MEdIC Series | The Case of the FOAM Faux Pas

The use of online open access secondary has increased recently. Many clinicians are turning to these resources for continuing education. There is debate about these resources that can occasionally result in conflict between early adopters and those with a more traditional approach. Please join us in discussing the case this of the FOAM Faux Pas. We would love your thoughts and advice.

SMACC

P.S. Teresa Chan, 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 The FOAM Faux Pas

by Brent Thoma (@Brent_Thoma)

It was only her sixth month as staff, but Stacy had found her groove. In addition to all of her board exam studying, she had been regularly listening to podcasts and reading up on the latest literature on her favorite medical blogs. She felt like she may be as up-to-date on the medical literature as she may ever be and she was finally starting to feel comfortable as the attending in the department. She just had to determine the disposition for a couple more patients and she’d be off to go prepare for a date with her husband that night. Then she saw Dr. Walters coming towards her – and he looked mad.

“Just what were you thinking yesterday!?” he asked her, angrily.

Stacy thought back to her day yesterday to try and figure out what he was referring to. She had urgently consulted him on a globe rupture and he hadn’t been upset with her then. There was also that patient with the corneal abrasion that she sent to him for follow-up. That case had been so simple though – she didn’t miss something, did she?

“I’m not sure what you’re referring to, Dr. Walters.”

“Tetracaine? You gave Tetracaine to a patient with a corneal abrasion? What were you thinking!? I thought we taught you better than that at this medical school.”

“Well…”

“Well what?” he cut her off, “She could have lost her eye! Who taught you that this was okay?”

“Well actually, Dr. Walters, I heard about it on a podcast. I understand that there’s some new evidence that suggests it’s actually safe to use dilute tetracaine in these pat-“

“A podcast…” he replied, “A podcast? So is that how we practice medicine these days? Looking up what some random quacks on the internet have to say? I thought we taught you better than that.”

Stacy’s eyes dropped to the floor as she began to question herself.


You are one of Stacy’s long term mentors and she just relayed this story to you. She is quite distraught both over how Dr. Walters responded and questioning her use of secondary sources such as blogs and podcasts for her education.

Key Questions

  1. How would you counsel Stacy about this negative encounter with her colleague? What are main factors contributing to the conflict? What should she do next?
  2. Do you think Dr. Walters’ skepticism of Stacy’s reliance on secondary sources is reasonable? With the large body of available primary literature how should emergency medicine physicians stay “safely” up to date?
  3. How would you have responded to Dr. Walters in this scenario?

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. Anton Helman, is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine, the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute and is on the advisory board of The Teaching Institute. He is the founder and host of Emergency Medicine Cases.
  • Dr. Tessa Davis, is a Paediatric EM physician in Sydney. She develops and encourages health innovation through Don’t Forget the Bubbles, GuidelinesForMe, iClinicalApps, Learnmed.

On May 1, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of The FOAM Faux Pas. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. 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

Author information

Eve Purdy, BHSc

Eve Purdy, BHSc

Medical student

Queen's University in Kingston, Ontario, Canada

Student editor at BoringEM.org

Founder of manuetcorde.org

The post MEdIC Series | The Case of the FOAM Faux Pas appeared first on ALiEM.

Hyperkalemia Management: Preventing Hypoglycemia From Insulin

InsulinInsulin remains one of the cornerstones of early severe hyperkalemia management. Insulin works via a complex process to temporarily shift potassium intracellularly. Though insulin certainly lowers plasma potassium concentrations, we often underestimate the hypoglycemic potential of a 10 unit IV insulin dose in this setting. The purpose of this post is to highlight the need for proper supplemental glucose and blood glucose monitoring when treating hyperkalemia with insulin.

