MEdIC Case: The Case of the Cognitive Overload

Welcome to season 4, episode 1 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

In this month’s case, a junior resident deals with some of the harsh realities of emergency medicine when she experiences the negative impacts of cognitive overload when caring for a sick patient.

MEdIC Series: The Concept

MEdIC: The Case of Cognitive Overload

By Dr. Sarah Luckett-Gatopoulos

Haley had come to think of the nurses in the emergency department as lifesavers. As a first year resident, she often found the nurses’ clinical acumen far exceeded her own; they sometimes reminded her to order investigations she hadn’t yet thought to initiate, and occasionally began the diagnostic workup with bloodwork while she was waiting to review with her staff preceptor. She started to think of the nursing staff as one of her safety nets in the department.

The department this evening was unusually busy and as a result of recent nursing shortages several nurses were working double shifts. When a nurse from the triage desk came into the department and asked Haley to see a tachypneic young man being wheeled into the resuscitation bay, naturally, she immediately put down the chart she was working on and went to assess the patient.

The 20-year-old man with a known history of asthma was tachypneic and appeared diaphoretic. The paramedics reported that he had been febrile and coughing for the past week, to the point that his ribs ached with each breath. He had tried using his rescue inhalers, but their effect was diminishing as the illness progressed. Over the past 24 hours his breathing had worsened and his cough was now productive of green sputum. Upon auscultating his lungs, Haley could hear extensive crackles in the right lung field with associated diffuse wheezing. Now highly concerned for pneumonia, she glanced up at the cardiorespiratory monitor which revealed that his heart rate was elevated at 135 and respiratory rate was 30. She figured that given the severity of his symptoms and presentation she should promptly initiate the departmental “sepsis protocol” while she waited to review the case with her attending, Dr. George.

‘Hi, I don’t think we’ve met. I’m Haley, one of the first year emergency medicine residents. I will be filling out the sepsis order set for this young asthmatic here in resuscitation bay 5. He looks pretty sick and I’m quite concerned about him. Could you start some of the work-up right away and I’ll review this with Dr. George as soon as he’s available.’ Haley signed the sepsis protocol, which included an order for extensive blood work, blood cultures and a litre of normal saline to be administered. She thought it would be most appropriate to review the case with Dr. George before proceeding with additional orders.

‘Not to worry,’ the nurse replied. ‘I’ve already started these,’ she gestured to the blood work order set in her hand. ‘I’ve put in 2 IVs, sent off blood work and cultures and he has some fluids running. I’ve also called the respiratory therapist to come assess him.”

Relieved that she had a veteran nurse on the case, Haley quickly reviewed the case with Dr. George. Following her discussion with her attending Haley signed a new order sheet, which included additional IV fluids, antibiotics, chest x-ray, urinalysis, and nebulizer treatments. She quickly dropped the new order sheet on the patient’s chart and then picked up a new patient’s chart. The next case was a simple finger fracture so she figured she’d have time to care for this patient while managing the sick asthmatic.

Upon completing the care for the patient with the finger injury, Haley was called into a trauma case and assisted with a chest tube. She then went back to review the board and realized she hadn’t checked on the asthmatic patient in almost 2 hours. She logged into the image viewing system to review his chest x-ray and was surprised to find it hadn’t been completed.

She approached the patient’s nurse and asked, ‘Do you know why our patient in resuscitation bay 5 hasn’t had his x-ray?’

‘Oh… I didn’t put that in. That’s your job.’ she replied. The nurse was simultaneously balancing the care for 5 emergency patients and appeared slightly flustered.

Haley glanced over at the patient who now appeared increasingly uncomfortable and fatigued. The respiratory therapist had started some nebulizer treatments but the patient appeared to be clinically deteriorating. Haley nervously asked the nurse, ‘How much fluid has he received? Did you give him anything for pain? Did you start the antibiotics?’

The nurse looked up at Haley, ‘I sent off blood work and started a bolus of saline as we discussed earlier. We can’t start additional interventions without a doctor’s orders. You need to order it if you want it done.’

