Pimping in the ED

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vtucci

Attending in Emergency Medicine
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Hello all.

As we are slowly wrapping up our second year and about to go headlong into third year, I thought I would ask a few of you masters out there: how should we prepare for pimping in the ED?

I already bought the Hamiliton and Madahaven texts and was hoping to read some chapters before or during my ED rotation and planned to cover some of the broader categories like abdominal pain, headache, shortness of breath. The ED does not seem to lend itself to the same manner of preparation as some of the other services (i.e., review the charts of current patients in anticipation of questions relating to their conditions). As patients are not usually warehoused in the ED and there are new patients on every shift and you can't anticipate what will walk through the door, how did you prepare?

Oh and Quinn, I pre-ordered your book but they keep pushing back the release date.:(

Thanks everyone. I just really want to shine. I love EM and can't imagine going into another specialty.

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Just know your patient. It helps to have done the medicine, peds, and surgery rotations because a lot of EM is based on those. You can't possibly know everything, and there aren't a lot of EM specific pimp questions (maybe ACLS, maybe). At least not at the 4 hospitals I have been to anyway.

Ok, maybe you should know some tox too. They like pesticides. And a little derm.
Check that, just know everything. It does help in studying for Step II though.
 
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It was already said; as an MSIV I found the most important part of the EM rotation is to know up to date information about your patient. Check on them frequently (how you doing, hows the pain, educate them about what your waiting on and why you got it) and refresh those lab/x ray screens. Get on the phone and find out why such and such is taking so long (if you think it is taking long). You dont ever want the attending to come tell you oh by the way, your patients troponin is back and its normal (now if it was super elevated, he might get the message from the nurse from a called in lab, in that case its cool). You want to swing by him and say mr so and so's chest pain is better after the nitro, and his troponin is back and is negative times 1...etc. Try to watch/do all the procedures you can; gown up, trauma shear the clothes off, and lend a hand when a trauma comes in... all without getting in the way. If I had a patient with a different attending, I would always let them know that I am going to stitch up a patient for so and so... this way they dont think you are falling behind on being on top of your patient.

Do not pickup too many, probably 2 max... and stay away from the really sick..just because you are not going to be able to stay on top of their managment and the attending is going to have to be all over it. Even if you are a stud and are capable, just needing to constantly order stuff etc usually takes a drs signature... The goal is for your attending to do nothing but say agree with yada yada and sign the chart. Less they have to do, the more you probably will shine.

As far as questions, I find that pimping is rather comfortable in the ED. As far as time to look up the questions, I agree that is limited but I find ED questions to be the easiest to anticipate and not so hard to find the information really quick. Lets say you present a patient with abdominal pain; you should also have filled out at least part of what you want to order (very minimal have a list to tell the attendings). So you say you want to order x, y, and z. The questions are going to be: What do we care most about in the abdomen as far as an emergency and what do we do to rule it out? Why do you really think this patient has pancreatits? Why did you order lab z; how about lab w? What are you going to do for this patient in the mean time?

Hopefully some others will chime in as well. Thats all I can say with my still limited experience. Good luck and enjoy your EM rotation!
 
Oh they love.. treatment of HyperK..

Know

1) Ca first to stabilize the heart.
2) the drugs that lower extracell K..
3) know total body K doesnt change until Kayexelate is used or dialysis..
4) Good luck

Oh I havent looked at Quinn's book but that might be a place to start..
 
It was already said; as an MSIV I found the most important part of the EM rotation is to know up to date information about your patient. Check on them frequently (how you doing, hows the pain, educate them about what your waiting on and why you got it) and refresh those lab/x ray screens. Get on the phone and find out why such and such is taking so long (if you think it is taking long). You dont ever want the attending to come tell you oh by the way, your patients troponin is back and its normal (now if it was super elevated, he might get the message from the nurse from a called in lab, in that case its cool). You want to swing by him and say mr so and so's chest pain is better after the nitro, and his troponin is back and is negative times 1...etc. Try to watch/do all the procedures you can; gown up, trauma shear the clothes off, and lend a hand when a trauma comes in... all without getting in the way. If I had a patient with a different attending, I would always let them know that I am going to stitch up a patient for so and so... this way they dont think you are falling behind on being on top of your patient.

