The Fast Track - Fall 2015 by ACOEP

The Fast Track Fall 2015 Issue

An Emergency Medicine Publication

DISPELLING THE

MYTHS

of the Graduate Medical Education Merger

OUTSIDE THE EMERGENCY DEPARTMENT PREPARED FOR ANYTHING at KCUMB

SPECIFIC TACTICS FOR TEACHING in the Emergency Department

DUAL DEGREE:

D.O., M.B.A.A Student Experience

FastTrack_Fall2015.indd 1

9/18/15 10:24 AM

FastTrack_Fall2015.indd 2

9/18/15 10:24 AM

The Fast Track EDITORS-IN-CHIEF

Tanner Gronowski, DO Veronica Coppersmith, DO Chris Swyers, OMS-IV Ariel Sindel, OMS-IV EDITORS

Andy Little, DO Drew Kalnow, DO Jeremy Lacocque, DO Danielle Turrin, DO Erin Sernoffsky John Casey, DO RC BOARD MEMBERS

Letter from the Editor

all is a time of change for many of us. First-year students are adjusting to the rigors of medical education, while fourth-years are

traveling the country to find the right residency. Our newly minted EM residents are just learning how to hone their craft; and attendings, fresh out of residency, are transitioning into their new roles. In each case, adapting to new environments—and new challenges—can be daunting. When I joined the Fast Track’s editorial staff a year ago, I felt many of the same apprehensions. Writing was one thing, but editing is a very different beast. It involves not only the ability to correct spelling and grammatical errors, but also the skill to make those changes while keeping the author’s voice intact. The nuances of editing also had to be balanced

Andy Little, DO, President Joe Sorber, DO, Vice President Drew Kalnow, DO, Treasurer Tanner Gronowski, DO , Secretary Veronica Coppersmith, DO Gina Moffa, DO Allison Remo, DO John Downing, DO Patrick Cary, DO Chase Ungs, DO Danielle Turrin, DO Daniel Engleberg, DO Steven Brandon, DO , Past President

with effective communication both with our writers and the rest of the

SC BOARD MEMBERS

invaluable. I’m thankful for that chance, and I’d encourage anyone who

Cameron Meyer, President Sasha Rihter, Vice President Timothy Bikman, Secretary Jeffery Weeks, Treasurer Deborah Rogers Michael Fucci Ariel Sindel Chris Swyers Chris Falslev Michelle Kinghorn Bryant Gray Kaitlin Fries, Past President

Fast Track staff. When those jobs were coupled with my Student Chapter responsibilities, I found adjusting to the new roles to be a challenge. There were a few late nights when, staring at a computer screen with deadlines looming, I questioned my ability to get the job done. Luckily, The Fast Track isn’t a one-person job, but rather a collaboration between the writers, editors, and personnel at the college. I’m grateful for the positivity and support we were all given through the process. The

Fast Track is truly driven by the residents and students of the college; it’s something that everyone in the ACOEP should be proud of. For me, the opportunity to reconnect with writing and publishing has been

has a passion for writing, teaching, and emergency medicine to get involved in the process. At times, the editing process has been challenging; but it’s a testament to my colleagues, the college, and our readership that The Fast Track continues to be a high-quality, resident and student-driven publication. We couldn’t do it without your support and enthusiasm. I know that, as we transition into a new editorial staff, The Fast Track—and ACOEP—are in good hands. Chris Swyers, OMS-IV OU-HCOM

PRINTING OF THIS ISSUE SPONSORED BY:

FastTrack_Fall2015.indd 3

INTERESTED IN CONTRIBUTING? Let us know: FastTrack@ACOEP.org

9/18/15 10:24 AM

Core Faculty Academic and Research Skills Development Course Sponsored by a David E. Kuchinski Memorial Grant from the Foundation for Osteopathic Emergency Medicine

WHEN: CME:

Part II - October 20, 2015 Part III - October 21, 2015 Up to 14 hours of Category 1A

Approval Pending

FOEM invites core faculty members and program directors to the Faculty Development Track at The Edge: Scientific Assembly in Orlando, FL! This course will explore: • Insight into the ACGME Application process and Milestones through lectures by ACGME staff • Improve research and academic teaching skills • Implementation of new common core standards • Ways to enrich and encourage research among physicians, residents, and students • Networking with other institutions and organizations to promote research across a broader spectrum • Improvement of grant writing to successfully fund vital research • Effectively securing publication and recognition for your work

Only $50 per session for faculty, and FREE to residents.

2015-FOEM-FDC-R5.indd 4 1 FastTrack_Fall2015.indd

Sign up for one or both phases! Participants can take both classes for the first time, or those who have already taken Phase II are welcome to return for a refresher course.

8/26/15 10:24 9/18/15 11:17 AM

Contents Presidential Messages............................................06 Merger Myths..................................................................08 Outside the Emergency Department...............12 Prepared for anything at KCUMB........................14

OUTSIDE THE EMERGENCY DEPARMENT

Specific Tactics for Teaching.................................16 Taking the Next Step..................................................20 Dual Degree................................................................22 Tricks of the Trade......................................................24

GHANA by Frederick Davis, DO PREPARED FOR ANYTHING

Upper Motor Neuron Signs.....................................26 Residency Spotlight....................................................29

FastTrack_Fall2015.indd 5

DUAL DEGREE

9/18/15 10:24 AM

The Fast Track Fall 2015

PRESIDENTIAL MESSAGE Resident Chapter

ong before I became a DO, I had a desire to be an emergency medicine physician. These two thoughts merged shortly after beginning my first year of medical school. I knew of the American College of Emergency Physicians, as I had read their publications in the ED lounge where I worked,

but was unsure if there was an osteopathic equivalent. While searching the internet I found that there was a conference coming up in Las Vegas for the American College of Osteopathic Emergency Physicians (ACOEP). I went to this conference where I knew no one. Luckily for me, that did not last long. I quickly met DOs from around the country who practiced emergency medicine and who were residents in osteopathic EM programs. While at this conference I had the opportunity to meet Mark Mitchell DO, then a member at large of the ACOEP Board of Directors, who noticed my enthusiasm for EM and encouraged me to run for a national student position within ACOEP. The next day I was elected the ACOEP Student Chapterâ&#x20AC;&#x2122;s conference committee co-chair. Little did I know that single event would prove to be a turning point that led me to where I am today. Over the last seven years, I have had the honor and privilege of being an officer within the ACOEP Student and Resident Chapters, serving two years as the Student Chapter President and now serving as the Resident Chapter President. During my time with the ACOEP, I have been truly blessed. I have had countless opportunities and experiences to serve, learn, improve, be inspired, be mentored and become a mentor. I have learned to be a better person in the many facets of my life - father, husband, son, friend and physician - and have had the opportunity to walk among the giants of the osteopathic and emergency medicine communities. If you said that, in my time of service within the ACOEP, I have gained more than I could ever give, you would be right. So as this is my last message to you as the Resident Chapter president, I invite all of our members to give ACOEP a try. Come to a conference, attend one of our review courses, write for one of our publications. If you do, I promise you will not be disappointed, you will feel welcomed and you will want to get more involved. Andy Little, DO ACOEP National Resident Chapter President Doctors Hospital, Columbus, OH

FastTrack_Fall2015.indd 6

9/18/15 10:24 AM

The Fast Track Fall 2015

PRESIDENTIAL MESSAGE Student Chapter

ouldn’t it be nice if there were a formula for medical school? X+Y+Z= dream residency. All you would have to do is make sure you have those three things and you would get into your favorite program. In reality, there are many different variables out there, and it is hard to know which

ones your favorite program is looking for. Some programs look for more obvious things, like grades and board scores. Others might not be so obvious. One variable proven to be valuable to students in the past is attendance at ACOEP conferences. As a fourth year student, I am visiting various programs and I have been surprised at how many EM residents I have encountered that I had met as students at past ACOEP conferences. Every program I have talked with has at least one resident that I have first met through the ACOEP. Obviously this is only one variable that programs might look at, but with the number of students that attend ACOEP conferences matching, it is a significant one. Why is it so valuable to attend conferences? First, it makes you look good. It shows programs that you are truly interested in emergency medicine, and that you are willing to do what many students aren’t. At conferences, you also learn information that will help you shine on your rotations and in your interviews. The skills labs at conference will give you confidence to perform procedures that most students don’t know how to do. Finally, at conference you will be given the opportunity to show programs who you are. Programs are involved in the ACOEP-SC events and get to know the students applying. It is impossible to get to know a person by looking at their paper application, but at conference they can interact with you and see the type of person you are. When they come across your application they can say, “I know this student from conference. She would be a great fit here.” It is impossible to know what exactly a program is looking for in a candidate, so it’s important to take advantage of every opportunity to improve your chances. If you come to conferences you will enjoy it, learn a lot, make friends, and you will be surprised at all the doors that will be opened for you. Cameron Meyer, OMS-IV ACOEP National Student Chapter President WVSOM, Lewisburg, WV

