KT Evidence Bites: ProCESS

Editor’s note: This is a new series based on work done by three physicians (Patrick Archambault, Tim Chaplain, and our BoringEM Managing editor Teresa Chan)  for the Canadian National Review Course (NRC). You can read a description of this course here.

The NRC brings EM residents from across the Canada together in their final year for a crash course on everything emergency medicine. Since we are a specialty with heavy allegiance to the tenets of Evidence-Based Medicine, we thought we would serially release the biggest, baddest papers in EM to help the PGY5s in their studying via a spaced-repetition technique. And, since we’re giving this to them, we figured we might as well share those appraisals with the #FOAMed community! We have kept much of the material as drop downs so that you can quiz yourself on the studies.

Paper: A Randomized Trial of Protocol-Based Care for Early Septic Shock

Citation: N Engl J Med. 2014 May 1; 370(18):1683-93. Epub 2014 Mar 18. PMID: 24635773

Nickname of study: ProCESS study

Summarized by: Patrick Archambault
Reviewed by: Teresa Chan & Tim Chaplin

Rationale for Study

1) Is protocol-based resuscitation better to usual care?

2) Is a protocol with central hemodynamic monitoring to guide the use of fluids, vasopressors, blood transfusions, and dobutamine (“Early Goal Directed Therapy”) better than a simpler protocol that does not include these elements?

Clinical Question

In patients with septic shock presenting to the ED, is a …

  1. catheter-based goal-directed resuscitation protocol better than
  2. usual care or a
  3. simplified goal-directed resuscitation protocol?
PopulationIn patients with septic shock presenting to the ED, is a catheter-based goal-directed resuscitation protocol better than usual care or a simplified goal-directed resuscitation protocol?
InterventionCatheter-based goal-directed sepsis protocol
Controla) Simplified goal-directed sepsis protocol

b) Practice as usual (no prompts by study coordinator and bedside physicians were not trained to deliver EGDT or protocol-based standard therapy)
Outcome1) hospital mortality rate at 60 days
2) mortality rate at 90 days
3) cumulative mortality at 90 days and 1 year
4) secondary outcomes (length of cardiovascular, respiratory, renal failure, length of hospital and ICU stay, discharge disposition)

Methods

RCT: outcome assessment was blinded but not healthcare professionals, intention to treat analysis

Results

1) Fluid administered in the first 6 hours was significantly different between groups (P<.001):

  • EGDT: 2.8L
  • protocol-based standard care: 3.3L
  • usual-care: 2.3L

2) Dobutamine use was significantly different between groups  (P<0.001):

  • EGDT: 8.0%
  • protocol-based: 1.1%
  • usual care 0.9%

3) Packed Red Blood Cells was significantly different between groups (P = 0.001):

  • EGDT: 14.4%
  • protocol-based: 8.3%
  • usual care: 7.5%

4) Primary outcome: 60 day mortality (P=.55 for three way comparison)

  • EGDT: 21.0%
  • protocol-based 18.2%
  • usual care: 18.9%

5) No differences in other primary endpoints.

6)  Secondary outcomes: Need for Renal replacement Therapy was higher in protocol-based standard care (P=0.04)

  • protocol-based: 6.0%
  • EGDT: 3.1%
  • usual-care: 2.8%

Conclusion

1) There is no significant advantage, with respect to mortality or morbidity, of protocol-based resuscitation over bedside care that was provided according to the treating physician’s judgment

2)  There is no significant benefit of the mandated use of central venous catheterization and central hemodynamic monitoring in all patients

Take Home Point

ProCESS identifies early recognition of sepsis, early administration of antibiotics, early adequate volume resuscitation, and clinical assessment of the adequacy of circulation as the elements we should focus on to save lives.

EBM Considerations

1) 10 years after the original EGDT Rivers study, the usual-care group has changed and has potentially integrated principles of the EGDT protocol, early recognition of sepsis, early antibiotics, lower tidal volumes, tighter blood sugar control.

2) We don’t know if randomization was concealed.

3) The EGDT group seemed sicker at baseline (more abdominal sepsis, lower BP, longer time to randomize) .

4) External applicability: these were all academic centers, a full research team prompting clinicians to act and follow time sensitive protocols (a study coordinator, bedside nurse and a dedicated research physician).

To download a copy of this summary click here.

 

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post KT Evidence Bites: ProCESS appeared first on BoringEM and was written by Eve Purdy.