Haley flipped through the order set in the patient’s chart and sure enough, her signed order sheet was right where she had placed it earlier. Haley had been so confident the orders would be completed. This nurse was one of the best she had worked with and she didn’t think she would have to get after her to do the work. Haley could feel her cheeks getting red… She kept thinking, ‘how could I have let this patient sit here for 2 hours without additional fluids or antibiotics! If he continues to deteriorate, this is on me!”

Discussion Questions

  1. How could Haley have avoided this dilemma?
  2. What strategies can physicians employ to lighten the cognitive load, decrease stress and avoid medical error?
  3. Should Haley disclose this medical error with the patient and how should she go about it?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month, our two experts are:

  • Dr. Amy Walsh
  • Dr. Jimmie Leppink

On October 14, 2016 we will post the curated commentary and expert responses to this case! 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.

Author information

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba

The post MEdIC Case: The Case of the Cognitive Overload appeared first on ALiEM.

AIR-Pro: Toxicology (Part 1)

Welcome to the Toxicology (Part 1) AIR-Pro Module. Below we have listed our selection of the 10 highest quality blog posts related to 5 advanced level questions on toxocology topics posed, curated, and approved for residency training by the AIR-Pro Series Board. The blogs relate to the following questions:

  1. Flumazenil in benzodiazepine overdose
  2. Acetaminophen – drawing and timing of levels
  3. Opioid overdoses
  4. Acetaminophen toxicity related to liver transplant
  5. Salicylates and hemodialysis

In this module, we have 6 AIR-Pro’s and 4 Honorable Mentions. To strive for comprehensiveness, we selected from a broad spectrum of blogs identified through and FOAMSearcher.We have a brand new chief resident team and want to thank the out-going team for all of their support!

AIR-Pro Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR-Pro stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥28 points (out of 35 total), based on our AIR-Pro scoring instrument, which is slightly different from our original AIR Series scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR-Pro Board members as worthwhile, accurate, unbiased and useful to senior residents. Only the posts with the AIR-Pro stamp of approval will be part of the quiz needed to obtain III credit. To decrease the repetitive nature of posts relating to these advanced concepts, we did not always include every post found that met the score of ≥28 points.

Take the quiz at ALiEMU

ALiEMU AIR-Pro Toxicology block quiz
(You will need to create a one-time login account if you haven’t already.)

Toxocology Module (Part 1) 2016: Recommended III credit hours

3 hours (20 minutes per article, 30 minutes for articles with podcasts)


Article Title Authors Date Title
EMPharmD: Flumazenil: Friend or Foe? Nadia Awad Nov 7, 2013 AIR-PRO
ALiEM: Utility of Pre-4-Hour Acetaminophen Levels in Acute Overdose Bryan Hayes Aug 5, 2015 AIR-PRO
StEmlyns: Opiate Overdose in the ED Simon Carley Feb 27, 2015 AIR-PRO
EMJClub: Treat and Release vs Observation After Naloxone for Opioid Overdose EMJ Club Nov 24, 2014 AIR-PRO
LIFTL: Liver Transplantation for Paracetamol Toxicity Chris Nickson April 30, 2016 AIR-PRO
ALiEM: 5 Tips in Managing Acute Salicylate Poisoning Kristin Fontes Nov 4, 2013 AIR-PRO
LITFL: Paracetamol/Acetaminophen Overdose Chris Nickson Sept 3, 2010 Honorable Mention
ALiEM: Tricks of the Trade: Naloxone Dilution for Opioid Overdose Bryan Hayes Nov 17, 2014 Honorable Mention
LITFL: Paracetamol Chris Nickson 2015 Honorable Mention
EMDocs: Pearls and Pitfalls of Salicylate Toxicity in the ED Samantha Berman & Josh Bucher Oct 13, 2015 Honorable Mention


Author information

Fareen Zaver, MD

Fareen Zaver, MD

Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro)
Emergency Physician
University of Calgary Emergency Department

The post AIR-Pro: Toxicology (Part 1) appeared first on ALiEM.

