I am Dr. Heather Murray, Emergency Physician and Medical Educator: How I Work Smarter

How I Work Smarter LogoIf you’re still trying wrap your mind around the Karpman triangle, the 3 Cs, and Kairos from last week’s post, don’t worry, we have some back to the basics goodness for you. Dr. Heather Murray (@HeatherM211) is an emergency physician primarily but wears many hats: Medical School Leader, Teacher of Evidence-Based Medicine, Journal Editor, Epidemiologist, and Canadian National Board Examiner. I have been told that she is a budding meme expert. But beyond titles, she clearly leaves a lasting impression with her learners. Indeed, fourth year medical student Eve Purdy nominated her to be part of the series. Dr. Murray kindly shared her pearls of wisdom with us.

 

 

  • Name: Heather MurrayHeather Murray Head Shot
  • Location: Kingston, Ontario, Canada (home of Queen’s University)
  • One word that best describes how you work: Intensely
  • Current job:  I have at least 3 jobs – I’m an academic emergency physician at Queen’s. I’m the director of 2nd year at our medical school. I’m the scholar competency lead as well (translation: I run the evidence-based medicine and research skills training program at our medical school). In my spare time I’m a decision editor at the Canadian Journal of Emergency Medicine.
  • Current mobile device: iPhone 4S (iPhone 6 in March when my plan lets me upgrade)
  • Current computer: MacBook Air

 

What’s your office workspace setup like?

Heather Murray Office

Double screens are the best for document editing and writing. Other essentials include a notepad – not a computer but an actual lined notepad – for daily tasks. I can’t let go of a pen – it feels good to write and cross things off manually. Like others, I use a whiteboard with active projects/deadlines listed, and can’t survive without Dropbox. Other essential items include several coffee cups, reading glasses and some nice things to remind me what’s important when I look up: pictures and notes from my kids and a canoe painting to remind me to unplug.

What’s your best time-saving tip in the office or home?

I set up my day with 3 tasks – a “must do,” a “should do” and a “nice to do.” Get those done and the rest is gravy (and I feel like a superhero).

What’s your best time-saving tip regarding email management?

I set my iPhone timer to limit the time I spend on email in a sitting – otherwise it can take over my day and I don’t do the things I need to do. So, 45 minutes at the start of the day and then I don’t open it again until I’ve finished a task. The timer really helps me avoid being hijacked. I work offline in between deluges of email.

What’s your best time-saving tip in the ED?

It’s counterintuitive, but sitting down and taking a careful history with each patient saves me loads of time. I leave the bedside with a differential diagnosis and a solid plan, and don’t need to go back and perform more exams or ask more questions. The best part? My patients are happy and I’ve established a nice bond by sitting and not appearing rushed or distracted.

ED charting: Macros or no macros?

No macros. I’m too old and set in my ways to convert. I’ve been writing on charts for decades and use that process to distill my thoughts, and I can’t give up control over my thinking to a macro. I’ll make mistakes! I worry that every chest pain and abdo pain look the same with a macro, and each one has a nuance or twist that I can capture better in free text. It’s more time consuming, but that’s a tradeoff I can live with.

What’s the best advice you’ve ever received about work, life, or being efficient?

It’s in David Sackett’s classic article “On the Determinants of Academic Success as a Clinician-Scientist.” If you haven’t read it, he talks in detail about 3 things:

  • Mentorship
  • Periodic Priority Lists
  • Time Management

This is timeless wisdom from a legendary figure.

Who would you love for us to track down to answer these same questions?

I’d love to hear from 2 non-emergency physicians and one Emergency Medicine legend:

  1. Dr. Bob Connelly (@Bob_Connelly) – neonatologist and renowned Queen’s University teacher. He is amazingly productive, technologically savvy and a design wizard.
  2. Dr. David Juurlink (@DavidJuurlink) – internist, toxicologist and clinical scientist at Sunnybrook in Toronto. His Twitter feed is filled with his practical, important research and useful tips for those of us in the ED trenches.
  3. Dr. Ian Stiell (@EMO_Daddy) – no introduction needed!

Author information

Benjamin Azan, MD

Benjamin Azan, MD

Emergency Medicine Resident

Icahn School of Medicine at Mount Sinai

Founder/Editor of foambase.org

The post I am Dr. Heather Murray, Emergency Physician and Medical Educator: How I Work Smarter appeared first on ALiEM.