#CanFOAMed goes SMACC

It’s certainly an exciting time for Social Media teachers and learners. The Social Media And Critical Care conference (#smaccUS) is coming to North America, and it’s been generating quite a buzz on our Twitter feeds this past week.

Digging into the conference program, we see quite a few Canadian superstars are helping out in the conference:

  • Teresa Chan
  • Pat Crosskerry
  • Sara Gray
  • Andrew Healey
  • Chris Hicks
  • David Juurlink
  • Sarah Luckett-Gatopoulos
  • Ken Milne (a.k.a. The SGEM, BatDoc)
  • Andrew Petrosoniak
  • Eve Purdy
  • Jonathan Sherbino
  • Brent Thoma
  • Stella Yiu

(NB: Please drop a comment below if you noticed someone is not on this list! I will amend to make it work!)

It is so exciting to see so many Canadians involved in this very international conference.  And I’m sure many of you will be there, but just might not be tied to any particular sessions.  So, in an effort to connect the Canadian contingent, we at BoringEM.org are posting this open survey and join a mailing list for Canucks @ SMACC.

P.S. We’re thinking about a T-shirt… and Eve Purdy is all over it already for a custom T-shirt.  Rupi Sahsi has also identified a good alternative on twitter already, so we have a great set of minds already coalescing on this topic.

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #CanFOAMed goes SMACC appeared first on BoringEM and was written by Teresa Chan.

The 3 Biggest Challenges of Medical School… and how to overcome them

Getting into medical school is hard. According to recent statistics, both applicants and University enrollment have been increasing. medischool hardThe desire to become a doctor is at an all-time high and many claim that the hardest part of medical school is actually getting in. Whether or not that statement is true remains debatable. This article aims to give a short list of the hardest non-clinical struggles medical students have. As a subjective piece, some aspects will be omitted, and you are welcome to further the list in the comments below. So here are the 3 biggest challenges of medical school… and how to overcome them.

1. Medical Terminology

Daunting at first, the textbooks are ridden with words that look like they require a degree in Lexicology just to pronounce. Medical dictionaries the size of a Russian classical novel petrify freshmen in the libraries- and rightfully so, with over 250 roots, dozens of prefixes and suffixes – the combinations are plentiful. Yet everyone
agrees that knowing the vocabulary of medicine is absolutely crucial to effectively practicing the craft. Medical terminology is about as complicated as a language

Fortunately, it has rules that can be utilized to your advantage. Breaking down medical terminology to its building blocks will aid in formulating the definition, rather than just remembering it. A tried and tested method is flash cards – never underestimate their usefulness.

2. Workload

In addition to the highly complex, long and seemingly abstract terms, the volume of information students are required to know is dumbfounding, especially in the first two years. Having to learn most of human anatomy, pathophysiology, pharmacology and microbiology is a daunting task. In the moment, you may feel terror in your heart as you complete peer-medical termsreviewed presentations, clinical exams and worst of all – written exams.

You need to remember that others have gone through what you are experiencing. And they survived. Find out how. Ask third year and fourth year medical students how they prepared for exams. Did they approach the tutor directly? Do any of the lecturers share useful information in office hours? How were the hardest exams passed? You can follow my example and use post-it notes around the apartment. In my first year, I found that study groups were very helpful with the complex concepts. In addition, I would recommend that you take full advantage of different learning methods. Record your own voice, join discussions or watch online videos – whatever you deem best.

3. Motivation and Burnout

Remember the question “Why do you want to be a doctor”? Now if you look at yourself in the mirror – sleep deprived, tired, unmotivated, not having seen your family and friends for what seems to be eons – and you have difficulty answering that question, you may be suffering from burnout. Ishak et al. (2013) have found that more than half of all medical students will suffer from burnout. It is a serious and complex problem. Contributors include lack of appropriate mentorship, poor exercise habits, unhealthy diet, lack of sleep, lack of autonomy, stress in the work place, exposure to trauma etc. Most often it is a combination of issues. According to the AAMC the 4-year graduation rate is at its lowest rate, 81% in 2009, and has seen a continuous decline in the last 30 years.

burnout

With all the work you are expected to do, the pressures you feel from everyone around you and especially from yourself, it is easy to go into a state of overdrive. Talk to your friends and family. Often they will be the first to recognize that something is wrong. Listen to them when they are concerned. If you think it is appropriate, contact the student help center in your university. Never forget – you are the future of medicine and people care about your wellbeing. I cannot stress this enough: you need to care about your wellbeing first and foremost.

