The Fast Track Summer 2013 - Issue 07
An Emergency Medicine Publication
Fall Conference 2013
San Diego Awaits!
New Features this Issue! Pediatric Pearls
Be on your game; when it comes to kids in the ED use these helpful tips to stay smart.
Emergency Medicine Review Studying for EM Boards? Check out the amazing EM review questions by Rosh Review
The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
The Fast Track EDITORS AND PUBLISHERS Kenneth Argo Ashley Guthrie Andy Little Danielle Turrin Issue Contributors Steven Brandon Vanessa Campbell Patrick Connolly Megan McGrew Koenig John Leavens Richard Limperos Andy Little Nicholas Reis Doni Marie Segerivas
NATIONAL OFFICERS ACOEP-SC PRESIDENT Ashley Guthrie VICE-PRESIDENT Jessica Bennett SECRETARY Kaitlin Fries
Welcome to another great edition of the FastTrack! We have come upon the transition time of the year for all of us and if you are anything like me, you are wondering where the time has gone. First of all congratulations to all our fourth years who have graduated! We can’t wait to see all the great things you do in Emergency Medicine. To our second and third years taking boards if you have not taken them yet, good luck, and if you have, try to take a deep breath and relax while you await your scores. As for all you first years, three cheers for you. You have made it through what is arguably the hardest part of school. Here at the ACOEP-SC we are gearing up for the Fall Scientific Assembly in San Diego, so mark your calendar for October 5-7. We are making plans for all the great things you already love about conference such as labs, lectures, and the Student Residency Expo. Something new, I am excited to announce, we will be holding mock interviews for our fourth years in order to help you prepare for your Emergency Medicine Interviews. Be sure to check Facebook for information on sign ups!! Don’t forget we are never too busy to hear from you. If you have questions, comments, suggestions, we want to hear from you. So please contact us by Facebook, or email!
TREASURER Brent Arnold
Sincerely,
CONVENTION CO-CHAIRS Nick Bair Tiffany Pham
Ashley Guthrie ACOEP National Student Chapter President OMS IV, NSUCOM
GME CHAIR Judd Shelton PUBLICATIONS CO-CHAIRS Kenneth Argo Todd Thomas RESEARCH CHAIR Suleman Ahmed CONSTITUTION AND BYLAWS CHAIR Christopher Thomas
On the Cover: San Diego, California municiple building. The statue is by Donal Hord
page 2
Presidential Message - SC
called Guardian of the Water.
CONTENTS
Letter from the Editor...................................... 05 By Kenneth Argo
Fall Conference Schedules........................... 06-07 Student and Resident Chapters
Ultrasound Corner............................................ 08-09 By Richard Limperos
The Fast Track
Issue 7 Summer 2013
An Emergency Medicine Publication
14
10
FACES OF ACOEP
18
PEDIATRIC PEARLS
26
DISASTER TRAINING
38
CAREERS IN EM
INCIDENT IN THE COFFEE SHOP By James Hensel
Pimpology............................................................. 12 By Megan McGrew Koenig
By John Leavens
Visual Diagnosis Question............................ 13 By Patrick Connolly
Pediatric Procedural Sedation..................... 18-21 By John Leavens
Emergency Medicine Review..................... 22-23 Rosh Review
Dear Graduates................................................... 24-25
By Vanessa Campbell
By Andy Little
Visual Diagnosis Answer............................... 31 By Patrick Connolly
A Retrospective Perspective........................ 34-35 By Steven Brandon
Residency Survival Guide.............................. 36-37 By Doni Marie Segerivas
By Nicholas Reis
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
PRESIDENTIAL MESSAGE - RESIDENT CHAPTER Greetings Residents, Congratulations to all of those 4th year residents who are approaching their last resident shift ever and are about to embark on life as an attending. What an exciting time of year of year for each of you. Congratulations on all of your hard work and to the start of this next chapter of your lives. A friendly welcome as well to all of the incoming interns who will soon be obtaining their new pagers and working their first shifts on the floor. You will make a lot of sacrifices over the next four years but the things you will learn and the lives you will touch will change your life forever! In the next few months, keep your eye out for numerous ACOEP deadlines: 1. July 1st: The start of the 100% Program Challenge. This competition pits residencies against one another to see can raise the most money for research. The winning program is acknowledged at the fall conference! 2. July 31st: Fall FOEM Competition Deadlines Submit for your chance to win money and accolades. 3. September 1st: Deadline for the Fall Conference Chiefs College Whether you are a current chief or hope to one day become one, we have a special leadership training track just for you! See the ACOEP.org website for more details on all of these opportunities! Thank you to each of you and I hope you all enjoy your summers! Best, Megan McGrew Koenig, DO, MBA, MS ACOEP Resident Chapter National President ACOEP Board of Directors
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The Fast Track
Letter From The Editor
I
would like to take a moment to attempt to persuade you. This request goes out to all Osteopathic medical students with an interest in Emergency
Issue 7 Summer 2013
An Emergency Medicine Publication
Medicine. I don’t often make wide sweeping requests or attempt to appeal to the charity in others. In this case theres a mutual benefit to be had, so I’ll make an exception. I’ve greatly enjoyed working on The Fast Track for these past three issues, and look forward to putting together one final awesome issue. With the Fall Conference in San Diego approaching, my year as Co-Editor is coming to a close, and it’s because of this that I am making this request. You see it takes many people to make The Fast Track the success that it is. This includes authors, editors, photographers, and visual designers. If you or another medical student you know has skills or an interest in any of these areas, we want to hear from you. You’ll have the honor of working on a quality publication, and helping to strengthen our readership while at the same time strengthening your CV. Additionally, many networking opportunities exist as a member of The Fast Track team. So from all of us here at The Fast Track, we want you! Please feel free to contact me directly for more information. Cheers! Kenneth Argo OMS IV (kenneth.argo@okstate.edu) Co-Editor The Fast Track
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Student Events Schedule Saturday - October 5
12:30pm - 12:50pm Welcome 1:00pm - 2:50pm EMS Lab 3:00pm - 3:50pm Basic Approach to the Poisoned Pt. 4:00pm - 4:50pm Lecture 7:00pm - 9:00pm Evening Mixer
Sunday - October 6
8:00am - 8:50am Lecture 9:00am - 9:50am Lecture 10:00am - 10:50am Lecture 11:00am - 11:50am Weapons of Mass Destruction 12:00pm - 12:50pm Lunch 1:00pm - 4:00pm Student Residency Expo 4:00pm - 4:45pm Information Meeting for Students running for ACOEP officer postions 5:00pm - 7:00pm ACOEP General Membership Meeting 7:00pm - 9:00pm Evening Social
Monday - October 7
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8:00am - 10:00am Elections and Student Chapter General Membership Meeting 10:00am - 12:00pm Skills Lab 12:00pm - 1:00pm Lunch 1:00pm - 2:50pm How to Write a CV 3:00pm - 5:00pm Mock Interviews 7:30pm - 10:00pm FOEM Gala (paid event)
2013 Fall Conference San Diego, CA October 5th - 7th Look for Hotel Deals on page 25
The Fast Track
Fall Conference, October 5th-7th 2013
ACOEP-RC
Issue 7 Summer 2013
An Emergency Medicine Publication
Come join us for 3 days of Education, Fun and Entertainment in sunny San Diego, California October 5, 2013 9a-10a Jeopardy Sponsored by Rosh Review ** 10a Insiders Guide to Excelling on the Boards 10:30a Career Panel 11:45 Lunch Sponosred by Team Health 12p-1p Young Physicians Round Table 1p-3p Membership Meeting (Elections) ** 3p-5p Advanced Airway Clinic Sponsored by EmCare 7p Night Out with EMP October 6, 2013 9a-12p Resident Career Fair 12p-4p Residency Fair ** 5p-7p General Membership Meeting 7p-9p Welcome Reception October 7, 2013 9a-2p Chief’s College Sponsored by Premier Physicians 7p-10p FOEM Gala
** Attendance Required for Re-imbursement page 7
For more information visit www.acoep.org/meetings.htm
Issue 2013 Issue76Summer Spring 2013
The Fast Welcome to the ULTRASOUND Track An Emergency Emergency Medicine Medicine Publication Publication An Corner! Every issue here you will find a new article on the exciting aspects of sonography in the ED!
