Round 1 (Altered Mental Status)

Hello, residents. My name is Zach Olson. I'm joined today by Mike Estefan and thank you for downloading this week's episode of the E-M clerkship podcast. This is E-M clerkships secret residency curriculum advanced content designed to test graduates of E-M clerkship. And today is round number one of the game. Here are the rules and feel free to play along with us. Mike will need to perform today's case in real A-Bem oral boards format. He has 15 minutes to complete the full history, exam, testing, treatments, consults, counseling, final disposition, everything, or I'm gonna cut him off. He does not know what this case is ahead of time. I'm gonna go ahead and text him EKG images and X-ray images during the recording and I'm gonna ask him to interpret those for you. These images will be posted online on both E-M clerkship.com and the E-M clerkship Facebook group with necessary licenses unless it's a public domain. Any advanced imaging he requests as well as lab results will be read out loud by me. If Mike hits all of the critical actions that I have listed out beforehand, he wins. And if he doesn't or if he performs a dangerous action, I win. It's that simple. These cases are created by me, Zach Olson. They have not been copied from A-Bem and they are certainly not real patients. But before we get started, let's just check in with our hero, Dr. Mike Estefan. Woo! How you doing, man? Woohoo! Hey, Zach, what's going on? How's it going? So you are a new resident, congratulations, and welcome to the fold. Tell me so how long, how far into emergency medicine residency are you? I am about four days into residency at this point. Wait, four days. So we're technically recording this in June here. So you've basically done some orientation stuff. Have you been in the department yet? I have one ED shift, but it was kind of like an orientation shift and I was pretty much useless at that time. So not that much. How many patients did you see? I think I saw six or seven patients over my 10-hour shift. It wasn't the most efficient thing I've ever done. What rotation are you on right now? Let's get some just so we know what things you're going to be strong at, what things you're going to be weak at here. Okay, so I am currently on anesthesia. I've been doing a lot of interventions and placing a lot of IVs. So hopefully anything with the airway, I can successfully maneuver through. But other than that, I feel like a brand new med student. It has been so long since I've thought about a lot of this. All right, well, we'll see if you have to intubate today's patient. So are you ready? I know you're nervous. Are you ready? I was ready as I'll ever be, I think. All right, it'll be all right, man. Let's do this. All right. Take out a piece of paper and a pencil. Place the paper sideways in front of you. An outline, a human body on the left side of it. Make it look kind of like a gingerbread man. And it's going to be kind of pre-drone for you on test day. But just go ahead and draw it for yourself now. Let me know when you're ready. Okay. I am ready. All right. Dr. Estefan, this is going to be a single patient encounter. You're going to have 15 minutes to complete this case. Before we begin, do you have any questions? No, I do not. All right, then. Before we begin, they're going to have you look at your computer screen and confirm the candidate information on there and click or do we? It's basically confirming your identity. Okay. All right. Let's begin. All right. What do you got for me? Dr. Estefan, you are working at ABM General when the charge nurse requests that you immediately come to bed one for a poorly responsive patient that was picked up by EMS from his house just across the street. Your team has been paid and is going to join you in the room. And the patient's already here. Okay. Thanks for that, Zach. So I welcome to the room. What do I see? You see a patient, a middle-aged male. He is pretty much completely unresponsive and pretty much abnic. Okay. Okay. So they're not breathing. So I am very concerned about their airway. Let's put a bag mask on and we'll put maybe 10 liters of oxygen in that mask and start ventilating the patient. All right. So one of your team members is performing bag valve mask ventilation on the patient. Okay. Do we have an opening set of vitals? The heart rate is 78. The respiratory rate was 4. The blood pressure is 124 or 78. And the O2 saturation now that you are begging him is 98%. 