CanadiEM Podcasts: CRACKCast, ClerkCast, CarmsCast, First Year Diaries

The same 65-year-old man who was seen earlier with an ICH has now recovered. His past medical history is remarkable for hypertension, dyslipidemia, a mechanical aortic valve replacement, diabetes, and sleep apnea. His list of medications include ramipril, atorvastatin, aspirin, metformin, and warfarin. Should his anti-coagulation be resumed? If so, how long should the clinician wait prior to re-starting his medications? Objective 1: Summarize the most recent guidelines regarding when to re-start anti-coagulation after ICH (ASA, DVT-P, Xa inhibitors, warfarin) Objective 2: What factors need to be taken into consideration when making this decision? Objective 3: Interpret the evidence behind the guidelines Objective 4: Describe instances where one would consider re-starting anti-coagulation earlier/later Objective 5: Develop an approach to re-starting anti-coagulation after ICH including which agent to use and why Objective 6: How would you approach this scenario? Objective 7: What do guidelines suggest? Objective 8: Would scenario change depending on type of valve? What if the indication was AF, not mechanical valve? Objective 9: Does the type of bleeding matter? (lobar versus deep ICH)

Core Questions:    Define confusion. What is your differential diagnosis for the confused patient? Differentiate between organic and functional causes of confusion. What is the Quick Confusion Scale (QCS) and how is it calculated? What is the Brief Confusion Assessment Method (bCAM) and how is it used? What is the Mini-Mental State Examination (MMSE) and how is it scored? What ancillary tests are used when working up the confused patient? What is the role of thiamine in the treatment of the acutely confused patient?   Wisecracks:    What simple tests can you use to assess concentration at the bedside? What treatments should be used for the patient with acute hypoglycemia causing confusion? List 5 emergent and 5 critical diagnoses that cause confusion.

Today on First Year Diaries I am joined by Dr. David Carr, a University Health Network emergency physician, renowned medical education speaker, and Toronto Blue Jays physician. In this episode, I asked him to impart his wisdom to new staff physicians like myself and share his approaches to a successful career in medicine. Later in the interview, we also discuss workflow strategies for the ED, common mistakes made by new physicians, and tips on how to maintain wellness/avoid burnout.   Questions: 01:57 – 03:05 - Can you please introduce yourself? (name, training, where you work, interests, etc.).   03:05 – 04:45 – Tell me about your philosophy, and what your career trajectory has been?   04:55 – 08:07 – How can new physicians get to become an educator like you?   08:07 – 12:43 – Do you have any tips for new physicians looking to reach their goals, and become a well-respected physician like yourself?   12:43 – 27:56 – Can you tell us about how you manage department flow efficiently and safely, especially during busy times? 20:41 – 23:56 – Tips to effectively manage flow 23:56 – 27:56 – Tips to effectively manage learners   27:56 – 32:45 – What are some mistakes that you’ve seen new physicians make? (Either clinical or non-clinical).   32:45 – 36:38 – What can new staff do to keep their wellness intact and avoid burnout? What are some strategies you use?   36:36 – 38:28 – Do you have any final comments you would like to share?

Core Questions: 1. Define coma and differentiate coma from lethargy and stupor. 2. Name five neuroanatomic structures involved in maintaining arousal. 3. List five critical and five emergent causes of depressed consciousness. (see Table 13.1) 4. Describe your approach to the history and physical examination for the patient with depressed consciousness. 5. Outline your exam to accurately assess the Glasgow Coma Scale (GCS). (see Table 13.2) 6. What is the FOUR score, and how is it calculated? (see Table 13.3) 7. What ancillary tests should be ordered in the patient with depressed consciousness? 8. Outline your plan of management for the patient with depressed consciousness. (see Figure 13.2) Wisecracks: 1. What is the best noxious stimulus to apply to evaluate GCS? 2. What are the oculocephalic and oculovestibular reflexes, and what information do they provide? 3. Describe decorticate and decerebrate posturing. 4. What is the utility of serum ammonia testing?

Core Questions:    List 10 life-threatening causes of syncope  List 10 medications that can precipitate syncope  What are the red flags on history and physical exam in syncope?  What are markers of increased short-term risk in syncope patients? (box)  What are 5 ECG findings to look for in the syncopal patient?   List five indications for admission and inpatient evaluation for the patient with syncope?   Wisecracks:    What is the significance of a patient presenting with syncope vs. near syncope?  What is the utility of orthostatic vital signs?  What degree of cerebral hypoperfusion is needed to cause unconsciousness?

