Here for a previous EMedHome Clinical Pearl on this topic)
The BLS sequence of steps for trained rescuers has changed from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and pediatric patients (excluding newborns).

Continuous quantitative waveform capnography is now recommended for intubated patients throughout the peri-arrest period - it is the most reliable method of confirming and monitoring correct ETT placement. Capnography can also serve as a monitor of the effectiveness of chest compressions and to detect ROSC.

Suctioning immediately after birth should be reserved for babies who have an obvious obstruction to spontaneous breathing or require positive pressure ventilation. There is no evidence that active babies benefit from airway suctioning, even in the presence of meconium, and there is evidence of risk associated with this suctioning. The available evidence does not support or refute the routine endotracheal suctioning of depressed infants born through meconium stained amniotic fluid.

There is increasing evidence of benefit of delaying cord clamping for at least 1 minute in term and preterm infants not requiring resuscitation.

Reference: Circulation, Vol. 122, Issue 18, Supp 3; November 2, 2010.

Go to http://www.emedhome.com/ to subscribe!

Finding Happiness in the Emergency Department

2010-10-25T18:23:00.000-07:00

Finding Happiness in the Emergency Department

by Sam Ko, MD, MBA
CAL/EMRA President, 2010-11

“It’s too busy in the ED these days.” “Another faker.” “Why can’t they go to their primary medical doctor?” Have you ever said these words or overheard them during a shift? It can be disheartening to work a shift and see the patient chart rack mount higher and higher, as you place a central line in the patient with septic shock, then evaluate a patient with chronic low back pain, and then examine the ears of a two-year old whose fever “came right back four hours after Tylenol was given.”

Recently, I’ve discovered the secret of being happy while working in the ED. It’s a simple idea, but has profound implications. The idea stems from Srikumar Rao’s talk, “Plug into your hard-wired happiness.” He states that our mental model of happiness is flawed. Our model is based upon the logic, “I’d be happy if...”

For example, do you remember when you were pre-med college student? You said, “I’ll be happy once I get into medical school.” Then when you were in medical school, you told yourself, “I’ll be happy once I get a high score on the boards.” Then when you were in residency, you said, “Life will be great when I’m an attending.” This mental model is flawed, because it never allows us to be happy in the current moment. Instead, we continually seek the next step to elusive happiness.

Now, can you recall a time when you were truly happy? It may have been while watching a sunset over the ocean, seeing a beautiful rainbow, or welcoming your child into the world. Why were you happy? It was because you accepted everything at that very moment. You didn’t say, “Oh, it’d be more perfect if there were less seagulls flying across the sky.”

The emergency physician’s role is to evaluate everyone who comes into the ED - regardless of how sick or not sick they appear to be - and rule out emergencies. Our realm of practice includes the most bogus visits to the most critical illnesses. The key idea is acceptance of this fact. To accept everything that is happening and every patient who comes in to the ED, no matter what. When I accept the patient with an ingrown toenail, the asymptomatic patient who meticulously measures their blood pressure at home, or the patient in DKA who doesn’t take their diabetic medications, I feel calmer and relaxed. If I don’t want to develop stress-induced hypertension, burst an aneurysm, or start loading up on benzodiazepines prior to work, I choose to accept all aspects of my field.

Every shift, we have the opportunity to relieve pain, alleviate fears, and save lives. It’s a privilege to be an emergency doctor and everything that comes along with it. So here’s the challenge: during your next shift, calmly accept everyone you see in the emergency department.

Reference: Rao, Srikumar. http://www.ted.com/talks/srikumar_rao_plug_into_your_hard_wired_happiness.html Accessed 8.31.10

Originally posted in CAL/ACEP Lifeline October 2010.