FastTrack_Fall2015.indd 7

9/18/15 10:24 AM

The Fast Track Fall 2015

Dispelling the

MYTHS

of the Graduate Medical Education Merger Leonard A. Stallings, MD EMRA RRC-EM Representative East Carolina University Brody School of Medicine Greenville, NC

Andrew G. Little, DO ACOEP Resident Chapter President Ohio University Heritage College of Osteopathic Medicine Doctors Hospital Columbus, OH

This is a confusing time in the world of graduate medical education. The recent Memorandum of Understanding that will merge the American Osteopathic Association (AOA) and the Accreditation Council of Graduate Medical Education (ACGME) into one single accreditation system (SAS) has created a lot of turmoil in the minds of many residents seeking to become experts in emergency medicine. As the elected voice of emergency medicine residents, we felt it important to join together with a unified voice to provide some insight into what we know in an attempt to dispel some of the most prominent rumors about the merger.

MYTH 1:Â My entire program leadership, including the program director (PD), will change once the AOA and ACGME merge. The ACGME Review Committee for Emergency Medicine (RC-EM) has announced they will equally consider AOA certification as one of the criteria to meet the qualifications for an EM program director.1-3

MYTH 2: My program will close when we undergo the ACGME accreditation process,

and I wonâ&#x20AC;&#x2122;t be able to take the boards when I graduate. Current AOA accredited programs will not automatically close during the ACGME accreditation process. These programs will maintain their AOA accreditation status until either ACGME accreditation is achieved or until June 30, 2020. The SAS will not affect board eligibility. Osteopathic certification exams will be recognized by the ACGME as valid and appropriate credentials for service as faculty members in ACGME training programs. No MD or DO will be required to take

FastTrack_Fall2015.indd 8

9/18/15 10:24 AM

The Fast Track Fall 2015

either certification exam; both certifications will be available to DOs who graduate from an ACGME accredited program. All DO residents will be encouraged to take osteopathic certification exams to demonstrate their competency in osteopathic principles and practices within the specialty.

To answer the direct question of whether a specific program will close, this will depend on the sponsoring institution’s desire to continue educating EM residents. We encourage our members to direct this question directly to their sponsoring institution’s graduate medical education department chairs.6-7

Under the current American Board of Emergency Medicine (ABEM) rules, a physician must have completed an ACGME accredited residency to be eligible for ABEM board certification. When an AOA program applies for ACGME accreditation it is given a “pre-accreditation” status, which signifies that an AOA accredited program is in the process of pursuing initial accreditation with the ACGME while still operating under its AOA accreditation. Our understanding is that a program’s pre-accreditation status – which in many cases will qualify DO residents in that program for advanced ACGME residencies and fellowships – will not change a DO physician’s eligibility for AOBEM board certification.4 ABEM certification will be available to program graduates once the ACGME confers initial accreditation upon the AOA program, even if it is conferred on the last day of residency.5 Initial accreditation is the status that is achieved once an AOA program is ACGME accredited.

MYTH 4: As an osteopathic medical student interested in EM, I will still have to apply to two distinct matches even after the merger.

MYTH 3: My AOA EM program will have to close with the ACGME merger. All osteopathic EM programs must seek ACGME accreditation before June 30, 2020 (after this date the AOA will no longer accredit GME programs) or face closure. Each program will have to meet the standards as determined by the RC-EM. Though there are some differences in the current ACGME EM standards and osteopathic EM standards, osteopathic EM programs are held to high standards that are similar to those of ACGME. We are hopeful that all osteopathic programs will be able to obtain ACGME accreditation if pursued.

The ACGME does not administer the allopathic MD match; rather, that is administered by the National Residency Match Program (NRMP) and the osteopathic match by the National Matching Services (NMS). Consequently, this is an issue that can be resolved only when the NRMP and NMS join in the merger discussions. However, if all programs are considered ACGMEaccredited after the transition to a single GME system is complete, it is likely there ultimately will be one match. During the transition, as AOA programs get approved by the ACGME, there will likely be conversations with the NRMP and the NMS to determine the best way to administer the match during the transition process.8 Unfortunately, this issue cannot yet be easily clarified, so there is no way to fully address this myth at this time.

MYTH 5: As an allopathic medical student I will have more competition for the allopathic spots, but I still will not be able to apply to the osteopathic programs even after the merger. Once the transition to a single GME accreditation system is complete, all DOs and MDs will have access to ACGMEaccredited training programs, including those with an osteopathic principles dimension. However, there is no specific date when osteopathic-focused programs must

FastTrack_Fall2015.indd 9

9/18/15 10:24 AM

FastTrack_Fall2015.indd 10

9/18/15 10:24 AM

The Fast Track

MYTH 6: If I graduate from an AOA residency program then I will not be eligible for an ABEM-sponsored subspecialty fellowship. Nothing stops an AOA graduate from matriculating into an ABEM sponsored fellowship if the program leadership deems him/her a desirable candidate. However, at this time you will not be able to sit for the ABEM subspecialty fellowship boards if you are not ABEM certified. The current policy of the American Board of Medical Specialties (ABMS) is such that an AOA residency graduate who is not certified by one of the member specialties (e.g.,

ABEM) cannot become certified in an ABMS subspecialty even with completion of an eligible fellowship. Unfortunately, at this time graduating from an AOA accredited fellowship program will not result in ABEM subspecialty certification.5

Fall 2015

begin accepting MD candidates. Prerequisite competencies and a recommended program of training are expected to be required for MDs to enter osteopathic-focused programs, though this has not been confirmed. The newly formed Osteopathic Principles Committee of the ACGME will develop the prerequisites and prior training requirements. MDs will not be able to enter osteopathic-focused training programs until standards for these programs have been developed and that individual program has become ACGME-accredited.3

In order to sit for an ABEM subspecialty examination for certification, an AOA graduate would have to complete a residency program that has been given ACGME initial certification, become board certified by ABEM, complete an ABEM-sponsored fellowship program, and successfully pass that examination. The designation of “pre-accreditation status” is an ACGME designation that the ABMS does not recognize in this context. Graduates from osteopathic programs who are AOBEM certified and complete an ABEM fellowship may apply for a certificate of added qualification (CAQ) through AOBEM (visit www.aobem.org for more information). The merger process will be ongoing until July 1, 2020, and as new information becomes available, the facts will be distributed. If at any time you have questions or concerns, please feel free to contact your representatives from EMRA and the ACOEP-RC by tweeting your questions to @ emresidents or @ACOEPRC. You can also email the EMRA RRC-EM Representative at rrcemrep@emra.org.

