The Gist:  Podcasts are a way to absorb information in an efficient, pragmatic manner and the Emergency Medicine world does them well.  While many medical schools record lectures and place them online, podcasts enable one to listen to lectures that are meaningful and relevant on an individual basis.  Choose your own lecturer, style, and classroom for a world-class education.  The quality and quantity of podcasts is continously growing, thus this entry will change accordingly (fellow students, share your opinions).

The Gist:  Podcasts are a way to absorb information in an efficient, pragmatic manner and the Emergency Medicine world does them well.  While many medical schools record lectures and place them online, podcasts enable one to listen to lectures that are meaningful and relevant on an individual basis.  Choose your own lecturer, style, and classroom for a world-class education.  The quality and quantity of podcasts is continously growing, thus this entry will change accordingly (fellow students, share your opinions).

The Gist:  Podcasts are a way to absorb information in an efficient, pragmatic manner and the Emergency Medicine world does them well.  While many medical schools record lectures and place them online, podcasts enable one to listen to lectures that are meaningful and relevant on an individual basis.  Choose your own lecturer, style, and classroom for a world-class education.  The quality and quantity of podcasts is continously growing, thus this entry will change accordingly (fellow students, share your opinions).

The Gist:  Warning!  Emergency Medicine blogs are an addictive supplement to both basic science and clinical medical education.  Subscribe to some of the following blogs to learn some medicine, prepare for the boards, and stay well-read with minimal effort.  Start with Life in the Fast Lane (LITFL).

•  Note:  Below, one will inevitably notice many references to LITFL.  My enthusiasm for LITFL is driven solely by the impact their endeavors have made on my own medical education. 
• Don't trust my opinion?  Here's a video, hosted by Dr. David Marcus, from Society of Academic Emergency Medicine's 2012 Conference in which a present resident reviews some popular blogs.  Note: this is not specific to students.
• Better yet, fellow medical students (or newly matriculated residents)...send me your suggestions!
• This is an evolving process and the following shall be updated accordingly.
  

Aren't blogs nerdy?  Perhaps, but they're engaging, intriguing, and relevant.  Moreover, if you read via an RSS feed app on your phone, nobody will ever know.

• You will probably find yourself surpassing your peers in clinical knowledge and mitigate some of need to study from dry, cumbersome books that are antiquated even prior to purchase.  
• This information is not in FirstAid for the USMLE.  Trust me: you, your board score, your clerkship evaluation, and your patients' care/experience will be augmented by reading these blogs.  
• Also, EM blogs will help you maintain your enthusiasm about the profession when docs bash the profession as a bunch of mere "meat movers" and when you're on less preferred clerkships. 

Here's a codified medical student based approach...a fundamental framework to this crazy intellectual world, not an exhaustive list (which you can find at LITFL here).  However, I think students really interested in EM would benefit from subscribing to the following blogs.

• The list below may seem long; however, you'll likely soon find yourself hoping that Funtabulously Frivolous Friday Five by LITFL had an alliterative counterpart for the remaining weekdays.  Also, it really doesn't take much time to go through these as they roll in...just substitute Facebook/Words With Friends/Draw Something, etc with blog reading.
• Copious blogs exist to sate various appetites.  For example, I don't read many of the narrative style blogs but there are a plethora on the web.  
• Additionally, I'm not covering the blogs associated with particular podcasts here, see this post instead.  
• Many students have found the below list to be overwhelming and have asked for a starting point.  First, check out:  Life in the fast Lane,  Academic Life in Emergency Medicine, and  EM Lit of Note .  Before long, you'll be wanting more. 

Lazy/Austere Approach:

The Gist:  Warning!  Emergency Medicine blogs are an addictive supplement to both basic science and clinical medical education.  Subscribe to some of the following blogs to learn some medicine, prepare for the boards, and stay well-read with minimal effort.  Start with Life in the Fast Lane (LITFL).

•  Note:  Below, one will inevitably notice many references to LITFL.  My enthusiasm for LITFL is driven solely by the impact their endeavors have made on my own medical education. 
• Don't trust my opinion?  Here's a video, hosted by Dr. David Marcus, from Society of Academic Emergency Medicine's 2012 Conference in which a present resident reviews some popular blogs.  Note: this is not specific to students.
• Better yet, fellow medical students (or newly matriculated residents)...send me your suggestions!
• This is an evolving process and the following shall be updated accordingly.
  

Aren't blogs nerdy?  Perhaps, but they're engaging, intriguing, and relevant.  Moreover, if you read via an RSS feed app on your phone, nobody will ever know.

