[BigBri.net]

ER Trip

So I stopped off in SLO on my way up to graduation, and had Grandma watch the kids while we went out with friends.  They were walking to the park, and Grandma hopped on my nephew’s Razr scooter.  She ate shit.  She fell from standing on the sidewalk and stopped herself with her face.  Lara got a frantic call from Grandpa for us to come home because someone was bleeding, and of course we were there in seconds. 

My mom was pretty banged up.  I superglued a little scratch on her head and had her put some ice on her face.  There was a little crepitus when I moved her nose, and of course I was concerned about TBI even though she had no LOC, no HA, etc.

She proceeded to drink a margarita and got ready for bed.

I convinced her to go get her head scanned.  I told her that it would help me sleep better. 

ED Physician starts doing his H&P, my mom is being difficult because it’s 10:00PM and she just wants to go to bed.  I decide to speed it up and give him a quick synopsis: “Mom fell from standing, landed on her face, did not break the fall with her arms, no LOC, complains of some neck pain…”

ED Physician: “Do you have neck pain?”

Mom: “Yeah”

ED Physician: “Don’t move your neck.”

Mom: [moves neck] “I just want to see if my nose is broken.”

ED Physician: [yelling] “DON’T MOVE YOUR NECK!”

Mom: [moves neck] “There’s nothing wrong with my neck.”

ED Physician: “I’m glad you have x-ray vision in your armamentarium.” [leaves room to get C-Collar and says under breath] “WOMEN!”

Her scans were negative, and we got out of there before midnight.

Scramble Update and Advice

I discussed some of this in previous posts, but here’s an update:

I was operating under the advice of many when planning the match.  I was told several times that there are always EM spots available in the scramble, as long as you are willing to go to some podunk town in BFE for residency.  My desire to stay on the west coast was strong, both for myself and my wife’s career.  I decided to apply to and rank only west coast programs, and if I didn’t match - I didn’t care where I went. 

After the Osteopathic match - programs were calling and emailing me for days to get me to interview.  I told them all that I was waiting for the allopathic match.  Most responded that they would not wait to fill their spots.  I decided to take my chances.

Despite good grades, scores, and audition rotations - I didn’t match.

On Tuesday, I scrambled from home because I live in SoCal.  I scanned my CAF, board scores, and LORs in PDF format so that I could email them to program directors.  At 9 AM, I emailed everyone.  I made phone calls from my cell phone and used my land line to fax my app.  I submitted ERAS apps to everyone that had an open spot.  I GOT NOTHING BUT BUSY SIGNALS from 9AM to noon.  I tried, but even the Osteopathic programs that had been courting me earlier had filled.

When I re-checked the NRMP site, every program had filled except Puerto Rico.  I quickly switched gears and started applying to IM and Traditional Internships.  I got one interview, and although they loved me, they questioned my dedication to IM because my personal statement and LORs all said EM. 

Luckily, a program director heard that I was scrambling and saved me a spot at a Traditional Internship.  I have a job for next year.  My current plan is to work my ass off and pray that I can fall into a PGY-II spot somewhere.  If not, I have no qualms about repeating my intern year.  The difference between an intern salary and an emergency physician salary is roughly $150,000.  That means that my match strategy was a $150,000 mistake.  Please don’t make the same mistake.

Some advice:

• Schedule audition rotations toward the end of the interview season at your top picks so that you will be fresh in their minds when making their rank list.  Schedule a “Practice” rotation before then, so that you can learn the ropes.  I did an audition rotation first thing fourth year.  By the time they made the rank list, I was a distant memory.  I was also very green early in my fourth year, so I didn’t have the knowledge and experience that showed in later auditions.
• Don’t count on the scramble.  I heard from many people that even traditionally non-competitive programs like OB-GYN and PEDS filled quickly.  Apply to a lot of programs, interview at a lot of places, and rank at least 10.
• Don’t count on the NRMP match.  If you do the allopathic match - set up a contingency plan.  Rank a few spots in another specialty or at Transitional/Internship years at the end of your rank list just in case. 
• Plan to scramble early.  Even some people at the top of our class had to scramble.  When you get letters of recommendation, ask the writers if they can write two copies - one geared toward your specialty, and a generic one.  Write a generic personal statement and upload it to ERAS just in case you need to scramble into another specialty.  Continue collecting letters of recommendation even after interview season - you might get a great letter in ERAS that can be used in the scramble.
• TAKE BOARDS EARLY.  The COMLEX-II is much easier than step I.  If you did poorly or even mediocre, you can easily look good by scoring better on step II.  If you do have to scramble, many programs will ask if you have passed your boards and are on track for graduation.  If you fail an exam and have to re-take it, that may look bad at the last minute.

Good luck everyone!

Bri

Scramble

I spent all day yesterday scrambling for a spot. When I started making plans for the match, I was operating under the advice I had heard many times: “You can always get a spot in EM, as long as you’re willing to train anywhere.”  Well, after the match there were only 5 categorical EM programs that went unfilled in the NRMP match.  All the advanced programs filled.  All the combined IM/EM and FP/EM programs filled, too.  I spent all morning calling, emailing, and faxing stuff.  All I got were busy signals.

Right now I’m working on an IM spot at Arrowhead.  While I’ve always wanted EM, my passion for medical puzzles and complicated patients has never been truly fulfilled in the ER.  I always had the idea of doing critical care in the back of my mind, especially after doing a MICU rotation at Arrowhead.