Introducing ACOEP’s

• Easily earn CME online • Access hundreds of hours of lectures from ACOEP conferences and events • Customized lectures for attending physicians, residents and students • Discounts available for ACOEP members

Available at: www.acoep.org/classroom

Digital-Classroom-R1.indd 1 FastTrack_Fall2015.indd 11

The ACOEP Advantage: Specialized. Personalized. 11

8/28/15 10:24 1:37 PM 9/18/15 AM

The Fast Track Fall 2015

Outside the Emergency Department

By Christine Goss, DO Good Samaritan Hospital, West Islip, NY

eing a resident in the New York metro area has its advantages, one of those being ready access to many unique training opportunities. The FDNY Foundation recently hosted the Third Annual FDNY Medical Special Operations Conference (MSOC), which I had the opportunity to attend and participate in. As an emergency medicine resident interested in the field of EMS and Disaster Medicine, having the opportunity to attend this conference in my backyard was too good to pass up. The conference occurs each spring and consists of three days of hands-on skills sessions, lectures, workshops, and the opportunity to see and work with some of the newest technology available in the field. Medical special operations consists of the combination of the fields of medicine and rescue and requires a large amount of dedication and training from those in the field. The conference attendees consisted of a diverse pool from across the nation, including those involved in federal, state and local urban search and rescue, military medical personnel, EMS fellows and program directors, and local EMTs and paramedics. Many of the attendees shared personal experiences from rescue operations in the Gulf Coast following Hurricane Katrina and the earthquake in Haiti. Lecturers were drawn from around the globe and were ready and willing to share their unique experiences in the fields of search and rescue, wilderness medicine, pre-hospital care, and confined space medicine. Highlights from the lectures included talks by Dr. Christopher Ho on his experiences in wilderness medicine at the Mt Everest base camp, and the unique medical challenges imposed by this harsh and isolated environment. Another small group session, led by Michael Kurtz and Dr. Douglas Isaacs, covered the unique medical challenges faced by rescuers in the care, assessment, and management of patients with prolonged entrapments. EMS

Capt. Paul Miano spoke on the unique challenges in pre-hospital management, communication, preparation for responding to Ebola in New York City. Other lectures and sessions covered topics ranging from field amputation to a tabletop earthquake scenario. One of the truly unique aspects of this conference was the ability provide hands-on experience, especially for those of us who rarely have the opportunity to venture out of the emergency department. The Randall’s Island FDNY Academy serves primarily as a training venue for the recruits of the FDNY. It boasts its own simulated subway station, realistic to the last detail with the exception of urine and rats(and fortunately for us, no live third rail), as well as a full ship mockup for simulating water emergencies and rescues. On the first afternoon, we were given a tour of the ‘ship.’ Our team climbed down a hatch into the lower levels in near pitch black the only light provided by headlamps we had brought with us and began searching out patients. These scenarios were designed to help with skills such as intubation in very confined areas, evaluation and management of patients that would require extended care prior to extrication, with discussions on hemorrhage control, management of compartment syndrome, and field amputations (Figure 1). Between sessions we had an opportunity to practice and perfect our intubation skills on a mannequin with significantly limited access available (Figure 2).

On entering the ‘subway station’ we were greeted with dark, smoke, and overwhelming noise.

FastTrack_Fall2015.indd 12

9/18/15 10:24 AM

The Fast Track Fall 2015

Another skill station focused on searchcanine handling and care. We watched the search dogs in action locating victims trapped in cars or in nearby tunnels. This was followed by an introduction to some basics and unique aspects of care for these highly trained canines from the veterinarians and trainers who work closely with them. These dogs function as valuable members of the search and rescue team and their safety and care during a rescue operation is the same as for any other team member. Through the afternoon we learned how to quickly evaluate our canine patient and had to work as team to improvise for evacuation and safe management of injured simdogs (Figures 3 and 4). The next afternoon consisted of workshops on patient packaging and extrication. A mock subway disaster allowed us to put the skills we had learned into practice. On entering the ‘subway station’ we were greeted with dark, smoke, and overwhelming noise. Our team carefully made its way under the subway platform to find our patient under a train. The first challenge was managing the patient’s uncontrolled hemorrhage in the limited space available. We worked quickly as a team in the dark to assess, treat, and reassure our patient, and then began the slow process of safely extracting our patient, now on a longboard with cervical stabilization in place, down the 40 feet under a subway car to the nearest ladder and up onto the platform (Figures 5 and 6). The FDNY MSOC is an excellent venue for any EM residents who are interested in EMS, pre-hospital care, or disaster medicine. The engaging lectures and hands-on skills sets provide the perfect balance of hands-on experience and background information for those with limited exposure to these fields, or those looking to expound on their skills.

FastTrack_Fall2015.indd 13

9/18/15 10:24 AM

The Fast Track Fall 2015

PREPARED FOR ANYTHING AT KCUMB By Katie VanNatta, OMS III KCU-COM

Would you know what to do if a bomb went off in a building next door? Would you know the proper way to put on personal protective equipment if there was a chemical hazard in your hospital? The second year students at Kansas City University of Medicine and Bioscience do! Along with the new changes in the first year curriculum at KCUCOM, the administration decided to add two Disaster Medicine courses to the second year curriculum. In the fall, the students studied Disaster Medicine which included both disaster related lectures and training in Basic Disaster Life Support through the National Disaster Life Support Foundation (NDLSF). The students received lectures from local trauma surgeons to review the different types of shock, approaches to treatment, and a review of fluid and electrolyte management. They also engaged in a full day of training for their Basic Disaster Life Support certification. The course taught how to apply core principles and concepts in emergency management and public health through the PRE-DISASTER and DISASTER Paradigm. Students learned the “all-hazards” approach to mass casualty management and population-based care across a broad range of disasters. Numerous different cases were presented where students explored, engaged in, studied, and applied the practice of SALT triage. At the end of the day, the students were paired up and sent into the OMM lab to find and triage 20 “patients” (aka stuffed animals) hidden throughout the lab. The instructors turned the lights off and simulated a hectic, loud emergency scene using a fog machine and speakers playing sirens, explosions, and panicked crowd noise. The chaotic, noisy environment made it all the more difficult. The most challenging part was trying to find all 20 patients!

During the second semester, the second year students were enrolled in Disaster Medicine II. Recently, the students became Advanced Disaster Life Support (ADLS) certified during a three day course held on KCU’s campus. During the first day, course directors from the NDLSF prepared the students through lectures about the complicated and unique features of disasters and public health emergencies. Lectures focused on triaging, health system surge capacity, community health emergency operations and response, and lastly legal and ethical issues in disaster. On the next training day students were broken up into small groups which rotated through three skills stations that included population scenarios, mass casualty triage, and surge. On the final and most exciting day, students were split into two groups and rotated between two more skill stations. One allowed students to practice putting on Personal Protective Equipment (PPE) correctly and decontaminating correctly. The other skill station used a human patient simulator to reproduce different traumatic patient scenarios and dangerous, complicating outside environmental factors a response team could encounter. After lunch, students were able to participate in a field mass casualty and triage exercises such as a bomb explosion or a plane crash. Faculty,

FastTrack_Fall2015.indd 14

9/18/15 10:24 AM

The Fast Track Fall 2015

Would you know what to do

IF A BOMB WENT OFF in a building next door?

staff, fellow students, and volunteers were able to put on makeup to simulate interesting wounds and injuries then assigned different patient presentations and cases to act out. The second year students were in charge of everything from incident command, to triage, to sending medical response teams out into the field. This exercise was a remarkably exciting and fun learning opportunity. The simulation allowed the students to be exposed to a practice scenario where they could learn from their mistakes and be better prepared for when explosions, burns, eviscerations, panic, and mass casualties become the real deal. I personally was “blown up” by a simulated bomb because another medical team failed to notice a bomb on a chair and proceeded to set it off by moving the chair. I’m not particularly excited for that to happen in real life. Undoubtedly, the importance of observing and surveying the scene became strikingly evident by that incident. KCU provided the use of their surgical “Cut Suits” for the military track students, who have trained on them before, to be able to practice responding in a more realistic trauma scenario. Through my personal experience, I would recommend anyone interested in disaster medicine to go through these courses. Often times, instructors needed to remind us of the unique

and important differences between the disaster medicine protocols versus the Advanced Cardiac Life Support that is traditionally taught in school. I would say don’t try to put someone in a PPE if you can’t tear duct tape very well. It was quite eye opening how long it takes to get into a suit and how hard it is to get out of a suit without being contaminated. Both ADLS and BDLS have taught my class to learn how to work together in teams, certainly more than ever before. We have some group assignments in our standard curriculum, but through these two courses we were forced to communicate more with a partner or in a small group. The table top skills sessions on the second day of ADLS were particularly interactive because we had about 15 people and everyone had a part to discuss in the practice disaster simulation. It taught students how to become more disciplined leaders and effective communicators. Efficient and supportive teamwork is essential in every aspect of effective medicine. The disaster courses were a refreshing break from the routine of classroom lecturing and constant reviewing of class notes. I will certainly remember the experience of running around with triage cards and lifesaving interventions to give to faculty and staff acting as aching, moaning, and bleeding patients. I feel after the two courses I have a better understanding of what disaster medicine is and would be able to help in a scenario!