Do not pickup too many, probably 2 max... and stay away from the really sick..just because you are not going to be able to stay on top of their managment and the attending is going to have to be all over it. Even if you are a stud and are capable, just needing to constantly order stuff etc usually takes a drs signature... The goal is for your attending to do nothing but say agree with yada yada and sign the chart. Less they have to do, the more you probably will shine.

As far as questions, I find that pimping is rather comfortable in the ED. As far as time to look up the questions, I agree that is limited but I find ED questions to be the easiest to anticipate and not so hard to find the information really quick. Lets say you present a patient with abdominal pain; you should also have filled out at least part of what you want to order (very minimal have a list to tell the attendings). So you say you want to order x, y, and z. The questions are going to be: What do we care most about in the abdomen as far as an emergency and what do we do to rule it out? Why do you really think this patient has pancreatits? Why did you order lab z; how about lab w? What are you going to do for this patient in the mean time?

Hopefully some others will chime in as well. Thats all I can say with my still limited experience. Good luck and enjoy your EM rotation!


Thanks EM Rebuilder. We have our ED rotation in our third year and for some of our class, it will be the first clinical rotation of the year. We don't get to pick what are schedule is third year.

I had planned on being on top of everything I can think of but am worried that if I haven't had medicine or surgery that I might not yet know everything to be on top of. For example, you mentioned to stay on top of the lab. Since most labs for the ED are sent stat (which theoretically, should be done within in the hour), at what point is it too long?

Ectopic- thanks for the comment about hyperK. I will file it in the memory bank.

I am waiting for Quinn's book to be released from amazon. ;)
 
Thanks EM Rebuilder. We have our ED rotation in our third year and for some of our class, it will be the first clinical rotation of the year. We don't get to pick what are schedule is third year.

I had planned on being on top of everything I can think of but am worried that if I haven't had medicine or surgery that I might not yet know everything to be on top of. For example, you mentioned to stay on top of the lab. Since most labs for the ED are sent stat (which theoretically, should be done within in the hour), at what point is it too long?

Ectopic- thanks for the comment about hyperK. I will file it in the memory bank.

I am waiting for Quinn's book to be released from amazon. ;)

basically since you are only seeing 2 pts at once.. check labs often.. and make sure you know your pt in and out... you will need a lot of info since you prob dont yet know "whats important" so ask away. They dont want you to see 8 pts at once or anything they just want you to be thorough..

g/l
 
oh and know that hyper K has peaked T waves.. i dont know why but i got pimped on hyperK on all 3 ed rotations i did (one as a 3rd yr).

That being said it is one of the most serious and most easily reversible conditions we see. DKA is another.
 
Thanks guys. I had heard the 1-2 patient "rule" and was planning on sticking to it like glue. :cool:

Hopefully it will work out and I will have had IM and surgery first and have a better grasp for what is truly important. Dare to dream? As much as I love pathology now, I don't think we will even start to be okay at this until third year.
 
Thanks guys. I had heard the 1-2 patient "rule" and was planning on sticking to it like glue. :cool:

Hopefully it will work out and I will have had IM and surgery first and have a better grasp for what is truly important. Dare to dream? As much as I love pathology now, I don't think we will even start to be okay at this until third year.


Last thing that I will mention is to keep in mind that since MSIIIs doing EM at you school is the norm, then the ED knows that they have fresh MSIIIs coming in who have NO experience whatsoever. They should be cutting you MUCH slack espically if its one of the first few rotations of the year. They will hopefully be focusing you on just taking good histories and developing presentation skills...
 
It really is not the norm just yet. We will be the third class that has emergency med third year. Maybe that is a good sign? ;-)

I am trying to hone my H&P skills as much as possible before third year. Guess, I'll just cross my fingers.
 
Know the only two reasons not to do a rectal exam on a trauma pt. or abdominal pain... 1. Doctor has no finger. 2. Pt. has no anus.
 