Incidence of Hypoglycemia

One of my favorite articles on the management of hyperkalemia was written by Dr. Weisberg in Critical Care Medicine [1]. According to the Weisberg article, a 10 unit dose of IV regular insulin has an onset of action of about 20 minutes, peaks at 60 minutes, and lasts 4-6 hours. Herein lies the problem in that IV dextrose only lasts for about an hour. Allon et al reported up to 75% of hemodialysis patients with hyperkalemia developed hypoglycemia at 60 minutes after insulin administration [2]. A retrospective review of 219 hyperkalemic patients reported an 8.7% incidence of hypoglycemia after insulin treatment [3]. More than half of the hypoglycemic episodes occurred with the commonly used regimen of 10 units of IV insulin with 25 gm of dextrose. A more recent study of 221 end-stage renal disease patients who received insulin for treatment of hyperkalemia reported a 13% incidence of hypoglycemia [4].

The overall incidence of hypoglycemia appears to be ~10%, but could be higher.

Risk Factors for Developing Hypoglycemia

The study by Apel et al identified three factors associated with a higher risk of developing hypoglycemia:

  1. No prior diagnosis of diabetes [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.0–5.1, P = 0.05]
  2. No use of diabetes medication prior to admission [OR 3.6, 95% CI 1.2–10.7, P = 0.02]
  3. A lower pretreatment glucose level
    • In mg/dL: mean 104 ± 12 mg/dL vs 162 ± 11 mg/dL, P = 0.04
    • In mmol/L: mean 5.8 ± 0.7 mmol/L vs 9.0 ± 0.6 mmol/L, P = 0.04

Renal dysfunction in and of itself may also be a risk factor for developing hypoglycemia. Some evidence suggests that insulin is metabolized by the kidneys to some extent. Furthermore, patients with acute kidney injury (AKI) have clinically relevant changes in insulin metabolism, as evidenced by increased hypoglycemic events and lower insulin requirements upon developing AKI [5].

Strategies for Avoiding Hypoglycemia

Preventing hypoglycemia is important. Some clinicians use up to 20 units of IV regular insulin as the hypokalemic effect is dose dependent [6]. Here is a suggested strategy for administering enough dextrose to counter the initial insulin bolus of 10 or 20 units. It is loosely based on the Rush University protocol [4].

Initial [glucose] Initial Dextrose Dose Supplemental Dextrose ** Glucose Monitoring
> 200 mg/dL None 50 mL (25 gm) of D50 if blood glucose < 70 mg/dL Hourly up to 3 hours
100-200 mg/dL 50 mL (25 gm) of D50 50 mL (25 gm) of D50 if blood glucose < 70 mg/dL Hourly up to 3 hours
< 100 mg/dL 100 mL (50 gm) of D50*
OR
50 mL (25 gm) of D50 + D10 infusion 250 mL/hr for first hour
50 mL (25 gm) of D50 if blood glucose < 70 mg/dL q 30 minutes for first hour, then hourly up to 3 hours

D50 = dextrose 50%; D10 = dextrose 10%

* There are drawbacks to administering 100 mL (50 gm) of D50. Dr. Adam Spaulding (@PharmERAtom) discusses D50 vs. D10 for severe hypoglcyemia in the ED. 50 mL (25 gm) of D50 + infusion of D10 might prevent rebound hypoglycemia and hypertonicity issues with an initial 100 mL (50 gm) dose of D50.

** A supplemental D10 infusion may be needed beyond one hour depending on blood glucose concentrations.

What about using dextrose only?

Theoretically, administering dextrose should stimulate insulin release (if the patient has a functioning pancreas) and thereby lower serum potassium concentrations. Early reports recommend against this technique for two reasons [7].

  1. Endogenous insulin levels are unlikely to rise to the level necessary for a therapeutic effect
  2. There is a risk of exacerbating the hyperkalemia by inducing hypertonicity.

On the flip side, a more recent randomized, crossover study was conducted in 10 chronic hemodialysis patients who were prone to hyperkalemia [8]. Administration of 10 units of insulin with 100 mL of 50% glucose (50 g) was compared with the administration of 100 mL of 50% glucose only. Infusion of a glucose-only bolus caused a clinically significant decrease in serum potassium by 0.5 mEq/L without any episodes of hypoglycemia. The insulin/glucose group saw a drop in potassium of 0.83 mEq/L at 60 minutes.