FastTrack_Fall2015.indd 15

9/18/15 10:24 AM

The Fast Track Fall 2015

Specific Tactics for Teaching in the Emergency Department Bruce St. Amour, DO, BSN, FACOEP

“Doctor” means “teacher1.” Although we are educated in how to treat medical problems by those ahead of us, we rarely receive any training on how to teach those coming afterward. The training we receive, although well intentioned, is often counterproductive and based on tradition instead of science. This purpose of this article is to provide a basic understanding of adult learning in the Emergency Department.

FastTrack_Fall2015.indd 16

9/18/15 10:24 AM

The Fast Track

The teacher’s main function is to provide three basic functions: safety, organization and instruction. The most important task that you, as the teacher, can provide is safety2. Without this function, little learning will occur. Unfortunately, this is also the most neglected of the three functions. In providing safety the learner knows that it is okay to ask questions, to practice skills, to make mistakes, to develop and to challenge the established thinking. Once an adult learner feels safe, they are free to internalize the information presented.

Fall 2015

TEACHING BASICS

5. Provide immediate feedback about the skill

SNAPPS7, 8 In this model, after seeing the patient the learner will summarize the history and physical exam findings, narrow the differential diagnoses and weigh the various diagnoses aloud. The student then probes (asks) the teacher to clarify any difficult or confusing issues and develops a management plan. Finally, the student selects areas for future reading, which helps him learn in a focused manner adding organization, not just knowledge. This technique enhances learner independence in clinical reasoning and medical decision-making and can easily be combined with other teaching tactics. The learner:

1. Summarizes briefly the history and physical

The next task of an educator is organization. When one begins to learn any skill they are a novice. There is little connection between learned facts. Each fact must be recalled as a lone bit of information that is not linked to anything else. Just like a jumbled closet, this can make it very hard to recall information. Just as when a closet is clean, a shirt can be found; if we teach the learner how to organize their information instead of trying to shove more in, we can teach them how to use what they know.

2. Narrows the differential diagnoses to 2 or 3 likely possibilities

The last major task of a teacher is to provide instruction. When starting a new topic it is best to start with broad strokes then fill in the details. This will help the novice learner organize the concept and provide the connections that will assist recall.

“One-Minute Preceptor”9

TEACHING MODELS (best used at bedside or at the doctor station)

1. Get a commitment

One-Minute Observation6 In this model, the teacher observes a specific behavior on which to give feedback. This is especially effective for teaching history and exam skills to younger learners. DO NOT interrupt the learner.

3. Analyzes the differential diagnoses 4. Probes the teacher by asking questions 5. Plans management for the patient 6. Selects a related problem for self-directed learning

This is also known as the Microskills Model. This model is fast and effective, but takes up to four minutes. The student must first commit to a diagnosis. The process is what is important, not the answer. This is not a short lecture but a quick hit and run. Use this with more advanced learners.

2. Probe for supporting evidence 3. Teach general rules 4. Reinforce what was right 5. Correct mistakes in thought process

1. Explain the purpose of the observation to the learner 2. Select a skill for observation 3. Inform the patient of what will take place 4. Leave the room and have the learner join you when finished

Aunt Millie10 This model of teaching focuses on developing pattern recognition, e.g., if you see a person who looks like and dresses like your Aunt Millie, she is probably your Aunt Millie. This is

FastTrack_Fall2015.indd 17

9/18/15 10:24 AM

The Fast Track Fall 2015

more relevant for advanced learners or simple cases and can be combined with other models like “What if” which is covered later in the discussion.

1. Learner sees the patient 2. Case presentation (30 seconds)

What If…13 This game is useful with simple cases. Difficulty can be tailored to the learner. After a simple case is presented, ask the learner, “what if… ?“ Then change aspects of the case that would complicate it. For example, if the learner presented a simple ankle sprain you could say, “what if the patient had to fly a significant distance tomorrow,” etc.

3. Learner writes note while attending sees patient

OTHER TACTICS Activated Demonstration11,12 The teacher “activates” the learner with a specific behavior to observe. “Watch how I perform a physical exam on this 1-year old.” This is followed by a discussion of what the learner observed and areas for future study.

1. Teacher gives the learner an observation assignment 2. Learner describes what they observed 3. Brief discussion occurs and independent learning assigned

GAMES Score of the Day This exercise is good for teaching clinical diagnosis and is best with advanced learners. After the learner sees the patient, but before any testing or treatment is started, the learner writes down the tentative final diagnosis. The attending sees the patient independently and monitors the case from afar. At disposition, the real diagnosis is compared to the tentative one. Often best to have multiple learners using this on the same day to promote healthy competition.

Pick Ten This game is excellent for beginners who need help with differential diagnosis skills. Have the learner see the patient then write down a possible diagnosis the patient could be presenting. Each can only be used once. Use the following pattern:

3 POSSIBLE 3 WEIRD AND WONDERFUL 3 DEADLY

Pocket Talks (Teaching Scripts)14 Pocket Talks are short, high-yield lessons prepared beforehand and kept in your “pocket” that target a specific concept or topic when the appropriate clinical setting arises. They are recycled again with the next set of learners. Examples of teaching scripts might include pain control for a patient with a long bone fracture or which antiemetic drug to use in a given situation. Over time, seasoned educators naturally create a portfolio of these for their students.

Start a Collection Start collecting common medical artifacts that have been deidentified (e.g., EKGs or x-rays). In a short time you will have a teaching file that can challenge learners during slow periods or particularly busy times while you care for patients. It is best to keep an electronic copy that can be manipulated.

End of Shift Reflection Learning is an acquisition of knowledge, skills or attitudes. Reflecting on new knowledge helps to make it stick better so you don’t have to learn it again tomorrow. In the same way, reflecting on your behavior gives you insight that can help you to grow in your attitudes. Ask learners to reflect out loud at the end of their shift. One example is, “What did you learn today or what is one thing you would do differently?” Be known for reflecting with your learners.

Specific Feedback General feedback is not helpful in directing learner’s efforts. “Keep reading” is not nearly as helpful as, “I notice you consistently struggle with antibiotic choices.” The more specific the feedback, the more change can result from it. By understanding the basics of adult medical education you are in a position to impact not only your patients but also your learners, and those of the following generations they will teach.

1 TENTATIVE FINAL DIAGNOSIS

FastTrack_Fall2015.indd 18

9/18/15 10:24 AM

ACOEP Staff Listing

The Fast Track Fall 2015

ACOEP staff is here to help you with everything we can. Donâ&#x20AC;&#x2122;t hesitate to reach out to us with any questions, or to stop by the registration desk at the conference to say hello! EXECUTIVE The Executive Department handles reimbursements, committee appointments, and much more. Stephanie Whitmer also handles all FOEM activities including competitions, the Gala, and exhibit sales.

Executive Director Janice Wachtler, BAE, CBA Direct Line: (312) 445-5705 Email: janwachtler@acoep.org

Director, Affiliate Management Stephanie Whitmer Direct Line: (312) 445-5712 Email: swhitmer@acoep.org

Executive Assistant Geri Phifer Direct Line: (312) 445-5700 Email: gphifer@acoep.org

EDUCATION The education department handles everything from speaker agreements, to advocacy and politics. They also work closely with the Student and Resident Chapters in planning events.

Director Kristen Kennedy, M.Ed. Direct Line: (312) 445-5708 Email: kkennedy@acoep.org

Senior Coordinator for Chapter Affairs Jaclyn McMillin, MS Direct Line: (312) 445-5702 Email: jmcmillin@acoep.org

EVENTS Contact the events department to register for conferences and events, ask questions about hotels, or clarify any scheduling.

Director Adam Levy Direct Line: (312) 445-5710 Email: alevy@acoep.org

ACOEP-Staff-Listing.indd 19 FastTrack_Fall2015.indd 1

EVENTS (continued) Senior Meetings Coordinator Lorelei N. Crabb Direct Line: (312) 445-5707 Email: lcrabb@acoep.org

Education & Events Coordinator Andrea Rayburn Direct Line: (312) 445-5703 Email: arayburn@acoep.org

MEMBER SERVICES Contact member services to renew your dues, ask questions about member benefits or login instructions

Director Sonya Stephens Direct Line: (312) 445-5704 Email: sstephens@acoep.org

Senior Coordinator, Data Management Gina Schmidt Direct Line: (312) 445-5701 Email: gschmidt@acoep.org

MEDIA SERVICES The media services department manage the website, social media, brochures, The Pulse and works with students and residents on The Fast Track.