I didn't read the whole thread but here's my opinion...


Pimping in the ED I think isn't so much to highlight what the student/resident doesn't know but more to make a teaching point.

I'm just a new attending myself but I like to ask the "pimp" questions in an effort to gauge the pimpee's (is that a word?) knowledge base and line of thinking. Ultimately however it is done as a way to introduce an important teaching point. I think if it is presented as a question and then followed by a simple case scenario, it can be used as a useful teaching tool. I try not to do it in such a way that would make a student/resident feel or look stupid.
 
V-

My book is just published, I got my copies now. If you can, cancel your order from amazon and order it from Barnes and Noble, you'll save about ten bucks!

Anyways, the above posters offer good advice. Take a thorough history. Your job as an M3 is NOT to make the diagnosis. Everyone knows that, basically, you have no medical knowledge. 3 years ago you were reviewing torts and depositions. So its a whole new world for all 3rd year med students.

Do a thoroguh exam. If the patient has any neuro complaint, do a good neuro exam. A thorough neuro exam doesn't take more than 3-4 minutes. READ up on patients in between while you are waiting for labs. See how your patient is doing with the nitro/morphine/toradol/valium or whatever. Chek their response to your therapy. Follow the patient to CT and ask the CT tech if they saw anything. Help the nurses. These are just general tips for the ED....

But for pimping, try to think of areas in your presentaiton where you migth get pimped. K is a good example. Try to listen to teh way the question is phrased. I.E.:
"In patients that present with CHF with borderline troponins, do they have a higher morbidity/mortality?" Uh, well, I would guess so.
"What do you think is the usefulness of oral contrast in CTs for blunt trauma patients?" "Uh, probably not very useful."

Even though you may NOT know, the way the person poses the question can be helpful, too.

Now, if you get asked "What serum test is a good screening exam for sarcoidosis?" And you have no clue, no problem, most people don't, those are true pimp questions and they are made to make you feel like an idiot.

That being said, the answer can be fund in most books, but especially the "Pimp Protector"
;)

Q
 
One of the above posters suggested staying away from the truly sick patients. I certainly understand that idea (especially if you are a freshly minted 3rd year). However, don't run away everytime a really sick patient comes in the ED! This is why we want to do emergency medicine, remember. Some of the best learning I've had in med school was via patients going down the tube in the ED. You shouldn't be running medical codes on your own, but you shouldn't hide in the back with all the sprained ankles and URIs either :)
 
V-

My book is just published, I got my copies now. If you can, cancel your order from amazon and order it from Barnes and Noble, you'll save about ten bucks!

Anyways, the above posters offer good advice. Take a thorough history. Your job as an M3 is NOT to make the diagnosis. Everyone knows that, basically, you have no medical knowledge. 3 years ago you were reviewing torts and depositions. So its a whole new world for all 3rd year med students.

Do a thoroguh exam. If the patient has any neuro complaint, do a good neuro exam. A thorough neuro exam doesn't take more than 3-4 minutes. READ up on patients in between while you are waiting for labs. See how your patient is doing with the nitro/morphine/toradol/valium or whatever. Chek their response to your therapy. Follow the patient to CT and ask the CT tech if they saw anything. Help the nurses. These are just general tips for the ED....

But for pimping, try to think of areas in your presentaiton where you migth get pimped. K is a good example. Try to listen to teh way the question is phrased. I.E.:
"In patients that present with CHF with borderline troponins, do they have a higher morbidity/mortality?" Uh, well, I would guess so.
"What do you think is the usefulness of oral contrast in CTs for blunt trauma patients?" "Uh, probably not very useful."

Even though you may NOT know, the way the person poses the question can be helpful, too.

Now, if you get asked "What serum test is a good screening exam for sarcoidosis?" And you have no clue, no problem, most people don't, those are true pimp questions and they are made to make you feel like an idiot.

That being said, the answer can be fund in most books, but especially the "Pimp Protector"
;)

Q

Hey Quinn. I just got the notification from amazon that they shipped me your book. I look forward to reading it.
 
Keep that pimp hand strong!
 
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