Bottom Line: Based on conflicting data, and considering that many patients have ESRD plus diabetes, this approach has potential but may not be ready for mainstream use. Also, hyperglycemia may be undesirable in some patients.

Take Home Points

  • The hypoglycemic effects of IV insulin last longer than a bolus of dextrose. More than one dextrose dose is often needed when treating hyperkalemia.
  • One ‘amp’ (50 mL, 25 gm) of D50 is not enough to counteract the hypoglycemic effect of insulin in patients with normoglycemia to start.
  • Make sure to check glucose at the hour mark after administering IV insulin. Insulin’s peak effect occurs at about 60 minutes and this is when hypoglycemia has most often been reported in the literature.

Dr. Scott Weingart and I discuss this issue on his EMCrit podcast 101: Avoiding Resuscitation Medication Errors – Part 1.

References

  1. Weisberg LS. Management of severe hyperkalemia. Crit Care Med 2008;36(12):3246-51. [PMID 18936701]
  2. Allon M, et al. Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney Int 1990;38(5):869-72. [PMID 2266671]
  3. Schafers S, et al. Incidence of hypoglycemia following insulin-based acute stabilization of hyperkalemia treatment. J Hosp Med 2012;7(3):239-42. [PMID 22489323]
  4. Apel J, et al. Hypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal disease. Clin Kidney J 2014;0:1-3. [free PDF]
  5. Dickerson RN, et al. Increased hypoglycemia associated with renal failure during continuous intravenous insulin infusion and specialized nutritional support. Nutrition 2011;27(7-8):766-72. [PMID 20971617]
  6. Blumberg A, et al. Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. Am J Med 1988;85(4):507-12. [PMID 3052050]
  7. Goldfarb S, et al. Acute hyperkalemia induced by hyperglycemia: hormonal mechanisms. Ann Intern Med 1976;84(4):426-32. [PMID 769633]
  8. Chothia MY, et al. Bolus administration of intravenous glucose in the treatment of hyperkalemia: a randomized controlled trial. Nephron Physiol 2014;126(1):1-8. [PMID 24576893]
Expert Peer Review
Expert Peer Review

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

ALiEM Associate Editor

Clinical Assistant Professor, EM and Pharmacy Practice

Clinical Pharmacy Specialist, EM and Toxicology

University of Maryland

The post Hyperkalemia Management: Preventing Hypoglycemia From Insulin appeared first on ALiEM.

Trick of the Trade: Ultrasound confirmation of pediatric endotracheal tube placement – TRUST your tube

ultrasound confirmation of pediatric endotracheal tube placementFollowing intubation the confirmation of endotracheal tube placement and depth is essential. While dynamic etCO2 monitoring has revolutionized the confirmation of endotracheal placement, there are still several circumstances in which this modality may be misleading (e.g. prolonged arrest, severe status asthmaticus/PE/pulmonary edema, etCO2 detector contamination with drugs/gastric contents). Additionally, etCO2 detectors cannot confirm appropriate endotracheal tube depth, leading to delayed recognition of mainstem placement.

Limitations of current confirmation tools

Chest x-ray, chest ultrasound, and physical exam can be used to confirm appropriate endotracheal tube depth, however, each has limitations. Ultrasound of the chest/pleura can assess for mainstem intubation by evaluating for bilateral pleural sliding. However, it is only about 50% sensitive (i.e. – bilateral lung sliding will occur in 50% of mainstem intubations) [1]. Chest x-rays are accurate for this purpose, but take significant time from ordering until interpretation. The physical exam for mainstem intubation is notoriously unreliable [2]. None of these techniques allow for dynamic assessment of tube placement during repositioning.

Recognizing these issues, we recently developed and validated a new ultrasonography technique that we call TRUST (Tracheal Rapid Ultrasound Saline Test) [3] that can provide rapid, accurate assessment of tube placement and facilitate dynamic repositioning.