Editor Erin Sernoffsky Direct Line: (312) 445-5709 Email: esernoffsky@acoep.org

Graphic Design Manager Tom Baxter Direct Line: (312) 445-5713 Email: tbaxter@acoep.org

9/15/15 10:24 9/18/15 10:46 AM

The Fast Track Fall 2015

Taking the Next Step:

Tools to help you succeed during Internship and 4th year Sasha Rihter OMS-IV WVSOM

As students and interns trying to prove our worth, we are always on the spot. In those tough moments when we are scrambling to recall an important detail we know we learned but are just not remembering, we turn to the tools we have stuffed in our coats and pockets. We can use anything, from smartphone apps to pocket-sized manuals, for that quick glance to jog our memory and look like a rockstar when the pressure is on. Here are a few good tools that are both pocket-sized and recommended by residents and fellow students.

SMARTPHONE APPS

EPOCRATES FREE A great basic tool found in most medical students, residents, and physicians’ pockets that comes in both Apple and Android formats. This program features everything from pharmacological information to BMI calculators to current research articles, all organized in a fairly intuitive format. The current version

available for Apple, Android and

can be changed and adjusted

Kindle Fire. This app includes

by community members, so the

access to procedure overviews,

information is a guide only. The

pill identifiers, basics of disease

reference links provided are

pathophysiology, management

useful to navigate to specific

and work-up. Another great

guidelines for treatment and

feature is the Differential

disease management. This app

PEDISTAT $2.99

Diagnosis lists to help guide

does have a history of minor

Another app from the QxMD

your thinking process. There is

glitches. Keep an eye for updates

folks with a focus on pediatric

an upgraded version, available

if a problem comes up.

EM care. Although not free, this

to medical students at a

app is priceless when dealing

discounted price, which expands

with the occasional pediatric

the already great features even

emergency. A quick guide

more. (Also worth checking out

to endotracheal tube sizes,

is “MedPulse,” Medscape’s free

medication doses and a slew of

news section. This is a separate app with customizable medical news feeds for keeping up with what’s new in the medical world)

of journals available, but you

to help coordinate care across

can search by keywords, star

providers. There is an upgraded

the one most are using.

WIKEM FREE this free app follows the principles of its big brother, Wikipedia, as an open-source reference guide. The information

Another great go-to tool found in

most physicians’ phones that is

FastTrack_Fall2015.indd 20

other useful, kid-specific info, this app is highly recommended by residents. With built-in calculations based upon the patient’s height, weight or known age, this app works to minimize critical errors in high stress situations.

specific publications and save

Created by OpenEM Foundation,

MEDSCAPE FREE

search engine to help access available. There are hundreds

appropriate messaging system

$174.99, but the free version is

This is a research journal the most recent publications

is working on an HIPPA-

version with more tools for

QXMD READ FREE

is vetted by physicians who provide updates and feedback on content. As with other open-source data, this source

papers to personalized folders. Also included is a proxy login that allows you to tap into your institution’s resources through the app. A great tool for journal clubs and for keeping you up-todate on the most cutting edge research findings.

UPTODATE SUBSCRIPTION REQUIRED While not free, this is an invaluable resource for extensive background and management information on virtually every ailment clinicians

9/18/15 10:24 AM

The Fast Track Fall 2015

deal with on a daily basis. Many institutions provide their students and residents with a subscription. Check with your library or administrator for help in getting access.

PALMEM $19.99 Another costly but very useful resource recommended by several EM residents, this app is filled with great pictures, useful

10 SECOND EM $4.99 A quick and easy app for students, residents and doctors alike. Available for both Android and Apple products, this app’s claim to fame is ease of usability and covering the basics in an easyto-read format. Great pictures

guides and functional resources. Very user friendly with intuitive features, it will quickly jog your memory and show you how to succeed on your rotation with quality images and user friendly

TARASCON ADULT EMERGENCY POCKETBOOK 4TH EDITION by Dr. Steven G. Rothrock $14 A pint-sized reference used by EMS and ER docs alike. This tiny guide is packed with great

guides.

guidelines and basic information.

POCKET GUIDES

times gets difficult to understand

with the need-to-know info easy

While the print is very small and at due to many abbreviations, its usefulness as a resource

to access for quick reference.

is undeniable. It is filled with

Includes guides for all your

essential tables, lists and figures

favorite guidelines, protocols,

that can be hard to memorize but

common medications and rules.

necessary for daily practice.

Recommended by residents and

THE STANFORD GUIDE TO ANTIMICROBIAL THERAPY (Pocket Edition) $25 This is the still the definitive antimicrobial guide that every physician should be comfortable referencing. If you look around the physicians’ and nurses’ desks during your next ER shift, I can almost guarantee some edition of this little book can be found. A new edition comes out each year and is a pocket-sized reference for the antimicrobial updates for that year. Included is a fungal and viral section. This book can be a bit difficult

physicians alike for its great use

to use, so if you decide to use

every day in the ED.

this as your bug-book of choice, familiarize yourself prior to

POCKET MEDICINE by Marc S. Sabatine, MD $50.00 (Kindle version available) Guideline-based medicine with

2015 EMRA ANTIBIOTIC GUIDE $16.99 This fantastic app features a huge list of diseases and their recommended antibiotics of choice. It is updated annually so always providing the most current recommendations. Easy to read, quick to reference, up to date information, this app is highly recommended by many EM residents. As Dr. Jennifer Zernec, chief resident from Ohio Valley Medical Center explained, “I use this app daily in the ER.”

quick, easy-access notes. This book is useful for the majority of 3rd and 4th year rotations and great for internal medicine rotations during residency. The guide is not meant for studying, but for referencing current guidelines of practice. It has great references and is very well organized, but useless unless you have some background in the content being discussed. There is also an Emergency Medicine version that is great once you start residency.

scrambling when on the spot. There are hundreds of applications and pocket guides

MAXWELL’S QUICK MEDICAL REFERENCE $7.95 (Amazon) This should be in every medical student’s pocket. It’s a tiny, life-saving guide for everything from writing admit notes to doing mental exams. There’s even an EKG guide and ACLS protocol reference. With plenty of space to add your own notes in the back, this has been my companion for the past 8 years; well-worn and often used it has been a great resource. This is not an inclusive guide but a great starter for all medical students heading out on rotation

available and it is easy to get overwhelmed. The best piece of advice given by all the residents and students interviewed was to pick one of the many resources and learn to use it well. Having a book or app that you cannot

quickly reference is a waste of money and resources. In the end, do not get bogged down by the multitude of options, but find a favorite that fits your budget and level of understanding and master the tool to help you get to the next step of your career. (Disclosure: The author has no relevant financial disclosures)

GOT A GREAT EM TOOL TO SHARE? Share it with @ACOEP-SC on Twitter, or on our Facebook page!

FastTrack_Fall2015.indd 21

9/18/15 10:25 AM

The Fast Track Fall 2015

D UA L DE GRE E :

D.O., M.B.A.- A STUDENT EXPERIENCE From the Clinic to Board Room- Translating the Business of Medicine

Andy Leubitz, OMS-III OU-HCOM

At some point early in medical school, we all become excited about discussing (or sometimes bragging about) the craziest presentation we’ve seen. We become impressed with lab values that don’t seem to add up to what you’d expect to see. It becomes a medical measuring contest to see who has the craziest or most interesting case. The first student talks about their DKA patient with glucose of 750 mpd, the next says they’ll see the DKA case and raise you four different stroke patients during one shift, the next claims they witnessed a House-like Tensilon test for their myasthenia gravis diagnosis. This goes on and on and the game becomes a semi-painless board review session (note the ‘semi’ painless). Somehow everyone is on the same page, bonding over medical jokes and arguing to our textbooks over why eponyms are still used today. We get used to the language, and it is used in casual conversation, almost like a secret code to get into this members only club known as the medical world. But we sometimes forget that not everyone shares this dialect. I

was reminded of this while talking about a Hashimoto’s thyroiditis case I saw in clinic one day. I started going on about the various surgeries that that patient might need when I realized my new cohort of classmates were just blankly staring back at me. However, this was not too surprising, as I just finished my second year of medical school and decided to take a break to work on a new program: business school. These were definitely not the normal lunchtime chats my new friends were used to. I was only one of three medical students at my school to participate in the new dual degree program offered, a combined D.O. and M.B.A. degree. We first complete two years of medical school and took boards. Then we begin a one-year master’s program. When that program is complete, we return to the hospital to complete our medical training. My normal schedule of histology, biochemistry, OMM, had suddenly changed to managerial finance, accounting, and business law. The language had changed.

