[BigBri.net]

Obesity

I told my patient she had gallstones but didn’t need surgery right now. (she’s about 350 lbs.) I explained that she may have pain when she eats fatty foods or large meals, and that she should eat small, low-fat meals. She asked: “Can’t you just give me a pill for my pain?”

Intern Life

I’m getting fat from cafeteria food. The scrubs that I stole from the OR have a hole in the crotch. It’s 3AM and I’m trying to keep my four ICU patients alive for the next four hours so I don’t have to write death summaries.

How [not] to Intubate

A common mistake – the ETT was 24cm at the lip.  I heard diminished breath sounds on the left, we pulled it back and taped it.  After the CXR came back, we rechecked – it was 28cm at the lip.  No wonder the vent was alarming high pressures.

Actual Conversation

Phone call with family member of MR patient with aspiration pneumonia:

Family Member: “How’s she doing?”

BigBri: “She’s got pneumonia…”

Family Member: “Oh no…how did she get pneumonia?”

BigBri: “Sometimes people have difficulty swallowing or for whatever reason some saliva or food gets into the lungs and causes a serious pneumonia.  She will need at least a few days of IV antibiotics.”

Family Member: “Oh…she has pneumonia in her LUNGS.”

BigBri: “…”

How [not] to place a central line (part 2)

As an intern, I’ve done a few IJ lines and a few femoral lines, but last night I did my first subclavian.  My coworker put in a right IJ, and the patient got agitated and pulled it out.  I put in the subclavian, and I knew something was wrong when I advanced the line over the guidewire.  It just felt like it was directed too superiorly.  I fully expected it to be up in the neck when I got the chest xray – a complication I had seen several times before.  This is what I got:

subclavian cxr

subclavian cxr

The radiologist’s report was: “Interval insertion of right central venous catheter with tip in the region of the left subclavian”

I inserted a guidewire and redirected it into the SVC with flouroscopic guidance – what a pain in the ass…

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!