There are a few things that one can do to prevent burnout:

  • The first is related to motivation. I can suggest that you search for motivation from within. The BoringEM series #DearPreMed highlights the importance of ensuring that your motivations for medical school are intrinsic. As one of many studies suggests, intrinsic motivation is more lasting and brings about better results as compared to extrinsic motivation. The ALiEM bookclub discussion on Drive also focused on intrinsic motivation. Find out what excites you and what makes you happy about getting up in the morning or on the wards. Then find ways to be involved in those things.
  • Seek out mentorship. Find someone who can help you when times are tough or when you need to talk through a case and to keep you on track when things are going well.
  • Sleep well. Eat well. Work out. Laugh. Love. Don’t forget to take care of your body and to fill yourself up with friends and family. Schedule these in. Make them a priority.

Bottom Line

Getting into medical school is hard. Surviving the first 2 years of medical school is hard. Graduating from medical school is hard. But doctors have the privilege of caring for patients. That is not a responsibility that should be taken lightly. So yes, becoming a doctor is hard, but it’s also incredibly rewarding. Remember to find ways to feel those rewards every single day.

 

Reviewed by Eve Purdy

Author information

Anton Gervaziev
Anton Gervaziev

The post The 3 Biggest Challenges of Medical School… and how to overcome them appeared first on BoringEM and was written by Anton Gervaziev.

Medical Education at the ICRE Social Media Summit

On October 22, 2014, the Royal College of Physicians and Surgeons of Canada (RCPSC) hosted the world’s first Social Media (SoMe) Summit in Health Professional Education in Toronto, ON, Canada.  This conference preceded the annual International Conference on Residency Education (ICRE).

Eve Purdy, Heather Murray, Brent Thoma and I were very excited to take part in this event, especially since our online #FOAMed and #MedEd heroes were all participating:

  1. Michelle Lin (@M_Lin) – The mastermind behind ALiEM.com (COI: Brent & I are both Associate editors for her blog). See her plenary speech here.
  2. Anne Marie Cunningham (@amcunningham) – The Welsh social media guru herself, whom is behind the blog Wishful Thinking in Medical Education. See her plenary speech here.

Many of the top educators from Canada were present as well, including the likes of: Jason Frank, Jonathan Sherbino, Felix Ankel, Fiona Moss, Leslie Flynn, Elaine van Melle.

Of course, the #FOAMed masses also did come out to this event, and it was very exciting for me to discuss issues around online education with the likes of Seth Trueger, Heather Murray, Anton Helman, Stella Yiu, Ian Pereira, Ali Jalali, Eve Purdy, Jeff Hill, Rob Cooney… and so many more! (I apologize if I left you off, but I’m going off of my photos from my phone, so if I’ve left you off the list it’ll be because I don’t have your photo is all!)

Four concurrent sessions were held:

  • Concurrent session #1 –Ethical and professional  use of Social Media for health professional education – which explored ethical and professional issues using an appreciative inquiry model to guide the discussion.
  • Concurrent session #2 –Best practices for Social Media platforms – which used a modified Delphi technique to speedily rate 151 quality indicators for blogs and podcasts, based on previous work done by Brent Thoma et al. (DOI: I did help with this session!)
  • Concurrent session #3 – Defining and evaluating Social Media education scholarship
    – which utilized a more traditional format for consensus building, where the discussants (lead by J. Sherbino) proposed statements and opened up the discussion to the floor for commentary.
  • Concurrent session #4 –How education theory should inform Social Media – which explored interactions between educational theory and its intersection with modern social-media teaching and learning.

All in all, I know that I will be excited to see what comes out of the consensus conference proceedings papers (which will be published in the Postgraduate Medical Journal), and we will keep you up to date as we go forward about other new exciting news in the area of Social Media Scholarship. Rumour has it that there may be interest in holding yet another #SoMeSummit.  If there is, would you attend?  (Drop you answers below!)

 

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Medical Education at the ICRE Social Media Summit appeared first on BoringEM and was written by Teresa Chan.

Medical Concept – Vertigo: The Basics

We recently had a great piece by Dr. Andrew Petrosoniak about the HINTS exam. As a medical student, however, his piece left me with more questions than answers. I decided to go hunting for some foundational concepts surrounding vertigo and bring you along for the ride.