Top Ten Financial Tips for Graduating EM Residents

2010-10-18T16:37:00.000-07:00

1. Save more than 20% of your income.

2. Have cash reserves for six months of expenses.

3. Automatically have savings deducted from check.

4. Take full advantage of employer's financial benefits, i.e. retirement, child care, advanced education, etc.

5. Max out your 401K, Roth IRA, or other retirement plan.

6. Review insurance policies (malpractice, disability and life insurance.)

7. Create an investment strategy based upon income, age, and risk tolerance.

8. Start an education plan for your children (529 or education IRA.)

9. Review estate planning and update your will or trust.

10. Start planning now to avoid income tax suprises next year.

Source: Lane Financial & Dew Wealth Management

Anthony Robbins

2010-10-16T22:04:00.000-07:00

I listen to Tony Robbins in the car. His books, Unlimited Power & Awaken the Giant Within are powerful. After listening to him, it gives me a different mental model to use and different perspective on reality.

Enjoyo this enlightening talk by Tony Robbins @ TED Conference.

Finding your niche in Emergency Medicine

2010-10-14T14:08:00.000-07:00

http://freeemergencytalks.net/wp-content/uploads/2010/03/Finding-Your-Niche-in-EM.mp3

*Right mouse click the link above to save.

Dr. Amal Mattu's lecture "Finding your niche in EM" is powerful. He discusses the importance of finding your unique area in emergency medicine. His tips are to:

1) Be the Expert.

2) Go into new areas that are not too saturated (like emergency EKGs)

3) Publish like crazy on a focused topic.

4) Be broad, and not too narrow.

5) Read everything on that topic.

Whether one is going into academics or community practice, it's important to have a niche. Now, go forth and specialize.

Dr. Ko's Advice To Graduates

2010-06-08T14:07:00.000-07:00

1. Be happy NOW.

2. Choose your passion. Find the point where your interests intersects the world's needs.

3. Define success. Figure out when you want to stop and enjoy.

4. Love others. If choosing between being nice or a jerk, be nice.

5. Enjoy the process, and focus less on the outcome.

6. Life is hard and intertwined with joy and woe.

7. Persistence is key to achieving what you really want.

8. Be thankful for everything you have and ask yourself, "How can I give back?"

9. Every day is a BRAND new day, and you can start fresh no matter what happened before.

10. Know that you will die. Think of it as the ultimate deadline. When you are worried about something, compare it to this fact.

Yours Truly,

Dr. Ko

Business Card Trick of the Trade

2010-05-21T13:39:00.001-07:00

Have you ever gone to a conference and gotten a grip of business cards in your hand?

I used to store mine in a little box in the deep recesses of a banker box never to be opened again.

But then I discovered how to leverage www.evernote.com and the iPhone. Here's what you can do:

1) Take a picture of each business card (the back side if there is something on it) with your iPhone.

2) Find your Evernote incoming email address, click here, if you don't know how.

3) Email all the business card photos to the Evernote email address using iPhone photos

4) Go to Evernote website and log in. You can search the business card photo's content by name, company, etc. etc.

5) Now throw each and every one of your business cards into the closest recycle bin like a ninja!

Prisoners Get Access to Healthcare, Should Others?

2010-03-11T22:31:00.000-08:00

Is health care a right in the U.S.? If not, then why do prisoners get it for free?

At some level we must believe that basic health care should be provided to the residents of the U.S. Can you believe that some prisoners get better health coverage than hard workers in America?

Of course someone could argue, they get cable TV. But not everyone in the U.S. does! Just because they get it in jail, doesn't mean that is a right. Then again, cable TV and other privileges can be revoked. If a prisoner is sick, regardless of their behavior, they will get seen by a health care practitioner.

One fear I have about making health care "free," will lead to the under appreciation of it. For example, public bathrooms are free and nobody really takes care of it.

"Why, when you use the public restroom, is everything wet?" ~ Dane Cook.

**Fast Forward to 3:10

Dr. Ko's Emergency Ultrasound Course

2010-03-03T20:25:00.000-08:00

Addictive Learning That Sticks

In a hurry? Enroll in the course here.

Learn by answering a few emailed questions every other day? SpacedEd co-founder and CEO Duncan Lennox says that is precisely what his product is doing for physicians. (SpacedEd was invented at Harvard Medical School.)