Core Questions:   Define cyanosis and explain what causes it? What is central cyanosis and what typically causes it? What is peripheral cyanosis and what typically causes it? At what concentration of deoxyhemoglobin does cyanosis present? List 10 differential diagnoses for cyanosis - Box 11.2? Describe your initial workup for the patient with cyanosis.- Figure 11.3/11.4 What is the oxyhemoglobin dissociation curve and what information can be taken from it? - Figure 11.1 Name four factors that shift the oxyhemoglobin dissociation curve to the left and three factors that shift it to the right. Differentiate between ferrous and ferric hemoglobin and describe how these forms of hemoglobin affect oxygen binding. What is methemoglobinemia and how does it present? What are the two biochemical pathways that are used to reduce methemoglobin? List 10 causes of methemoglobinemia - See Box 11.1 What is sulfhemoglobinemia and when should you suspect it? Differentiate between primary, secondary, and relative polycythemia and how does it cause cyanosis?   Wisecracks:   What is the colour of the blood in a patient with methemoglobinemia? What is clubbing and what causes it? What SpO2 is present on the monitor in the patient with a methemoglobinemia? What is the hyperoxia test and how does it help you in your workup of the cyanotic patient? What is the dose of methylene blue when prescribed to treat patients with methemoglobinemia?

From CAEP 2019 I always love the activities and experiences at CAEP, but year after year I’m drawn to the Simulation Olympiad. Every time I think it’s just incredible. This year, I decided to talk with some of the people who make the SIMOlympiad such a great experience for audiences and participants alike. In my first interview, I heard about what the average SIM team looks like, how the competition runs, and what the scope of the material covers. We also got the details on what the characteristics of a winning team look like and how SIM hopefuls can start the team that will win it all at CAEP 2020. Here is my interview with Dr. Tamara McColl of the University of Manitoba and judge for the CAEP 2019 SIMOlympiad.   (If you like to follow along, the show questions are below) 1. Tell us about yourself, what you do, where you work, and what your involvement is in the CAEP Simulation Olympiad.  2. What is the Simulation Olympiad at CAEP for our listeners who have not attended the session or have never been to CAEP? What is the structure and what you do? 3. What kind of cases are simulated? Can you tell us an example of a good case and how the teams went through it? 4. Tell us what you look for when you see a good SIM team (both medical management and crisis resource management or CRM)? 5. How can residents and interdisciplinary teams get ready for SIM? What should they prepare to become successful at the Olympiad and at SIM in general? 6. If future teams/residents want to get involved, how do they make this happen?  7. Any last comments?   Contact Dr. Kevin Dong: junghwan.dong@medportal.ca Dr. Tamara McColl: tamaramccoll@gmail.com

Core Questions: 1. What structures are affected by UMJ, LMJ, and NMJ lesions, and what are causes of weakness associated with each? 2. What are common signs of UMN, LMN, and NMJ dysfunction? 3. What are (7) pathophysiologic causes of non-neurologic weakness (Box 10.1)? 4. What is the DDx of neuromuscular weakness? (Table 10.1) 5. Describe an approach to general weakness in the ED. Wisecracks: 1. Differentiate between “plegia” and “paresis”. 2. List (5) DDx‘s for non-neurologic weakness (based on pathophysiologic processes). 3. List (5) non-emergent causes of peripheral neuropathy (Box 10.2) 4. Explain how you recognize an ED patient that may be approaching the end of life.

Today’s episode is to aid new physicians to traverse through the first few months of their independent practice safely and effectively. As a new physician myself, I had the luxury of having many mentors and colleagues who were gracious enough to help me find my way in providing safe patient care. Additionally, they assisted me on integral aspects that we don’t necessary learn or get exposed to as a resident, such as billing, department flow, and the politics of the ED. However, as a new staff, there are so many uncertainties that you must face alone, and I wanted to find a guide to help me transition more effectively. After not finding something that fit the bill of what I truly wanted, I decided to tackle the issue myself and find colleagues who would help me out with the task of navigating through the First Year of Practice. Questions: Can you please introduce yourself? (name, training, where you work {academic, community, etc}, any other work you are doing {tox, primary care, etc.}). How is it being a new ED staff physician 6 months into practice? What has been the biggest difference been so far being a staff vs. a resident? Can you share an interesting story as a staff? (can be anything – having residents, billing experience, research you are working on etc.) What is the best thing about being a staff physician? What are some struggles/challenges of being a new staff physician? Do you have any billing tips for new physicians? What kind of tips do you have for management of your financial assets? (investments, taxes, accountants, etc.) Any tips on work-life balance? (wellness, coping with struggles, travel, etc.) Take Home Points: Ask questions to fellow colleagues about difficult cases, department flow, and billing. You will need help with the transition to practice so ask the people who have done it before you. Don’t commit to too many things initially. Remember, it’s a marathon not a sprint. Plan ahead and make sure to find a good balance between work and life. Find time to learn about billing during your residency. Make sure to have a good feel for it so that once you are staff, you don’t leave money on the table (you deserve it!). Live like a “resident” and plan for the future. Planning for retirement and finding a good financial advisor and an accountant is pivotal for your future. Be humble and continue to learn. You will not know everything at the end of your training. Keep reading around cases and develop yourself to become better every day.