This post has been written by Jefferson Hayre, Med II student at Dalhousie Medicine New Brunswick. During his elective in the Emergency Department at the Saint John Regional Hospital, Jefferson experienced the wide variety of clinical emergency medicine. He was encouraged to log his learning experience, read around the various clinical presentations  and to reflect on the issues that he was exposed to. This piece of work is extremely well written, researched and insightful, it should serve as a great model for any future elective medical students who write an reflective learning log.

Dr David Lewis

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Emergency Medicine Elective – Learning Log

Jefferson Hayre, Med II

Dalhousie Medicine New Brunswick

 

The beauty of doing an elective in the Emergency Department is the broad range of topics a student can see in just a few shifts. This log is a record of a few topics that I saw multiple times during my elective, and is a reflection on some of the things I learned, both in terms of medicine and about myself, while encountering these patients and having these experiences.

 

1. Examination of the ear in suspected Otitis Media

It became clear to me on my first night working in RAZ that many children present to the Emergency Department with complaints of general unwellness and ear pain. With these children, came the need of performing effective otoscopy in children. The first step, and perhaps the most important, is proper position of the patient and yourself. Getting the parent involved is a must. Position the patient sitting on the parent’s lap and then have the child place their head against the chest of the parent with one ear pointing out. Have the parent use one arm to hold the child’s head against their chest and use their other arm to hold the child’s body and arms in. This provides you with easy access to the ear, and prevents the child from moving or pulling at the otoscope with their hands. I found it equally as important to ensure that I was comfortably positioned, so that I could steadily hold the otoscope and perform the examination. Using the largest tip that comfortably fits in the ear maximizes the visual field and makes examination of the ear easier. It then becomes a matter of knowing what to look for. The tympanic membrane should be evaluated for colour, position, mobility, and translucency. The triad of bulging tympanic membrane, impaired mobility, and redness or cloudiness have been shown to be strong indicators of acute otitis media.

In reading up on acute otitis media I was lucky enough to come across a program from the Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Centre called ePROM or Enhancing Proficiency in Otitis Media. Here they have a number of online courses for clinicians, but they also have a few free modules. I completed a few of these to help me with my proficiency in otoscopy. The first module I did allows you to work through 25 short videos of the tympanic membrane and select a diagnosis. This module then gives you immediate feedback on what you should have seen and what the correct diagnosis is. The second module was a game that gives you five seconds to look at a tympanic membrane and make a diagnosis of acute otitis media, otitis media with effusion, or no effusion.

 

Module: http://pedsed.pitt.edu/34_viewPage.asp?pageID=1880440666

Game: http://pedsed.pitt.edu/34_viewPage.asp?pageID=1445510805

 

Once the diagnosis of acute otitis media is made treatment should begin. The first line of treatment includes analgesics such as oral ibuprofen or acetaminophen. It not recommended to use decongestants or antihistamine in children with acute otitis media as they do not improve healing or reduce symptoms. The next big decision is in regards to a watchful waiting approach of a prescription for antibiotics. It is recommended that antibiotics be given for children under 2 years old and children 2 years or greater who have had otaglia for more than 48 hours, have had a temperature greater than 39°C in the past 48 hours, have bilateral acute otitis media, or have otorrhea. If the child is two or greater and do not have any of the above symptoms, a watchful waiting approach can be used. While the use of antibiotics is associated with a quicker reduction in symptoms, there is an associated increased in adverse events from the antibiotics such as rash, diarrhoea or vomiting. This is an important discussion for the clinician to have with the parent.

 

2. Psychiatric interview in the emergency department

The Emergency Department presented me with my first opportunity to take a history from a patient with an acute psychiatric presentation. This was perhaps one of the more intimidating things I did during my elective, but was a great learning experience. Patients presenting with psychiatric problems are often assessed in RAZ. The first thing I noticed about my experience with these patients is that it takes a lot longer to get a history than other patients. Often these patients have long complicated histories, both psychiatric and other medical conditions. Additionally, the importance of a detailed social history in this population is critical. The other challenge that faced me in this situation was taking notes. I brought in additional paper to record my notes and then once I finished with the patient I left and synthesized the notes and then wrote them in the chart. This worked well for me, as the psychiatric interview is hard to keep on track and organized as the conversation can change frequently. By synthesizing after, it allowed me to organize the note and include the most pertinent details.