I am Dr. Richard Bounds, Associate Program Director: How I Stay Healthy in EM

Dr. Richard Bounds is an emergency physician from Newark, Delaware. His habits and beliefs definitely resonate with the philosophy of maintaining every day wellness. Despite being the Associate Program Director, Dr. Bounds uses the strategy of prioritizing to still make time for himself and his family. Here’s how he stays healthy in EM!



  • richard-boundsName: Rich Bounds, MD, FACEP
  • Location: Christiana Care Health System, Newark, DE
  • Current job(s): Associate Program Director, Emergency Medicine Residency, Co-Director, Medical Education Fellowship
  • One word that describes how you stay healthy: Priorities
  • Primary behavior/activity for destressing: Trail running

What are the top 3 ways you keep healthy?

  1. Relationships. My wife and 3 kids come first, and it’s a constant challenge when you’re in an academic career with shift work and seemingly endless demands for your time. But I know that making time for them and keeping my family as the top priority will make me a better person and a better physician.
  1. Exercise. I try to do something just about every day, no matter how busy things get. I’ll get up before sunrise to get a run in with my headlamp, or I’ll just hit the gym for 20 minutes after work. Sometimes all I can do is squeeze in 50 push-ups before my shower. I find that I just feel so much better if I’ve done something active each day.
  1. Sleep. I used to live by the “sleep when you’re dead” philosophy, usually getting 5-6 hours per night at most, so that I could get more done. As I’ve gotten a little older, and wiser, I’ve realized how critical good sleep is for overall health. And it’s not just quantity, but also quality. I follow the 10-3-2-1 rule for better quality sleep: no caffeine for 10 hours before bed, no alcohol for 3 hours before bed, no food for 2 hours, and no “screen time” (computer, TV, iPhone) for 1 hour before bed.

What’s your ideal workout?

Depends on the purpose of the workout. Every workout for me has a goal/purpose to it. If I need to just unwind and shake out some stress after a shift, I love to head out for an easy run on the singletrack. I don’t look at my watch to follow my heart rate or pace, and I just enjoy being in the woods. For actual training, my ideal workout is 4 to 6 intervals of 8-12 minutes each at threshold on my road bike through the rolling hills of Amish country.

Do you track your fitness? How?

I use a GPS device that tracks heart rate, pace, power on the bike and routes, and I upload my data to Strava. I enjoy the social component of the online software to see what my friends are doing with their training and find new routes on the roads and trails.

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

The best way to prepare for a night shift for me is to try to switch out of it! Nights crush me. I don’t sleep well before or after them. My kids always wake me up despite two white noise machines and earplugs. I now ask the scheduler to never schedule me for more than 1 or 2 at a time, and that helps. My wife does everything she can to stay out of the house and let me sleep. When I work weekend overnights, she actually takes the kids and goes out of town!  Night shifts are the absolute worst part of our job, in my opinion, and I think that we under-appreciate the detrimental effects nights have on our health.

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

I used to eat and snack constantly, unable to go more than 3-4 hours without eating something, and I was always getting “hangry.” In the past year, I’ve actually gone somewhat “paleo” or at least “primal” with my diet. Basically focusing on a high fat, high protein diet with lots of fresh fruits and vegetables, cutting out most processed foods, grains, and sugar as often as possible. With a family and the challenges of my schedule, I’m not strict about it, but I stick to the diet about 80% of the time, and cheat 20% of the time. Can’t pass up pizza and beer with the neighbors on a Friday evening, and I always eat whatever my wife puts on the table. But since adopting this way of eating, I don’t get the highs and lows, or hunger pangs, anymore, and my metabolism is much more even keel.

How do you ensure you are mentally in check?

My wife, Lily, really keeps me in check. I am very “type-A” and am always looking to be the over-achiever in all that I do, whether related to work projects, athletics … really anything. Last week, I started a jigsaw puzzle with my daughter, and I was sneaking into the family room every chance I could get, just to find a few more pieces that fit! She is very honest with me and lets me know when I am out of balance, or over-doing it in some aspect of my life. Otherwise, I try to take one day totally off per week to do something with the family. I get outside as often as possible. I really try to prioritize my spiritual life, and almost never miss Mass on Saturday night or Sunday.