At some point in our medical training, we all encounter the dizzy patient. It can be difficult to determine who has vertigo and who is merely lightheaded.

Pathophysiology

vertigoVertigo is an illusion of movement. It results from a disturbance in the vestibular proprioceptive system. Of patients who present with ‘dizziness’, those who report that ‘the room is spinning when they are not’ or that ‘they are moving when the room is not’ are the most likely to have true vertigo. But keep in mind that not every patient with vestibular pathology describes their dizziness in this way. In one innovative study, patients were asked to describe their dizziness initially and then again ten minutes later; amazingly, half changed their descriptions.

Our vestibular system comprises peripheral (outside the brain) and central (inside the brain and spinal cord) components. The peripheral vestibular system includes the semicircular canals and the utricles. The semicircular canals are tubes containing fluid called endolymph. When we move our head in the three planes of angular motion, the endolymph moves with us, pushing on receptors called hair cells, which transmit information about our location in space to central vestibular system components, which include nuclei in the medulla and pons. The utricles and saccules detect linear movement through similar receptor hair cells. The cerebellum participates as well, sending and receiving signals to and from our eyes and receptors in our muscles and providing additional information about our position in space.

Etiology

Patients who are indeed suffering true vertigo can be divided into two etiologic categories: those suffering central vertigo and those with peripheral causes. Peripheral causes account for the vast majority of vertigo presentations. The goal of evaluation, however, is always to rule out a central cause, which can have more serious consequences and specific management strategies

Peripheral Causes of Vertigo

  1. Benign paroxysmal peripheral vertigo is caused by an otolith (calcium carbonate crystal) from a utricle becoming dislodged and ending up in one of the semicircular canals, usually the posterior. Whenever the head moves in the plane of that semicircular canal, the endolymph – and the patient’s sense of where she is in space – is disturbed, creating the sensation of the room spinning.
  2. Acute labyrinthitis is an inflammation of the labyrinthine organs caused by a viral or bacterial infection that often presents with vertigo and unilateral or bilateral hearing loss.
  3. Acute vestibular neuronitis is an inflammation of the vestibular nerve, usually caused by a viral infection. Unlike labyrinthitis, it does not cause hearing loss.
  4. Meniere’s disease is caused by excessive fluid in the endolymph leading to aural fullness, hearing loss, and tinnitus, in addition to vertigo.
  5. Herpes zoster oticus is a vesicular eruption in the ear caused by reactivation of the varicella zoster virus.

Central Causes of Vertigo

  1. Cerebrovascular disease, causing an arterial occlusion in the posterior circulation can affect the vertebrobasilar system and create vertigo.
  2. Cerebellopontine angle tumour is a neuroma at the angle of the pons and cerebellum that causes a distinct set of cranial nerve findings, as tumour growth progresses and impinges on cranial nerves V, VII, and VIII. Hearing loss, tinnitus and vertigo may present initially, progress to mid-face hypo-esthesia and disequilibrium, and if untreated, death due to brainstem compression.
  3. Migraine headaches may induce vertigo. There may be associated symptoms of aura, nausea, vomiting, and phono- or photophobia.
  4. Multiple sclerosis can cause vertigo through demyelination of white matter in the central nervous system. This is particularly likely if the demyelinating event occurs in the cerebellum or involves cranial nerves.
  5. Drugs, including alcohol, streptomycin, and gentamycin, can cause vertigo through ototoxicity. Other drugs that can produce vertigo include anticonvulsants, antidepressants and caffeine. A careful review of medications is essential, especially in elderly patients, who are more likely to be on multiple medications and are particularly susceptible to the effects of polypharmacy.

Diagnosis

When a patient presents in the emergency department with vertigo, use a step-wise approach to arrive at a diagnosis and plan.

Step 1: Ascertain timing and triggers

Elicit the timing of the dizziness and any factors that provoke it. Was the dizziness abrupt in onset or did it progress gradually? How long have the symptoms lasted? Are they intermittent or constant? Is there anything that aggravates or alleviates the dizziness? Understanding timing and triggers is generally much higher yield than having the patient describe the character of their symptoms.

