0:00

Hello,

0:00

Residence. My name is Zach

0:03

Olson. I'm joined today by Maddie Watts,

0:05

and thank you for downloading this month's

0:07

episode of the EM clerkship

0:09

Pod guest. This episode is sponsored

0:11

by Pearson Roberts Insurance, my personal

0:13

independent life and disability insurance

0:15

agent. We will talk more about Pearson Roberts

0:18

later in the episode So let's get into it.

0:20

Today is round number three

0:23

of Maddie's game. Maddie will need to perform

0:25

today's case in real ABAM Oralboard

0:27

format. She has fifteen minutes to complete

0:29

the full case. She does not know what the case is ahead

0:31

of time. If Maddie hits all of the critical

0:34

actions that I've listened out beforehand, she wins.

0:36

And if she doesn't or if she performs a dangerous

0:38

action, I win. These cases were created by

0:40

me. They're not derived from actual ABM cases that

0:42

I had, they're not real patients. Maddie,

0:45

take out a piece of paper and a pencil. Place the paper

0:47

sideways in front of you, outline a human body

0:49

on the left side of it, and let me know when you are ready.

0:52

I'm

0:52

ready.

0:53

Alright. We'll

0:56

talk more about how residency's gone once we're

0:58

done here, but I'm getting ready to your

1:00

butt. Let's see. Doctor

1:04

Watts. This will be a single patient

1:06

encounter. You will have fifteen minutes

1:08

to complete the case Before begin, do you

1:10

have any questions?

1:12

Nope. Then

1:14

let's begin. You are working

1:16

at clerkship General Hospital. When you hear a

1:18

trauma alert, called overhead, summoning

1:21

you and the one other nurse in the hospital

1:23

to bed side for a patient being brought in

1:25

by EMS after a car accident.

1:28

Alright. Let's head in the room. Is the

1:30

patient here yet?

1:32

Yeah. The patient is

1:34

here with you, miss. Alright.

1:36

EMS, can you give a report?

1:38

Sure. Yeah. So we have thirty

1:40

year old female here. Her name is Alima

1:43

Woodberg. She was in

1:45

a motor vehicle accident, just

1:47

prior to her arrival, and here

1:49

she is.

1:51

Alright. Let's go ahead

1:53

and get her moved over to the

1:55

main table here, and we'll get started with our

1:57

primary and secondary survey. nurse,

1:59

I'd like you to go ahead and work on getting access unless

2:01

medic you already have some access?

2:03

Yeah. We were able to establish access.

2:06

Okay.

2:06

Great. What access do you have?

2:08

Sixteen gauge

2:11

in the left AC.

2:12

Alright. Awesome. in that case, nurse, if you can

2:15

just work on getting the patient on the monitor. Hi.

2:18

Can you hear me? I'm Dr. Watts. What's

2:20

your name?

2:21

Hello, Dr. Watts. My

2:24

name is Alima. Alright.

2:26

Airways intact. Alima, I'm gonna be

2:28

just doing a broad assessment of you, and then I'll come

2:30

back and kind of get some more history from

2:32

you. So airways intact,

2:35

do I see symmetric chest rise?

2:38

Yes. Okay.

2:40

I listen with my set the scope, do I hear

2:42

breath sounds on both sides? Yes.

2:45

Okay. I

2:47

feel for a carotid pulse. Do

2:49

I feel a good pulse?

2:51

Yes.

2:52

Okay. And

2:54

then is are

2:56

her eyes open? Yes.

2:59

Okay. Does she seem to be

3:02

moving all four extremities spontaneously?

3:05

Yeah.

3:06

Okay. And then

3:09

is she following commands if I ask her to

3:11

raise her arm? Will she raise her arm?

3:12

Yes. Okay.

3:13

So GCS fifteen.

3:16

So that's our primary survey. Secondary

3:20

survey. Before I start, I just kinda wanna

3:22

hear what was the mechanism of the CAR accident?