The other large difference in interviewing psychiatric patients is performing the mental status examination. The mental status exam allows the examiner to have a uniform approach to the interview and categorize their findings. It also allows other healthcare professionals to quickly review the patient. The mental status exam has five components, which I will quickly review below:

Appearance and Behaviour

You need to determine the patient’s level of consciousness. Is the patient awake and alert? Do they respond to your questions appropriately and in reasonable time? It is important to examine posture and motor behaviour. How is the patient positioned? How are they moving? Are they moving with voluntary control? Do their movements change with certain topics or people? The patient’s dress, grooming, and hygiene should be evaluated. Are they dressed appropriately? Are the clothes clean and properly worn? Are the patient’s hair, teeth, skin and nails well kept? Next, examine the patient’s facial expressions both at rest and during conversation. Does it change with topics or people? Does it change at all, or stay immobile throughout the interview? Finally, you must evaluate the affect of the patient, the external expression of the patient’s inner emotional state. Does the affect vary appropriately with the conversation, or does it become extreme or inappropriate? Or is it labile, blunted, or flat?

Speech and Language

You must evaluate the quantity, rate, volume, and articulation of the speech. Do they talk a lot or very little, loudly or softly, quickly or slowly? Do they articulate their words? You must access the fluency of the speech. Do they speak with a normal flow and normal inflections? Or do they pause often or are they monotone when they speak?

Mood

The patient’s own understanding of their emotions is assessed. It can be evaluated by asking how their overall mood is? Determine what their mood is at the current moment, and how it has been recently? Establish a time frame for their mood. Has it been labile or unchanging? This is an appropriate place to discuss suicidal ideation. Start with broad questions and focus in. Questions like, “Do you get discouraged or feel blue?” “What do you see for yourself in the future?” “Do you ever feel like life isn’t worth living?” “Have you ever thought about doing away with yourself?” “How do you think you would do it?” can help elucidate suicidal ideation.

Thought and Perceptions

First assess the thought process. Are thoughts logical, relevant, organized, and coherent? Do they speak circumstantially and with unnecessary detail? Do they have derailment or flight of ideas? Evaluate the content of the speech. Do they have any compulsions or obsessions, phobias or anxiety, or feelings of unreality or depersonalization? Do they have delusions? Evaluate the patient’s perceptions. Do they have illusions or hallucinations? The patient must also be evaluated for their insight and judgement. Do they know why they are at the hospital? Do they know that their mood, thought, or perception is abnormal and part of an illness? Do they have good judgement? Evaluate how they answer questions about their job, family situation, money, or interpersonal conflict. Questions like, “How do you plan on getting help after leaving the hospital?” can be useful in evaluating judgment.

Cognitive Function

Cognitive assessment includes looking at things such as their orientation to place, time, and person, their attention span, their memories, their ability to learn new things, and more. Specficic tests exist to evaluate this such as the Mini-Mental State Exam (MMSE) or the Montreal Cognitive Assessment (MOCA).

The psychiatric history and mental status exam have many components to them. This opportunity to practice them was a great chance for me to further solidify the important components of the exam, and also allowed me to become more comfortable interviewing psychiatric patients.

 

3. Interviewing the Elderly

It is certainly not uncommon to see many elderly patients in the emergency department. This presents a challenge to the clinician as elderly patients often have complicated past medical histories and current medical problems, and are often on many medications. These interactions often take more time, due to their complexity.

There are certain additional components of the interview that must be included when evaluating elderly patients. In addition to the medical conditions the patient is facing, it is extremely important to understand how these are affecting the patient’s function. Elderly patients should always have their activities of daily living (ADLs) and their instrumental activities of daily living (IADLs) assessed. These include bathing, dressing, toileting, eating, transferring, and feeding for the ADLs and cooking, shopping, banking, housekeeping, laundry, transportation, taking their medications, and using the telephone for the IADLs. It is also important to see what supports they have in place. Do they have family who lives near by or a neighbour who checks in on them? Do they have social supports and people to talk to?

When interviewing the older patient, the clinician needs to remember that elderly patients often underreport their symptoms and overestimate their health. The clinician should always be aware of the potential for cognitive impairment in this population. It is always advantageous to obtain a collateral history in when working with elderly patients as this can help combat these issues.