Anti-NMDA-Receptor Encephalitis

EncephalitisAnti-NMDA-receptor encephalitis is a severe and treatable immune-mediated disorder which presents with a rapid progression of  psychiatric and neuropsychiatric symptoms. Although only first reported as a diagnosis in 2007, an exponential number of cases have since been described, suggesting that the disease is not rare but rather under-diagnosed. Emergency physicians play an important role in recognizing this disorder, as prognosis is largely dependent on early treatment with immunotherapy.

Case

A 47 year old man was brought to the ED after 2 witnessed seizures. Further history revealed the patient did not have a history of epilepsy, but had a seizure 1-week prior preceded by a viral prodrome. His workup at a neighboring hospital for the first-time seizure included a normal CT and EEG study and discharge after 24 hours. Since discharge, his wife, parents, and friends report that he has had unusual behavior. His wife mentions that “he has been more inward”, and his friend who brought him to the ED says “he seemed subdued.”

During current ED visit, he is initially afebrile, yet later develops an oral temperature of 100.4F. His heart rate is 93 bpm, respiratory rate 20 bpm, blood pressure 144/76, and SaO2 (RA) is 98%. On exam, he is unresponsive but breathing spontaneously. Pupils are equal and reactive, and there is no sign of head trauma. Heart sounds are normal, lungs are clear to auscultation, and his abdomen is soft, nontender, and not distended. He has equal, strong pulses in all extremities. His left arm is in a sling from a clavicle injury he sustained during his first seizure, but otherwise there is no deformity or tenderness to his extremities. On a limited neurological exam, he is nonverbal, does not follow commands, and has notable rigidity of his extremities. There are no rashes or markings on his skin. During the patient’s stay in the ED, he is noted to be catatonic, with several episodes of facial twitching.

ED workup included a normal head CT. CSF analysis was suggestive of viral encephalitis. The remainder of his lab studies, including a CBC, BMP, UA, ABG and later blood culture were otherwise unremarkable. The patient was admitted to the hospital for further neurological workup with the working diagnosis of encephalitis, specifically concerning for Anti-N-methyl D-aspartate (Anti-NMDA) receptor encephalitis.

Anti-NMDA-Receptor Encephalitis

Anti-NMDA-receptor encephalitis is a severe form of immune-mediated encephalitis first described in the neurology literature in 2007 [1,2]. In an analysis of 100 cases, the median age was found to be 23, with a range from 5-76 years. The disease predominately affects women (91 of the 100 patients). All patients presented with psychiatric symptoms or memory problems, with seizures being reported in 75 of the cases. Decreased mentation as well as autonomic dysfunction was also common. Ovarian teratomas were found in half of the cases, and these patients had better outcomes with removal of the tumor [1].

Retrospective studies report a multi-stage presentation, with prodromal symptoms of headache and low-grade fevers present for 0-2 weeks on average. This viral prodrome is followed by the rapid progression of psychiatric and neuropsychiatric symptoms which usually bring the patient to seek medical attention and hospital admission. These symptoms include personality changes, memory problems, unresponsiveness, dyskinesia, seizures, autonomic instability, central hypoventilation, and cardiac dysrhythmias [4]. Given the wide spectrum of presentation and unfamiliarity with this disorder, many patients will have a delayed diagnosis. Diagnosis is often suspected when patients do not respond properly to treatment of their presumed diagnosis, such as alcohol withdrawal, seizure disorder, neurotropic viruses like HSV encephalitis, or intoxication [3,5].

Further workup usually reveals an abnormality on EEG, MRI, or CSF analysis. Once a diagnosis is suspected, patients may undergo testing for specific autoantibodies in the serum or cerebrospinal fluid. Early recognition is imperative as patients often respond to proper immunotherapy or complete tumor removal, if an ovarian teratoma is known [6].

In the past year, EM:RAP, and TPR have brought attention to anti-NMDA-receptor encephalitis, making ED providers more aware of this often under-recognized diagnosis. This week ALiEM Book Club discussed “Brain on Fire – My Month of Madness,” a personal account of a young woman diagnosed with anti-NMDA-receptor encephalitis.