3:25

Yeah. So

3:27

she another driver had called. She

3:29

had basically they saw her, like, drive

3:31

off the road into a ditch, and she hit

3:33

a tree pretty hard. She

3:35

we had to it took about ten minutes for us to get

3:37

her out. AIRBigs went off. She

3:39

was restrained.

3:41

Okay.

3:42

Any obvious injuries that she's reporting?

3:45

Yeah. She's complaining of

3:47

some pain in the left ankle. Okay.

3:50

Left ankle pain. Are you hurting anywhere

3:52

else, ma'am?

3:53

my ankle. Oh my god.

3:56

Okay. Alright. Well, I wanna

3:58

check you out head to toe and then

3:59

we'll get we'll start addressing this ankle.

4:02

Okay? Can we get an opening

4:04

set of idles as well?

4:05

Sure. Her temperature

4:07

is ninety eight. Her heart rate is 105

4:09

Her respiratory rate is ten. Her blood pressure

4:12

is 105 over sixty five. Her

4:14

o two saturation is ninety two percent.

4:16

Okay.

4:17

Okay. Alright.

4:20

So looking at her head, do I see any

4:22

obvious lacerations or

4:25

hematoma?

4:25

She has an abrasion

4:27

to the front of her head. Okay.

4:29

Is it actively bleeding? No.

4:33

Okay.

4:33

Sounds

4:35

like her eyes are open, when I check

4:37

her pupils, what size are they in? Are they reactive?

4:42

Two millimeters reactive by laterally.

4:45

Okay.

4:46

Okay. Any obvious orbit

4:49

trauma

4:51

No.

4:52

Do her facial bones feel intact? Yes.

4:55

Okay. When I open her mouth, does she

4:57

have any blood in the orofarings or

4:59

any teeth that are knocked out of place? No.

5:01

Okay.

5:03

When I press on her

5:06

chest, does she have any chest wall tenderness?

5:09

No.

5:10

Okay. And I heard breath sounds

5:12

on both sides. Were they clear? They

5:14

were clear.

5:16

Okay. cardiac

5:18

sounds she it sounds

5:20

like she was a little bit tachycardic. Do I hear

5:22

any murmur?

5:24

No murmur. Okay.

5:27

Regular rate?

5:29

Yes. Okay.

5:31

i'm Looking

5:32

at her abdomen, does she have any, like,

5:34

bruising or abrasions?

5:36

No. Seapeltside?

5:37

belt fine No.

5:39

And any

5:40

bruising or abrasions to the chest wall?

5:42

No.

5:42

Okay.

5:43

When I palpate her abdomen, is

5:45

it soft non tender?

5:47

Yes. Okay.

5:49

When I press on her pelvis,

5:51

Is it stable to anterior

5:54

post to your compression?

5:55

Yes. Okay.

5:58

Okay. And

5:59

then I kinda

6:02

take her right and left arm and try to

6:04

range them. Does she have any pain with range

6:06

of motion?

6:07

No. Nope.

6:10

Any abrasion or deformity to her upper

6:12

extremities? No. Okay.

6:16

Which ankle is hurting? Left.

6:19

Okay. So I'll start with the right leg. Can I arrange

6:21

her right leg completely without any pain?

6:23

Yes. Any

6:24

obvious deformity?

6:26

No. Okay.

6:27

And then her left leg, any

6:30

deformity to the knee or femur

6:32

area?

6:33

No. Okay.

6:34

What does her ankle look like?

6:36

It's severely swollen. She's

6:39

guarding it. It's tender. There's a

6:41

laceration on the side of it,

6:44

very painful looking.

6:47

Okay. And it's swollen, but does

6:49

it look like her foot is

6:51

completely out of joint

6:53

compared to her Tibia and Pibia?

6:55

No. Just super swollen. Okay.

6:57

Do I feel good fetal pulses

7:00

on both sides? Yep.

7:02

Okay. And posterior

7:04

tibial as well? Yeah.

7:06

Normal. Okay.