• You will probably find yourself surpassing your peers in clinical knowledge and mitigate some of need to study from dry, cumbersome books that are antiquated even prior to purchase.  
• This information is not in FirstAid for the USMLE.  Trust me: you, your board score, your clerkship evaluation, and your patients' care/experience will be augmented by reading these blogs.  
• Also, EM blogs will help you maintain your enthusiasm about the profession when docs bash the profession as a bunch of mere "meat movers" and when you're on less preferred clerkships. 

Here's a codified medical student based approach...a fundamental framework to this crazy intellectual world, not an exhaustive list (which you can find at LITFL here).  However, I think students really interested in EM would benefit from subscribing to the following blogs.

• The list below may seem long; however, you'll likely soon find yourself hoping that Funtabulously Frivolous Friday Five by LITFL had an alliterative counterpart for the remaining weekdays.  Also, it really doesn't take much time to go through these as they roll in...just substitute Facebook/Words With Friends/Draw Something, etc with blog reading.
• Copious blogs exist to sate various appetites.  For example, I don't read many of the narrative style blogs but there are a plethora on the web.  
• Additionally, I'm not covering the blogs associated with particular podcasts here, see this post instead.  
• Many students have found the below list to be overwhelming and have asked for a starting point.  First, check out:  Life in the fast Lane,  Academic Life in Emergency Medicine, and  EM Lit of Note .  Before long, you'll be wanting more. 

Lazy/Austere Approach:

The Gist:  Warning!  Emergency Medicine blogs are an addictive supplement to both basic science and clinical medical education.  Subscribe to some of the following blogs to learn some medicine, prepare for the boards, and stay well-read with minimal effort.  Start with Life in the Fast Lane (LITFL).

•  Note:  Below, one will inevitably notice many references to LITFL.  My enthusiasm for LITFL is driven solely by the impact their endeavors have made on my own medical education. 
• Don't trust my opinion?  Here's a video, hosted by Dr. David Marcus, from Society of Academic Emergency Medicine's 2012 Conference in which a present resident reviews some popular blogs.  Note: this is not specific to students.
• Better yet, fellow medical students (or newly matriculated residents)...send me your suggestions!
• This is an evolving process and the following shall be updated accordingly.
  

Aren't blogs nerdy?  Perhaps, but they're engaging, intriguing, and relevant.  Moreover, if you read via an RSS feed app on your phone, nobody will ever know.

• You will probably find yourself surpassing your peers in clinical knowledge and mitigate some of need to study from dry, cumbersome books that are antiquated even prior to purchase.  
• This information is not in FirstAid for the USMLE.  Trust me: you, your board score, your clerkship evaluation, and your patients' care/experience will be augmented by reading these blogs.  
• Also, EM blogs will help you maintain your enthusiasm about the profession when docs bash the profession as a bunch of mere "meat movers" and when you're on less preferred clerkships. 

Here's a codified medical student based approach...a fundamental framework to this crazy intellectual world, not an exhaustive list (which you can find at LITFL here).  However, I think students really interested in EM would benefit from subscribing to the following blogs.

• The list below may seem long; however, you'll likely soon find yourself hoping that Funtabulously Frivolous Friday Five by LITFL had an alliterative counterpart for the remaining weekdays.  Also, it really doesn't take much time to go through these as they roll in...just substitute Facebook/Words With Friends/Draw Something, etc with blog reading.
• Copious blogs exist to sate various appetites.  For example, I don't read many of the narrative style blogs but there are a plethora on the web.  
• Additionally, I'm not covering the blogs associated with particular podcasts here, see this post instead.  
• Many students have found the below list to be overwhelming and have asked for a starting point.  First, check out:  Life in the fast Lane,  Academic Life in Emergency Medicine, and  EM Lit of Note .  Before long, you'll be wanting more. 

Lazy/Austere Approach:

The Gist:  The airway is one of the fundamentals of emergency medicine.  It's imperative to be familiar with terminology and procedures associated with the airway.  Fortunately, there is a cornucopia of excellent information to make this easier for a beginner navigating endotracheal intubation and the airway in general. Below is a basic outline of the initial approach to learning endotracheal intubation, courtesy of the dedicated podcasters and bloggers.