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

Honestly, with three kids, the biggest challenge is the shift work and the erratic schedule. The shifts combined with all the administrative work as an APD just makes it more difficult to carve out family time. It’s really tough working every other weekend when you have school age kids. When I work all weekend, I try to take off Friday or Monday, or both, but the kids are in school then, so I still miss out on time with them. Our scheduler puts us in as working the whole weekend or off the whole weekend. Lately, I have started swapping one weekend shift, either Saturday or Sunday, with other colleagues, to split it up. That way, I work just about every weekend for one day, but then I am off one day to spend time with my family.

Best advice you have received for maintaining health?

Best advice I have received was from one of my colleagues, Heather Farley. (She has actually just taken a new role as the director of provider wellness for our hospital system.) As I was moving up the ranks rather quickly, taking on a greater load of tasks and leadership roles, she told me “every time you say YES to something, you are saying NO to something else.” For example, if you are going to join this committee that just requires 2 hours per month of your time, that’s 2 hours per month you have lost with your kids. I’m a very “service-oriented” person by default, but that advice has helped me to say “no” to things that are not advancing my career goals or bringing me value in other ways.

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

Kate Groner
Heather Farley
Gordon Reed

Author information

Zafrina Poonja

Zafrina Poonja

ALiEM Assistant Editor,
How I Stay Health in EM series
Emergency Medicine Resident
University of Saskatchewan

The post I am Dr. Richard Bounds, Associate Program Director: How I Stay Healthy in EM appeared first on ALiEM.

Ultrasound for the Win! Emergency Medicine Cases: Volume 1 Book

us4tw-book-cover Ultrasound for the Win

The Ultrasound for the Win! book, available now on Amazon and coming soon to the Apple iBooks Store, is a compilation of real ultrasound cases that have been featured on the blog’s Ultrasound for the Win! Series.

Who is this book for?

This collection of cases is geared towards anyone interested in learning more about point-of-care ultrasound, including medical students, residents, pre-hospital personnel, and physicians.



How can I use this book?

The book is a self-learning tool for students or residents that can be used as part of a curriculum in Emergency Medicine. The case-based format begins with case objectives, and encourages the reader to develop a differential diagnosis. As the cases progress, the reader learns how point-of-care ultrasound can narrow down the differential or provide a diagnosis, thus improving and expediting patient care.

The interactive iBook features video clips that allow the reader to see the actual clips that were obtained at the bedside from real patients.

Additionally, the book features Expert Peer-Review by physician leaders in the field of Point-of-Care Ultrasound including Dr. Chris Moore, Dr. Mike Mallin, Dr. Resa Lewiss, Dr. Mike Stone, and many more!


How do I reference this book?

Shih, Jeffrey and Lin, Michelle. Ultrasound for the Win! Emergency Medicine Cases: Volume 1. September 2016. ISBN: 978-0-9907948-6-8.

Available Now


Author information

Jeffrey Shih, MD, RDMS

Director, Emergency Ultrasound Fellowship Program,
The Scarborough Hospital
University of Toronto
Assistant Editor, Ultrasound for the Win Series,
Academic Life in Emergency Medicine

The post Ultrasound for the Win! Emergency Medicine Cases: Volume 1 Book appeared first on ALiEM.

10 Tips to Become a Successful Interviewer: Do’s and Don’ts

successful interviewerAs fall approaches, senior medical students and Emergency Medicine (EM) residency programs alike are beginning to prepare for the upcoming interview season. As part of the process, many programs have current residents interview potential candidates – their future colleagues! For most residents, though they have often been the interviewee, this is the first time they have filled the role of the interviewer. Among all the busy shifts and learning everything you need to know to be an amazing EM physician, there is little time for practice or formal training. To help, we have compiled our top “10 Tips to Become a Successful Interviewer.” Here’s to making this interview season the best one yet!


10 tips for successful interviewing infographic

Author information

Meg Pusateri, MD

Meg Pusateri, MD

Chief Resident
Department of Emergency Medicine
University of Louisville

The post 10 Tips to Become a Successful Interviewer: Do’s and Don’ts appeared first on ALiEM.