7:07

And She's got good cap

7:10

refill in that toe. It doesn't seem like it's

7:12

ischemic?

7:13

Correct. Okay.

7:14

Is she able to bend her

7:17

knee completely and bend at the completely

7:19

without pain? Yes.

7:21

Okay.

7:22

Has EMS given her

7:24

anything yet for pain?

7:26

Yeah. We

7:28

gave her fifty mics of fentanyl. There's

7:30

one other thing. We found a pill bottle in

7:32

your car. Okay.

7:33

okay

7:34

Yeah. I was a little concerned with with her

7:36

small pupils and her low aspirations. What

7:39

did you have a label on the pill bottle?

7:42

Yeah. Methadone.

7:43

Okay.

7:44

Okay. And she's still

7:47

what's her respiratory right now?

7:49

Ten.

7:50

Okay.

7:53

Alright. If she's protecting her airway,

7:55

we'll just keep an eye on it, but we may need to

7:57

give her

7:59

some

7:59

naloxone. So let's go ahead

8:02

and actually, let's give

8:05

point one intranasal of naloxone.

8:08

Alright. Do you give it? And she goes, oh my god. My

8:10

ankle hurts way worse. Okay.

8:13

And we have IV access

8:16

let's Did she have

8:18

any medical problems, first of all?

8:20

Yeah. She has a history of hepatitis c,

8:22

depression and opiate use disorder. Okay.

8:25

Any

8:25

kidney problems? No.

8:28

Okay.

8:28

Any heart failure?

8:31

No. Okay. Alright.

8:34

We could give her some

8:36

tour at all. We could do thirty

8:38

milligrams for now to help

8:40

with her pain. So

8:42

we'll start with that if the nurse can draw

8:44

that up and give it. And

8:47

then looking back her ankle.

8:49

So it sounds like it's very

8:52

obviously swollen. Any open

8:54

component that's bleeding

8:56

It's swollen. There's

8:59

laceration to the left side of it. Patient

9:01

goes, doctor, I'm allergic to tardle.

9:03

Okay. Thank you for clarifying. I should have

9:06

asked your allergies before we did that.

9:09

What are her respirations now?

9:11

the

9:12

Sixteen.

9:14

Okay.

9:17

weekend We can do another

9:19

fifty mics of fentanyl, but let's just keep

9:21

her on the monitor and

9:23

make sure we're watching her respiratory rate. I

9:25

wanna keep her pain under control, but I don't

9:27

want to overdose her. Okay.

9:31

And

9:32

before we

9:34

just focus on the ankle, I

9:36

do want to roll her and

9:38

check for any c t

9:41

and l spine tenderness. Is

9:43

she complaining of any back pain or neck pain?

9:46

She has

9:46

tenderness of the cervical spine without

9:49

step offs. No tenderness of the

9:51

thoracic or lumbar spine.

9:52

Okay. Let's go ahead and put her in a

9:55

c collar for now before

9:57

we get until we get some c spine imaging.

10:00

Alright. See collar applied.

10:02

Okay. Alright.

10:04

How's her pain now that we gave a little bit more

10:06

fentanyl?

10:07

the

10:08

it's controlled.

10:10

Okay. So

10:13

I would like to get a

10:15

CTC spine given that she's got some seasine

10:17

tenderness. I also would like to

10:19

get some films of both

10:21

her left ankle and

10:23

left knee, given that she's got

10:25

an obvious afformity. If

10:29

we have an ultrasound in the room, I'd also

10:31

like to go ahead and do it fast. She's not

10:33

complaining of any abdominal tenderness. but

10:35

an e fast would be helpful just to make

10:37

sure that I don't see any blood in her abdomen.

10:42

Fast

10:42

is negative. acle

10:44

x-ray is crossing. Sorry. I didn't

10:46

have a knee x-ray prepared. It's normal. Okay.

10:49

Okay. So

10:50

the x-ray just came through. It

10:53

looks like she has a she

10:56

has fractures of both her fibula

10:58

and Tibia at

11:00

the looks

11:01

like medial and lateral

11:04

malleolus.