ULTRASOUND
for foreign body detection Richard Limperos, MD, RDMS Clinical Assistant Professor of Emergency Medicine, OU-HCOM
Ultrasound Director, Doctors Hospital Emergency Medicine Residency, Columbus, O For this article we are going to look at a frustrating problem we all encounter in the emergency department, soft tissue foreign bodies. They are a significant source of concern for both the patient and the emergency provider. They can be difficult to find and even more difficult to remove. Missed foreign bodies are also a leading cause of malpractice suits. Ultrasound can help with both detection and removal, but it is not 100% sensitive for ruling out a foreign body.
something that will transmit the ultrasound beam with no attenuation, called an acoustic standoff. This allows the foreign body and superficial tissues to be in the middle of the field of view, where the resolution is the best. Some examples of acoustic standoffs include an extra gel thick layer of gel, a 250 cc bag of saline, or when scanning a hand or foot, you can place the affected area in a water bath.
Look for an object that appears hyperechoic or brighter and whiter than the surrounding tissue. This can be challenging, because the normal skin and muscle fascia will also be hyperechoic. Other distinguishing Image A – shadowing behind a foreign body There are a few key characteristics include techniques to detect the shadowing, where the area foreign body with ultrasound. The ultrasound directly below the foreign body will be black or beam very close to the probe has an acoustic anechoic. (Image A) Another artifact that can “dead zone,” where the beam is unfocused and help distinguish a foreign body from normal has very poor resolution. Superficial foreign fascia is reverberation. Directly below the bodies will often lie in this acoustic dead zone foreign body, the bright surface of the foreign and will be difficult to detect. To overcome body will show a repetitive shadow directly page this problem, we must separate the probe posterior to the object. (Image B) slightly from the skin and soft tissue with 8
The Fast Track
Issue 7 Summer 2013
An Emergency Medicine Publication
Dr. Limperos
Ohio With time, inflammation will form around the retained foreign body. Inflammation and infection will make the foreign body easier to see, because inflammation causes edema around the object. This will appear as a black or anechoic rim or may be organized and have the same appearance as an abscess around the object. (Image C) Therefore, if you cannot see the foreign body on the first visit, bring the patient back in a few days to be rechecked and rescanned. After the foreign body is located, removal can be attempted. Even with ultrasound, getting the object out can be very challenging. Two techniques can be employed to aid in removal. With the hydrodissection technique, the anesthetic needle is inserted adjacent to the foreign body with ultrasound guidance and the anesthetic is injected around the object. This separates the foreign body from the surrounding tissue and creates a wheal on the skin indicating the area to incise. The second technique employs real-time ultrasound guidance to direct a pair of alligator forceps to the foreign body.
Image B – reverberation artifact posterior to a catheter
Image C – hyperechoic foreign body with hypoechoic purulence surrounding the object
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
The faces of th ACOEP residents partaking in
Some of our resident members on a mission trip in Honduras. Way to go!!
Would you like to find your smiling face in our next issue? Email a picture of your Student Chapter or Residency Program to acoepfasttrack@ gmail.com
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Laura Fil DO, Ault DO pose f Osteopathic M
Marla Frederick DO, Erin Robinson DO, Josh McCaughey DO during a wilderness medicine exercise
The Fast Track
Issue 7 Summer 2013
he ACOEP
An Emergency Medicine Publication
the ultrasound lab at spring conference
The Student team that won the Medical Jeopardy that was put on by the Resident Chapter
Jacob Bair DO, David Levy DO, and Brian for a picture after placing at the New York Medical Societies Research Competition.
Students being intrstucted by the faculty and residents from West Palm Beach at their Skills Lab Resident and Student officers posing at the ACOEP welcome reception in Ft. Lauderdale
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Pimpology 101 The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Top Things to Know on your EM Rotations Megan McGrew Koenig DO,MBA,MS
Q: How does an esophageal foreign body look different than one in the trachea? ESOPHAGEAL FOREIGN BODIES A: They orient in the coronal plan in the esophagus and sagittal plane in the trachea.
TRACHEAL FOREIGN BODIES I. Most commonly inhaled items: a. Nuts / food II. Most commonly lodged locations: a. Vocal Cords (adults) b. Cricoid Cartilage (children) c. In adults, FBs tend to be right sided because of the right mainstem angle; however, in children the branch is at a more equal angle so right vs left FBs a more equal III. Other details: a. Peak incidence of aspiration is in 2nd year of life b. Most airway FBx are not visible on plain films as they are often food/organic products - Cap refill >5sec - Oliguria - BUN/Creatinine elevation - Hyperglycemia without h/o DM - AMS with a GCS <11
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I. Most commonly ingested items: a. Coins (children) b. Food bolus (adults) II. Most commonly lodged locations: a. Cricopharyngeal musc. - C6 (children) b. Aortic arch - T4 c. GE junction/LES - T11 (adult) III. Medical Management a. Food Bolus - Give 1-2 mg glucagon followed quickly by swig of water to attempt to dislodge IV. Surgical emergencies a. Button batteries - If lodged in the esophagus, batteries can burn the tissue within 4 hours and cause per foration within 6 hours. - if the FB has passed into the stomach, the pt can be observed. -If at 48 hours the battery hasnâ&#x20AC;&#x2122;t passed the pylorus or there are GI symptoms, then it needs to be removed. b. Size - objects larger than 2x5cm will not pass on their own c. Sharp - some sharp objects have passed on their own without perforation, but this is a pt that should be admitted to for evaluation for surgical removal V. Other details a. 80% of ingestions are by children
For more quick, easy, factual pimp question information dont forget to check our Pimpology 101 in our next issue of the Fast Track......