SpacedEd is a platform designed to allow learners and teachers to harness the educational benefits of spaced education. It is based upon two core psychology research findings: the spacing effect and the testing effect. In more than 10 randomized trials completed to date, spaced education has been found to:

Improve knowledge acquisition,
Increase long-term knowledge retention (out to 2 years),
Change behavior,
Boost learners’ abilities to accurately self-assess their knowledge.

In addition, spaced education is extremely well-accepted by learners.

The SpacedEd approach is predicated on a set of core principles:

Short Repeated Bursts: Because it uses a regular schedule and an adaptive algorithm, learning can be delivered in small amounts that can take as little as 3 minutes a day.
Push Learning: The learning comes to you on a regular schedule. You don’t have to remember to do it or set aside large chunks of time.
Adaptive: The daily content adapts based on past performance automatically to drive long-term retention while requiring less time.
Immediate Feedback: Once a question is answered, detailed educational feedback is provided. Users are also given performance data (their course progress and performance relative to peers) which feeds their addiction to the courses.

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Emergency Ultrasound

Do you practice emergency medicine?

Have you ever used an ultrasound machine?

Want to get updated on the latest ways to leverage ultrasound?

If your answer is, "Yes," to any of the above...

...then sign up for this course now!

------------------------------------------------------

The "Emergency Ultrasound" course includes 25 questions with images, videos, and detailed explanations. More importantly, each explanation ends with a primary Clinical Bottom Line so you can apply it immediately in your practice.

------------------------------------------------------

Thanks to all faculty, staff, & colleagues at Loma Linda University and Riverside County Regional Medical Center in Southern California for their assistance in creating this ultrasound course.

Check out this EM Ultrasound Course now!

Ten Emergency Medicine Websites I Love and Will Marry

2010-02-11T18:34:00.001-08:00

1. http://www.epmonthly.com - EM news, ultrasound images, and "WhiteCoat's Callroom"

2. http://academiclifeinem.blogspot.com/ - All things related to Academic EM

3. http://emcrit.org/ - Crazy amounts of information on nexus of EM and Critical care

4. http://edwinleap.com/blog/ - Amazing EM blogger

5. http://myemergencymedicineblog.blogspot.com/ - Powerful Clinical Pearls

6. http://www.ncemi.org/ (best viewed in Internet Explorer) - Loads of information, medical calculators, and cool small pox images

7. http://gruntdoc.com/ - Classic ER

8. http://www.sonoguide.com/introduction.html - Best EM ultrasound site alive

9. http://allbleedingstops.blogspot.com/ - Movin' Meat

10. http://www.erpocketbooks.com/ - Tricky Cases, Free Ultrasound Images, & Pocket books

Needle Sticks and Scapel Injuries

2009-11-30T14:55:00.001-08:00

I've been stuck by a sharp object twice in my medical career. The first time, I was doing a lumbar puncture, aka spinal tap, on a 3 week old neonate for a complete septic workup. I had everything prepped and had the long spinal needle in my right thumb and middle finger. As I was turning to ask the assistant something, I poked myself at the tip of the index finger. Fortunately, the needle was clean and I had not even began the procedure. I washed up immediately and was not concerned about infection or tetany (I had my tetanus shot 2 years ago)

Recently, I was about to place a chest tube on a patient.

I prepped the skin and injected generous amounts of lidocaine into the tissue. I made a small incision with my scalpel above T4 level along the anterior axillary line and placed the bloody scapel on the sterile drape over the mayo stand.

I turned to grab the Kelly's and instead stabbed myself with the scalpel on my right thumb through the latex glove. Blood oozed immediately into the glove and yet I felt no pain.

My attending told me, "Sam, wash your hands like you've never washed them before." Luckily, the surgical residents were right next to me and took over the procedure. We didn't know too much about this patient, so it was frightening to consider that I could become infected with HIV, Hep B, Hep C, or other bugs.

Although, I've taken care of several staff with needle exposures, I'd never personally really felt the fear of the unknown. A rapid HIV test was ordered on the patient, along with Hep B and Hep C testing. The wait felt like it took forever and I was offered a triple combination of HIV antiviral medications. Should I take them? I pondered as I looked over the CDC recommendations:

As you can see above, I am in the "Source HIV status unknown" and "More severe injury type." CDC does not generally recommend taking PEP. However, I opted to take one dose now, as its most effective in the first 1-2hrs, plus I got some Zofran ODT to prevent nausea/vomiting.