FastTrack_Fall2015.indd 22

9/18/15 10:25 AM

The Fast Track Fall 2015

The dual degree program is not an entirely new concept, but it is a route that more and more students are taking advantage of today. According to AACOM, thirteen out of the thirty osteopathic medical schools in the United States are currently offering a combined D.O./M.B.A. degree, and that number is expected to rise in the years to come. How do we explain this trend of students choosing to stay in school even longer? You’d think after eight years of undergrad and med school that more schooling is the last thing on anyone’s mind. Personally, I was very hesitant on

headlines, I thought it would be best to get a real grasp on what all of that meant, what it really meant, before I could take steps to help improve the healthcare system. During an interview with Dr. Peter Bell, D.O., M.B.A, of Doctors Hospital in Columbus, OH, we discussed why he had decided to go back to school and earn his M.B.A. degree. “First thing I noticed was [that healthcare] was going from a sense of abundance to scarcity (this was the 1990’s). At one time we had seemingly unlimited resources, then healthcare started to get leaner; medicine and medical education seemed to

My normal schedule of histology, biochemistry, OMM, had suddenly changed to managerial finance, accounting, and business law.

THE LANGUAGE HAD CHANGED.

pursuing another degree, more years in school, more loans (and interest), and having to learn something in which I had absolutely no background. Like many other students, my biggest concern about the program was the odd year out of the medical realm. After studying only medicine for the last two years, how would the transition back to the ‘normal’ world of college go? Would I forget everything and then show up for third year rotations with a huge disadvantage? These and other questions rattled around in my head, but after talking with half a dozen docs who also had their business degrees- either earned during medical school, right after, or twenty plus years after their residency -the general consensus was to take advantage of the “free time” I had while in school and knock everything out at once. The next question I asked myself was whether this program was right for me. There are other avenues for students looking to add to their skill sets: MHA, MPH, Bioinformatics, etc. Stemming from an interest in undergrad, I was interested in health policy and the public health aspect of healthcare. I quickly learned that many people have this same passion, to improve the system and to help people. But most any of us just did not know where to begin. With legislation such as the PPACA, Medicare and Medicaid reform, and insurance compensation constantly grabbing the

morph. It was more about regulations and compliance with policy than being creative with treatment plans. Quality was still top priority of course.” He went on to discuss how today’s system is more value-based, but the incentives for quality and innovative work are not always there. We discussed the language barrier between physicians and some of the executives managing the hospitals. The goals of the business of medicine and the practice of medicine were the same; but without speaking the same language they were taking drastically different paths. By having some doctors and other medical professionals in the boardroom with the executives, the conversation could become more productive, rather than a laundry list of quality benchmarks that medical staff had to hit so the hospital could keep its doors open. Dr. Bell affectionately called this meeting of the minds “chief” speak - doctors talking with CEOs and CFOs using a common vernacular that all parties could understand. It really comes down to understanding both the medical and business lingo. By utilizing people with experience in both the medical and corporate world of healthcare, we can set realistic expectations and guidelines that allow for quality patient care, but also allow the hospital to ‘stay in the black’ and keep the doors open.

FastTrack_Fall2015.indd 23

9/18/15 10:25 AM

The Fast Track Fall 2015

TRICKS OF THE TRADE Veronica Coppersmith, DO St Luke’s University Health Network, Bethlehem PA

Dirty Epi Drip In severe anaphylactic shock refractory to IM Epinephrine (EpiPen), the recommendation is to administer IV Epinephrine (Adrenaline) to stabilize the patient, and ultimately to start an epi drip at 1-4 ucg/min. However, when you have a patient in front of you in severe anaphylactic shock, it’s the wrong time to call pharmacy and wait for them to mix and send up an Epi drip. It’s an even worse time to realize that you don’t understand the concentrations on the different Epi bottles. “If I need an Epi drip at 1-4 ucg/min and I have Epi at 1:1000 or 1:10,000....” Those concentration calculations aren’t easy in the safety of your own home, let alone when you’re trying to figure out how to save your crashing patient. An error could prove fatal. To reduce dosage errors, just go by the mg of Epinephrine to determine dose. Code cart Epi is 1mg, itdoesn’t matter if it’s 1:1000 or 1:10,000. This is just how diluted it is, but 1 mg of Epi is 1 mg of Epi, no matter what the concentration. To get an Epi drip going on your anaphylactic patient now, why not make your own at bedside? Take the 1 mg vial of Epi (either 1:1000 or 1:10,000). Inject it into a 1L Normal Saline bag and shake it up. This results in very convenient dosing: if there is 1mg in 1L Normal saline, then there is 1mcg Epi in every mL of the Dirty Epi Drip. Label the bag “Epinephrine 1mcg/mL”. Run wide open ideally through an 18 Gauge peripheral line until the anaphylaxis is under control. An 18-gauge will run in at 20-30 mL/min, resulting in Epi being delivered at 20-30 mcg/min (same as the recommended 0.1mg Epi Q5min). You can put the bag under pressure to achieve up to 100 mcg/min, or titrate the rate with the roller-clamp as needed to stabilize the patient’s hemodynamics.

If you are trying to figure out how fast your Dirty Epi Drip will run into your patient (or how fast any IV Fluid should be running in), all the IV catheter packages list how fast the fluid will run through them (see image). For instance: 14G = 350 mL/min, 18G = 105 mL/min, and 20G = 60 mL/min. However these are the max flow speeds under pressure, and vary by needle brand. This is a known MacGyver method for a quick Epi Drip at bedside to make in a pinch, however this is not an approved treatment for anaphylaxis. Please check with your hospital supervisor before using any medication in an unapproved fashion. This trick of the trade has been discussed on several of the emergency medicine podcasts and blogs, so if you need more information or want to look into it more, feel free to browse for them! PHOTO BELOW: By Jfoldmei (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/ by/3.0)], via Wikimedia Commons

FastTrack_Fall2015.indd 24

9/18/15 10:25 AM

The Fast Track Fall 2015

Building Strong Bridges By, Erin Sernoffsky ACOEP Staff

What a cool feeling. This year’s Scientific Assembly will be the 7th one I’ve attended and some of the students I met way back in Boston are on the verge of completing their residencies. At that conference the Fast Track didn’t exist. There were no Regional Student Symposiums. No Rapid Fire Madness, social media presence or dedicated websites. I’m sure it feels long to those of you working through medical school and residencies, but seven years is a short amount of time for this level of growth. The credit for this progress is twofold—first and foremost it’s due to the dedication of students and residents, all committed to growing our College and creating lasting change. It’s also due to a partnership that I’m not sure exists in other associations. ACOEP’s staff is genuinely, personally dedicated to our members. I can attest first hand to lengthy staff meetings, conversations and long hours all centered on member feedback and the desire to provide the best services and education possible. We talk to our members, develop relationships, ask questions, pour over course evaluations, and send out surveys, all in an effort to find out exactly what you need and how we can improve.

You spoke, we listened,

AND TOGETHER WE CREATED NEW OPPORTUNITIES.

THINGS TO BE ON THE LOOKOUT FOR: New Regional Student Symposiums Dedicated online lectures created for ACOEP’s Digital Classroom Social and networking events for students and residents Wilderness Track at the Spring Seminar Online and in-person Board Review courses for graduating residents

The strength of this partnership between staff and members can be seen in the new Regional Student Symposiums, the New Physicians in Practice Track, the growing Digital Classroom, increased member benefits. You spoke, we listened, and together we created new opportunities.

Advocacy and political action training

For those attending the upcoming Scientific Assembly, I strongly encourage you to sit in on a committee meeting—insert plug the Communication and Publications committee! Come to the Welcome Reception, explore the exhibit hall and lecture room. Staff is available all day every day to answer any questions.

…and so much more!

New podcasts

If you aren’t able to join us in Orlando, always feel free to contact us in the home office. Let us know what’s working, what we can do better, and how we can continue to be a valuable partner. We depend on each other. Our dedication to our members keeps us strong. Your involvement keeps us moving forward. It really is an incredible feeling to see how far we’ve come, and to look down the road to all of the great projects we’ll take on together.