Acute vestibular syndrome is an abrupt (over seconds to hours) onset of dizziness, nausea, vomiting and gait unsteadiness lasting days to weeks. Vestibular neuritis and posterior circulation stroke are the main causes for this syndrome. If the patient is complaining of chronic dizziness, lasting weeks to months, then one should consider a growing mass in the posterior fossa, or drug side effects as possible causes. Vertigo that is intermittent without any provoking factors can be caused by posterior circulation transient ischemic attacks or vestibular migraines. Finally, brief episodes of vertigo that are triggered by head movement and resolve when movement is stopped, point towards BPPV.

Step 2: Determine whether the vertigo is isolated or associated with other symptoms.

The most worrisome causes of vertigo are central, including cerebrovascular accidents and intracranial masses. Because these causes have serious consequences and specific treatments, it is important to ascertain the likelihood of a central cause.
The cerebellum and brainstem are small structures; it is unusual to find an ischemic lesion or mass that affects only the vestibulocochlear nerve’s nucleus. The presence of other neurological signs and symptoms (resulting from compromise of other central structures) point toward a central cause. A quick mnemonic for associated neurological symptoms is the 5 Ds: dizziness (vertigo), diplopia, dysarthria, dysphagia and dysmetria (cerebellar ataxia). Sensorimotor deficits in the extremities and loss of consciousness also support a central cause of vertigo. Even so, other aspects of the history and physical exam must be integrated into the decision-making process, since they will affect pre-test probability; central causes of vertigo may still be associated with an otherwise normal neurologic examination.

Step 3: Rule out a central process.

If the patient presents with acute vestibular syndrome, apply the HINTS bedside examination.

Briefly, the HINTS exam includes:

  1. Head Impulse Test: This test measures the integrity of the vestibulo-ocular reflex. If the Head Impulse Test is abnormal it implies that the vestibular nerve is impaired. A normal HIT implies that the lesion is central, and should be considered an abnormal finding on the HINTS exam. The most important point however is that the head impulse test can ONLY be performed when the patient is experiencing vertigo symptoms.
  2. Nystagmus: Unidirectional, horizontal nystagmus suggests a peripheral lesion. All other nystagmus (direction-changing, bilateral, purely vertical) should raise the suspicion for a central etiology.
  3. Skew Test: This test reveals vertical strabismus caused by a supranuclear lesion in the posterior fossa, a central cause of vertigo.

If any one of the above is abnormal, the sensitivity for a central cause is about 100% and stroke management should be initiated. If the HINTS test in inapplicable, but the patient’s history and exam raise suspicion for stroke, stroke management should again be initiated.

If suspicion for central lesion remains low, try to rule-in a peripheral process.

Step 4: Identify the peripheral cause.

Acute severe dizziness lasting 24 hours or longer that presents with no other neurological findings, a unidirectional horizontal nystagmus, and a positive head impulse test indicates acute vestibular neuritis or labrynthitis (if hearing is also affected). Consult ENT, consider corticosteroids, and manage nausea and vomiting.

Recurrent positional vertigo that is elicited by changes in head position, lasts less than one minute, and resolves during rest are key features of benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike maneuver is used to elicit nystagmus, which can indicate which canal is affected. A posterior canal defect causes vertical torsional nystagmus when the head is extended and hung over the edge of the bed. For a visual explanation of the Dix-Hallpike, click here. Posterior or anterior canal BPPV can be managed with the Epley maneuver, which aims to reposition the displaced canalith. A similar maneuver to replace a horizontal canalith involves lying supine and turning the head towards the unaffected side in 90 degree increments. These maneuvers can be attempted in the emergency department, but patients can also use them to manage vertigo symptoms at home. Some physiotherapists have expertise in the Epley maneuver, and may be helpful for patients who have difficulty mastering this challenging routine at home.

Recurrent spontaneous attacks of dizziness are typical of Meniere’s disease, and are usually accompanied by unilateral ear fullness, hearing loss, and roaring tinnitus. Episodes may last for hours. The HIT test, however, may be normal as the peripheral vestibular system is intact. Always be mindful that such recurring attacks may represent TIAs and impending basilar ischemia, especially if they appear with an accelerated frequency.

Conclusion

In summary, when a patient presents with vertigo, the most useful tool at your disposal is a detailed history and relevant physical exam. The timing, triggers and associated symptoms should all help you narrow the differential diagnosis for your patient’s vertigo. The physical examination can further help establish the pre-test probability for those important-to-catch central causes, so that you can pursue appropriate investigations and management.