Trick of the Trade: Tracheal Rapid Ultrasound Saline Test (TRUST)

Our TRUST technique uses point-of-care ultrasonography of the anterior neck to confirm tube placement and position in an average of 4 seconds. The endotracheal tube cuff is inflated with saline rather than air to allow visualization. Cuff visualization at the level of the sternal notch corresponds to an ETT tip that is just inferior to the clavicular heads.

Assessing the endotracheal tube position

  • Place a high-frequency linear probe in transverse position over the anterior neck at the level of the sternal notch.

Pic 1 - TRUST probe position

 

  • Deflate the ETT cuff using a 10 mL syringe, noting the volume of air removed.
  • Reinflate the cuff using the same volume of normal saline.
  • As the saline is being injected attempt to visualize the bright posterior walls of the cuff filling within the trachea. Swirling air bubbles will often be seen.
Ultrasound showing swirling air bubbles from endotracheal tube cuff (transverse view of the anterior neck)

Ultrasound showing swirling air bubbles from endotracheal tube cuff (transverse view of the anterior neck)

If the cuff is not seen, sweep the probe superiorly along the trachea to the level of the vocal cords to search for the saline-inflated cuff. Once air bubbles have dissolved, the saline inflated cuff is recognized by its posterior wall, appearing as horizontal hyperechoic lines interrupted by shadowing from air within the endotracheal tube.

Labeled TRUST

Repositioning a misplaced tube

The sternal notch is the optimal point for the cuff of the tube.

If the cuff is visualized cephalad to the sternal notch, consider inserting the tube further to prevent extubation. The movement of the cuff can be followed dynamically during repositioning with ultrasound.

What if you cannot see the tube?

If the cuff is not visualized from the sternal notch to the larynx, then the cuff is either deep to the sternum, signifying a tube tip that is likely maintem, or in the esophagus [Read more about recognizing esophageal intubations by ultrasound by Dr. Mark Favot.] If there is no evidence of an esophageal intubation, hold the probe at the sternal notch and slowly withdraw the tube until the saline-filled cuff is visualized. As long as your cuff is not overinflated, moving the tube while the cuff is inflated with saline should not cause mucosal damage moving from the smaller mainstem bronchus towards the larger trachea.

If doubt exists whether a saline-filled cuff is being visualized on screen, you can withdraw the saline from the cuff while observing the structure in question. If the structure shrinks and disappears – it was the cuff!

Ultrasound demonstrating deflation of saline-filled endotracheal tube's cuff

Ultrasound demonstrating deflation of saline-filled cuff of endotracheal tube

Can we TRUST the evidence?

We studied this technique in children undergoing intubation for elective surgeries, and found it took an average of 4 seconds to perform and was 98.8% sensitive and 96.4% specific for correct ETT depth of insertion. However, care should be taken in using this technique with adults, as TRUST has not been validated in patients >18 years of age.

Is it safe to TRUST your tube?

Normal saline is regularly used as a cuff-inflation medium in aeromedical transport and ENT procedures that are associated with a risk of laser-initiated airway fire. There is no evidence that it is associated with any increased risk of cuff rupture. In the unlikely event of a cuff rupture, the volume of saline entering the airway is similar to that used during ETT suctioning and should not pose a risk to the patient. Despite the safety of saline, I usually replace it with air after positioning the tube to limit confusion during handover to other physicians.

Conclusion

TRUST is a novel rapid bedside ultrasound technique that can help optimize endotracheal tube position. It holds great promise in evaluating possible ETT dislodgement in critically ill patients without the delay typically associated with chest radiography, and allows for dynamic tube positioning under real-time sonographic guidance. It is not yet validated in adults – if any readers are interested in collaborating on such a study, please let the author know!

References

 

Edited by Dr. Brent Thoma.