11:05

the And

11:06

it also looks

11:09

like a dislocation.

11:11

My ortho skills are

11:13

not phenomenal, but that does not look

11:15

normal. So I definitely

11:18

want to consult my orthopedic trauma

11:21

team.

11:21

In

11:23

the meantime, just wanna make

11:25

sure that I check her pulses

11:27

again, make sure her compartments are

11:29

soft, and

11:30

her left calf.

11:34

So this is

11:36

clerkship general. We are ortho. You and

11:38

your one nurse, just FYI. So

11:40

they're not available and pulses

11:43

and everything are still good. Okay.

11:44

And then let's

11:47

get another set of vital signs as well.

11:50

Sure. Temperature

11:52

ninety eight, heart rate, ninety five,

11:54

respiratory rate, twelve, blood pressure, 105

11:56

over sixty five, OT saturation, and

11:58

ninety two percent,

11:59

and the CT

12:02

of your c spine is normal.

12:05

Okay.

12:05

I also given that

12:07

her stats are still a little bit low, I'd like to get a

12:09

portable chest x-ray. And

12:11

then after that, will probably need to

12:13

call the nearest hospital

12:15

with orthopedics onboard for

12:18

transfer because I bet this is gonna need

12:20

surgery. Okay.

12:22

I just got the chest x-ray.

12:25

Let me take a look at that.

12:29

I

12:29

see lung markings going all the way out

12:31

on both sides. I don't think she has any

12:34

Mothorax. She he

12:38

I don't see any

12:41

obvious rib or clavicle

12:43

fractures.

12:44

She's

12:47

got

12:47

a pretty sharp diaphragm on

12:49

the right. The left is

12:51

a little bit hazier.

12:56

So could be, like, a layered

12:58

out effusion or

13:00

Hemothorax, but it may just be that

13:02

it's a little bit of a hazier film

13:04

throughout Her cardiac silhouette looks

13:06

normal.

13:08

the Okay.

13:11

Since the left side

13:13

looks a little fuzzy. Can I take my ultrasound

13:15

probe and see if she has an effusion

13:17

or hematherex on the left? That's

13:20

normal. Okay.

13:21

Okay. Alright.

13:23

I'm still I guess her shots are a little low

13:25

because she was breathing at

13:28

a lower rate, but I

13:31

might put her just on a liter of

13:34

oxygen to bring that up. And

13:38

then Can I go ahead and call

13:40

the nearest tertiary care

13:42

center to see if they'll accept

13:44

transfer?

13:46

So you page out to them and the

13:48

nurse says, hey doc, patience not

13:50

responding. Oh,

13:52

gosh. Alright. So

13:54

I am well, looking at our EKG

13:56

strip and this

13:58

is not looking good.

13:59

I see a wide complex tachycardia

14:02

polymorpic So

14:05

I'm worried about tour sod's. So

14:08

can we give some mag and

14:11

then

14:12

Actually, well, no, we need

14:14

to shock her first. So can we get the pads

14:17

on? And then

14:19

we'll need to do a defibrillation.

14:23

paths

14:23

on defibrillation.

14:25

You have a pulse.

14:27

the guy

14:28

Okay. Can we

14:30

get a repeat rhythm

14:31

strip strip?

14:33

Sure.

14:38

She's

14:38

gonna grab a whole twelve lead here.

14:41

Alright.

14:41

So I'm looking at her twelve

14:44

lead.

14:45

Looks

14:47

like she's got a rate of about sixty.

14:51

I see P waves in a narrow

14:53

QRS. I

14:54

think this is a sinus rhythm, but

14:57

definitely looks like a long QT

14:59

even just eyeballing it. That

15:02

would

15:02

explain why she went into Dora Sods.

15:04

the

15:06

Okay. So we let's

15:09

go ahead and give some mag, but

15:11

then I probably should ask her more about her

15:13

medication history. Ma'am, what

15:15

meds are you taking? Is she awake and talking

15:18

yet?

