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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, November 13, 2017

The Crashing Patient Conference: A Must Go!

As I was putting together my slides for the ACEP 2017 Conference, I saw a tweet pop up. It was by Dr. Amal Mattu (@amalmattu) advertising about The Crashing PatientConference in Baltimore in October 2017. It was the very same month I was going to Washington DC for my one month of clinical rotation at George Washington University Hospital. I was super-excited! It became a top priority to register myself for the conference. I was dreaming of meeting my Emergency Medicine gurus in person and this was an excellent opportunity, which I could hardly lose.

The Crashing Patient Conference is an annual one da conference which has many short lectures with ‘to the point’ pearls. This year’s theme was resuscitation and risk management. There were different lectures encompassing critical care, resuscitation, shock, cardiology, endocrine emergencies, orthopaedics, paediatrics, urology, burns and most importantly medico-legal.

I will summarize the pearls here from each session. Dr. Mike Winters reviewed critical care quickies with an interesting case that he had encountered.
1)     Before intubating the patient,  preoxygenate with 40-60L/min by NRBM
2)     RSI drugs: remember TBW for etomidate and IBW for ketamine (Obese patients were found to be dosed inappropriately)
3)     ED ventilator settings matter, especially if there is increased length of stay in ED!
4)     Deep sedation is known to increase mortality. Target lighter level of sedation. Opioids (Fentanyl) are first line!

Dr. Khoujah talked about delirium, which is misdiagnosed most of the time.
1)     In patients with suspected delirium, pay attention to “attention”.
2)     Use modified Richmond Agitation and Sedation Scale to screen delirium.
3)     Delirium = predisposing condition + precipitating insult; treat the underlying cause
4)     Change the environment ie allow relatives to be besides the patient, put a date time and location on wall facing the patient, try to minimize physical restraints.
5)     Most importantly, prevent delirium before you have to treat it!

Dr. Manning discussed on ventilator settings in severe asthmatics.
1)     Stick to the basic asthma medications
2)     Maintain permissive hypercapnia by balancing acidosis and auto-PEEP
3)     Indication for intubation: cardiac arrest, exhaustion, agitation, silent chest and severe hypoxia
4)     Lower the respiratory rate, allow patient time to breathe. Reduce I:E ratio to 1:4.
5)     Increase tidal volume to 8-10ml/kg, lower the PEEP and increase the flow rate 80L/min and gradually taper FiO2.
6)     Trouble shooting : a)Post-intubation hypotension- disconnect from vent, let them exhale then check for pneumo. b) Post-intubation hypoxia- do the above and check the tube c) post-intubation arrest- ACLS, go easy on bagging, needle the chest
7)     When in doubt, disconnect and let the air out!

Dr. Bontempo discussed about deep neck space infection and things to remember.
1)     The most common etiology of deep neck space infection is odontogenic; specifically infections of lower 2nd and 3rd molars.
2)     One should be worried if voice change, shortness of breath, neck pain, DM, CRP >100
3)     Anticipate a difficult airway, start broad spectrum abx, drain the pus out.

Dr. Dubbs discussed about the law suits faced due to missed diagnosis of cancer in ED. She suggested:
1)     Always have a high index of suspicion- prolonged symptoms, weight loss, B symptoms, voice change, stool change, anorectal lesions, post-menopausal bleeding
2)     Watch out for the fine printed reports- incidental findings, abnormal cell counts, etc.
3)     Discuss with the patient
4)     Document your discussion and have a great QA process

Dr. Bond (@Docbond007) talked about spinal epidural abscess and posterior shoulder dislocation.
1)     The incidence of epidural abscess has increased in past 2 decades, keep a high suspicion for patients presenting with spine pain.
2)     In patients with spine pain without any neuro deficit, but with fever, risk factors, then check CRP/ESR; if elevated get an MRI spine.
3)     Get X-ray axillary view in suspected posterior shoulder dislocation. Ensure humeral head is in glenoid cavity.

Dr. Lu discussed the complications of myocarditis. It can be deadly in kids. Hence
1)     Always be wary of subtle signs
2)     Consider myocarditis if dyspnoea, chest discomfort and antecedent viral illness.
3)     Consider myocarditis if persistent unexplained tachycardia.

In the section on ‘Salt, sugar and sex’, Dr. Willis summarized that
1)     Persistently hypoglycemic- think adrenal insufficiency
2)     Hypoglycemia +hypotension – Adrenal insufficiency until proven otherwise
3)     If there is any suspicion give empiric steroids. (Hydrocortisone 100mg iv, Dexamethasone 5mg iv, fludrocortisone 0.1mg iv

During the conference, Dr. Mattu kept the audience engaged by his fun quiz. He was kind to gift me the signed copy of the second edition of ‘Avoiding common errors in Emergency Department’ which I will treasure the most.

Although it was a long day, but due to short engaging presentations in a TEDx like format, it was very fun filled, motivational and interesting conference. A definite must go!

Summary prepared by:

Nikhil N. Tambe - @nikhil16mar

Emergency Medicine Resident 
Masters in Emergency Medicine (GWU)
Kokilaben Dhirubhai Ambani Hospital, Mumbai
Instructor (American Heart Association)
Lifesupporters Institute of Health Sciences, Mumbai

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