The Fast Track
Visual Diagnosis
with Patrick Connolly, DO
Issue 7 Summer 2013
An Emergency Medicine Publication
A 71 y/o male with a chief complaint of shortness of breath and cough which had been ongoing for one month. He states that in the past few weeks he had pain across his chest and pain in his lower back. He reports no prior history of similar pains or a history of back problems. Patient describes the pain as sharp and stabbing. He states he has been taking NSAIDS for the pain with mild relief. He also states that he hasnâ&#x20AC;&#x2122;t been to a doctor in at least 25 years. The patient denies any recent trauma. Are you looking to enhance your ability to match at the residency of your choice? Then make sure you plan on attending the ACOEP Scientific Assembly in sunny San Diego, CA. There youâ&#x20AC;&#x2122;ll be abe to meet with students from around the country, attend student specific lectures and take part in the resident fair, where EM programs from around the country will be present to meet you and answer any questions. To register visit www.acoep.org today.
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Incident in the Coffee
T
his year, my soon to be OMS-III medical school class had the pleasure of taking “Basic Life Saving” and “Advanced Cardiac Life Saving” two weeks after the spring semester wrapped up. Which means, we got to use two “precious board studying
days” to take those classes. Needless to say, the general attitude about the classes’ scheduling was less than excited. Yet, when does any medical student find themself thinking “Oh, perfect timing!” when a BLS/ACLS class is scheduled? I was kind of excited about ACLS because I had never taken it before. However, I had taken BLS a few times. I will openly admit that in the few times I have taken BLS classes, I have not had the most eager attitude during the whole ordeal. My mind would often drift, and I would think about what I would rather be doing; only being sure to grasp the “important details” of what seemed to be easy and straight forward material. I may be sticking my neck out on this one, but I don’t think I am the only medical student
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who has felt this way.
The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
e Shop
by James Hensel OMS III
The performance exam of the BLS class involved, as you all know, responding to a person who has been found down on the ground in a public setting. As testing proceeded, small groups of students would run through the motions eager to get out of class.
I remember
hearing someone say, “This isn’t how we are going to find our patients…” Again shamefully, this is a sentiment I shared up until a couple of weeks ago. I was four days away from taking my Step One COMLEX, and I was searching for a new study spot to keep me going with a change in scenery. My wife and I live just outside “Small Town, USA” and have driven by a “Coffee and Antiques” shop that I thought I would
On the ground was an elderly woman lying motionless
check out that day. Upon walking into the shop I quickly became aware it was more an antique’s shop, and not so much a coffee shop. I almost turned right around and walked out, but I decided to take a lap around what appeared to be a vacant antique shop. Still having hopes of finding a cup of coffee, I carefully looked around the front counter hoping to see coffee shop equipment I could wait on. As I was about to dejectedly head back home to read, coffeeless, I took one more glance behind the counter and froze in my tracks. On the ground was an elderly woman lying motionless, not sleeping. After a few eternal seconds of frozen disbelief, I went into an autopilot mode I didn’t know I had. I threw open the gate of the counter and tried waking this poor woman, who was already gray in color and whose hands were cool to the touch. I confirmed a lack of breathing a pulse, and with one locked arm and my core strength began chest compression cycles while calling 911 with my other hand (I was completely alone in this store). page 15
The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
While on the phone with the dispatcher, I remember being surprisingly collected. I reported I was with a woman who I found not breathing without a pulse. I explained exactly where I was, even though that was my first time to set foot in that store. Within minutes the professionals were on the scene, and took over. They seemed grateful that, one - someone had been there, and two – that someone had started basic lifesaving. While waiting to talk to the police and investigators who invariably showed up, I watched carefully hoping to see that I had unknowingly found this woman in ventricular fibrillation, and that a good “shock” would bring her back to life. Sadly, she had no rhythm that could be defibrillated, and after a few cycles of CPR and rhythm analysis, she was whisked away to the hospital down the road. After speaking with the police and letting them know I was just a passerby who happened page 16
to find this unfortunate woman (who could have easily not been seen by someone
The Fast Track
not desperate for coffee) and who happened to be a medical student who knew basic lifesaving, I went home and called my parents. That’s what you should do if/after you
Issue 7 Summer 2013
An Emergency Medicine Publication
find a person on the ground like that, call your parents. While speaking with my dad, he explained to me that it wasn’t only a good thing that someone (me) discovered that woman, but that it was significant that I, a trained medical student, discovered this woman. Someone else with no clue of what to do beyond yell for help and call 911 in a panic could have been the first on scene. Yet, it was me, who had just jadedly sat through a BLS class, who provided this lady a shot at survival. Later that day, I was able to find out that the poor woman did not pull through. I was saddened, but not too surprised. It would have been easy to feel that my and others’ efforts were all in vain, but I thought about something my mom told me (now you see why you should call your parents). If anything, my actions provided comfort to the family of the woman by letting them know that as soon as she was found someone took action to save the life of their mom, wife, sister, etc. They can know that she was not just found and declared dead at the scene. When I take a step back and think about it, it is kind of odd that so many of us (me included) can have a jaded attitude about a class whose title literally describes why we want to become doctors. My experience that day opened my eyes. For one, I became VERY thankful for the training I have received and will receive, especially the previously groaned about BLS class. When I was able to think back to what happened during that 15 minute blur, I realized that it was the BLS class that provided me the “emergency autopilot mode” I had that day. The events of that day also showed me that we as medical students are not just going to be doctors in hospitals and clinics. We will be doctors wherever we go. This means that even the simple things, like BLS classes, should be taken seriously. We very well may be called upon when we least expect to be.
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Issue 2013 Issue76Summer Spring 2013
The Fast Welcome to Medicine the PEDIATRIC Track An Emergency Emergency Medicine Publication An Publication PEARLS! Every issue here you will find a new article on the some of the Do’s and Don’ts of taking care of kids in the ED!
Pediatric
Procedural Sedation John Leavens, MD Clinical Assistant Professor of Emergency Medicine, Good Samaritan Hospital It is often necessary for emergency physicians to administer procedural sedation and analgesia to patients 18 years of age or younger for conditions involving pain, anxiety or both. Children may not be able to verbalize their fear and pain, so it is even more crucial that they are optimally sedated and provided pain relief. Due to the complexity of procedural sedation in the pediatric population, guidelines have been issued by the American College of Emergency Physicians (ACEP), the American Academy of Pediatrics (AAP) and the American Society of Anesthesiologists (ASA).
include: oral and nasal airways, laryngoscope blades, tubes, stylets, and laryngeal mask airway [LMA] devices), Pharmacy (the drugs for sedation and analgesia and their antagonists, as well as basic emergency drugs like atropine and epinephrine), Monitors (preferably including ETCO2), and Equipment (ex. defibrillator).