98% great, great. And just to confirm, he does have a pulse. He does have a pulse. His heart rate is 78. Okay. Great. Is there anyone in the room who can tell me a little bit more about him? There's no one in the room family will maybe be here in five to ten minutes. Okay. Well, in the meanwhile, we can start two large bore IVs. He's on oxygen. We can get him on the monitor. Okay. Okay. You have two IVs. What gauge would you like? 18 gauge is fine with me. All right. So you have two 18 gauge IVs. You're bag valve masking him and he is placed on the monitor. And do we know where he was picked up from? He was picked up from his house just across the street. His home. Okay. An EMS Bridal Over. Okay. Can we get a stat, a point of care, blood glucose? I would also like to empirically give him Narcan. And if we could get an EKG going, that would be great. All right. So they're working on those things. How much Narcan would you like? Oh, boy. Could I call pharmacy and see what they recommend? Sure. You'd call pharmacy and they said give him two milligrams. Two IVs. I think that's right. She's now untested. Yeah. Two. They'll give you two milligrams IV Narcan. Okay. We'll do two milligrams IV Narcan. Was there any response to the Narcan? There was no response to the Narcan. I just sent you the EKG. I mean, when you receive it and if you interpret it. Okay. And the blood glucose is 35. Oh, boy. Okay. Can we get, I guess, let's see, two amps of D50 and push that. Sure. The nurse pushes two amps of D50. Okay. And I'm still waiting on that EKG. My internet connection is not the greatest. It's on its way. They're going to get as soon as possible and transferring it to you through the telephone waves. Okay. And while we're waiting, kid, can we also drop some blood? I'm not sure what labs I'm going to order yet, but just to have, we could draw rainbows for now. All right. The nurse just drew a rainbow. Great. Great. And is he able to breathe on his own at this point? His respiratory rate is four. But after the glucose, it's improving. It's probably about eight right now. Okay. Okay. And what is the patient's last name? The patient. There's an ID in his wallet. His name's John Johnson. He's 51. Okay. Mr. Johnson, are you awake? And I'm sternal rubbing him while doing this. The patient kind of opens his eyes and starts to make eye contact with you, but he's pretty sleepy. Okay. All right. I think we should prepare to intubate just because it sounds like he's not going to be able to protect his airway. So we have a bag valve mask at bedside. I would like suction. I would like a Mac three with a 7.5 ET tube with the stylet. I would also like an LMA and a Craig kit for backup. And I think that is all I want right now. Oh, and I guess we could drop some meds. We could get some automodate and some rock your ownium. Actually, now we'll go six in a colon. I know the dose is a little better. The respiratory therapist applaud your excellent setup. The glucose is starting to kick in. The patient is now speaking in full sense as in control and so away. Okay. Great. Mr. Johnson. Are you there? Yeah. Yeah. Oh. Do you have any idea what happened? I'm doing fine. Okay. What's the last thing you remember? I was just at home. I think I was on my couch watching some TV. And then all of a sudden you're in the hospital. Yeah. Okay. Do you know what hospital you're at? No. Okay. You're at A-Bem General. Okay. Can you tell me what day of the week it is? I think it's Thursday, Wednesday. I don't know who cares. Okay. And can you tell me what time of the year it is? Spring, is it summer, is it winter, is it fall? It's summer. Okay. Good. Well, it sounds like you're feeling a lot better. I have to ask you a couple quick questions. Do you have any major medical problems, Mr. Johnson? Yeah. What problems do you have? I have high blood pressure. I have high cholesterol. Doctors said they're watching my kidneys. I'm a diabetic. Okay. Do you take insulin for your diabetes? No. Okay. What medications do you take? For my diabetes. For everything. In general. All your medications. I'm on hydrochloroethyzeide, a statin, a torvostatin, and gliburide. Okay. One was the last time you took your gliburide. Today, I guess. Okay. Right before you passed out. I guess. Okay. All right. Do you have any allergies to any medications or latex? No. Okay. And has this ever happened to you before? No. Okay. As far as what testing I want to do, it sounds like this guy was just hypoglycemic from maybe excess medication use. I know sometimes they give octriotide to help kind of curb that, but he, I definitely think he needs to be admitted for at least observation to make sure his BG doesn't tank. Meanwhile, I'd like to start him on a dextrous drip, maybe like a d10 drip. Okay. He's starting on d10. What rate would you like? Can I call pharmacy and ask what they