Learning Resource: Closing the Gap

For fourth year students interested in Emergency Medicine this is the time when most are finally getting to do EM rotations. There are a lot of objectives packed into these four week blocks. You need to figure out if this is really the kind of medicine you want to practice. You need to "audition", showing your aptitude and fit for EM, and secure letters of recommendation evaluation. You also want to start improving your clinical skills and getting some procedural experiences under your belt.  The latter is where todays post come in.

The scope of EM practice includes numerous procedures, including high stakes ones like pericardiocentesis, cricothyrotomy, and resuscitative thoracotomies. While you will learn to do these eventually, at this stage it will be higher yield to focus on the procedures that are more readily available, like wound management. You should get opportunities to do wound repair during your rotations and your future residency will expect you to arrive with some degree of experience with basic wound closure techniques.

The world of FOAMed (Free Open Access Medical Education) is overflowing with great resources for procedural education. The "Closing the Gap" site, lacerationrepair.com, is a particularly nice resource that consists of a set of videos and annotations covering the majority of wound repair techniques you need to know. Start with simple interrupted sutures, check out the corner stitch, and work your way through the advanced techniques, like layered closure.

Enjoy!

R.E.B.E.L. EM and the Importance of Airway

In this brave new world of FOAMed one of the big challenges is vetting which sources of information are worth following. The work of Salim Rezaie (@SRRezaie) on his R.E.B.E.L. EM blog, should be a a must read for anyone trying to keep up in EM. He is a prolific contributor to #FOAMed with recent posts exploring the need for an insulin bolus in DKA and what actually matters in post-LP headaches.  But the one that prompted this long over-do "shout out" was a review of preoxygenation and apneic oxygenation that you should go read right now.

Your communication skills are probably those most critical to your overall success in medicine, but you can argue that airway skills come in a close second. If you train at an ACGME-approved residency program in the U.S. you will be required to perform 35 intubations to meet requirements.  Ask any Emergency Physician and they will tell you that 35 is just the beginning. Real competence likely happens somewhere around "triple digits". 

You have to start somewhere, and early in the development of your airway skills you are going to need some extra time to figure out where you are and what you are looking at.  These techniques for maintaining excessive oxygenation during the peri-intubation period are good for the patient and great for your chances of completing the intubation. The FOAMed world is full of wonderful Airway resources, and R.E.B.E.L. EM is a good place to start.  

Also see this primer on intubation from The Short Coat by Lauren Westafer (@LWestafer) and this lecture by Rich Levitan posted on the EMCrit blog by Scott Weingart (@emcrit).

Scoring Procedures

One of the goals most students have for an EM rotation is to get some procedural exposure and experience.  There are some procedures that that the residents will happily give to you, like ABG's, NG tubes, suturing, and anything involving pus.

However, the procedures you are really hoping for are the ones with greater complexity, like intubation, central venous access, and lumbar puncture.  These are usually much harder to get.  You may even be in competition with an intern for these, especially in July and August.

Here are some tips that can result in more complex procedural opportunities:

1. Be involved - Your supervisors will be much more interested in finding cool stuff for you to do if you are engaged and participating in what the team does.  
2. Be ready - You need to have background knowledge on indications, contraindications, landmarks, and technique for any procedures you would hope to get the chance to do.  Your supervisors may use screening for this knowledge to decide if you get the chance to do the procedure.  Also, take any chance you get to practice on a simulator before trying this on a real person.  
3. Be proactive - It does not hurt to ask for the opportunity.  The worst thing that happens is they say, "no".
4. Be honest - Actually, the worst thing that can happen is that you claim to have experience you do not have, get found out, and then get demolished in your evaluation and letter.  Lack of experience won't keep you from some opportunities but lack of honesty will