Cross your fingers for me!

Wikipedian

I’m officially a Wikipedian.  I was searching for an article on the PERC Rule, and Wikipedia didn’t have one - so I was forced to write it. 

I really find clinical decision tools helpful because it means I’m practicing evidence-based medicine.  If I document PERC Rule negative, It’s like I’ve got a mountain of evidence backing me up.   If you’re interested in a handy mnemonic for the PERC Rule, see this post.

http://en.wikipedia.org/wiki/Pulmonary_Embolism_Rule-out_Criteria

New Plates

Here’s Devin installing my new plates!

ED Mnemonics

Here are a few mnemonics I picked up that helped me out…

HAD CLOTS: PERC Rule - Risk factors for PE
Hormone use
Age >50
DVT/PE History
Coughing Blood
Leg Swelling - Unilateral
O2 Sat < 95%
Tachycardia
Surgery/Trauma History - Recent

AMPLE: Important history items in trauma patients
Allergies
Medications
Past Medical/Surgical History
Last Meal/Last Menstrual Period
Events/EMS/Environment

PHAILS: Toxins that cannot be decontaminated with charcoal
Pesticides
Hydrocarbons
Acid/Alkali
Iron
Lithium
Solvents

DUMB BELSS: Cholinergic Toxidrome
Diarrhea
Urination
Miosis
Bronchospasm
Bradycardia
Emesis
Lacrimation
Salivation
Sweating

ME DIE: Differentials for Osmolar Gap
Methanol
Ethanol
Diuretics (Mannitol, Sorbitol)
Isopropanol
Ethylene Glycol

MUDPILES: Differentials for Anion Gap Acidosis
Methanol
Uremia
DKA
Paraldehyde
INH, Iron
Lactate
Ethanol, Ethylene Glycol
Salicylates, Starvation, Solvents

AEIOU: Indications for dialysis
Acidemia
Electrolytes (Potassium)
Ingestion (Drugs)
Overload (Fluid)
Uremia

I STUMBLED: Toxins that can be removed by hemodialysis
Isopropanol
Salicylates
Theophylline
Uremia
Methanol
Barbiturates
Lithium
Ethylene Glycol
Depakote

AEIOU TIPS: Differentials for Altered Mental Status
Alcohol
Endocrine
Insulin
Opiates
Uremia
Toxins, Trauma, Tumor
Infection
Psychosis
Stroke, Seizure, Shock

Living Connected

I’m writing this post from my iPhone using the Wordpress app. It’s nice to be more connected. I’m also using a cool FTP picture uploader to send photos from the iPhone to my gallery. Look for more up-to-the-minute updates and photos from wherever I am!

Here’s a photo of us at Disneyland yesterday. There’s more in the gallery!

The character of the Emergency Physician

I usually don’t distribute stuff forwarded to me in an email, but this one was pretty cool.  I kind of wish I had it when I was writing my personal statement for ERAS and doing interviews.  I think it really nails the character of the Emergency Physician. 

Read more »

Recycling the Lifedrive

After getting the iPhone, my wife and I had some toys that went into obselescence.  One of them was my old Palm Lifedrive.  Although the touchscreen was getting a little worn out, it still has a lot of life in it.  It has a decent battery life, a bright 480X320 screen just like the iPhone, wifi, bluetooth, and a 4GB hard drive. 

I ran across an interesting program - TCPMP.  It has since been discontinued, but here’s a link to the Palm version: TCPMP

I loaded up the Palm with videos for my son, and bought a cheap $4 set of headphones for him.  I even have the car charger, so he can watch videos on long car rides. 

The only downside was that it can’t handle some files with high bitrates (above about 1000k/s).  I use Avidemux to transcode the files and resize them to the Palm’s native 480X320 resolution.

Medical Latin

 Some useful and poignant phrases with translations.  Great for your next tattoo, or when prescribing medical marijuana “ql“. If nothing else, you can tell your partner you want to do it “more ferarum”.

primum non nocere
“first, to not harm”
A medical precept. Often falsely attributed to the Hippocratic Oath, though its true source is probably a paraphrase from Hippocrates’ Epidemics, where he wrote, “Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things: to help, or at least to do no harm.”  
 
cura te ipsum
“take care of your own self”
An exhortation to physicians, or experts in general, to deal with their own problems before addressing those of others. 

lege artis
“according to the law of the art”
Describes something genuine, true, real, tested, proven, not assumed, not placebo. The ‘art’ referred to in the phrase is medicine.   

locus minoris resistentiae
“place of less resistance”
A medical term to describe a location on or in a body that offers little resistance to infection, damage, or injury. For example, a weakened place that tends to be reinjured.  

ad pondus omnium (ad pond om)
“to the weight of all things” More loosely, “considering everything’s weight”.
The abbreviation was historically used by physicians and others to signify that the last prescribed ingredient is to weigh as much as all of the previously mentioned ones. 

quantum sufficit (qs)
“as much as is enough”
Medical shorthand for “as much as needed” or “as much as will suffice”.

quantum libet (ql)
“as much as pleases”
Medical shorthand for “as much as you wish”. 

coitus more ferarum
“congress in the way of beasts”
A medical euphemism for the doggy-style sexual position.