Why is the airway important?  Without one, you don't have a patient.  Or, rather, you don't have an alive patient.  Furthermore, these procedures are fun, humbling, make an enormous difference on patient outcomes, and there's a unique exhilaration in the improvisation and collaboration that accompanies a difficult airway (like this one).  Also, with the amazing advent of fiberoptic laryngoscopy, many attendings encourage utilization of these devices for the novice intubater.  These devices are great, but I think that solid comfort with standard laryngoscopy is paramount.  Best bet?  Arrange to do an anesthesia rotation during clerkships!

I had an incredible experience on my anesthesia rotation and realized that part of the experience was derived from the didactics I inadvertently received by following various podcasts and blogs.  I was so impressed with the information put out there by Emergency Medicine physicians that I felt others could benefit from this information and intervene on their first airway with confidence, skill, and knowledge.  Sure, much of the basic endotracheal intubation skill revolves around the sheer number performed but the experience is much more pleasant, beneficial, and interesting with a basic understanding.

Do you want to own the airway?  Everything one needs is here, courtesy of the fine folks at Life in the Fast Lane, the ultimate source for Emergency Medicine education on the web.  By far, the most comprehensive "all in one" reference.

• Airways exist on a spectrum of difficulty and one may be fooled into a false sense of security in the initial assessment of the airway.  Expect an airway to be difficult unless proven otherwise.  Dr. Carroll does a great job emphasizing this point.

• Note, this podcast talks some about drugs used in Rapid Sequence Induction (RSI) and vaguely about rocuronium (a drug I prefer over succinylcholine), and this conversation, while part of the airway dialogue/process, shall be addressed separately..it would just be too cumbersome here.

EMCrit's Podcast 70 - Airway Management with Rich Levitan - This lecture is incredible.

The Gist:  The airway is one of the fundamentals of emergency medicine.  It's imperative to be familiar with terminology and procedures associated with the airway.  Fortunately, there is a cornucopia of excellent information to make this easier for a beginner navigating endotracheal intubation and the airway in general. Below is a basic outline of the initial approach to learning endotracheal intubation, courtesy of the dedicated podcasters and bloggers.

Why is the airway important?  Without one, you don't have a patient.  Or, rather, you don't have an alive patient.  Furthermore, these procedures are fun, humbling, make an enormous difference on patient outcomes, and there's a unique exhilaration in the improvisation and collaboration that accompanies a difficult airway (like this one).  Also, with the amazing advent of fiberoptic laryngoscopy, many attendings encourage utilization of these devices for the novice intubater.  These devices are great, but I think that solid comfort with standard laryngoscopy is paramount.  Best bet?  Arrange to do an anesthesia rotation during clerkships!

I had an incredible experience on my anesthesia rotation and realized that part of the experience was derived from the didactics I inadvertently received by following various podcasts and blogs.  I was so impressed with the information put out there by Emergency Medicine physicians that I felt others could benefit from this information and intervene on their first airway with confidence, skill, and knowledge.  Sure, much of the basic endotracheal intubation skill revolves around the sheer number performed but the experience is much more pleasant, beneficial, and interesting with a basic understanding.

Do you want to own the airway?  Everything one needs is here, courtesy of the fine folks at Life in the Fast Lane, the ultimate source for Emergency Medicine education on the web.  By far, the most comprehensive "all in one" reference.

• Airways exist on a spectrum of difficulty and one may be fooled into a false sense of security in the initial assessment of the airway.  Expect an airway to be difficult unless proven otherwise.  Dr. Carroll does a great job emphasizing this point.

• Note, this podcast talks some about drugs used in Rapid Sequence Induction (RSI) and vaguely about rocuronium (a drug I prefer over succinylcholine), and this conversation, while part of the airway dialogue/process, shall be addressed separately..it would just be too cumbersome here.

EMCrit's Podcast 70 - Airway Management with Rich Levitan - This lecture is incredible.

The Gist:  The airway is one of the fundamentals of emergency medicine.  It's imperative to be familiar with terminology and procedures associated with the airway.  Fortunately, there is a cornucopia of excellent information to make this easier for a beginner navigating endotracheal intubation and the airway in general. Below is a basic outline of the initial approach to learning endotracheal intubation, courtesy of the dedicated podcasters and bloggers.

Why is the airway important?  Without one, you don't have a patient.  Or, rather, you don't have an alive patient.  Furthermore, these procedures are fun, humbling, make an enormous difference on patient outcomes, and there's a unique exhilaration in the improvisation and collaboration that accompanies a difficult airway (like this one).  Also, with the amazing advent of fiberoptic laryngoscopy, many attendings encourage utilization of these devices for the novice intubater.  These devices are great, but I think that solid comfort with standard laryngoscopy is paramount.  Best bet?  Arrange to do an anesthesia rotation during clerkships!