recommend? Sure. They're just going to come to bedside to help you. Okay. Understandable. They'll start at 100, I guess. Understandable. Okay. And I would like to call our EDObs and admit this guy for observation. Sure. They're going to give you a call back in the second family's here. Okay. I'd like to talk to the family if that's okay. Sure. And the nurse also wants to know what labs you wanted. And wants to confirm that you received the EKG? Oh, I still have not received the EKG actually. Geez. All right. The EKG looks pretty good. Okay. In the nurse's experience judgment. She used to be a ED attending. Actually, I pulled it up on my phone. I was waiting for it on the laptop. You cheated. It's all right. Go ahead and interpret it for the audience. My bad. I thought I would come through. So I it's a rate of about 70. It looks regular to me. I do not see any wide PR intervals. I don't see any wide QRSs. And I don't see any grossly deviated ST segments in either direction. Okay. As far as I could tell looking at a small iPhone screen. As far as labs go, I think we should probably I really don't know what to order for labs for this guy. Maybe besides another blood glucose in I don't know every hour Bd checks every hour. Okay. You said the family was there? Yeah. Okay. Hey guys, I'm Dr. Estefon. I am one of the residents taking care of your family member, Mr. Johnson today. Oh, what happened? What happened? Luckily it's June and not July yet. I know all the interns start in July. Yeah. Luckily. Yeah. So apparently from what I understand, he was found down in his house unconscious. And when he came here, he was not breathing well. So we had to breathe for him a little bit. And it turned out he had a very low blood glucose level. Which is uh, can kind of cause the symptoms. Yeah. He's back with it now. We gave him some glucose through an IV. And he's responsive answering questions. It sounds like he's alert and oriented. Thank God. He's had such a bad. He's had a bad couple weeks. I'm glad he's doing all right. What's what's been going on in the past couple of weeks? Well, he lost his job. And then like a month ago, he was in a divorce. That was pretty pretty rough. And so he's just been drinking a lot. And he just hasn't been doing well. He's been pretty, pretty depressed, I think. Oh, okay. You know, that, um, that makes sense to me, you know, as far as his symptoms go. And I, um, I think I need to talk to the nurse to order a few more value or a few labs, okay, to make sure he's doing all right. Yeah, whatever you need to do. Okay. Nurse over here is you. What do you want? All right. Um, could I get a, um, an ethanol level? Could I get LFTs? Could I get an ammonia level? Um, could I get an aspirin and acetaminophen level and an electrolyte like a BMP? All right. The nurse has its scent off. And we can also add some thymine to his, his d10 drip to a little late for that. But the nurse is given thymine. Great. Um, the ED OBS attending gives you a call back. Hey, what's up, Mike? Hey, what's going on? Um, so I have a patient for you that I am currently admitting to OBS, but he might need a little more care. He's this middle-aged gentleman who's had to kind of a rough couple of weeks, um, recently emotionally and apparently has been binge drinking a lot. He was found down at his house, um, came in barely breathing. He had a blood glucose of 35. We gave him some dextrose, uh, and set him up on a d10 drip. Um, I ordered some basic labs, but, um, it sounds like he should probably be observed to make sure his BG's, you know, stay fine and he doesn't go into alcohol. We should probably put him on seawall. Okay. It's psychonborn. Uh, I have not called psych yet, but they should probably be what are the overdose on? We don't know if it was an overdose or not. Um, he's taking gliboride, um, which could have been a cause for his low blood glucose, but he has a history of diabetes and he, um, you know, he's been drinking a lot lately is for what I heard. So it's also possible that he just hasn't been eating and I saw it. I saw it's alcohol level came back at about point on six here. You think he's just drunk? Okay. Uh, no, I don't think so because he, his respiratory depression was pretty profound. We had to bag him. Okay. How long do you want me to watch him for? Um, I don't know. 24 hours and see how it goes from there. Okay. You know, if he starts withdrawing, he's going to be have to be admitted. Okay. But we don't, we really don't have that good of a history. So I don't, I don't know if this guy's going to start withdrawing on you or what. But, yeah. Um, well, I mean, do you think he needs psych or do you think it's