Author information

Mark Tessaro, MD

Mark Tessaro, MD

Pediatric Emergency Medicine Physician

Research Lead, Emergency Point-of-Care Ultrasound Program

Hospital for Sick Children, Toronto

Assistant Professor, University of Toronto

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Diagnose on Sight: Lip Swelling

angioedemaCase: A 24 year old male presents with right sided lip swelling that began several hours ago. This is the second time he has had this type of swelling. His mother has also had this before. He currently has no urticaria, dyspnea, wheezing, or stridor. What is the cause of this patient’s symptoms?

 

 

Diagnose on Sight Poll

Answer
References

Author information

Jeff Riddell, MD

Jeff Riddell, MD

ALiEM Assistant Editor

Diagnose on Sight series;

Chief Resident

UCSF-Fresno Emergency Medicine Residency

The post Diagnose on Sight: Lip Swelling appeared first on ALiEM.

I am Dr. Sam Ghali, EM Faculty and Ultrasound Expert at The University of Kentucky: How I Work Smarter

How I Work Smarter Logo As you can see from our How I Work Smarter (HIWS) mapping post, Lexington Kentucky is emerging as a powerhouse of EM leaders and social media gurus. After WildcatEM HIWS contributions from Matt Dawson, Rob Rogers, and Chris Doty, we have Dr. Sam Ghali (@EM_ResUS) taking a swing. Dr. Ghali is an up and coming member of the SoMe circuit with a focus on point-of-care ultrasound, resuscitation, and critical care. Nominated by Haney Mallemat, Dr. Ghali generously shares his thoughts about career and life management.

 

  • Name: Sam Ghali, MDGhalie Square
  • Location: Lexington, KY
  • Current job: Emergency medicine faculty at the University of Kentucky Medical Center
  • One word that best describes how you work: Instinctively. I’m a very instinctive person, consistently going with my gut. Work is no exception.
  • Current mobile device: iPhone5
  • Current computer: 15”-Macbook Pro, 13”-Macbook Air, Dell (Office Desktop), Dell (Extraneous PC) 

What’s your office workspace setup like?

Office Pic Crazy Desktop

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

If you listen to podcasts (or any educational audio) at normal playback speed, the following tip will transform your efficiency: Increase the playback speed! Make sure you have an audio player that allows this option (most do, but some don’t). This speed is almost universally expressed as a multiple of regular speed (1X). At first this may overwhelm you, but I promise your brain will quickly adapt. The amount of information per time your brain can digest far exceeds that provided by average human talking speed. Start at 1.2X or 1.3X and work your way up. The optimal speed will certainly depend on the speaker you’re listening to {for ex: I like Michelle Lin at around 2.4X :-) }, but in general I usually find myself listening at about 2X to 2.5X speed. Obviously this technique gets you through the material in unbelievably less time, but importantly it also allows me to focus far better, as my mind tends to drift at slower speeds!

Disclaimer: After engaging in this for several consecutive hours, you may temporarily find it somewhat frustrating talking with people since it takes everyone “forever” to say what they’re trying to say.

Close 2nd: If you’re really trying to get stuff done– turn your Twitter notifications OFF!

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

If using Gmail: Hit the # key (Shift + 3). (Make sure keyboard shortcuts are turned on under Settings) This is my favorite key. I use it quite liberally. ;-)

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

I work in an academic setting and see the majority of my patients in conjunction with the residents. I like to see the patients before they do or at least before they “present” the patient to me. My philosophy is that residents are training to be attendings; and as attendings, they won’t be “presenting” patients. So why train for 3 (or 4) years to perfect this drill? After seeing the patient myself– and attaining that (unibased) instinctual, humanistic gestalt that can only be drawn from personal patient contact– I can now have a much more meaningful and productive conversation with resident as I ask them what they think, why they think it, and what they want to do. I find this strategy to be incredibly efficient and all the while allowing for optimal teaching/learning.

ED charting: Macros or no macros?