I had an incredible experience on my anesthesia rotation and realized that part of the experience was derived from the didactics I inadvertently received by following various podcasts and blogs.  I was so impressed with the information put out there by Emergency Medicine physicians that I felt others could benefit from this information and intervene on their first airway with confidence, skill, and knowledge.  Sure, much of the basic endotracheal intubation skill revolves around the sheer number performed but the experience is much more pleasant, beneficial, and interesting with a basic understanding.

Do you want to own the airway?  Everything one needs is here, courtesy of the fine folks at Life in the Fast Lane, the ultimate source for Emergency Medicine education on the web.  By far, the most comprehensive "all in one" reference.

• Airways exist on a spectrum of difficulty and one may be fooled into a false sense of security in the initial assessment of the airway.  Expect an airway to be difficult unless proven otherwise.  Dr. Carroll does a great job emphasizing this point.

• Note, this podcast talks some about drugs used in Rapid Sequence Induction (RSI) and vaguely about rocuronium (a drug I prefer over succinylcholine), and this conversation, while part of the airway dialogue/process, shall be addressed separately..it would just be too cumbersome here.

EMCrit's Podcast 70 - Airway Management with Rich Levitan - This lecture is incredible.

The Gist:  Social media like Twitter can have great utility for medical students and learners and, in my opinion, encourages active learning. One has the option to listen or join in to conversations happening around the globe.

First, check this out

I revel in existing as an efficiency machine.  This serves as my way of cultivating a professional/medical/student life while allowing time to maintain my personal life and interests.  I listen to podcasts and lectures on double-speed as I pound away at the gym, commute around town, clean, and experiment in various culinary endeavors.  Similarly, I follow blogs by checking Google Reader as I sip my morning coffee, serenaded by the voices of my childhood on NPR's Morning Edition, and on the Feeddler app on my iPhone whenever I'm waiting on something. And then?  Then, I discovered Twitter.

I didn't intend to join Twitter.  In fact, I scoffed a few weeks ago when a friend predicted that I would soon have a Twitter account and manage to "ruin" this popular culture haven with medical tweets.  He was right; however, I discovered I was in good company in the Emergency Medicine world.

It's a stream of continuous goodness!  Presently, it seems like I'm sitting in the audience at the Society for Academic Emergency Medicine (SAEM) conference whilst seeing 35 patients a day in a rural Alabama family medicine clinic.  Attendees link presentations and pictures while disseminating core messages from lectures.  Additionally, I'm getting an inside view of medical education.  The experience almost feels like cheating as I'm learning more about the residency and medical student education process.  In fact, I've learned a great deal about my own learning style while following these conversations

Recommendations garnered from SAEM 2012 tweets:

• Twitter Accounts:
• Some recommend two twitter IDs  versus one that is also professional
• Don't Violate HIPPA - when in doubt, don't post something.
• Don't complain/be negative
• Comply with school/site guidelines
• Everything is public, be on good behavior

The Gist:  Social media like Twitter can have great utility for medical students and learners and, in my opinion, encourages active learning. One has the option to listen or join in to conversations happening around the globe.

First, check this out

I revel in existing as an efficiency machine.  This serves as my way of cultivating a professional/medical/student life while allowing time to maintain my personal life and interests.  I listen to podcasts and lectures on double-speed as I pound away at the gym, commute around town, clean, and experiment in various culinary endeavors.  Similarly, I follow blogs by checking Google Reader as I sip my morning coffee, serenaded by the voices of my childhood on NPR's Morning Edition, and on the Feeddler app on my iPhone whenever I'm waiting on something. And then?  Then, I discovered Twitter.

I didn't intend to join Twitter.  In fact, I scoffed a few weeks ago when a friend predicted that I would soon have a Twitter account and manage to "ruin" this popular culture haven with medical tweets.  He was right; however, I discovered I was in good company in the Emergency Medicine world.

It's a stream of continuous goodness!  Presently, it seems like I'm sitting in the audience at the Society for Academic Emergency Medicine (SAEM) conference whilst seeing 35 patients a day in a rural Alabama family medicine clinic.  Attendees link presentations and pictures while disseminating core messages from lectures.  Additionally, I'm getting an inside view of medical education.  The experience almost feels like cheating as I'm learning more about the residency and medical student education process.  In fact, I've learned a great deal about my own learning style while following these conversations

Recommendations garnered from SAEM 2012 tweets:

• Twitter Accounts:
• Some recommend two twitter IDs  versus one that is also professional
• Don't Violate HIPPA - when in doubt, don't post something.
• Don't complain/be negative
• Comply with school/site guidelines
• Everything is public, be on good behavior

The Gist:  Social media like Twitter can have great utility for medical students and learners and, in my opinion, encourages active learning. One has the option to listen or join in to conversations happening around the globe.