ACEP guidelines suggest the use of sucrose for minor, painful procedures for infants less than 6 months old. Oral sucrose can be used to reduce signs of distress due to a minor, painful procedure in preterm and term neonates (less than 28 days old). Sucrose appears to be less effective Preparation for sedation in infants between 1 month A forearm fracture requiring procedural sedation and 6 months of age. Oral and analgesia is even more important in sucrose should be given pediatric sedations due to a greater range in approximately 2 minutes before an invasive equipment sizes and availability. The AAP offers procedure. The appropriate sucrose solution a mnemonic that is applicable to all ages of can be placed on a gauze and then into a children and levels of sedation. The mnemonic baby’s bottle nipple to avoid overdosing and “SOAPME” stands for Suction (both Yankauer and hyperglycemia. Facilitative holding (swaddling suction tubing), Oxygen (as well as the optimal the child with extremities flexed), kangaroo page means of providing it), Airway (available properly care (patient held tight to the parent’s chest), or 18 sized devices for positive pressure ventilation to breastfeeding are additional ways to comfort
The Fast Track
Issue 7 Summer 2013
An Emergency Medicine Publication
an infant during an invasive procedure. Infants and young children are more likely to have airway obstruction during sedation due to a relatively larger tongue, epiglottis, and occiput. Patients should also be evaluated for tonsillar hypertrophy and its resultant obstructive sleep apnea, because children with these problems are more likely to obstruct their airway with milder forms of sedation and should receive less sedation/analgesia. Loose teeth may also pose a particular problem with the pediatric patient. Children desaturate more quickly after apnea than even moderately ill adults, due to their higher metabolic rates, compliant chest walls and tendency towards early fatigue.
This child may benefit from sedation during bedside drainage of this empyema
The most common complication of ED sedation in children is hypoxia. Children may not tolerate a mask or the nasal cannula, but with blow-by oxygen at high flows (6-8 L/ minute in patients less than 2 years of age, and 8-10 L/minute for those 2 years of age and older), a comfortable increase in FiO2 can be achieved. The majority of hypoxic episodes can be treated with nothing more than repositioning of the head. A shoulder roll for the small child, a chin lift, manually opening the mouth, and the use of the oral/nasal airway all will help to reestablish airway This foriegn body (piece of an earing) was removed under patency. It is essential that the practitioner procedural sedation after failed attempts with local only
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The Fast Track An Emergency Medicine Publication An Emergency Medicine Publication
Issue Summer Issue 67 Spring 20132013
have a familiarity with the sizing of airway adjuncts and the appropriate dosing of reversal agents prior to the sedation. The BVM and LMAs are excellent rescue devices for the pediatric patient just as they are for the adult. Both ASA as well as AAP guidelines recommend consideration of the administration of supplemental oxygen for moderate and deep sedation. Continuous quantitative endtidal CO2 monitoring should be used to avoid unrecognized apnea and hypoventilation. Clinical assessment alone does not identify hypoventilation as frequently as capnography and it may not identify all patients with apnea. If capnography is not available, it is critical to maintain vigilant assessment of frequency and depth of respirations by a practitioner whose sole responsibility is to monitor the patient. Dissociative sedation with ketamine may be the easiest and most efficacious means of sedation and analgesia in the pediatric ED. The pre-adolescent patient does not have to be premedicated with midazolam to prevent emergence delirium. Ketamine is safe to use without anti-sialogogues (such as atropine) for the sedation of older children and for those not having oropharyngeal procedures. If premedication is used, the best candidate is probably ondansetron, which may be added to ketamine to decrease the incidence of vomiting. Etomidate or propofol, when combined with an analgesic such as fentanyl, can provide deep, brief sedation. Myoclonus is a dose dependent side effect of etomidate that can be ameliorated with a pretreatment dose of .05 mg/kg etomidate or with either a pre- or postetomidate dose of 0.015 mg/kg midazolam. Nitrous oxide at 50% concentration can be used with concurrent local anesthesia for safe and effective procedural sedation in healthy children undergoing painful procedures. A gas scavenging system should be used for protection of health care providers. Nitrous oxide may be combined with other sedative analgesic agents to augment sedation, but patients receiving these combinations should be carefully monitored for deepening sedation, possible respiratory depression, and other adverse events. Nitrous oxide may be less effective in reducing procedure-related distress in younger children compared with older children.
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Chloral hydrate may be used to provide effective procedural sedation in pediatric patients undergoing painless diagnostic studies. However, children receiving chloral hydrate should be properly monitored due to the risk of respiratory depression and hypoxia. Chloral hydrate should not be considered a first-line agent in children older than 48 months because of decreased efficacy as compared with younger children. Chloral hydrate
The Fast Track
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An Emergency Medicine Publication
has the potential for re-sedation and may produce residual effects up to 24 hours after administration. Chloral hydrate may be used safely and effectively in properly monitored children who have congenital cardiac anomalies and are undergoing painless diagnostic procedures. Chloral hydrate should not be used in children with neurodevelopmental disorders due to an increased incidence of adverse effects and decreased efficacy as compared with healthy children. Pediatric patients receiving chloral hydrate should not be intentionally fasted because of increased procedural sedation failure rates. At this time, no universally applicable evidence based set of clinical indicators has been established to determine safe discharge after pediatric procedural sedation. Emergency physicians, in conjunction with their institutions, must develop criteria for safe discharge. ď&#x192;&#x152;
References: 1. Gross JB, Bailey PL, Connis RT, CotĂŠ CJ, Davis FG, Epstein BS, et al. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. (Clinical guideline) 2. Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, Marett BE, Moore J. American College of Emergency Physicians. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005;45(2):177-196. (Clinical guideline)3. American Society of Anesthesiologists, Ambulatory Surgical Care Committee. Statement on the safe use of propofol. Approved October 27, 2004. http://www.asahq.org/ publicationsAndServices/standards/37. Accessed May 17, 2007. 4. Mace SE, Brown LA, Francis L, Godwin SA, Hahn SA, Howard PK, Kennedy RM, Mooney DP, Sacchetti AD, Wears RL, Clark RM. EMSC Panel on Critical Issues in the Sedation of Pediatric Patients in the Emergency Department. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. Ann Emerg Med. 2008;51(4):378-399, e1-e57. (Clinical guideline) 5. American Academy of Pediatrics, Committee on Drugs. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum. Pediatrics. 2002;110(4):836-838. (Clinical guideline)
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Emergency Medicine Review with 1. Which of the following is the classic metabolic disturbance seen in aspirin toxicity?
A. Metabolic acidosis B. Mixed respiratory acidosis and metabolic alkalosis C. Mixed respiratory alkalosis and metabolic acidosis D. Mixed respiratory alkalosis and respiratory acidosis
Find more questions like these by visiting roshreview.com
2. What is the most common presentation in a patient diagnosed with an abdominal aortic aneurysm?
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A. Asymptomatic B. Back pain C. Flank pain D. Hypotension
3. Which of the following statements is true regarding appendicitis?
A. An appendicolith is identified in the majority of cases of appendicitis B. Leukocytosis is seen in the majority of cases C. Perforation is rare in patients younger than 2 years D. The presence of an appetite makes the diagnosis unlikely
4. Which of the following supports the diagnosis of biliary colic?
A. An ultrasound that shows an empty gallbladder B. Pain that is relieved by eating food C. Radiation of abdominal pain to the lumbar region D. Steady abdominal pain localized in the right upper quadrant
5. Which of the following is the preferred imaging study to diagnose acute diverticulitis?
A. Barium enema B. CT scan C. Endoscopy D. Plain abdominal film
The Fast Track
Review Answers Question 1: Answer C. Ingestion of small quantities of salicylate stimulates the central respiratory center leading to respiratory alkalosis, which is the initial metabolic disturbance. However, at toxic levels, salicylates interfere with the Krebs cycle and lactic acid is produced leading to an anion gap metabolic acidosis. Therefore, the classic metabolic disturbance is a mixed respiratory alkalosis and metabolic acidosis. In patients who are hypoxic, salicylate-induced non-cardiogenic pulmonary edema should be considered.