References

  1. Dalmau J, Gleichman AJ, Hughes EG, et al. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol 2008; Dec;7(12); 191-8. PMID: 18851928
  2. Dalmau J, Lancaster E, Martinez-Hernandez E, et al. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol 2011 Jan;10(1):63-47. PMID: 21163445
  3. Punja M, Pomerleau JJ, Devlin MW, et al. Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis: an etiology worth considering in the differential diagnosis of delirium. Clin Toxicol 2013 Sep-Oct;51:794-7. PMID: 23962100
  4. Wandinger K, Saschenbrecker S, Stoecker W, Dalmau J Anti-NMDA-receptor encephalitis: A severe, multistage, treatable disorder presenting with psychosis. J Neuroimmunol. 2011 Feb;231(1-2):86-91. PMID: 20951441
  5. Armangue T, Petit-Pedrol M, Dalmau J Autoimmune Encephalitis in Children. J Child Neurol. 2012 Nov;27(11):1460-9. PMID: 22935553
  6. Titulaer MJ, McCracken L, Gabilondo I, et al. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study. Lancet Neurol 2013 Feb;12(2):157-65. PMID: 23290630

 Image credit

 

Expert Peer Review

Author information

Jordana Haber, MD

Jordana Haber, MD

Attending Physician

Department of Emergency Medicine

Maimonides Medical Center

The post Anti-NMDA-Receptor Encephalitis appeared first on ALiEM.

MEdIC Series | The Case of Breaking Bad News Badly

DNR canstockphoto4969800Code status. Do not resuscitate. Allow natural death… These can be some of the most daunting concepts for new learners to explain to patients, but they can also be the most critical. Depending on the circumstances, discussing these topics may be difficult for the most advanced clinicians.  This month’s ALiEM MEdIC series case considers how we might help a learner through a bad experience with end-of-life care discussions. Please join us in discussing the case this month, we would love your thoughts and advice.

SMACC

P.S. Eve Purdy, Brent Thoma, Sarah Luckett-Gatopoulos and I would also like to invite you all to register for the ALiEM MEdIC pre-conference workshop at SMACC.  Come out and be part of a LIVE version of the ALiEM MEdIC case development and release for a special SMACC version of the case series!

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of Breaking Bad News Badly

by Dr. Stephen Singh (@SSingh_MD)

“I’m not sure that went so well…” William said to Sally. William was a first-year off-service resident rotating through emergency medicine. Sally, a third-year emergency medicine resident, was reviewing the case with him.

“I think…. I think the patient and his wife are upset with me…” William continued. The patient was Mr. Theodore Smith, a 78-year-old gentleman with stage four prostate cancer with metastases to the bones. He had come to the emergency department in a pain crisis, and a decision had been made to admit him to hospital to optimize his pain control.

“Why do you think that?” probed Sally, a budding medical educator. She had encouraged William to discuss the patient’s end-of-life goals, using the hospital’s ‘Code Status’ form as a prompt to open the discussion. She had even asked William if he was comfortable with the discussion, and he had stated he felt very confident, as he had just finished is in-patient internal medicine rotation.

“Like you asked, I was trying to get them to complete the code status form, to make it easier for the admitting team. But it sounds like no one had discussed this before with them,” William explained.

“How did you bring it up?”

“I asked them if they wanted everything done if something bad happened,” William explained. “They seemed confused, so I went through the checklist on the sheet, and that seemed to confuse them more. They wanted to know what this had to do with alleviating his pain, and why I was asking them these questions. Mr. Smith started to cry, and his wife asked me why I had to put him through more suffering. They then demanded to speak with the ‘real doctor.'”

Sally understood as she had had a similar experience when she was a first-year resident. Though able to empathize with William, she reflected that she was not well equipped to help sort this out now that there was clearly an issue between William and his patient. Not wanting to complicate the situation for the busy Senior Medical Resident, she and William come to you as the supervising staff emergency medicine physician and explain the situation.

Key Questions

  1. How should questions about a patient’s ‘code status’ be brought up?
  2. Who is responsible for helping to determine a patient’s goals of care?
  3. How can one “repair” the physician-patient relationship after a code status or goals of care discussion goes awry?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Dr. Ashley Shreves, an Assistant Professor of Emergency Medicine & Geriatrics and Palliative Medicine, Mt. Sinai in New York City.
  • Dr. Susan Shaw, Critical care & Anesthesia physician in Saskatoon. She teaches at the University of Saskatchewan, working to improve the system in Saskatchewan, Canada.

On January 29, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of Breaking Bad News Badly. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on January 29, 2015.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

 

Image from CanStockPhoto

Author information

Teresa Chan, MD

ALiEM Associate Editor

Emergency Physician, Hamilton

Assistant Professor, McMaster University

Ontario, Canada
+ Teresa Chan

The post MEdIC Series | The Case of Breaking Bad News Badly appeared first on ALiEM.

PV Card: Testicular Ultrasound for Torsion and Epididymitis

Testicular Torsion sm“Time is testicle.” Every minute drags by while you are awaiting your ultrasonographer to arrive to scan your patient to rule out testicular torsion. Why not take a quick look yourself? What are you looking for? This is an excellent PV card by Drs. Matthew Dawson and Mike Stone on the topic of testicular ultrasound, giving the basics about testicular torsion and acute epididymitis.