just, um, you know, it probably wouldn't hurt for them to come see him. I'll go. I can give him a call. That's fine. Anything else I need to know? Uh, he has no allergies to any medications. Um, his family is here. All right. Yeah. I think that ends your case. Oh, right. How was that? Oh, did you like that? Is that fun? Is that a good time? Uh, I was more tacky, like, for sure. And I'm, I probably look like I'm withdrawing from. I'm diaphyritic. I'm tacky, cardiac, like, I thought you did a pretty good job actually. You know, so like, obviously, what was the key, just what was the key moment of that case that where everything kind of clicked? Uh, getting collateral from the family, I think. Getting that, yeah. So getting that history and the blood glucose, right? And that was why I put this case as one of your first ones because I, you know, you need to know that in all these ultra mental status patients, Mike, you need to be getting that blood glucose up front and you did a very good job with that. Um, it makes a big, big difference. And in the, in the real rule, too, I mean, you'll see this. You'll, you know, the case I had to be kind of sneaky with it because usually EMS is going to get this for you. And so unless someone's just dropped out of a car, usually you're going to end up getting this but not always. And it's definitely a big decision point. And if you get these patients glucose, um, frequently they will, they will turn around quite quickly. Um, okay. What else do you think, tell me just your overall thoughts on the case? Um, do you think you hit all the teaching points? Do you think you, you know, what I just give me your overall vibe? Any other thoughts that you have? Sure. So I, I still think that I probably missed a few labs, you know, work up for someone with ultra mental status. I didn't do too much of a physical exam. I actually completely forgot to do a physical exam, um, which I don't know the value of a physical exam and someone who's, you know, completely out, you know, except in the setting of trauma. I really don't have too much experience with that. Um, as far as everything else, you know, I felt like I was probably a little slow to respond, uh, to, uh, non-responsive patient. It took me a second for the gears to start turning like ABCs. Okay. What am I doing? Like, oh, he's apnic. Like I should probably breathe for him kind of thing. But I think once the gears started turning, it started to pick up a little bit. Yeah, and I think you did a very good job at that part actually. I think that was probably more you feeling like you were slow to respond, but honestly you went straight to a bag valve mask, which is the appropriate thing to do. Sometimes in the real world, I would be the one with the bag valve mask. They'll say, I'm taking a patient back from the lobby and I'll just go grab a bag myself. And it just controls the whole stage. I thought you were all over it. You're right on top of needing to intubate him, which makes sense because you're on an anesthesia rotation, obviously. And part of this is me practicing too. I mean, usually in a couple minutes, if you administer D50, the patient's going to start waking up. And you, you know, especially on cases like this, if it's something where you fix the problem where it's a glucose and you give them glucose and they start to wake up, then you don't need to intubate that. You know, it's so just the timing of that. I thought you did a really good job with the resuscitation piece of it. There's, you got your two IVs, you got the patient place on the monitor. They're going to do everything. They're going to ask you what size IVs you want. So I thought you did good. You administered Narcan, which was good. And I don't the double check my dosing too. I think it varies a lot. I usually do two, but point on four, but honestly, EMS is usually the only gives it. So I don't actually order it that much because usually it's already given. I know the intranasal dos is. Yeah, yeah, yeah. You can do like IV Tuto. Some people go like point 01, but they like stack them a bunch, but I just kind of wanted the reason I chose to. I didn't really think about, you know, pre choosing the dose that you should use, but I didn't want you to worry about that. I just said two and just let you know. So I thought you hit that thing good. You did a good job recognizing, you know, the thine mean and the seawaw. And you did a good job putting in for the repeat glucose is. Let's see here. What did he overdose on? So it's been a while since I've reviewed my pharmacology, but I know gliboride is, you know, a medication used to lower blood sugar. So in the absence of insulin, I