Issue 7 Summer 2013
An Emergency Medicine Publication
Question 2: Answer A. Most abdominal aortic aneurysms (AAA) are picked up incidentally on physical examination or imaging studies, such as ultrasound or CT scan, that are being done for other reasons. These patients are usually asymptomatic. It is estimated that up to 3% of men older than 50 years of age have an occult AAA. Most aneurysms greater than 5 cm can be palpated; however few are associated with an audible bruit. The risk of rupture for AAAs <4cm is minimal. However, once the diameter is greater than 5 cm, the risk of rupture increases and consultation with a vascular surgeon is warranted. The greatest risk of rupture is seen in rapidly expanding AAAs. The classic triad of a ruptured AAA is pain, hypotension, and a palpable pulsatile abdominal mass. The associated pain is usually in the abdomen, back, or flank and can mimic other common conditions such as renal colic, constipation, and musculoskeletal back pain. Bleeding from rupture is typically is retroperitoneal. The diagnosis can be made by bedside ultrasound, which has a high sensitivity for detecting AAAs. However, ultrasound poorly detects rupture due to bleeding into the retroperitoneum. A CT scan is highly sensitive for detecting AAAs and rupture and is the test of choice in hemodynamically stable patients. Question 3: Answer C. Appendicitis is the most common surgical cause of abdominal pain. The highest incidence occurs in patients 10 to 30 years of age, although the highest misdiagnosis rate is in infants and elderly due to atypical presentations. Leukocytosis (>10,000/mm3) occurs in up to 96% of patients diagnosed with appendicitis. The primary inciting event is obstruction of the appendiceal lumen, most commonly from an appendicolith. Obstruction leads to increased intraluminal pressure and distention of the appendix (visceral pain / periumbilical pain). Increased distention leads to vascular compromise of the appendiceal wall and bacterial invasion leading to localized peritoneal inflammation (somatic pain / RLQ pain). Question 4: Answer D. The term colic is misleading in the diagnosis of biliary colic. Most patients with biliary colic complain of a steady pain, not colicky, in the right upper quadrant or epigastrium. The pain of biliary colic is thought to be caused by contraction of the gallbladder, with transient obstruction of the cystic duct or common bile duct by the stone. With continued obstruction, inflammation of the gallbladder wall leads to cholecystitis. Physical exam in biliary colic usually reveals mild tenderness to palpation in the RUQ. Lab tests are usually normal. The diagnosis is made clinically and by demonstrating stones in the gallbladder on ultrasound. Plain films have limited role to detect gallstones because less than 10% of gallstones contain calcium. Management is usually supportive. Question 5: Answer B. CT scan is the preferred imaging study to diagnose acute diverticulitis. CT has the advantage of evaluating the colon and the structures around it, so it can make the diagnosis of diverticulitis, simultaneously evaluate the extent of disease, and identify complications such as abscess and bowel perforation. Findings on CT consistent with acute diverticulitis include the presence of diverticula, inflammation of pericolonic fat, thickening of the bowel wall to more than 4 mm, free abdominal air, and abscess. The sensitivity of CT for the diagnosis of diverticulitis ranges from 69% to 95%, while the specificity ranges form 75% to 100%.
Find more questions like these by visiting roshreview.com
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Dear Graduates, Congratulations!! This little note finds each of you having achieved something great and stupendous. Some of you have graduated from medical school while others of you have completed your residency in emergency medicine, both are truly amazing when you think of all of the time, effort and sacrifice you have been through over the past several years. This should come as no surprise, but you have truly ascended above your peers and have done what few if any would ever consider or even attempt. Over the past few months you’ve counted down, whether it be on Facebook, via email or in your passing’s by. And now you find your self at a new phase in life, a new challenge, and a new summit to climb. But God willing you will continue to succeed in your future endeavors as you have in the past. For those graduating from medical school, I say good luck! I hope you’ve enjoyed the parties in your honor and the pats on the back because if there is one thing intern year has to offer, it is very little of that. The next year will be the year where you truly define what kind of resident and emergency physician you are going to be. A lot will be asked of you, and only you will have a say in how hard you work, how much you study and how well you get along with others (basically its all on you!). Know that your senior residents are there to help you, some by giving encouragement, and others by letting you know where you stand and how much you have to learn. Know that your attending physicians will not all be amazing teachers, in fact few will be, but each will practice in a style all their own, convey knowledge the best way they know how and that in fact will teach you as much as anything else. For our graduates about to take on the role of attending physicians, I for one look forward to being in your shoes, yet know I’m still lucky enough to have a few more years to get there. My only piece of advice to you is to take great care of people, keep learning and finally remember how you got to where you are currently. Whether each of you like it or not, you got here with some help. It might have been very little, but there were people in your life helping nudge you here, polish you there. If your mentors where like mine, they became surrogate parents, siblings and some of my best friends. Please remember these individuals, and above all become one for someone else. In medicine we currently stand at a crossroads, where we currently have far more students looking for help, than we have people to mentor and guide them. So I ask that each and every one of you, call up your medical school, email your residency coordinator or go to the ACOEP’s mentor page and enlist yourself in the cause of tomorrow, the cause or mentorship. Myself and many other residents and students have benefited by fellow members of this profession taking the opportunity to become a mentor, so I ask you to do the same. Sincerely, A Friend.
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Program Spotlights... If you havent had the chance to check out the NEW AOA approved EM programs, please take the time to check these out: Comanche County Memorial Hosp - Emergency Medicine Residency Adena Health System - Emergency Medicine Residency
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Issue 7 Summer 2013
An Emergency Medicine Publication
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Hotel Deal Close to Conference!! Sheraton Suites San Diego at Symphony Hall 701 A Street San Diego, CA 1-800-962-1367 Info: $150 per night (plus tax) King/2 double Suite room Group: American College of Osteopathic Emergency Physicians
Only 10 blocks from the Conference Center San Diego Bay Views Near the Gas Light District
*Cancellation policy: In the event of a cancellation less than 90 days prior to arrival, liquidated damages in the amount of 50% of the sleeping room revenue will be due, plus applicable taxes and service charges. *Must reserve by September 4th 2013 page 25
The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
G
rave events have ravaged the United States so far during 2013. In April, two bombs exploded at the Boston Marathon. Three people were killed and countless
more injured. In May, an EF5 tornado ripped through Moore, Oklahoma. 24 people were killed and hundreds more injured. Currently, in June, the Black Forest fire rages through Colorado. Over 400 homes have burned down so far and the fire is still not contained. These tragic events were unexpected and sudden, requiring swift responses by personnel trained to deal with disasters.
