POTD: Test taking tips

Today I’m going to be covering some test-taking strategies.

Focus on your weaknesses:

Don’t waste too much of your time reinforcing your strengths. Study your weakest topics that you don’t have daily exposure to in residency. If you have very limited time to study, consider filtering your Rosh Review question bank by your weaker topics, like Environmental, Heme/Onc, etc. 

Spaced repetition:

In order to retain information long term, you will likely need spaced repetition of the material. Don’t finish all of the environmental questions 3 months before the test. Try to revisit the material by doing some of those questions again, or by reviewing some of your notes.
Try to incorporate mental repetition into your daily routine. For example, quiz yourself on some topics that you learned earlier that day while you’re on the train or while you’re walking. 

Quick blocks:

Try to study in small blocks more frequently. 

Actively learn:

Don’t just passively nod your head and highlight each wrong answer you get in Rosh Review. Try to mentally quiz yourself after reading the explanations. Consider keeping a document with high yield notes.

Answering the questions:

All questions are created equal, and unanswered questions are marked as incorrect. Give yourself time to finish the test! Don’t spend too long on one question – it’s more important to finish the entire test.

Know your learning style:

Supplement your learning and tailor your study plan to your learning style. There are excellent free videos (https://www.intrainingprep.com/) and EMRAP Crunch Time audio reviews for the boards. 

Never pick an answer that uses “absolute terms:”

Avoid answer choices that include: always / never. 

If in doubt, pick the “long correct” answer: 

The detailed beautifully explained answer choice is often correct. They might include double options, more information, and caveats. 

1-2 days before the test:

Review a high yield document with a bunch of buzzwords and highly tested concepts. I’ve attached one of my favorite ones to this document. This will help refresh concepts you’ve reviewed a few weeks ago. I highly, highly recommend using this!!! I think like 20+ questions last year came up from this document. 

They’re not trying to trick you:

If the question stem obviously sounds like a PE, it’s probably a PE. Don’t overthink it. Just make sure you read the question carefully, and then move on.

I hope this helps! I know most of this is pretty obvious, but trust yourself and go with your gut. 

References:

https://knowledgeplus.nejm.org/blog/10-mistakes-studying-for-the-boards/ 
https://www.roshreview.com/blog/how-to-increase-your-emergency-medicine-board-exam-score-by-10-points/

POTD: Tips for writing your CV

I wanted to share some tips for creating an excellent CV. I thought this might be helpful as PGY-2s start thinking about writing their CVs over the summer for jobs/applications. It’s easier to slowly add a line or two over time rather than to frantically create one over 3 days.

Formatting:

• Keep it organized and professional. Use a simple font and clean headers. Don't try to be original.

• Put the most important stuff at the top.

• Order it in reverse chronology – most recent at the top for each section.

• As a general rule of thumb, try to keep your resume within 1 page. However, your CV can be longer since it is more comprehensive. In medicine, they’ll ask you for your CV, but if you’re applying for something corporate, then they will likely want your resume. (Or both.)

• Be consistent throughout with your formatting.

• Save the doc / send it as a pdf

• Label your pages with your last name & page #.

• Use bullet points, and try to keep things succinct.

The sections:

• Of course, start off with some of your personal information. At the minimum, include your name, phone number, and best email address.

• Organize your CV by having clear headers. As a resident, it’s appropriate to start off your CV with a “Training and Education” header with your residency, medical school, and undergraduate schools listed.

• Presentations & lectures: include your morning reports, M&Ms, grand rounds presentations, etc. If you’ve presented at national conferences, include that too! Consider breaking out your presentations & lectures as “National” (where you presented at conferences) and then “regional/local” (Maimo/med school presentations.)

• Publications: designate if it’s peer reviewed vs non-peer reviewed. Use proper citation style.

• Include your residency & leadership activities. You can group them however you find appropriate, but take some time to brag about your chiefdom, research and QI projects, and extra-clinical stuff (e.g. event medicine, scholarly tracks, med school clubs, etc.) The majority of my interviews were spent on talking about this section. If it's still in progress, just say where you are in the process.

• Awards - Gold Humanism, AOA, etc.

• Professional affiliations - SAEM, ACEP, etc.

• Certifications - don't ask me why, but they want your random certs listed like ACLS, ATLS, etc.

• Include a hobbies section! People want to get to know you, and it’s okay to be honest and quirky. It can be endearing and a great ice breaker.