Since I’m seeing most patients with residents, my notes typically consist of a Dragon-dictated blurb of what I want on the chart. Macros are super efficient and I think’s they’re great as long as we’re aware of their pitfalls and their potential to lead to medicolegal crucifixion.

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

Family first, always. Control your career, never let your career control you. We have a tendency to get so caught up in work that we forget how precious and short life is. Don’t let this happen. Keep in mind life can be taken away from us or our loved ones at any moment. Remember, in the end– all we’re left with is memories.

Is there anything else you’d like to add that might be interesting to readers?

As emergency physicians– and as human beings– I think one of the greatest things we can do is to find ourselves, know ourselves, believe in ourselves; and never, ever lose sight of who we truly are.

  • We should never underestimate the power of our minds; used properly we can accomplish most anything.
  • We must realize that we determine our own futures
  • As we go through our careers–and our lives–we must be confident, yet remain humble. On our journey we will cross the paths and touch the lives of many people along the way. Be kind to them.
  • Never stop learning. Never stop teaching. Never stop loving.

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

  1. Andrew Sloas (@PEMEDpodcast)
  2. Stephen Smith (@smithECGBlog)
  3. Jeffrey Kline (@klinelab)

I’d like to thank Haney Mallemat (@CriticalCareNow) for tagging me, as well as Michelle Lin (@M_Lin) & Ben Azan (@BenAzan) for having me on the series. Truly an honor!

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. Sam Ghali, EM Faculty and Ultrasound Expert at The University of Kentucky: How I Work Smarter appeared first on ALiEM.

I am Dr. Nadim Lalani, Assistant Program Director and Life Coach: How I Stay Healthy in EM

How I Stay Healthy logo

Dr. Lalani (@ERMentor) is no stranger when it comes to wellness. He is without a doubt an individual who is always striving to improve himself on every level. Currently, he is the Assistant Program Director of the University of Saskatchewan FRCPC EM Program, creator of the blog ERMentor, and has recently completed his certification to be a Life Coach (check out his personal website here). When he’s not in the ED torturing his residents with his top secret set of tough questions, he can be found on the golf course working on his pro swing. Dr. Lalani is a mentor to many, and his residents often look to him for advice outside of medicine. Take a look at how he stays healthy in emergency medicine!

  • Name: Nadim Lalani CEd, MD, FRCPCLalani
  • Location: Saskatoon, Saskatchewan
  • Current job(s): Adult and Pediatric Emergency Physician. Assistant Program Director U of S FRCPC EM Program. Soon to be dad and ICF Certified Life Coach.
  • One word that describes how you stay healthy: “Constant practice” – I am still learning to be a picture of health.
  • Primary behavior/activity for destressing: In winter: Going to the gym then local coffee joint with a friend or book. In summer: Working on my golf game – usually with Bluetooth headphones connected to music on my smartphone. I find hitting chips and putts for a couple of hours meditative.

 

What are the top 3 ways you keep healthy?

  1. Sleep. I’ve learned the hard way just how important sleep is. I always nap before an evening/night shift and use a facemask and earplugs to block out light and sound. As a bonus, my cat Mookie is always there – he hasn’t missed a nap in 10 years! (I don’t know how he does it.)
  1. Train. No doubt – you need to be physically fit to be effective in EM. I work out with a personal trainer twice a week. I have improved tolerance of shift work and better sleep since I made this change. Being a fit person is more about changing who you are than it is the creation a new habit – so I let it happen gently, expect relapses, and actually gave myself two years to become this new person.
  1. Go easy on myself. Being healthy of mind and spirit is as important as having a titanium body. FACT: YOU ARE HUMAN! You need to be able to vent, share your hopes, dreams, fears, failures and inadequacies. Learn about emotional intelligence and mindfulness. Have an outlet … talk! (I also journal).

What’s your ideal workout?

Lifting RIBS! Seriously – 60 min of circuits that combine upper body, lower body, core and rowing/skipping/box jumps, repeated 3-4 times.  I also jog at a modest pace twice a week. But I need to make more of an effort to stretch.