15:19

She's like, oh, that was

15:22

that was something. I saw the

15:24

light. I take

15:26

cetalapram, forty milligrams q day

15:28

for my depression, and I take

15:30

methadone, a hundred milligrams a day

15:32

for my his of opiate use disorder that I'm in

15:34

recovery from. Okay.

15:37

Yeah. That would make sense.

15:40

Okay. Well,

15:43

We need

15:45

to keep giving mag and

15:47

watch her QT.

15:49

Let's do another EKG

15:51

in like twenty minutes. Let's

15:53

give her two grams of mag.

15:55

the Okay.

15:58

okay And

16:02

then can we get a repeat set of vitals?

16:05

Sure.

16:06

Her temperature is ninety eight. Her heart

16:08

rate is ninety nine. Her respiratory rate

16:10

is sixteen. Her blood pressure is one twenty over

16:12

eighty. Her o two saturation

16:14

is ninety nine percent. Okay.

16:17

And how's

16:18

your pain? say I got the I got the transfer

16:20

center on the line. I don't know if there's anything else you wanted me

16:22

to do before you talk to them.

16:24

No. I think I'm okay.

16:27

I will talk to them now.

16:30

Hey,

16:30

this is a major trauma center.

16:33

Hey.

16:33

So I have a thirty year

16:36

thirty year

16:36

old female here who drove

16:38

off the highway and headed a tree and had ten

16:40

minute extircation. She came

16:42

in was GCS fifteen protecting

16:44

her airway, had

16:47

some

16:47

two millimeter pupils and

16:50

respiratory rate of ten turns

16:52

out with some further history she has

16:54

opioid use disorder on methadone and

16:56

was given some fentanyl en route as well,

17:00

we

17:00

we gave her

17:01

a little bit we reversed her and then gave her a little bit

17:04

more because she's allergic to torridol

17:06

and wanted to keep

17:08

her pain controlled. And she

17:10

ended up with her

17:12

other

17:12

medications, how having some QT

17:15

prolongation, went into polymorphic

17:18

VTech. We defibrillated her

17:20

and got her back. She's now in

17:22

sinus rhythm, Her only injury

17:24

is that she has a tip

17:27

fib fracture and ankle dislocation

17:29

on the left She's

17:31

got intact pulses and

17:33

no signs of compartment syndrome, but I do think

17:35

she will need surgery and we don't

17:37

have orthopedic year, so I wanted to transfer

17:39

her for that. But then additionally, with

17:42

her now towards

17:44

odds, she's gonna need medical management

17:47

as well. Our repetitive k g showed her in sinus

17:49

rhythm, and we're giving mag, but we will continue to

17:51

monitor and make sure she's stable prior

17:53

to transfer. any

17:55

other medicines other

17:55

than the mag? That

17:58

we've given

17:59

ah we've

18:01

given that and

18:04

the fentanyl, and we gave some naloxone

18:07

initially. And that's all we've given

18:08

so far. Alright.

18:10

Sounds

18:10

good. We'll see her. and

18:12

that ends your case. Victory

18:22

at last. We're like, we we're

18:24

like, we need to get a revenge case.

18:26

We need to I I was so proud of

18:28

myself

18:28

with my primary and secondary survey, and

18:30

then I did only, like, half of

18:33

my sample ample history, whatever

18:35

you call it. I did not do a very

18:37

good history.

18:38

story Alright. We'll

18:40

get

18:40

it we'll get into the whole case. Obviously,

18:43

completely brutal intended to be so.

18:45

But before we go through that, let's talk about

18:47

our sponsor for the month, Pearson Robinson Insurance.

18:50

One of the biggest financial tasks that you need to complete

18:52

during residency is to purchase your personal

18:55

disability insurance policy before you

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aren't intending. And to be honest, the whole process does

18:59

take a few months. So with everything that you have on your

19:01

to do list, this financial task tends

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to be put off until your final year of residency

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in the last few months. and then

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kind of crunching it in before you become an attending.