Other random tips:

• For each project or leadership related bullet point that you have, make sure you include the following:

  • What was the deliverable

  • Who was it for

  • What was the impact

  • Your methods

• Tailor it to the job. For example, I created a little bucket called “International experiences” since I was applying for a Global Health fellowship. Remember, a community job CV will look different from an academic position.

• Unless it’s super notable, I think high school is too far back to include. But the cool stuff you did in college or med school is great.

Final touches:

• Get feedback. I sent my resume to 5-6 friends, and 3-4 attendings before ultimately submitting it. You don’t have to take everyone’s advice, but you’ll find most tips to be generally helpful.

• Be neurotic - people use your CV as a harbinger for your attention to detail and your professionalism. Keep your grammar, spelling, and formatting perfect.

POTD: Naloxone

Today, I’ll be touching on the life-saving medication Naloxone.

Epidemiology:

In the US, there are three million people with opioid use disorder (OUD). 68K+ people died from opioid overdoses in 2020, nearly 40% higher than 2019. The deaths were primarily attributed to synthetic opioids.

Patients who have overdosed on opioids will show the classic triad of constricted pupils, decreased respiratory rates, and somnolence. You should consider naloxone administration in OUD patients with RR<8 and GCS<12.

Naloxone:

Naloxone is the antidote for opioid overdose since it is an opioid antagonist. Naloxone is available intranasally, intramuscularly, nebulized, and intravenously.

The onset of action is within 1-2 minutes, but remember that the half-life is 20-90 minutes. The half-life of the opioids are longer, so it’s recommended to observe these patients for at least 3 hours.

The first question you must ask – could this patient die from apnea? If so, you can bolus large amounts of naloxone. If the patient is somnolent but not apneic, you can titrate smaller doses at a time.

In a patient with OUD, there is a higher likelihood that you will precipitate withdrawal through the administration of naloxone. Therefore, start with lower doses of narcan for OUD patients compared to opioid-naive patients. As a side note - some of the doses below are controversial depending on the source that you’re looking at. Remember, the dosing of naloxone depends on the route.

Intranasal narcan:

• 4mg in one nostril intranasally

• Redose as needed

• MMC ED Pharmacy has kits with two 4mg spray bottles

• Available over the counter in New York

IM/IV dosing:

• Apneic/dying patient: administer 2mg-4mg IM/IV off the bat

• OUD patient in overdose: 0.1mg IV (0.4 mg IM) aliquots, q1-2 minutes. Consider larger doses if your patient isn’t responding appropriately. Synthetic opioids may require higher doses (sometimes up to 10mg IV.)

  • Titration: The goal is to titrate to a point of adequate ventilation and airway protection, but not necessarily full arousal. But the patient should be arousable.

• Opioid-naive patient in overdose: 0.4mg IV/IM

Initiating a drip:

• Because the half-life of narcan is short, you may want to consider starting a drip for patients requiring repeat doses.

• Calculate the amount that the patient required to wake up to an appropriate level and then put them on a drip ⅔ of that per hour.

Nebulized naloxone:

• If the drip is taking a while to set up, you can consider administering nebulized naloxone by mixing the 0.4mg vial with NS.

I would recommend having them placed on a monitor in resus with an EtCO2. If your patient develops respiratory distress, consider non-cardiogenic pulmonary edema as a side effect and get a CXR. These patients may require intubation.

EMRAP just did a piece this month about the importance of dispensing Narcan kits in the ED (as opposed to just a prescription for it, which goes largely unfilled.) This is a lifesaving medication, so I highly recommend giving a kit to every OUD patient in the ED.

https://www.emrap.org/episode/emrap20223/takehome

Last couple of pearls and tidbits:

• Check the skin: you may find fentanyl patches which can be causing their overdose. Fentanyl patches come in doses 12mcg-100mcg/hr and require changing q72h. Just keep in mind that the effects may linger after removal.

• Consider making push-dose naloxone. Naloxone comes in 0.4mg vials. If you mix the vial with 10cc of NS, you will be able to give 0.04mg/ml aliquots easily.

• If there’s literally no response to the naloxone at high doses, consider alternate etiologies. Pontine stroke may be a mimic.

• Watch the show “Dopesick” on Hulu. It follows the story of oxycodone coming to market and the Sackler family. It’s crazy.

• You can have your own take-home Narcan kit. Just pick it up from our friendly ED pharmacists. You could save a life!

• Also, as a reminder, Relay for Life is also an amazing service for nonfatal opioid overdoses.

References:

https://wikem.org/wiki/Naloxone

https://emcrit.org/ibcc/opioid/

https://litfl.com/naloxone/

https://www.ncbi.nlm.nih.gov/books/NBK553166/