Do you track your fitness? How?

I track my body composition every six months. I just got a Fitbit and am getting better at tracking my diet and cooking more at home. Although I think it’s more important to be fitter and see the gains in your work/life than to focus overly on body habitus. The literature is pretty clear on the inverse relationships between being overweight and job performance, workplace stress, branding and achievement – so I am trying to get “fighting fit”.

How do you prepare for a night shift? How do you recover from one?

Preparation: Sleep, hydration and nutrition. I hang out at home and do little. If I work out, it’s late in the afternoon followed by supper and a nap, for about 2-3 REM cycles. I get up an hour before shift to watch TV, Tweet, and Facebook in a room with bright light. I usually have a snack and grab coffee to go.

Recovery: Eat, hydrate, and nap [yup Mookie is there too]. I get up after about 4 hours. Again, post-nights I try to do little as I am cranky and have poor attention. I go to bed early and usually sleep the night.

How do you avoid getting “hangry” (angry due to hunger) on shift?

I sometimes struggle with this. The key is to plan your patient load/reassesses so that you can actually go for a meal, maybe have a protein bar handy just in case you get that trauma alert. I take time to eat in the nurses’ lounge and share banter. On nights, I have decreed 3 am as “Toast O’clock” at which time I usually crush a couple of PB and J pieces of toast with milk!

How do you ensure you are mentally in check?

Pre-shift: I listen to the right music to get my head in the right space. Never go in hungry, sad, angry, or emotional. In the car I take a moment to check in with myself – this is crucial these days with hospital overcrowding. I simply ask myself to do good work with each patient in front of me. I allow myself to plod along and try not to feel the pressure to “move the meat”.

On shift: Working in the ED is just like a video game! Be mindful of your emotional state as you go through the shift. When empathy levels are critically low – you need to power up! Take a break, eat, sit, then get back in the game.

Post-shift: My wife is my greatest support. This may sound odd, but I had to learn how to speak about my problems and understand that it’s okay to be vulnerable and show emotion. Recently, I treated a young healthy non-smoker with a new diagnosis of terminal cancer. He was crying, scared, and alone, and it got to me. I allowed myself a moment to process my feelings. I then shook it off and finished the shift. I came home and let it all out in my wife’s arms. Talk about ugly cry!

What are the biggest challenges you face in maintaining a longstanding career in EM? How do you address these challenges?

Changes – especially hospital overcrowding are killing job satisfaction. Thankfully I also work paeds and rotate through our 3 ED’s. This has insulated me from chronic exposure to our busiest site. I also do not work full-time and derive a lot of job satisfaction from training my residents. If you need help finding purpose and balance – hire a life coach.

EM is hard. There is no substitute for solid residency training and being a life-long academic. I am confident in my skills and knowledge – it has immunized me from the stresses of job. I also have a lot of fun at work and enjoy pulling pranks – like the time I secretly coached the ED volunteer on a Wellen’s Syndrome EKG. I then made a bet with my resident that the kid could interpret that EKG. He was like “that kid? In the volunteer vest? No freakin’ way!” You should have seen the shock on my resident’s face (when the kid threw back the EKG saying “pfft! That’s Wellen’s Syndrome! At least gimme something challenging!”) It was PRICELESS!

Maintaining a caring spirit. Being a human in medicine is emotionally exhausting. Learning how do deal with your emotions can help you cope and thrive – read up on emotional quotient (EQ). Also, life doesn’t give anyone a free pass. You will encounter situations that have the potential to destroy you. There is courage in seeking professional help to navigate through these difficult times.

Best advice you have received for maintaining health?

“Live richly” – fill your days with family, people, learning, meaning, and experiences – you only get one go-around.

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

Rob Woods
Shawn Dowling
James Huffman

Author information

Zafrina Poonja

Zafrina Poonja

ALiEM Assistant Editor,

How I Stay Health in EM series

Emergency Medicine Resident

University of Saskatchewan

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