A
disaster is defined as; a sudden catastrophic event bringing excessive damage, loss, or destruction. A mass casualty incident is defined as; any event where
resources, such as personnel or equipment, are overwhelmed by the number and severity of casualties. These events often go hand-inhand. Both disasters and mass
Preparing for th
disaster training durin
casualties require responders to be quick thinking, adaptive, creative, assertive, and cool under pressure. These qualities are also highly regarded in the physicians who practice medicine in the emergency room.
E
mergency medicine has a natural correlation to disaster medicine, but any physician on the scene will be looked to as a leader in a mass casualty situation.
This includes doctors in multiple specialties and situations in and out of the hospital. Therefore, training to deal with disasters during the medical education process will benefit you as a healthcare provider in addition to the community you serve. Preparing for disasters could occur at every step of medical training, but some are getting a head start and including this training as part of the medical school curriculum. Rocky Vista University College of Osteopathic Medicine (RVUCOM) in Parker, Colorado, hosts a National Disaster Life Support Foundation course for all students before venturing out on third year rotations.
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T
he schools dean, Bruce Dubin, DO states, “Since 2011, we have recognized the need for physicians to train in the methodologies of disaster response. Whether they are
natural events (hurricanes, tornadoes, earthquakes, floods, etc.), or the result of human
Issue 7 Summer 2013
An Emergency Medicine Publication
interaction (bioterrorism, chemical spills, explosions, etc.), physicians are participating in multidisciplinary response teams that are highly coordinated and demand broad understanding of the precepts necessary to provide a good disaster response.” Mass casualty training is not only for the safety of the patients involved, but the team providing that care. He goes on to explain, “A physician responder who has not been trained appropriately in disaster response runs the risk of becoming more of a hindrance or even worse, another victim. A highly trained physician, as part of a disaster team, can provide
he unexpected:
ng medical education by Vanessa Campbell OMS III
highly skilled resources and help ensure positive disaster response. Because medical students are often on the scene when many natural disasters occur, the Rocky Vista
University requires all students to become certified in both basic and advanced disaster support. This is a regular part of our curriculum.”
T
he American Medical Association endorses the National Disaster Life Support Foundation
(NDLSF) as the training program for health care professionals and emergency response personnel for mass casualty events. Information on this program can be found at their website, www.ndlsf. org. The NDLSF courses include Core Disaster Life Support (CDLS), Basic Disaster Life Support (BDLS), and Advanced Disaster Life Support (ADLS). Topics covered include surveying your situation, organizing mass triage, medical decontamination, legal implications of disaster medicine, utilizing the media and emergency resources,
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and more. Courses are held all over the country throughout the year. You can sign up for courses online or organize a course to come to you at your home institution.
P
reparation for everything unexpected is not realistic, but preparation for something things in the face of the unexpected is. While the lecture series in the NDLS courses
are helpful, by far the most exciting part of this training program comes at the conclusion of the ADLS course in the form of a half-day mock disaster situation complete with sound effects, smoke, walkie-talkies, and actors in full moulage. These actors not only look convincingly real, but act out their role intensely while screaming, running, and distracting.
A
lexander Ryan, a 4th year medical student at RVU, says, “the mock disaster at the end not only gave us a chance to apply the skills we had learned, but gave us insight as
to what can go wrong and how to think on your toes when you’re presented with a mass casualty incident. ADLS was useful because it gave us extra knowledge of what to do in an emergency situation, which can happen at any time. It gives us a leg up.”
E
veryone in medicine knows practice makes perfect is not just an empty phrase. “Being able to properly assess and manage a mass casualty situation revolves around
being as prepared and as exposed as possible. Whether these exposures are mock or real life scenarios, the adrenaline-hyped tempo of disaster situations takes some getting used to,” said Regan Stiegmann another 4th year student at RVU. page 28
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M
edical school is not the only
time to utilize disaster
Issue 7 Summer 2013
An Emergency Medicine Publication
training. It can occur during residency in the form of a quick NDLSF course or afterwards in the form of a fellowship. There are roughly 15 ACGME fellowships in disaster medicine. A list of these programs can be found on the Society for Academic Emergency Medicine website at www.saem. org. There are currently no AOA disaster medicine fellowships. If you want to know if a residency program you are looking into for emergency medicine incorporates any disaster-training course into their curriculum, you will usually need to look beyond the websites and contact the program directly. If you attend a residency that does not train in disaster medicine, talk with your program about attending or hosting a course.
W
hether you have taken a course or completed a fellowship, disaster training can provide career opportunities at local, state, national, and international levels.
And equally importantly, disaster training prepares you and your community for the unexpected.ď&#x192;&#x152; Photo credits: Michael Waring, OMS-III, RVUCOM page 29
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An Emergency Medicine Publication
Issue 7 Summer 2013
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Visual Diagnosis Answer
with Patrick Connolly, DO
Issue 7 Summer 2013
An Emergency Medicine Publication
Exam of the patientâ&#x20AC;&#x2122;s aorta with the bedside ultrasound showed a dilated Abdominal Aortic Aneurysm with large thrombus within the lumen. The line only measures the open lumen (3.56cm); you can see there is almost 3.5cm of thrombus residing in the lumen. The patient remained in stable condition. He was sent for immediate CT scan of the Abdomen and Pelvis with contrast. The impression was: HUGE INFRARENAL ABDOMINAL AORTIC ANEURYSM MEASURING AT LEAST 9 CM IN DIAMETER. ABUNDANT, ECCENTRIC INTRALUMINAL THROMBUS WITHOUT EVIDENCE OF LEAK OR RUPTURE. BIFURCATION VESSELS ARE NORMAL IN CALIBER WITH SOME ANEURYSMAL DILATATION OF THE COMMON ILIAC BIFURCATION ON THE RIGHT MEASURING 3 CM. THERE IS NO EVIDENCE OF DISSECTION In all the patient was diagnosed with new onset atrial fibrillation with RVR, 9cm AAA, extensive lung disease in the pleural and parenchyma with malignant appearing mediastinal adenopathy, and widespread metastatic osseous and liver lesions. page 31
Chiefâ&#x20AC;&#x2122;s College The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Presented by the ACOEP Resident Chapter October 7th2013 San Diego, CA
Are you a current Chief Resident at an AOA Emergency Medicine Residency? Are you looking to find ways to excel, find your nitch or learn to navigate the political process? Need Help with your CV? Then you need to join the ACOEP Resident Chapter this October for the 1st annual Chiefâ&#x20AC;&#x2122;s College where we will be learning the above from some of the Brightest minds in Emergency Medicine. Our speakers include: Jeff Greenspan MD Eric Snyder MD Kevin Klauer DO, JD To register visit the link below today!!
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www.surveymonkey.com/s/WSHWJPZ
The Fast Track
Issue 7 Summer 2013
An Emergency Medicine Publication
Q: What is the most common finding in patients with chronic salicylate toxicity? A: Change in mental status associated with weakness, tinnitus, lethargy, confusion, drowsiness, slurred speech, or seizures.
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
A Retrospective
Perspective
by Steven Brandon, D.O.