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And don't get me wrong, at least you are purchasing this

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before you become an attending. So you won't lose

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out on the residency discount, but there are several

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reasons why you need to on this now.

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The biggest one is that the policy is

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cheapest and has fewest exclusions, the

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younger and healthier you are. The

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concern you should have is not that you get disabled while in residency,

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which does happen, but the more common issue is

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that you end up hurting your back or injuring

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your arm you see a doctor or

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counselor, something for anxiety or depression, something

19:34

that's seemingly minor. And then the

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insurance company freaks out and they write exclusions

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things in each don't wanna go there. Go to WWW

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get your questions answered. Now back

19:56

to our case. Again, Maddy, this was intended

19:58

to be brutal. I I

20:01

taunted you like a week ago. I said, oh, I got a

20:03

hell of a case.

20:04

I know for the listeners

20:07

out there, Zach texted me. What

20:09

was it? Be aware? I

20:11

don't remember why you texted me, but

20:13

it it scared me in just a little

20:15

bit. It came to me

20:16

in a dream. Brace yourself. That was

20:18

what it was. Brace yourself. I think I had a

20:20

I had a good case come in a dream or something along

20:22

those lines. And it

20:25

was so creative and evil. How

20:28

do you think you did? What did you

20:29

do well? What did what could you have done

20:31

better? Well, I haven't done my

20:34

travel month yet. But my roommate

20:36

who is an orthopedic intern is on

20:38

her trauma month, and we were talking about

20:40

how nerve wracking it is when you first have to

20:42

do the primary secondary survey in front

20:44

of all of the EM docs and surgeons

20:46

and everybody. So I actually feel

20:48

like I did a pretty thorough

20:50

primary and secondary survey So

20:52

I'm proud

20:52

of myself for that. I think

20:54

after that,

20:55

I was expecting there to

20:57

be more. Like, I knew you're gonna do something cruel, so I

20:59

was expecting more trauma

21:01

wise, and then I wasn't thinking

21:03

about medical stuff. And

21:06

I'll admit, I kinda

21:07

dismissed, oh, has

21:10

opioid use disorder and hepatitis c, but she doesn't

21:12

have a bunch of other

21:14

comorbidities. So it's kinda like forgetting the

21:16

medical stuff. And sure

21:19

enough, there was medical stuff to

21:21

be had. Yeah.

21:24

So I would agree with you on that.

21:26

So you you killed the primary and secondary

21:29

survey. It sounded like you had

21:31

done your trauma rotation and

21:33

you haven't and you're ready to rumble there. So that was very,

21:35

very good. It was, I think, perfect. I'm

21:37

sure Mike will critique something, be, like, oh, you

21:39

miss somebody. As far as I'm concerned, that

21:41

was pretty pretty damn good. You

21:43

got the collar on. You checked the airway. You did the

21:45

whole primary and secondary enough ultrasound

21:48

and all of that. You didn't forget to

21:50

roll the patency. in the real

21:52

world, like everyone always remembers to roll the patient. But

21:54

on the test, it's harder

21:56

when you're just kind of verbalizing it. To

21:58

remember, I have to roll the patient and feel down the

22:00

back too. So you did good with

22:02

all of that. And

22:04

I think the spot where things kinda

22:06

spiral the so there's a couple of things.

22:08

the the spot where things got

22:11

out of control a little bit was kind of

22:13

that, like, sample history.

22:16

I don't recall

22:18

you I don't think you asked about allergies.

22:20

I didn't know. But

22:22

even the allergy list was meant to kind of point

22:24

you towards, though. She's just a drug

22:27

person. It was kind of meant to throw you off or get her to blower

22:29

off. It goes all in in the whole methadone,

22:31

prolonged QT thing, that's a

22:33

classic. Like, I'm pretty sure one of my tenings gave

22:35

me that one in resin see, like,

22:37

you that that is a classic kind of residency

22:40

case, the method on prolonged q

22:42

t thing. Whatever setting, you

22:44

know, whatever setting it's in. There

22:48

wasn't anything else really as far as the history

22:50

other than the allergies, which would

22:52

have been a dangerous action not to check.