PV Card: Testicular Ultrasound

Testicular Ultrasound 1

Testicular Ultrasound 2

You can download this PV card:  [MS Word] [PDF]

Author information

Scott Kobner

Medical student

New York University School of Medicine

ALiEM-EMRA Social Media and Digital Scholarship Fellow

Founder, EdintheED.com

The post PV Card: Testicular Ultrasound for Torsion and Epididymitis appeared first on ALiEM.

Must-Know EM Pharmacotherapy Articles of 2014

canstockphoto23105821There is so much literature to sift through each year, it becomes nearly impossible to stay abreast of it. Here is a quick summary of the 6 must-know Emergency Medicine pharmacotherapy articles from 2014, in my humble opinion.

 

Articles

1. High-Dose Droperidol and Risk of QT Prolongation2. Dexmedetomidine As Adjunct Therapy for EtOH Withdrawal - RCT3. A Simpler Dosing Regimen for Digoxin-Specific Antibody Fragments4. Treatment for Calcium-Channel Blocker Overdose: A Systematic Review5. Bactrim + ACE-Inhibitor (or ARB) + Older Adult = Increased Sudden Death6. Is That IV Antibiotic Before ED Discharge Really Necessary?
46 patients treated with high-dose droperidol (10-40 mg) were studied prospectively with continuous holter recording.

What they did

Patients initially received 10 mg droperidol as part of a standardized sedation protocol (for aggression). An additional 10 mg dose was given after 15 min if required and further doses at the clinical toxicologist’s discretion.

Continuous 12-lead holter recordings were obtained for 2-24 hours. QTc > 500 msec was defined as abnormal (with heart rate correction – QTcF).

What they found

Only 4 patients had abnormal QT measurements, three given 10 mg and one 20 mg. All 4 had other reasons for QT prolongation. No patient given > 30 mg had a prolonged QT. There were no dysrhythmias.

What it means

There was little evidence supporting droperidol being the cause and QT prolongation was more likely due to pre-existing conditions or other drugs.

Calver L, et al. High dose droperidol and QT prolongation: analysis of continuous 12-lead recordings. Br J Clin Pharmacol 2014;77(5):880-6. [PMID 24168079]

Originally posted Jan 4, 2014 as University of Maryland (UMEM, @UMEmergencyMed) pearl.

Four small case series (one prospective, 3 retrospective) have concluded that dexmedetomidine (Precedex) may be a useful adjunct therapy to benzodiazepines for ethanol withdrawal in the ED or ICU. They are summarized in a previous ALiEM post.

A new randomized, double-blind trial evaluated 24 ICU patients with severe ethanol withdrawal.

Group 1: Lorazepam + placebo

Group 2: Lorazepam + dexmedetomidine (doses of 0.4 mcg/kg/hr and 1.2 mcg/kg/hr).

  • 24-hour lorazepam requirements were reduced from 56 mg to 8 mg in the dexmedetomidine group (p=0.037).
  • 7-day cumulative lorazepam requirements were similar.
  • Clinical Institute Withdrawal Assessment or Riker sedation-agitation scale scores were similar within 24 hours.
  • Bradycardia occurred more frequently in the dexmedetomidine group.

In my opinion, a major limitation of this study is that patients had more than 24 hours of treatment before randomization. Eleven of the 24 patients were already intubated when the trial started. The best place to use dexmedetomidine is probably in the early treatment course to help avoid intubation altogether. I’m not sure this very exclusive trial (24 patients included/209 excluded over 4 years) provides any answers for the patients who may benefit most from this therapy. A reduction in benzodiazepines is not even the correct outcome to measure. That may lead to the erroneous notion that we don’t need benzodiazepines (as has happened in some of the other studies). We should be looking at reduction in intubations and ICU length of stay.

Mueller SW, et al. A randomized, double-blind, placebo-controlled, dose range study of dexmedetomidine as adjunctive therapy for alcohol withdrawal. Crit Care Med 2014;42(5):1131-9. [PMID 24351375]

Originally posted May 3, 2014 as UMEM pearl.

Digoxin-specific antibody fragments (Fab) are safe and indicated in all patients with life-threatening dysrhythmias and an elevated digoxin concentration. However, full neutralizing doses of digoxin-Fab are expensive and may not be required (not to mention cumbersome to calculate).