“I’m sending one of you to an AMA conference where you will eat free food, stay at a nice hotel and try your darndest not to embarrass this hospital.” -Dr. Bob Kelso, from Scrubs television show
Free food and nice hotels, Dr. Kelso is spot on with that assessment of conference attendance. However, there are many other things to do at medical conferences aside from not embarrassing your hospital. I’d like to take this opportunity to expound upon what Dr. Kelso mentioned and talk about the benefits of conference attendance. Do you hate paying for pens? Me too! Well it is a scientific fact that attendance at one
and resident chapters of the ACOEP have their elections. I strongly encourage you to look into that, the benefits are endless. There are also committee meetings at each conference at which they would be more than happy to have younger people involved, you’d be amazed at how valuable your insight and opinions are to those committees. Additionally the Foundation for Osteopathic Emergency Medicine (FOEM) sponsors many student and resident competitions. And these competitions are easy to enter. Did you see at least one interesting case in the entire last
Conference attendance will help you get into residency. national conference will get you enough free pens to last at least one year. Life as a student is tough and stressful, and attending a conference is a great way to start enjoying this career you have chosen. Conference attendance is really the best way to get involved in your profession. Between committees and board member positions, there are so many opportunities for ANYONE to get involved. With days full of activities and lectures, you can’t help but grow professionally. Every fall the student page 34
year? Of course you did. Just write it up and submit it. That was actually how I first became involved with the ACOEP two years ago and I have never looked back. It is also be a great resume builder to say you have presented a case at a national conference. Conference attendance will help you get into residency. There, I said it. And let’s be honest, as a student this is what you are most interested in. I cannot over-emphasize the value of the networking opportunities
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at conference, and this is coming from someone who always hated the idea of networking. Consider the people who always attend these conferences, those who are most involved in the profession, the college, and yes, residency programs. Program Directors (PDs) like students who will become productive residents. When they see a student going out of their way to
Issue 7 Summer 2013
An Emergency Medicine Publication
Don’t underestimate the value of your exposure to current residents. attend a conference and participate, it makes a great impression that they will remember. And PDs usually attend these conferences, so go up and introduce yourself. A conference is a more relaxed setting in which they will be more likely to have time to talk and get to know you. And the same could be said for anyone who might be a core faculty member at a residency. Don’t underestimate the value of your exposure to current residents. There are can be over 100 residents at these conferences. They are the people who are most in tuned with what you are going through as a student. Pick their brains, they each have an abundance of unique advice about the whole residency application process. During my application process, the most valuable advice came from residents at the time. Both ACOEP and ACEP have annual residency fairs for students to attend. These are such great opportunities. Here you have a room full of PDs and their residents who are all SUPER eager to talk with you about yourself and their program. I definitely received at least one interview because of my interactions with a resident at a residency fair I attended as a student. If you come across someone at a conference who you think could be a good source of information, you should get their contact information. After meeting and talking with them, just ask if you could have their contact information. Tell them you would appreciate being able to contact them in the future to get their advice. (Again do not underestimate how valuable even a resident can be.) Then you email them after the conference thanking them for their time and that you look forward to contacting them in the future for advice. And just like that, after attending only one conference, you have had two significant interactions with someone new who can potentially provide you valuable insight and help in the future. This is such an easy thing to do, especially at ACOEP conferences. We are such a close knit group that there’s more opportunity to meet key acquaintances.
Enter shameless plug for the next ACOEP conference here:
Okay it’s in San Diego, and that should be all you need to hear. It is in just a few months, October 2013. Just imagine how great it will feel relaxing on the beach after you have met tons of great people, some of whom can help you in the pursuit of your dream residency. I’ll see you there! page 35
The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Residency Survival
by Doni Marie Segerivas D.O. - Good Samaritan Hospital Medical Center
A
s my Emergency Medicine residency comes to an end I’m approached by my juniors who continuously ask, ”Do you have any advice on how I can make the best of my remaining years?” After thinking about my prior years, I came up with a few things…
The first year of residency will be brutal. It is long hours and the responsibility has shifted onto your shoulders. You’re going to meet new people with different personalities. Lack of sleep, long hours working, and minimal social life can stack up to stressing you out. To make the best out of it, here are some useful tips: Be yourself! Be enthusiastic and show your sense of humor. Working in the Emergency Department is a hard job and most people appreciate a little levity. This of course is harder said than done, but try to stay positive and kill people with kindness. No matter what time of day or night, no matter how many hours you have worked straight, be polite and respectful. This by no way means to allow people to walk over you. Be firm, yet respectful when need be. However, politeness will go a LONG way and this will set you apart from your other colleagues. Keeping this precedent will also create a standard for your juniors to follow which aids in a teamwork mentality. Communicate! As physicians, some of us get into this mindset of writing orders and not communicating with our nurses. In a busy Emergency Department, simply mentioning an important order to your nurses will go a long way. Don’t be that doctor that puts in an order STAT and wonders why it wasn’t done an hour later. Telling your attending, “Well, I put in the order” isn’t going to fly when both of you knew how imperative it was to get it done. If your staff is busy with other assignments, take care of it yourself. Don’t get sucked into the mentality of “I am a doctor, I don’t do this.” If your patient needs to be on the monitor and you’re in the room speaking with him/her, just do it. It’ll take a longer time for you to inform someone that it needs to be done, yet alone him or her finding the time to do it. Your staff will appreciate it and will bend over backwards for you if you make this a habit.
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Take time for yourself! Whether that’s spending time with your family, working out, watching a movie, or going out for a couple of drinks with friends, make sure you give yourself a time out. These next few years
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las Told Guide by a 4th Year EM Resident
Issue 7 Summer 2013
An Emergency Medicine Publication
are going to be extremely stressful. You need to find some outlet to decompress. If you don’t, you’ll find yourself even more stressed out as the year’s progress. Don’t burn yourself out. Work hard and move fast! Be the best resident you can be. Don’t be that resident that signs out procedures or vaginal exams. You’ll quickly earn a bad reputation in the Emergency Department if you make this a habit! Initial perceptions are hard to change. Get your stuff done before sign outs or stay afterward to get it done. Signing out ridiculous tests to your co-residents to follow up on should also be avoided. Know why each test is ordered and its importance in your work up. Also, do not lie. You’ll get caught and look like a complete moron. When presenting a patient, be short and to the point. Start with the chief complaint, age, and sex and follow it up with PERTINENT information and have a plan in mind. Nothing is worse than hearing a laundry list of ridiculousness. As emergency physicians we have a very short attention span. Know your limits! “Primum non nocere” is a Latin phrase that means, “First do no harm”. Don’t be afraid to ask a senior, attending, or even a seasoned nurse to help you out. They are there to help you out. Don’t be afraid to err on the side of looking like a moron in the interest of the patient’s safety. If you do mess up, admit your mistakes, and learn from them. When you find yourself in a critical situation, go to your basics and take a deep breath. Remain calm, even if you want to go to the bathroom to change your underwear. You’re bound to mess up…you’re in residency. Admit your mistakes and learn from them. Know when to ask for help. It’s important to know what you do know as well as what you don’t. Learn from everybody! This also goes for the less than desirable attending physicians that we all have to work with from time to time. Learn from everyone’s style of medicine. You’ll learn what you like and don’t like and will incorporate it into your own art of medicine. You’re bound to mess up, this is what residency is for. Good Luck!