Overall, everything turned out OK for me (pending studies). I gained several insights about needle sticks during this encounter:

1) Although the risk is very low, it's mind-boggling freaky to be faced with the diseases that can change your life.

2) During procedures and traumas, it's particularly important to SLOW down and be aware of each and every sharp object on the table.

3) Percutaneous injuries are very common in the hospital. Even with all the safety mechanisms, more automatic methods need to be created to prevent them.

For example, in the central line kits, there is Styrofoam piece designed to temporarily place needles into.

My suggestion: Please place one in the chest tube kit!

Seven Lessons Learned from Ambulance Ride Alongs

2009-11-17T22:10:00.001-08:00

I am on EMS this month as part of my residency training. This includes time with police, firefighters, 911 operators, and ambulance crews. Today, you will gain from my experiences with hanging out with an AMR ambulance team.

1. Be nice to the EMTs/Paramedics. They determine who comes to your ER. Typically, patients can request which hospital to go to. However, if a patient is clueless about where they want to go, the ambulance crew will decide for them. Otherwise, they will bring all indigent vomiting/diarrhea patients to you.

2. Listen to EMS providers. Sometimes the ride to the hospital takes a while, and there is a paramedic in the back talking to the patient for a solid 15-30 minutes. They ask a lot of questions and can give you a significant amount of history.

3. Teach an EMT/Paramedic something each time you meet one. A lot of these guys/gals are eager to learn. Because they are truly the "front-line" they can help you with diagnosing critical situations.

4. Give free food. It's tough being out on the road. EMS providers don't get as many perks as police officers or firefighters, but definitely deserve props for the work they do in the community. In my opinion, they are truly unrecognized heroes.

5. Help them access a place to sit for paperwork. Documentation is a necessary evil in the practice of medicine. It's much easier to sit in a non-moving site to finish up charting on paper and computer.

6. Give them feedback. If you see an EMS provider and recall a patient they brought in previously, tell them about what happened during the ER stay. A lot of paramedics and EMTs remain in the dark about the ultimate outcome of the patient they bring in.

7. Don't sweat IV access. It's challenging to get an IV on patients, and even more difficult in the back of a vehicle bouncing along the roads. If they don't get an IV, please give them a little slack.

Overall, we have to respect them. Listen and teach. They have a lot of information to give and are willing to learn.

Easy Ocular Application of Fluoroscein

2009-11-08T02:03:00.000-08:00

Below is a Blog Post in Tricks of the Trade that I helped write. Thanks Dr. Lin!

Trick of the Trade: Easy ocular application of fluoroscein

Gently instilling a fluorescein drop into a patient's eye requires that the patient keep his/her eye still. What do you do for a patient who can't quite stay still enough, such as an infant? This is an innovative trick of the trade, written by Dr. Sam Ko (Loma Linda EM resident) and Kimberly Chan (Loma Linda medical student).

A 14-month old male is brought into the Emergency Department by his mother because he is rubbing his eye and inconsolably crying. You suspect a corneal abrasion or foreign body and decide to quickly evaluate his cornea using the fluorescein stain. Using the method below, you’ll be able to perform the exam with little discomfort to the patient.

1. You will need a small vial of saline (left) and a fluorescein strip in packaging (right).

2. Open only one end of the fluorescein strip package.

3. Insert saline flush vial into the package.

4. Flush saline in and out of the packaging several times until the fluid in the bottle turns yellow.

5. Now that the saline vial contains fluorescein, use the container like an eye dropper.

Pearls to consider:

Defects in the corneal epithelium will appear green under the light.
Beware that mucus can also stain green. If you aren’t sure which is which, ask the patient to blink. The mucus will move, but the defects won’t.
Remove contact lens before this exam, because they can become permanently stained (perhaps a cool Halloween trick for next year?).
Pseudomonas easily grows in fluorescein dye, so never reuse or share dye.