 

4. Interprofessionalism and Teamwork in the Emergency Department

During this elective I was presented with the opportunity to work with some of the department’s nurses for a shift. I worked with one nurse in triage for two hours and then a few nurses in Acute for two hours. This really helped me to understand the flow of the emergency department a lot more than just working with the physician.

While working in triage I got to participate in the evaluation of patients when they first arrive in the department. I learned about the Canadian Triage and Acuity Scale and what each category means and how the nurse assesses the patient. This gave me a greater understanding of what happens when a patient walks in to the department, how long they take to see the triage nurse, and what they do after seeing the nurse.

Working with the nurse in the department allowed me to complete the patient’s journey through the department. I saw the nurses initial visit in with a patient, how they draw blood and set up IVs and how they send the blood to the lab. I gained appreciation for their comprehensive charting of medications they give to the patient and other documentation they perform.

During my shifts in the emergency department I also interacted with paramedics, respiratory therapist, X-ray technicians, EKG technicians, pharmacists, and porters. I think the greatest display of interprofessionalism and teamwork was during a cardiac arrest. You could tell that through both their individual training and training together each profession knew exactly what their role was in the situation and how to effectively communicate what they are doing and what they need from each other.

One of my favourite parts of the Emergency Department is this teamwork, both interprofessionally and intraprofessionally. I saw doctors and nurses collaborate and work together for the benefit of the patients as well as doctors consult each other on tough cases and help each other out when needed. They would bounce ideas of each other, provide a sounding board, or when things got frustrating or annoying they could discuss this together.

 

5. Ankle Sprains

In my time in the Emergency Department we saw a number of patients with ankle injuries. I enjoyed seeing these patients as we had recently completed the MSK component of our clinical skills course. In this course we learned how to perform an appropriate history and physical exam. Just from the history of the patient I was able to formulate in my head what I expected to find on physical exam. Knowing the mechanism of injury allowed me to determine if the sprain was lateral, medial, or syndesmotic. The patients I saw all described sprains that inverted the foot, therefore causing a lateral ankle sprain. By determining if they were able to walk after the injury allowed me to classify the ankle sprain’s severity. On physical exam I was able to apply the Ottawa ankle rules to help rule out a break. I palpated the posterior 6 cm of the lateral and medial malleolus, the base of the fifth metacarpal and the navicular bone, looking for tenderness. From these exams we ruled out the need for an X-ray. The patients were told to rest and apply cold to the ankle as well as to take NSAIDs for the pain.

 

6. Breaking Bad News and Dealing with Death

This elective in Emergency Medicine was my first true exposure to breaking bad news and I can clearly remember the two occasions on which bad news was delivered. These experiences were not just situation in which I learned how to deliver bad news, but also situations in which I learned about by own reaction to bad news.

One of the cases I was involved with was a patient who came into the department with cardiac arrest and resuscitation was not possible. This was my very first experience with a patient dying. My own reaction to this surprised me. In the moment it never occurred to me that I was doing compressions on a man who was about to die, and even after resuscitation efforts were withdrawn I didn’t really grasp that this patient had died. However, when we went to tell the wife of this patient, that was when it all became very real for me and it started to sink in. After talking to the wife for a few minutes we resumed our day. I remember finding it hard to move on to the next patient and over the next few days found myself thinking about this patient, his wife and family, and how they must be doing right now. I found comfort in talking to my classmates about my experience, as we reflected on how death is a very real part of medicine, and how we are fairly sheltered from it now in Med II, but that it will become a very real part of our future careers. I think it is extremely important for you’re the clinician’s own wellbeing to develop relationships with fellow professional in which you can discuss these incidences and the emotions they evoke. I think it is important to vocalize what you feel, share it with others, and not keep it bottled up inside. I am glad that I shared my feelings with my classmates as it helped me deal with situation.

The second experience I had with breaking bad news involved a patient in his 60s who came into the department with new onset seizures. Through history taking, the physical exam, and subsequent tests we learned that this patient had metastatic melanoma that had spread to his brain. I was with one of the residents, who delivered the news to the family and the patient. She followed McMaster’s six point SPIKES protocol for delivering bad news.