Based on pharmacokinetic modeling and published data, a new review suggests a simpler, more stream-lined dosing scheme as follows:

  • In imminent cardiac arrest, it may be justified to give a full neutralizing dose of digoxin-Fab.
  • In acute poisoning, a bolus of 80 mg (2 vials), repeat if necessary, titrated against clinical effect, is likely to achieve equivalent benefits with much lower total doses.
  • With chronic poisoning, it may be simplest to give 40 mg (1 vial) at a time and repeat after 60 min if there is no response.

Chan BS, et al. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol 2014;52:824-36. [PMID 25089630]

In a precursor to a forthcoming international guideline on the management of calcium channel blocker poisoning, a new systematic review has been published assessing the available evidence.

A few findings from the systematic review:

  • The majority of literature on calcium channel blocker overdose management is heterogenous, biased, and low-quality evidence.
  • Interventions with the strongest evidence are high-dose insulin and extracorporeal life support.
  • Interventions with less evidence, but still possibly beneficial, include calcium, dopamine, norepinephrine, 4-aminopyridine (where available), and lipid emulsion therapy.

Stay tuned for the international guideline coming out soon. One treatment recommendation from the new guideline, reported at the 8th European Congress on Emergency Medicine September 2014, is not to use glucagon.

St-Onge M, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol 2014;52:926-44. [free full-text PDF]

Originally posted October 9, 2014 as UMEM pearl.

A new population-based case-control study in older adults has linked the administration of trimethoprim-sulfamethoxazole (Bactrim, TMP-SMX) to increased risk of sudden death in patients also receiving angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB).

Hyperkalemia is the suspected cause. Compared to amoxicillin, TMP-SMX was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76) within 7 days of exposure to the antibiotic.

Practice Change

In older patients receiving ACE-Is or ARBs, TMP-SMX is associated with an increased risk of sudden death. When appropriate, alternative antibiotics should be considered.

Fralick M, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population-based study. BMJ 2014;349:g6196. [Free open access link]

Many of the oral antibiotics prescribed in the ED have good bioavailability. So, a one-time IV dose before discharge generally won’t provide much benefit.

In fact, a new prospective study found that a one-time IV antibiotic dose before ED discharge was associated with higher rates of antibiotic-associated diarrhea and Clostridium difficile infection. One-time doses of vancomycin for SSTI before ED discharge are also not recommended (see Academic Life in EM post by Zlatan Coralic).

Bottom Line

Though there are a few exceptions, if a patient has a working gut, an IV dose of antibiotics before ED discharge is generally not recommended and may cause increased adverse effects. An oral dose is just fine.

Haran JP, et al. Factors influencing the development of antibiotic associated diarrhea in ED discharged patients home: risk of administering IV antibiotics. Am J Emerg Med 2014;32(10):1195-9. [PMID 25149599]

Originally posted December 6, 2014 as UMEM pearl.

Image credit: (c) Can Stock Photo

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

ALiEM Associate Editor

Clinical Assistant Professor, University of Maryland (UM)

Clinical Pharmacy Specialist, EM and Toxicology

The post Must-Know EM Pharmacotherapy Articles of 2014 appeared first on ALiEM.

Welcome Dr. Matthew Zuckerman: 2015 ALiEM-AAEM Social Media and Digital Scholarship Fellow

Matthew Zuckerman

Welcome to the newest member of our team, Dr. Matthew Zuckerman (@matthew608b), who is an Assistant Professor in Emergency Medicine at the University of Colorado, Anschutz Medical Campus. He will serve as our inaugural 2015 ALiEM-AAEM Social Media and Digital Scholarship Fellow, working on advancing medical education and upgrading the AAEM e-book “Rules of the Road for Young Emergency Physicians.”

Matt is a medical toxicologist and practicing emergency physician, who is the creator and host of the ToxTalk toxicology podcast. This podcast has been downloaded over 100,000 times, recognized by iTunes and the National Science Foundation’s Radio360 website, and has been cited as a social media toxicology resource by BMJ and Annals of Emergency Medicine. His current interests include the use of social media in medical education and obesity as a special population in medical toxicology.

ALiEM-AAEM brochure front

 

 

We are very excited to have Matt join our team and our other fellows Sam Shaikh (ALiEM-CORD) and Scott Kobner (ALiEM-EMRA). We anticipate great things from this collaboration!

 

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief

Editorial Board Member, Annals of Emergency Medicine

UCSF Academy Endowed Chair for EM Education

UCSF Associate Professor of Emergency Medicine

San Francisco General Hospital

The post Welcome Dr. Matthew Zuckerman: 2015 ALiEM-AAEM Social Media and Digital Scholarship Fellow appeared first on ALiEM.