First, check this out

I revel in existing as an efficiency machine.  This serves as my way of cultivating a professional/medical/student life while allowing time to maintain my personal life and interests.  I listen to podcasts and lectures on double-speed as I pound away at the gym, commute around town, clean, and experiment in various culinary endeavors.  Similarly, I follow blogs by checking Google Reader as I sip my morning coffee, serenaded by the voices of my childhood on NPR's Morning Edition, and on the Feeddler app on my iPhone whenever I'm waiting on something. And then?  Then, I discovered Twitter.

I didn't intend to join Twitter.  In fact, I scoffed a few weeks ago when a friend predicted that I would soon have a Twitter account and manage to "ruin" this popular culture haven with medical tweets.  He was right; however, I discovered I was in good company in the Emergency Medicine world.

It's a stream of continuous goodness!  Presently, it seems like I'm sitting in the audience at the Society for Academic Emergency Medicine (SAEM) conference whilst seeing 35 patients a day in a rural Alabama family medicine clinic.  Attendees link presentations and pictures while disseminating core messages from lectures.  Additionally, I'm getting an inside view of medical education.  The experience almost feels like cheating as I'm learning more about the residency and medical student education process.  In fact, I've learned a great deal about my own learning style while following these conversations

Recommendations garnered from SAEM 2012 tweets:

• Twitter Accounts:
• Some recommend two twitter IDs  versus one that is also professional
• Don't Violate HIPPA - when in doubt, don't.
• Don't complain/be negative
• Comply with school/site guidelines
• Everything is public, be on good behavior

The Gist:  Dabigatran, while more convenient than standard warfarin therapy in non-valvular atrial fibrillation, may have more complications than originally touted, including an increased incidence of myocardial infarction (MI).  Exercise caution in patients with dabigatran (for multiple reasons).

I'm wary of dabigatran.  There's no good test to determine the degree of anticoagulation, although apparently the response is "predictable," and there's presently no available reversal agent for this drug.  Unfortunately, many patients take their medications in unpredictable fashion (or are predictably non-compliant, which we can sometimes deduce in warfarin patients upon seeing a sub-therapeutic INR).  Bleeding complications from this direct thrombin inhibitor are surfacing with unnerving frequency and severity... However, the plot thickens...

Earlier this year, the Archives of Internal Medicine published a  a meta-analysis of the dabigatran non-inferiority trials.  Out of seven trials with a pooled n=30514 individuals, dabigatran was associated with a greater risk of MI with an odds ratio (OR) of 1.33 (95% CI 1.03-1.71).  The paper assessed these rates when shorter studies were included or excluded in the analysis.
The original RE-LY trial demonstrated 34% reduction in incidence of stroke and PE in patients on dabigatran compared with warfarin.  Increased risk of MI in the cohort receiving dabigatran? A whopping 38% compared with warfarin.  The statistical significance of the increase MI incidence disappeared in the revised data (1).

What explanation underlies this increase in MI?  I'm not really sure, but here are some possibilities:

• Concomitant aspirin use.  Not tracked by most of the studies (neither was CAD)
• Protective benefit with MI
• On dabigitran there's increased excretion of 11-dehydrothromboxane B2, a metabolite of thromboxane A2, possibly demonstrating increased platelet activation/aggregation (which would be offset by the aspirin inhibition of TXA2 in patients taking both medications) (2).  This would explain the point mentioned above.
• Some protective effect conferred by warfarin

The convenience of dabigatran, proffered by the lack of dietary restriction and freedom from anticoagulation clinics, may entice patients but we should still exercise caution utilizing this drug.  Patients are excited to switch to this medication (excluding the financial burden) without necessarily understanding the uncertainty associated with trauma, bleeding, and ACS risk.  It's difficult for providers to undertake these risk versus benefit conversations without elucidation of the actual adverse effects of the drug.

Bottom Line:  You can bet I'm going to keep close tabs on patients I see on dabigatran.

References:
1.  Uchino K, Hernandez AV. Dabigatran Association With Higher Risk of Acute Coronary Events: Meta-analysis of Noninferiority Randomized Controlled Trials. Arch Intern Med. 2012 Jan 9.

