Tactical Medicine News Blog

Medicolegal woes often can be tracked back to poor documentation by the physician. This article is a retrospective chart review of 384 EM resident charts, focusing on the documentation of the neurologic exam. Charts were selected if their chief complaints were neurologic or psychiatric in nature. A non-validated measurement tool for evaluating a neurologic exam was created based on discussions with attending emergency physicians. I have to agree with the chosen criteria. Documentation in each of the following criterion receives 1 point for a maximum score of 8.

In patients requiring central venous access, which vein do you prefer? In descending order, I prefer subclavians, internal jugulars (IJ), and then femorals. There is increasing evidence that subclavian central venous lines are superior to femoral lines (JAMA 2001) with respect to iatrogenic infection and thrombosis rates. In 9% of subclavian lines, however, the line tip ends up in the ipsilateral IJ, instead of the superior vena cava (SVC) – see chest xray below. These lines are unusable in the long term because of the risk of cathether thrombosis in this low-flow area. The line must must be rewired.

Ernest Wang, MD Clinical Assistant Professor, NorthShore University HealthSystem Academic Director, Center for Simulation Technology & Academic Research (CSTAR)Associate Program Director, University of Chicago EM Residency

Patient care versus education This is the tug-of-war struggle that residency programs constantly grapple with. Residents work in an apprenticeship model where they are both patient providers and learners. Both are critical in residency training, but they sometimes negatively impact each other. For instance, EM residents hand-off their patients to covering residents while attending their weekly conference classes. In contrast, residents may skip that day’s board teaching rounds to manage an acutely decompensating patient.

Placing an IV in the external jugular vein requires venous distension maneuvers. This means having the patient perform a Valsalva maneuver or be placed in a Trendelenburg position. Have you ever had a patient who didn’t quite get the Valsalva maneuver concept, or couldn’t tolerate a head-down position?