am going to go with the gliboride. Do you know what category of medicine it falls into? Because this is a fairly well-known group of overdoses that you need to know for sure. No, I do not. So gliboride is what's called a sulfoniarea. And so there's yeah, so there's several of them. I mean, so there's like glipazide is another one you hear glimeparide, gliboride. And the way I always remember this is if it ends in the eye, you better hide. I know it's stupid, but these are as far as the oral anti-hypoglycemia or whatever the category is called. It's essentially what they're doing is they're stimulating the pancreas to secrete insulin. And so they're notoriously long-acting. And so patients who have a sulfoniarea overdose, the general teaching is if it was an intentional overdose or if you had any hypoglycemia and like kids, that's a no-brainer. You have to observe that and get your cereal glucose. And yeah, no, go ahead. And you alluded to on there the octrea tide. So good job. So I had a case of a sulfonia overdose as a fourth year. I just didn't know if gliboride was the sulfoniarea or whatever I can't pronounce that. But yeah, I remember we used octrea tide. We admitted him to OBS and we just got BG's every hour. I think in an intentional overdose with hypoglycemia, it would be very reasonable. I'm not sure if it would meet the criteria of a critical action or not. To be honest, I guess, you know, ask some of the people at your program and see what they say. I'm not sure if it would technically be critical action. I feel like that's more administrating glucose and things like that, but definitely a well-known antidote for sulfonia overdoses. Okay. So yeah, I thought you did pretty good. You were the one thing that was a little slow for you that I had to help you with was kind of picking up. I think, you know, with your history, you could have dug in a little deeper with the patient and realized either the patient's kind of withdrawn, not really giving you anything, lots of yes-to-no answers. You didn't get a social history on him, which I probably would have given you. There's so many social factors. I would have given you any of them. What do you do for work? Are you married? Do you drink any alcohol? There's a lot of areas in there where you could realize that this guy was that this was possibly an intentional overdose, which it was in my brain. I definitely dropped the ball there. So I kind of gave it to you, but I think the big thing on this case that I thought you were very good with your initial resuscitation. I know you were beating yourself up for that. I thought you'd actually be very good with that. And I thought you did the right disposition. The main aspect is that history and exam. I think, you know, a little more intense just kind of trying to pick out some factors of the history. You got medications, you got allergies, you got med and surgical, you know, just maybe a little social or seeing if families coming or talking to EMS, you know, EMS could have said we saw a bottleneck's to him or something, but trying to really parse that out, you needed about 30 seconds more of history taking. Just a few more questions. I think it would have I went to have had to give it to you. And as far as the physical exam, like you said, you didn't really do a physical exam. So you would, so it's not even though it's not necessarily a critical action, you would score very low in that category on the real test, which is kind of like gathering like a data gathering. I have to look at the different categories, but you would score very low in that category by not doing an exam. So whatever you do, whether you're using or using like a little checkbox in front of you or something, you need to make sure that one of those boxes is exam so you check it. I mean, you have the whole, you have the whole frickin gingerbread man there, dude. Come on. No, um, yeah. You know, just to be honest, I know we should probably start wrapping this up here, but on the real test, the physical exam for me, and I can't go into specifics, obviously, but I felt like physical exam for me was the part that threw me off the most because when I was preparing, I did a lot of self-study and did a lot of mental preparation in when I would say, you know, cardiac exam or abdominal exam or whatever in the book, I would read what the examination was around test day. They, they're verbally were telling it to me, and I had trouble processing that information. And what I wasn't using, because I wasn't the reason I wanted you to draw out that gingerbread man is because it's a very good way to check off parts of the body. Now initially, the temptation is going