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The Fast Track
An Emergency Medicine Publication
Issue 7 Summer 2013
Careers in Emergency Medic E
mergency Medicine is still one of the most exciting, dynamic and rapidly growing specialties in medicine. The number of emergency physicians nationwide has grown
by over 40% since the late 90’s, with roughly 2,000 PGY-1 positions filled last year. The number of medical school graduates pursuing careers in Emergency Medicine has grown exponentially, reflecting what many believe is a shift in the practice values of the next generation of physicians. From a practical standpoint, it makes perfect sense. Emergency Medicine is a large specialty involving the management of diverse pathology in people of all ages. It “involves a little bit of everything.” Its shift-work nature frees physicians from the shackles of being on call, and its focus on acuity means that once patients are discharged from their care, no follow-up on behalf of the emergency physician is necessary. These characteristics make Emergency Medicine very attractive; especially for those who are unsure of what specialty they want to go into. However, therein lies a potential problem for individuals who decide to pursue Emergency Medicine, and for the specialty as a whole: pursuing it for the wrong reasons. With less than a year until graduation, and even less time until the match, it seems appropriate to reassess some of the realities of what a life in Emergency Medicine will mean.
T
he hours are arguably the most attractive aspect of working in the Emergency Department for most students. Most physicians work three to four twelve-hour shifts
per week. That’s 12-16 shifts per month, leaving the EM physician with an equal amount of time to pursue any personal or professional activities they choose – not bad! But there are two things that so many students fail to consider adequately before taking the plunge. First, the nature of shift-work means that there will be many holidays and personal occasions that will be missed – period. That goes for young and veteran attendings alike. It also means doing day shifts, then night shifts, and then back to days, and so on and so forth… Schedules obviously vary from one institution to another, but the fact is, a normal page 38
circadian rhythm is very hard to maintain. Whether or not one can maintain health and
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cine
by Nicholas Reis OMS IV
Issue 7 Summer 2013
An Emergency Medicine Publication
happiness in such a routine is something prospective applicants need to be very honest with themselves about. Even more important, is for candidates to honestly accept that working in the Emergency Department as a resident or attending physician is hard work – far more exhausting than what is fully appreciable as a medical student on rotation. From clock-in to clock-out, Emergency Medicine physicians are hoofing it! The work is physically, mentally, and emotionally exhausting. To survive an entire career working in such a demanding environment demands energy and enthusiasm that only a genuine passion for the work can sustain.
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nother big attraction for medical students is the diversity in Emergency Medicine. Emergency physicians deal with the whole spectrum of humanity – young, old,
rich, poor, innocent, criminal… They harness knowledge and employ skills from every discipline. Emergency physicians are often referred to as “jacks of all trades, and masters of none”. Many buy into this expression, but I’m not sure it endorses the right values students should embrace, and I’m not the only one. Says Dr. Deborah Lardner of NYIT-
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Issue 7 Summer 2013
COM’s Department of Emergency Medicine, “I prefer to say that we as EM physicians are masters of particular aspects of all specialties, namely, those involving the acutely ill and injured.” This philosophy better portrays the gravity of emergency physicians’ responsibilities. Whether a given physician sees fit to handle a given situation him or herself, or consult the problem out to other specialists depends on whether or not he or she has mastered the knowledge and skills necessary to safely execute appropriate care. The reality is, it’s not enough to complete a residency in Emergency Medicine to reach the level where handling any and every situation that comes through the department doors is done with 100% confidence. It takes an entire career’s worth of continuing education and commitment to the field, and still one will never master it all. Yet emergency physicians are called to do so.
P
ossibly one of the most alarming conceptions that some have, and one that frankly is pathologic for the practice of Emergency Medicine and how others view what
Emergency docs do, is that resuscitation and stabilization marks the end of a physician’s responsibilities toward patients; everything else is the next guys problem. A common line used by many prospective candidates is: “I like the idea of treating whatever the patient comes in for, passing them on to the next level of care, and not having to worry about anything else.” What happened to striving to provide the most comprehensive care possible within the knowledge, skills, time and space boundaries one practices in? Isn’t that in the purview of all physicians, and a tenet emphasized in every osteopathic medical school nation-wide? “You can’t provide the best care possible with the mindset that all I need to do is take care of this patient’s acute issue and send them away”, says Bruce Smith, an EM physician at St. Anne’s, a small community hospital in Massachusetts’ south coast. “ER docs should always think about what the next step is going to be for the patient, and try to make sure that whoever assumes care after you is able to complete as smooth a transition as possible. By helping them out, you’re helping the patient out. And this is an overlooked responsibility by too many EM physicians…” Dr. Smith offers an example: “Take for instance a traumatic upper extremity injury. I could, thinking of page 40
my responsibility to provide adequate analgesic care, go ahead and administer a nerve
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block (not uncommon), or I could go about providing analgesia using another method, because I remembered that hand/plastics is going to need the arm or hand neurologically
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An Emergency Medicine Publication
intact in order to properly assess the patient. The latter is better for the patient because it expedites, and therefore improves their care.”
I
t is altogether understandable, and legitimate for student physicians to consider lifestyle when determining what career path they will choose. Who wouldn’t?? But the
reality is, far too many either put too much emphasis on it, or aren’t honestly considering everything else it takes to be a successful Emergency Physician. The result is far too many young physicians entering a specialty for which they are not well fit, with adverse effects for themselves and the specialty as a whole. The evidence is in the numbers…Emergency Physicians suffer the highest burnout rate out of all medical specialties. For the 2013 Physician Lifestyle Report, Medscape surveyed more than 24,000 U.S. physicians across 24 specialties to determine which physicians suffer from the most burnout and how that burnout impacted their lives. Medscape defined burnout as a “loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.” Overall, nearly 40% of the survey participants said they are suffering from burnout. Of the Emergency Medicine physicians surveyed, 51% said they suffered from burnout, again higher than any other specialty. When asked to score their happiness at work from 1 (very unhappy) to 7 (very happy), burned out physicians gave a very low score. Overall, burned out physicians rated their job satisfaction a 3.53, compared with 5.38 for physicians who were not burned out.
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e all know that to become a physician requires a lifetime of hard work, dedication, and sacrifice. To enter into a specialty that doesn’t fit right could be a devastating
mistake both for one’s personal life, and for the specialty itself. With that in mind, it is time for all students participating in the upcoming match to think honestly about not only what specialty of medicine best fits them, but also which one they know they can make a meaningful contribution to. page 41
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Issue 7 Summer 2013
Photo references Summer 2013 The Fast Track Pg 5 – we want you - http://www.3g-bikes.eu/images/uncle-sam-we-want-you1-kopie_1.png Pg 36 – camo - http://www.wallgc.com/images/2012/11/green-minimalistic-military-camouflagebackgrounds-HD-Wallpapers.jpg Pg 39– ER - http://surgery.slu.edu/er/uploads/images/er_pan.jpg
ACOEP - Student Chapter 142 East Ontario Street Suite 1500 Chicago, Illinois 60611 page Phone: 312.587.3709 42 Fax: 312.587.9951 E-mail: bthommen@acoep.org
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