22:54

and the the

22:58

Methadone and the sotelipram also prolongs

23:00

QT too. Yeah. So

23:02

both of those together was kind of a a bad combo.

23:04

But she didn't overdose or anything. She would have

23:06

been a person, you know, with well

23:09

controlled opioid use disorder just on

23:11

her typical Methadone, which typically

23:13

you would see and someone who's being, like, sent home with a

23:15

prescription for Methadone. That's someone who's

23:17

pretty stable. on Methode. because

23:19

usually, initially, you have to chill up every day and you're doing

23:21

drug tests and things like that. So just be sent home

23:23

with a bottle of it. That

23:25

person has been on that for a while

23:27

and stable. So that would be

23:29

the main spot. I would sorry.

23:31

Be careful on on

23:33

trauma. You do your primary and secondary survey, but don't

23:35

forget about medical history. in, like, the

23:37

allergies and stuff. And then the other thing where you kinda

23:39

and I actually see I see this

23:41

from trauma. We just

23:43

do airway. where I'm at. Basically,

23:45

as emergency medicine people at our main

23:48

trauma center, and then we have trauma surgeons and stuff

23:50

doing the rest. And the thing

23:51

that I see them miss and the residents on their

23:53

team and stuff this is

23:56

that the reason for the accents,

23:58

you'll get some crazy fall

24:00

and an old person may

24:02

fall down a flight of stairs or something. They come

24:04

in and they're all binged up. Mhmm. But they don't,

24:06

like, dive into, why did this person

24:08

fall? The car accident

24:10

would be a classic of know, it's a single vehicle

24:13

accident. Why did this

24:15

car just drive off the road? Right?

24:17

Like, that's not a normal know, did

24:19

they fall asleep? Like, what is going on? Like, why

24:21

did that happen? And so you will see that a

24:23

little bit as kinda getting to the why behind the

24:25

trauma. That does get missed in

24:27

the real world. So, like, classic

24:30

examples would be the the car

24:32

accident or whatever where they had syncope or a

24:34

seizure. Right? Mhmm. And

24:36

then, like, falls and geriatric people, like, they had stroke

24:38

or something, you know, or low blood

24:40

sugar or whatever, and it causes them to get weak

24:42

and fall, which is a classic thing with like

24:44

geriatric fall cases is why did they fall

24:46

I don't really care as much about they hit their arm with

24:49

the skin tear. Yeah. It will scan your

24:51

head, you're on a blood thinner and, you

24:53

know, your arms probably mind will bandage it up. like, why

24:55

did you fall all of a sudden? Mhmm.

24:57

So pay attention to that

24:59

too. The only other things, did

25:02

you catch once like, you identified

25:04

the Tore Sods well, you identified the

25:07

prolonged QT. Once I once you

25:09

kinda went that way, you immediately went back and

25:11

circled back to the medication. kinda put

25:13

it together. So that was all good. You treated it fine

25:15

with the magnesium. The only

25:17

other thing, did you catch that the patient had

25:19

a laceration over the ankle? You

25:21

said that and I

25:24

just kinda kept going.

25:26

So

25:26

what so what would be your concern there?

25:30

I

25:30

guess it's an open

25:32

fracture then. So

25:34

would you wanna cover with antibiotics?

25:38

Yeah. I'd

25:38

probably update their tetanus and do

25:41

antibiotics. So anyways,

25:43

those were those were like a couple other

25:45

things thrown in the case. This case was meant to trip you

25:47

up. Like, it was It

25:50

was got two and o. It was got two and o. You're whipping out things

25:52

like, dysklesias, which is a medicine. Like, I'm like,

25:54

what is going on? You like an

25:57

attending, so we we had to we had to

25:59

make it trixie. We had to make it

26:01

trixie on purpose. But I

26:03

don't know, there's a lot of good learning points and

26:05

stuff. You did great. Like, again, you nailed the primary and

26:07

secondary survey from a trauma perspective. You nailed

26:09

the treatment of torsons once you kinda got got there.