Crystal Meth: Multiple Pictures are Worth a Million Words

2009-09-09T13:44:00.001-07:00

Healthcare Cost Reduction Idea

2009-09-08T16:18:00.000-07:00

If a person requires dialylsis for end stage renal disease and are unable to pay for it, the patient can get Medicare to fund the dialysis.

"The cost of kidney dialysis averages about $44,000 per year per patient, using 1993 figures. The average cost for the transplant patients in our study, including the transplant surgery and medical care for the first year following surgery was $89,939. After the first year, costs for the transplant patients averaged $16,043; mostly for medications to prevent rejection.

http://www.umm.edu/news/releases/kidcost.htm

I wonder if it'd be better to open up a market for kidney transplants.

Why Medical Students Stay Up During Call

2009-08-12T04:22:00.001-07:00

Med Student: Dr. Bausch, I've got several hours more work to do tonight, and you don't. How come you're always going to sleep, and I'm always staying awake?

Roy Bausch: Simple. You're a mathemetician, right? Now, I get paid a fixed salary by the BMS, no matter how many hours I'm awake. You pay a fixed tuition to BMS, no matter how many hours you're awake. Therefore, the more I sleep, the more I earn per waking hour, and the more you stay awake, the less you pay per waking hour. Got it?

~House of God by Samuel Shem, MD

Top 20 Tips for Intern Year

2009-06-18T21:07:00.000-07:00

1. When ordering a test or taking any action on a patient, ask your self the question, “Why am I doing this?” If it doesn’t change the patient’s outcome, reconsider your plan.

2. Evolve your communication skills to the maximum. Keep your attendings, senior residents, nurses, patients, and patient’s families up to date on the plan.

3. Ask questions when you don’t know the answer. Its okay to ask the nurse and even the actual patient, “What do you think is going on?”

4. When you’re on call overnight and sleeping in your plush intern bunk bed, and a nurse calls you about a patient with abdominal pain, chest pain, or difficulty breathing, get out of bed & go to see them ASAP.

5. If a diabetic patient comes in with nausea and vomiting with no chest pain or SOB, still consider Acute Coronary Syndrome (ACS) in your differential.

6. If someone yells at you or criticizes you, ignore the instinctual reaction of defending your position. Simply state, “Sorry. Mea culpa. It won’t happen again.” Even if it was not your fault.

7. Be nice to nurses, BUT don’t always listen to them.

8. Teach something to a medical student, nurse, PA, a junior resident at any free moment. Spend the additional 2 minutes to P.I.M.P. Doctor comes from the Latin word, doctoris, which means teacher.

9. If you say you are going to be somewhere, or promise to do something, follow through. If you can’t, let them know as soon as you realize it.

10. Be generous with pain meds. It’s better to give narcotics to fakers than to have a person in really bad pain. In trauma patients, consider fast acting fentanyl 1 mcg/kg

11. Do the things that scare you and see the patients that you find challenging. Be aware of your backups in case you suck. Feel the fear, and do it anyway.

12. Try not to hook up with co-workers, nurses, med techs, etc.

13. Exercise regularly.

14. During vacation weeks, go somewhere that requires a flight. You’ll come back much more refreshed. Also, don’t request vacations in the first week of a rotation, you might be lost when you come back.

15. When calling a consult, be sure to know the patient. Then introduce yourself by name. Verify that it is the correct service. Ask for their name. Ask how they are doing today. Begin with, “This consult is for…” and tell them the rest. End the conversation with, ‘Do you have any other questions about this consult?”

16. Try not to call bogus consults. You will recognize them after you’ve been an intern for that service.

17. If you have an infant who is crying, inconsolable, and everything else is normal, get the lidocaine eye drops. It just might be a corneal ulcer.

18. In the ED, ask the patient, “What made you decide to come in TONIGHT?” and if it’s a chronic problem, “What does your primary medical doctor think about this?”

19. If it doesn’t make sense to you, question your attendings and senior residents in a diplomatic way. They are human and make mistakes too.

20. Forgive yourself for the mistakes b/c you will absolutely make them. Just learn from each. James Allen wrote, “Circumstances don’t make a man, they reveal him”