FastTrack_Fall2015.indd 25

9/18/15 10:25 AM

The Fast Track Fall 2015

A Unique Presentation of

UPPER MOTOR NEURON SIGNS IN VERTEBRAL ARTERY DISSECTION: A CASE REPORT Gabriel Hintzsche, DO, Sarah Boulos, DO, Michael Neeki, DO FACEP Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, CA

ABSTRACT Vertebral artery dissection (VAD) is a relatively rare disease1 that can present with a multitude of signs and symptoms. Here, we report a case of VAD presenting with upper motor neuron signs secondary to ischemic stroke in a 31 year old male. A review of the relevant anatomy provides insight as to the pattern of brain injury.

INTRODUCTION Cervical artery dissection is one of the most common etiologies of ischemic stroke in young and middle age patients. It accounts for approximately 20 percent of ischemic strokes. Vertebral artery dissection (VAD) is a relatively rare disease entity with an estimated annual incidence of 1 to 1.5 per 100,000 people.1 Common etiologies include minor trauma from sports and neck manipulation, major and penetrating neck trauma, and spontaneously after a seemingly trivial injury.

As reported in a systematic review from Johns Hopkins University School of Medicine of 1972 patients, VAD has a varied clinical presentation. The most common symptoms were dizziness or vertigo (58%), headache (51%), and neck pain (46%). The classic presentation of Hornerâ&#x20AC;&#x2122;s syndrome (ipsilateral meiosis, ptosis, and anhydrosis) only occurs in approximately 22% of patients with similar rates of sensory deficits and cranial nerve palsies (21%).1 Upper motor neuron signs (spasticity, hyperreflexia, Babinskiâ&#x20AC;&#x2122;s sign) have not been described in vertebral artery dissection as of this literature review. Here, we report a case of extracranial vertebral artery dissection presenting with hyperrefexia and clonus along with sensory and motor deficits.

CASE REPORT Approval for this case report was obtained by the Institutional Review Board.

FastTrack_Fall2015.indd 26

9/18/15 10:25 AM

The Fast Track Fall 2015

A 31 year old caucasian male was brought into the emergency department (ED) by emergency medical services (EMS) complaining of right upper and lower extremity weakness. The patient was found to be altered and laying on the floor. A recent history of headache was reported by family.

admitted to a left-posterior neck pain occurring immediately after lifting a box at work two weeks prior to presentation to the ED. Subsequently, he experienced a left frontal headache occurring several hours later. He then began self-medicating with aspirin 81 mg twice a day.

The patient’s past medical history was unremarkable per EMS. The only medication the patient took was aspirin and an over the counter medication containing acetaminophen, ibuprofen, caffeine a recent headache. The patient was employed at a retail department store where his job consisted of moving boxes of merchandise.

This history alerted the emergency department team to obtain a CT angiogram (CTA) of the neck and head to rule out cervical artery dissection (Figure 1). The results demonstrated a focal dissection of the right vertebral artery at the level of C3-C4 with contrast flow above the dissection and a diffusely small caliber left vertebral artery. A follow-up magnetic resonance image (Figure 2) of the brain with and without intravenous contrast demonstrated the VAD as well as an acute infarct in the left cerebellum and a punctuate infarct of the left pons and right cerebellum.

Vital signs upon arrival to the ED demonstrated a blood pressure of 127/75, heart rate 95, respiratory rate 12, temperature 98.1 ⁰F, and room air O₂ saturation of 100%. On examination, the patient was noted to be alert and oriented to person and place only with a reduced Glascow Coma Score (GCS) of 14 secondary to confusion. The patient demonstrated a right lateral gaze preference, equally reactive 3 millimeter pupils, severe dysarthria, mild right facial weakness with decreased tactile sensation, decreased grip strength of right hand as well as a right pronator drift, and decreased right hip flexion. Sensation of the right upper and lower extremities was decreased. Myoclonus was elicited on the right lower extremity. Babinski’s test was negative bilaterally. Examination of the cardiovascular, respiratory, and gastrointestinal system did not reveal any abnormal findings. As per a stroke protocol, a non-contrast CT scan of the brain was obtained within 10 minutes of the patient’s arrival. It was only significant for a lateral maxillary sinus mucous retention cyst. Laboratory analysis was significant for blood glucose of 162 mg/dL, carbon dioxide of 22 mmoles/L, Troponin I of 0.55 ng/mL, white blood cell count of 12,800 with 96% segmented neutrophils, prothrombin time 14.4 sec, INR 1.1, HbA1C 5.1%, and TSH 1.02 mIU/mL. Liver function tests, lipid panel, and all other chemistries and hematology values were within normal limits. A urine drug screen was also negative. The electrocardiogram demonstrated normal sinus rhythm and non-specific ST-T wave changes. A portable chest x-ray showed no acute abnormality. The National Institute of Heath Stroke Scale score was 10. Since the patient’s symptom onset was unknown and likely greater than 3 hours prior to arrival and he demonstrated clinical improvement during his ED course, thrombolytic administration was withheld. On re-evaluation, the patient

The patient was admitted to the intensive care unit for hourly neurologic examinations and telemetry monitoring. Anti-coagulation was discussed with the patient. Due to the risk of hemorrhagic conversion of the ischemic stroke, anticoagulation with aspirin 325 mg PO daily was chosen over heparin administration. The patient was anti-coagulated with aspirin in the intensive care unit. Despite a transient worsening of his GCS, the patient never required any surgical intervention. He was eventually discharged to a rehab facility with a moderate resolution of his presenting symptoms.

DISCUSSION The vertebral arteries course through the transverse foramina of the cervical spine and give rise to the posteroinferior cerebrellar arteries before converging to form the basilar artery. They are responsible for the posterior circulation of the central nervous system which supplies the brainstem, cerebellum, thalamus, medial temporal lobe, visual occipital cortex, and the auditory/vestibular centers.2 The most common ischemic manifestations of VAD are located in the cerebellum (as in this patient), lateral medulla (lateral medullary syndrome), and thalamus, and rarely in the spinal cord.3,4,5 Some case reports of spontaneous VAD have demonstrated pontine infarction, however, this has not been adequately described in the literature.6,7,8 Our case report describes a young adult suffering a pontine and bilateral cerebellar ischemic stroke secondary to

FastTrack_Fall2015.indd 27

9/18/15 10:25 AM

The Fast Track Fall 2015

spontaneous VAD. The patient’s symptoms included the more commonly described symptoms of headache, neck pain, nausea and vomiting as well as the less common signs of sensory and motor deficits. This patient’s motor paresis presented as signs of an upper motor neuron lesion manifested as clonus and spasticity.

FIGURES

A literature search using PubMed and Google Scholar with the key words, “vertebral artery dissection” and separate searches including each of the words, “spasticity”, “clonus”, and “hyperreflexia” yielded one case report that describes a 47 year old male suffering a C1-2 Brown-Sequard syndrome secondary to VAD with slight arm spasticity as one of the presenting symptoms.9 According to our literature search, upper motor neuron signs have not been described in the presentation of VAD with pontine and cerebellar infarctions. We postulate that thromboembolic mechanisms were the cause of this patient’s location of infarction. The location of the dissections in this patient was at the level of C3-4 on the right and, as interpreted by our neuro-interventionalist, the possible narrowing of the vertebral artery at C2 on the left. Recent literature states that ischemia from VAD can result from arterial-arterial thromboembolism, hypoperfusion, or both. However, thromboembolism is the most common cause.10 Evidence leads us to believe that clot formation from turbulent flow caused by the dissection followed by embolism to the pontine arteries arising from the basilar artery as well as the posteroinferior cerebellar artery is the most likely explanation of ischemia in this patient.

Figure 1. CT angiogram demonstrating right VAD

Pontine infarction can explain the patient’s upper motor neuron signs. Descending motor fibers from the cortex travel through the internal capsule to the cerebral peduncle of the midbrain. They travel through the pons and continue as fibers of the pyramidal tracts to cross the midline at the caudal medulla, giving way to the lateral corticospinal tract before synapsing with lower motor neurons at the ventral horn of the spinal cord. A lesion at the level of the pons is suspected to damage the descending upper motor neuron, thus exhibiting stereotypical upper motor neuron signs as our patient demonstrated.

CONCLUSION To the best of our knowledge, pontine infarction and upper motor neuron signs are rare in vertebral artery dissection. We hope to make clinicians aware of the possibility of VAD when faced with a clinical presentation suspicious for upper motor neuron lesion in a patient with neck pain.