Peer reviewed by Dr. Sarah Luckett-Gatopoulos (@SLuckettG) and staff reviewed by Dr. Andrew Petrosoniak(@petrosoniak).

References

  • Edlow, J. A. (2013). Diagnosing dizziness: we are teaching the wrong paradigm! Academic Emergency Medicine, 20(10): 1064-1066.
  • Kerber, K. A. (2009). Vertigo and dizziness in the emergency department. Emergency Medicine Clinics of North America, 27(1): 39-viii
  • Labuguen, R. H. (2006). Initial evaluation of vertigo. American Family Physician, 73(2): 244-251.
  • Lin, M. (2011). Acute vestibular syndrome and HINTS exam.
  • Swadron, S. P. (2011). A simplified approach to vertigo.
  • Video for diagnosing posterior stroke.

Reviewing with the Staff (Dr. Andrew Petrosoniak)

Remember, ALL vertigo gets worse with movement – both central and peripheral. In BPPV, movement causes the symptoms. Spend your time during the history deciding the timing and triggers of vertigo and not the quality of symptoms. Studies have confirmed that the symptom quality is not a reliable predictor of the underlying etiology. Continuous vertigo has a different set of causes than does intermittent vertigo. Spend your time differentiating between the two. If vertigo is continuous, think of it as acute vestibular syndrome and use the HINTS exam.

Author information

Romesa Khalid
Romesa Khalid
Romesa Khalid is a medical student at McMaster University.

The post Medical Concept – Vertigo: The Basics appeared first on BoringEM and was written by Romesa Khalid.

#TipsforEMexams: Dr. Christopher Hicks shares his EM Exam Tips

Name: Chris Hicks, MD, MEd, FRCPC, Survivor of the 2009 Royal College EM exam

Where are you now? Emergency physician, trauma team leader at St. Mike’s in Toronto.  Associate program director, FRCP-EM training program, University of Toronto.

 

My Tips:

  1. Learn to think like an examiner.  It may surprise you to learn this, but the people who concoct the FR exam are actual humans, just like you and me.  You should read chapters with an examiner’s eye — pay particular attention to points that might make for a good question.  That is, lists, boxes, key DDx or management summaries.  Examiners, like the rest of us, are inherently lazy.  They seek ease of both creation and assessment.
  2. No summary notes. I started typing out summary notes of Rosen chapters back in the day.  Like Woodsy, I quickly realized two things: a) You learn more from writing your thoughts down on paper, and b) it is a HUGE waste of time to summarize stuff you already know.  There’s no point in writing out the Wells criteria or the pathophysiology of cardiogenic shock if you have it in your head already.  Remember, when you re-visit your study notes later in the year, you would like to have a concise database of stuff you didn’t already know when you first wrote it down.  Saves time, saves cognitive real estate.
  3. Keep working. Consolidation is key.  No, not that kind of consolidation you epic nerd.  Although it is tempting to forsake all your worldly responsibilities from January onward in favour of putting nose to book, it actually really helps a lot to come to work, to rounds, to study group, etc.  Working shifts is particularly important — study trauma arrest one week, run one the next: http://en.wikipedia.org/wiki/Dual-coding_theorydual coding theory tells us that’s a recipe for the formation of staunch long term memory and recall.
  4. Practice your oral exam “scripts”. The oral exam is as much about how you say something as what you say.  True, there are no points for style, and we likely fetishize “examsmanship” in practice orals well beyond what is truly necessary.  Having said that, nothing wrong with providing a slick answer.  Having a rehearsed and generic “script” for your trauma, medical, peds cases (and so on) will help the words flow smoothly.  Rehearsal is the key: afterJanuary 1, you should be doing about one full practice oral exam per week, up until a few weeks before the actual event.
  5. Run. ​​Or bike, or walk, or exercise, or spend time with friends and family, or play music, or do whatever it is that makes you feel good.  At a certain point, the only thing that will make you feel good is studying.  This, my friends, is the point at which you need to be able to pull back and GO OUTSIDE, or something equivalent.  The occasional distraction and indulgence is important, if not necessary to survival, especially late in the game.  When all else fails, there’s always this.

My nominations:

Lisa “The Duchess” Thurgur (Ottawa)
Dave Messenger (Kingston)

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #TipsforEMexams: Dr. Christopher Hicks shares his EM Exam Tips appeared first on BoringEM and was written by Teresa Chan.