The Gist:  Reducing one's consumption of red meat is associated with a reduction in mortality, even when adjusted for BMI, alcohol consumption, smoking, and other co-morbid conditions.  Cut back on the red meat (and hot dogs) and substitute with fish, legumes, or nuts.  It's intuitive, repeatedly studied, and delicious!
My Family Medicine attending for April and May nicknamed me "Tofu."  Apparently, one should not bring tofu for lunch on the first day of rotations at a primary care clinic in the very rural South, even if it's cooked in a delicious dijon-rosemary sauce.  Each day my lunch seems to fascinate the office staff and nurses as discussion begins regarding these seemingly bizarre legumes ("what is a lentil?"), fresh vegetables, and spices such as coriander and cumin.
I recently came across a prospective observational study in April's Archives of Internal Medicine, however, that allows me to justify my odd food preferences to the crew that lives on fried pork chops and hamburger steak.  Yet another morsel of evidence that vegetable based food is good for us and has an impact on outcomes people tend to care about - such as death.

• Hazard Ratio (HR) (95% CIs) for cardiovascular disease mortality was 1.16 (1.12-1.20) for total red meat and 1.21 (1.13-1.31) for processed red meat
• HR (95% CIs) for cancer mortality were 1.10 (1.07-1.13) for total red meat
• Bacon and hot dogs tended to be associated with a higher risk than other items
• The authors performed a substitution analysis (the analysis of which is beyond my present ability/desire) that demonstrated reductions in mortality (10-14%) associated with small substitutions of  fish, poultry, legumes, or nuts in place of a serving of red meat...Amazing! 

A few super quick, tasty, easy vegetarian recipes that are amongst my staples:
References:
Pan A, Sun Q, Berstein A, et al.  Red Meat Consumption and Mortality.  Arch Intern Med. 2012;172(7):555-563. doi:10.1001/archinternmed.2011.2287  

The Gist:  An easy way to gauge the seriousness of a patient's illness - determine the patient's texting (or engagement in Facebook, Angry Birds, or Draw Something).  The cell phone sign - the triage equivalent of the "Hamburger Sign" in appendicitis?

I suggest that medical students beginning their clerkships read a short, humorous piece in this month's Annals of Emergency Medicine entitled "It's This Texting Thing."  The author codifies the observations we make regarding a patient's interactiveness into an easy rubric, scaled from 1-5, to assess the severity of an emergency department (ED) patient's ailment based on the patient's texting.  For example, a patient who texts during the examination without looking up is awarded a 1 whereas a patient who is not texting at all gets a 5 (and very likely a body bag as the patient is probably actively exsanguinating or pulseless).  A patient with a score of 3 is probably suffering a ailment of the following severity:  cerebrovascular accident, diverticulitis, or perhaps a fracture.  Sure, the article was probably partially written out of the frustration of extracting a history out of a patient glued to their device of choice and is placed in the journal for entertainment value .  Funny.  Simple.  And, in my experience, fairly accurate.

Anecdotally, I can corroborate this rubric's predictive value, although I came to this conclusion in a more roundabout fashion.  As a zealous medical student, I spent an "off day" during my first month of third year clerkships in the ED.  I entered a patient's room in the ED and began with my routine introduction and history taking.  The patient's "worst headache of her life" brought her to the ED.  I took a stellar history and completed a thorough physical exam, although it was rather difficult at times, as she was engrossed in her Droid, playing Angry Birds or updating her Facebook status.  I eagerly went to present to my attending.  Before I began, my attending asked the crucial questions in the ED, "Well, is she sick or not sick?  Is she staying or going home?"  My attending then shared with me one of the keys to patient assessment in the ED.  "Generally," she said, "you can figure that out within the first 30 seconds you see the patient."  So true.

In the hundreds of patient encounters since that time, I've slowly developed skills in rapidly ascertaining a patient's overall status.  Hopefully this will eventually translate into the sought-after clinical "gestalt."  Generally, one only needs marginal common sense and observational skills - how eager they are for a sandwich, whether they are watching tv or fiddling with a phone, or the difference in pain perception when one is overtly palpating versus palpating through a stethoscope.  Conversely, the absence of these types of behaviors in "tough guy" (or gal) patients have acted as clues that these patients were sicker than they let on.  Regardless, observation of patient's non-verbal cues is an important part of patient assessment (and can be both frustrating and supremely entertaining).

References:
Svesko V.  It's This Texting Thing.  Annals of Emergency Medicine Volume 59, Issue 5 , Pages 438-439, May 2012