Figure 2. Magnetic resonance angiogram demonstrating a right VAD.

FastTrack_Fall2015.indd 28

9/18/15 10:25 AM

The Fast Track

LOCATION: Palm Springs, CA

Fall 2015

Desert Regional Medical Center (DRMC)

NUMBER OF RESIDENTS: 5 currently (AOA accredited for 6 per year for total of 24; just opened with 5 interns)

ED CAPACITY: 27 beds

ED VOLUME: ~71,000 visits per year

HOSPITAL FACTS: 387 bed tertiary care center. Level 2 Trauma Center, and the only trauma center between Phoenix, Arizona and the San Jacinto Mountain pass in California. DRMC is also a comprehensive stroke center and STEMI center.

WHY DRMC ? DRMC serves the large retirement community of Palm Springs, California while also servicing the younger and often underserved surrounding communities of the Coachella Valley. Winters bring a large population of seasonal residents without local primary care that adds to dispositional complexity. The four mentioned factors provide a wide variety of patients in a busy, high acuity emergency department well-suited for training. The pathology at DRMC is second to none, providing a perfect environment to manage critically ill patients on every shift while achieving procedural excellence. The hospital is located near a major freeway and recreation areas for off-road vehicles, providing a steady stream of blunt trauma. DRMC also sees its fair share of penetrating trauma from the surrounding communities, providing well-rounded trauma training.

IN YOUR FREE TIME: Palm Springs is a well-known vacation community with excellent eateries, bars, and hotels, allowing for playtime close to work. If you are willing to drive 45 minutes you can rock climb in the world famous Joshua Tree National Park. In 1½hour you can be skiing at Big Bear Lake. A little farther, 2 hours, and you can relax on the beaches of LA County, Orange County or San Diego. If you like sports there are numerous minor league professional teams nearby and many major league and college teams as well. These teams include the LA Lakers, Clippers, Dodgers, and King;, Anaheim Angels and Ducks; San Diego Chargers and Padres; UCLA Bruins, and USC Trojans.

Things to remember: DRMC is a new developing emergency medicine training program that you can help mold to your needs as a trainee. All of the DRMC attending physicians have worked primarily in non- academic centers and will teach an evidencebased but real world approach to emergency medicine. DRMC is committed to didactic excellence with weekly lectures, monthly morbidity and mortality conferences, guest speakers, journal clubs, and plans to develop a full simulation and ultrasound program. The DRMC ED attending staff are all members of a large primarily emergency medicine group and will not only teach the practice of medicine but also the business side, which is frequently absent in training programs.

FastTrack_Fall2015.indd 29

9/18/15 10:25 AM

FastTrack_Fall2015.indd 30

9/18/15 10:25 AM

The Fast Track Fall 2015

References REFERENCES FROM PG 8:

1999;153:114-6.

1. http://osteopathic.org/inside-aoa/single-gme-accreditation-system/Pages/default.aspx

11. Wilkerson L, Sarkin RT. Arrows in the Quiver: evaluation of a workshop on ambulatory teaching. Acad Med 1998;73(10 Suppl):S67–9.

2. http://aoa-executivereport.informz.net/informzdataservice/ onlineversion/ind/bWFpbGluZ2luc3RhbmNlaWQ9NDM2NDE5MSZzdWJzY3JpYmVyaWQ9ODEyOTk1NzUx

12. Paukert, JL. Difference between novice and expert problem solving. EMF/ACEP Teaching Fellowship Program. Aug 2009.

3. http://acgme.org/acgmeweb/Portals/0/PDFs/Nasca-Community/PD_Qualifications_forWeb.pdf 4. http://osteopathic.org/inside-aoa/single-gme-accreditation-system/Pages/faq-board-certification.aspx

13. Mattu A. Education at the Bedside. EMRAP Educator’s Edition Episode Four. July 2009. 14. McGee S. A piece of my mind. Bedside teaching rounds reconsidered. JAMA 2014;311:1971–2.

5. ABEM Single Accreditation System (SAS) Frequently Asked Questions https://www.abem.org/public/docs/default-source/faqs/ single-accreditation-system-faqs.pdf?sfvrsn=26

REFERENCES FROM PG 26:

6. http://osteopathic.org/inside-aoa/single-gme-accreditation-system/Pages/faq-accreditation-processes.aspx

1. Gottesman RF, Sharma P, Robinson KA, Arnan M, Tsui M, Ladha K, Newman-Toker DE. Clinical characteristics of symptomatic vertebral artery dissection; a systematic review. The Neurologist. 2012 Sept;

7. http://acgme.org/acgmeweb/Portals/0/PDFs/Nasca-Community/Timeline.pdf 8. http://osteopathic.org/inside-aoa/single-gme-accreditation-system/Pages/faq-students.aspxaspxbWFpbGluZ2luc3RhbmNlaWQ9NDM2NDE5MSZzdWJzY3JpYmVyaWQ9ODEyOTk1NzUx

18(5):245-60. 2. Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD. Tintinalli’s emergency medicine; a comprehensive study guide. 7th ed. New York: McGraw-Hill Companies, Inc.; 2011. 1124 p. 3. Park KW, Park JS, Hwang SC, Im SB, Shin WH, Kim BT. Vertebral artery dissection: natural history, clinical features and therapeutic considerations. J Korean Neurosurg Soc. 2008 Sept; 44(3):109-15.

1. Shapiro I. Doctor means teacher. Acad Med 2001;76:711.

4. Schievink, WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar; 344:898-906.

2. McLeod SA. Maslow’s hierarchy of needs (2007). Retrieved from http:// www.simplypsychology.org/maslow.html on 3/11/15.

5. Crum B, Mokri B, Fulgham J. Spinal manifestations of vertebral artery dissection. Neurology. 2000; 55:304.

REFERENCES FROM PG 16:

3. Miller GA. The magic number seven, plus or minus two: some limits on our capacity for processing information. Psych Rev 1956;63:81-97. 4. Brown JS, Collins A, Duguid P. Situated cognition and the culture of learning. Ed Research 1989:18;32-42. 5. Krathwohl D. A revision of Bloom’s taxonomy: an overview. Theory Into practice (Routledge) 41(4):212-218. 6. Kuo AK, Irby DI, Loeser H. Does direct observation improve medical students’ clerkship experiences? Med Educ 2005;39:518. 7. Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Acad Med 2009;84:517–24.

6. Koch S, Murtaza A, Rabinstein AA, Reyes-Iglesias Y, Romano JG, Forteza A. Diffusion-weighted magnetic resonance imaging in symptomatic vertebrobasilar atherosclerosis and dissection. Arch Neurol. 2005 Aug; 62:1228-31. 7. Siegel D, Neiders T. Vertebral artery dissection and pontine infarct after chiropractic manipulation. Am J Emergency Med. 2001 Mar; 19(2):171-2. 8. Amin FM, Larsen VA, Tfelt-Hansen P. Vertebral artery dissection associated with generalized convulsive seizures: a case report. Case Rep Neurol. 2013 May-Aug; 5(2):125-129.

8. Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med 2003;78:893–8.

9. Goldsmith P, Rowe D, Jager R, Kapoor R. Focal vertebral artery dissection causing Brown-Séquard’s syndrome. J Neurol Neurosurg Psychiatry. 1998 Mar; 64(3):415-416.

9. Neher JO, Gordon KC, Meyer B, et al. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract 1992;5:419–24.

10. Morel A, Naggara O, Touzé E, Raymond J, Mas JL, Meder JF, Oppenheim C. Mechanism of ischemic infarct in spontaneous cervical artery

10. Cunningham AS, Blatt SD, Fuller PG, Weinberger HL. The art of precepting:Socrates or Aunt Millie? Arch Pediatr Adolesc Med.

dissection. Stroke. 2012 May; 43:1354-61.

FastTrack_Fall2015.indd 31

9/18/15 10:25 AM

Join EMP for a revolution. ACEP Booth 1009

Your voice matters. Make sure you have one. Own the revolution.

Learn more about the revolution. Visit emp.com or call Ann Benson at 800-828-0898. abenson@emp.com

FastTrack_Fall2015.indd 32

Founder US Acute Care Solutions. Opportunities from New York to Hawaii.

9/18/15 10:25 AM