S – Setting

P – Perception

I – Information

K – Knowledge

E – Empathy

S – Summary

The resident prepared the setting by gathering all of the family in the room, ensuring they all knew who she was and positioned herself so they could all see her. She then talked about what they already knew and what they suspect might be happening. In this she also assessed how much the patient and their family wanted to know. She then, in simple language, broke the news that the tumour spread to the brain. She then gave the family time to accept the news and understand it. She did not provide any other information right away, but rather took a few minutes to allow the patient and the family react and for the news to sink in. During this time she provided the family with empathy, offering physical contact and tissues for their tears. She waited for the family to speak and ask the first question. She gave them an appropriate amount of information at the time, explaining that they have provided the patient with medications to prevent future seizures and that they will back to discuss some of the options in time. She gave them an opportunity to ask a few questions and then left them to be together. I was very impressed with how the resident did this and her implementation of the SPIKE criteria.

 

7. Ultrasound examination of the Aorta

Ultrasound provides a quick and effective screening of the abdominal aorta to rule out an Abdominal Aortic Aneurysm (AAA). Pathology of the abdominal aorta can have catastrophic effects. When an AAA ruptures there is a mortality of approximately 90%. If a patient presents with abdominal discomfort, risk factors, and physical findings such as hypotension, back pain, or a pulsatile abdominal mass, aortic pathology should be ruled out. Point of Care Ultrasound has proven to be a cost effective and quick imaging technique that spares the patient from radiation or contrast exposure. Point of care ultrasound has a sensitivity of 97.5-100% and specificity of 94.1-100% for detection of an abdominal aortic aneurysm.

Ultrasound of the abdominal aorta is performed with a low frequency curvilinear transducer and is performed trans-abdominally. Begin with a transverse view of the aorta by placing the transducer just inferior to the xiphoid process, with the transducer mark to the patient’s right side. The celiac artery, superior mesenteric artery, renal arteries, and vertebral bodies can all be used as reference points (Figure 1).

 

 

Figure 1 – A, Transducer position for transverse (short-axis) views of the proximal abdominal aorta. B, Celiac artery is seen branching into the common hepatic artery (HA) and splenic artery (SPL). C, Superior mesenteric artery (SMA) is seen along with the left and right renal arteries, splenic vein, aorta (Ao), and inferior vena cava (IVC). Note the position of the vertebral body posterior to the aorta.

Once a transverse view is obtained slide the transducer inferiorly down the abdomen while maintaining visualization of the aorta. Just superior to the umbilicus you will visualize the aorta divide into the left and right common iliac arteries (Figure 2).

Figure 2 – A, Transducer position for transverse views of the distal abdominal aorta. B, Distal aorta in a transverse plane showing division into the right and left common iliac arteries.

After visualization and assessment of the aorta in the transverse view a longitudinal view should be obtained. Again, begin just inferior to the xiphoid process and rotate the transducer 90 degress so that the marker is facing the head of the patient. Once again find the aorta and you may be able to visualize the celiac and superior mesenteric artery (Figure 3).

Figure 3 – A, Transducer position for longitudinal views of the proximal abdominal aorta. B, Proximal aorta is seen in a longitudinal plane branching into the celiac artery and superior mesenteric artery (SMA). The splenic vein is seen in cross section as is crosses over the SMA.

The diameter of the aorta should be measured. It is important to ensure that the transducer is positioned perpendicular to the aorta and not oblique to ensure an accurate measurement. This measurement is important for interpretation of the exam.

The definition of an arterial aneurysm is when the diameter is 50% greater than expected so in the case of the abdominal aorta, an aneurysm is defined as the aorta having a diameter greater than 3.0 cm.

 

References:

 

Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. Philadelphia PA: Wolters Kluwer Health | Lippincott Williams & Wilkens. 2013

 

Garg A, Buckman R, Kason Y. Teaching medical students to break bad news. Can Med Assoc J 1997;156:1159-64

 

Klein JO, Pelton S. Acute otitis media in children: Treatment. In: UpToDate, Edwards MS (Ed), UpToDate, Waltham, MA. (Accessed on May 1, 2015.)

 

Maughan KL. Ankle sprain. In: UpToDate, Eiff P (Ed), UpToDate, Waltham, MA. (Accessed on May 1, 2015.)

 

Tainter CR. Abdominal Aorta. In: Point of Care Ultrasound. Soni MD, Arntfield R, Kory P. Philadelphia PA: Elsevier. 2015

 

Wald ER. Acute otitis media in children: Diagnosis. In: UpToDate, Edwards MS, Isaacson GC (Ed), UpToDate, Waltham, MA. (Accessed on May 1, 2015.)