to be that you're checking off the areas of the body that you're covering with your, you know, like, oh, neuro, I check, put a check next to the head, you know, cardiac or whatever. But really, the better way to probably do it is just to not miss the exam and use that gingerbread man to kind of put a check or something's abnormal. And either, you know, either it's clearly abnormal or just something to jog in memory because what can happen is if you have a bunch of abnormal exam findings or if they bury you in, you know, 100 findings or whatever they decide to do on the test day, that'll kind of help you keep track of those abnormals by using. So make sure you're utilizing that that gingerbread man and make sure you're not missing your history, your exam. Yeah, I totally, you know, as soon as the case started, aside from writing down vitals and writing down what I've ordered so far, I, yeah, I completely neglected the left side of my page. Yeah. And I mean, and if you think that the stress level is going to be any lower on the final test of your life for you to become an attending when you're in Chicago in a closed hotel room all alone, you know, the stress will be there. And so this is going to be partially getting used to the stress of it. I think, you know, how do you think for me? And I feel like we got this case actually pretty close to a good difficulty level for you. Yeah, I felt like, you know, it was totally within reach for me to ace it. I didn't ace it, but, you know, I think that anyone else in my position, you know, week one in turn hadn't seen a patient since January except for last week. You know, could have done well here. Now, now here's the deal. So this is the game, right? I can't, you know, as much as you're, you did awesome on this case. I wrote out the critical actions before hand and I can't deviate from that just because I like you. Okay. Sure. So I'm going to tell you what the critical actions were. In my opinion, you probably missed one of those critical actions. Which means I win. And I, you know, I made the case. So of course I'm going to win. So I always get away. But the critical actions were get a finger stick blood glucose. Obviously, I don't want you seeing this on a BMP or something, right? You know, in our later. So you did that. You administered glucose. That was a critical action. You put the patient in for medical observation. I don't necessarily know if you had a good understanding of the physiology of why you're doing it, but you at least did it. So you hit that critical action. You did get the Tylenol and aspirin levels. You almost missed that. Okay. And then I pretty much had to drag you into, I wrote down psychiatry consult, but really just addressing the psychiatric component of this case. Either consulting psychiatry or, you know, saying like we need to put this patient on a psychiatric watch or or just something along those lines or, you know, asking questions about heavy Ben suicide. You didn't really address that component of it. I think you probably wouldn't miss that at all. And so that would be the critical action you missed. Which I don't, I think you actually would have probably passed this case in the real world and been fine, but I'm being harder on you than the real world will be. But I thought you did great. I thought you did great. So yeah, good job. You know, this was a sulfon urea overdose was kind of the unintentional sulfon urea overdose, I should say. You really actually, you're smarter than you think. You need to know that you're smarter than you think, but well, there's always room for improvement, Yeah, yeah, I got a lot of reading to do. I bet your program director would be proud. I think they should be. I thought you really showed some pretty advanced thinking on some of this case. So you have good bones, especially for being less than a week in the residency. Dude, I appreciate that. Have you ever sinned a case like this even before? Have you ever done something just like this where you kind of are orally going through it? Not this intent. We had something called intern boot camp or EM intern boot camp right before I graduated in medical school. And so we did these very low key oral case-based things where the residents who were quizzing us were super lenient and would be like, "Oh yeah, you forgot you ordered this chestex right here it is." But you were definitely a little more of a hard-ass than. Oh yeah! Pressure's on. All right, let's wrap it up. Thanks for listening everybody. That wraps up this episode of round number one of the game. Zach won Mike Zero. Until next week, keep working hard, keep studying, and be sure to enjoy your shift.