26:11

What are some other things you can do to treat

26:14

torsons? Let's say it's persistent. Like,

26:16

maybe they're going in and out of it type

26:18

of You shocked them. You did the magnesium. But

26:20

if they keep going into it, what are some of the things

26:22

you can try? Well,

26:24

I know with tour side.

26:26

Sometimes it's because they're bradycardic, and

26:28

so you can, like, overdrive pace, but

26:30

she wasn't bradycardic. Perfect.

26:32

Yep. No. That's exactly that's

26:35

exactly what I was kinda getting at, and then I agree with you. She wasn't prayed

26:37

to cardiac. I think I did a case

26:39

with Mike on that. Wasn't it like a vagal

26:41

and diving into the water, like a

26:44

diving injury or something. Yeah.

26:46

I can You gotta love the trauma you gotta love the trauma

26:48

medical combos. They're just they're just

26:50

great cases to tripped up on.

26:52

But so you can do

26:55

isoproterenol. This won't be what our deep dive

26:57

is on. You can do like isoproterenol, which

26:59

is like a chemical, makes the heart rate go

27:02

faster. or you can do, like, TransUnion's pacing where you

27:04

just, like, using

27:05

electricity, turn them up to a faster rate.

27:07

With the ideas you're avoiding credit card again,

27:09

you decrease the chances that they go into.

27:12

tour

27:12

shots. And that's that's

27:14

all I got. I don't know if you have any other final thoughts

27:16

on the case. Oh, you I I agree

27:18

that you crushed the primary and secondary survey. I

27:20

think that was I'm pretty

27:22

sure that was perfect. Oh, well,

27:23

thanks so much. I did, like,

27:26

a trauma alert, which is our

27:28

lowest level of trauma. I did

27:30

a practice one with one of attendings when I was in the

27:32

department, and I was struggling.

27:35

So I

27:35

went home and I practiced it. So I'm glad to see

27:37

the practice paid off.

27:40

Yeah. No. Again, you did the trauma

27:42

piece of it while it was just getting tripped up

27:44

on why the trauma happened and the

27:46

medical component of it. And that's, again, that's

27:48

something you see when you're, you know,

27:50

It's just something you see in the real world. No. I'll

27:53

stop there. Anyways, how's residency going?

27:55

Bring us up to speed on your development

27:58

and journey.

27:58

It's been

27:59

going good. I am about

28:02

to finish my pediatric EM month, which

28:04

has been really fun. I've enjoyed

28:06

it a lot. I got

28:08

to do a few LPs

28:10

on very, very small babies,

28:12

which was fun and a

28:13

good learning experience and finally

28:15

feel like I about that. I finally feel like I

28:17

can see tympanic membranes, which

28:20

took the entire four weeks to feel good

28:22

about that. So, yeah,

28:24

it's been good. That's

28:26

perfect. That's I think those would be, like, the big things you'd wanna

28:28

take away from, like, a pediatric. Yeah. Definitely the

28:31

LPs. Not that you have to do

28:33

a ton, just in the real, you know,

28:35

just like a regular department. You know, if you're

28:37

working out in the community somewhere, you're not gonna

28:39

have a ton, but they do happen and you need to be

28:41

able to do it. And then, yeah,

28:43

I agree seeing the seeing the TM

28:45

is. It's harder than the

28:47

LP. Yeah. Honestly.

28:48

honestly says

28:49

So good job.

28:52

And again, great job on the case. And

28:54

our mid month, our deep dive, we

28:56

are gonna do some stuff on black box warnings.

28:59

and how it applies to Emergency Medicine. So I don't think it's something that gets

29:01

talked about much, so I'm looking forward to that.

29:03

But until then, keep

29:05

working hard, keep