The Fast Track - Fall 2013

The Fast Track Fall 2013 - Issue 08

An Emergency Medicine Publication

Special features Wild Medicine (NEW) Lightning injuries

Tricks of the Trade Removing ear foreign bodies

Interview Season Advice Courting a program

Residency Spotlight

Ready for Fall Conference?

Details on pg. 6-7

Fast Track TheTheFast Track An Emergency Medicine Publication

Issue 8 Fall 2013

EDITORS AND PUBLISHERS Kenneth Argo Ashley Guthrie Andy Little Danielle Turrin Drew Kalnow Tanner Gronowski Issue Contributors Jason Anderson Steven Brandon Patrick Connolly Ashley Guthrie Megan McGrew Koenig Richard Limperos Brian Lehnhof Andy Little Cara Norvell Nicholas Reiss Danielle Turrin

NATIONAL OFFICERS ACOEP-SC PRESIDENT Ashley Guthrie VICE-PRESIDENT Jessica Bennett SECRETARY Kaitlin Fries

Presidential Message - SC Wow, where did this last year go? The new school year is a time for grand new beginnings and bitter sweet endings! With the beginning of the new school comes all the excitement and promise a new school year has to offer. What will you do with your next school year? For us here at the ACOEP student chapter we are winding down to the end of our term on the National ACOEP Student Chapter Board.

I feel very privileged to have worked with such a great team of students, but now it is time to pass the torch and make way for new talent. Without such great student members and such a supportive parent chapter, we could not bring you all the things you love about the ACOEP student chapter. Things such as the great Fall and Spring Conferences, the Student-Residency Expo, the Leadership Academy, the FastTrack, the FOEM Poster and Research Competitions, and Facebook Video Competitions.

What I ask of you, is to take some time and figure out how you can contribute to Emergency Medicine. Maybe it is by writing an article for the FastTrack, or perhaps you want to tell the world about your local chapter Emergency Medicine club in one of our Facebook video competitions. Maybe you are doing some great research that you would like present through the FOEM poster competition. Or perhaps you have bigger plans and you would like to run for a National ACOEP student chapter office at the Fall Scientific Assembly. No matter how big or how small your contribution may seem to be, we can only continue to make Emergency Medicine a great specialty with the help of great people like you. So take advantage of the new beginning and make this year everything you want it to be!

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

CONTENTS Letter from the Editor...................................... 05

By Kenneth Argo

Fall Conference Schedules........................... 06-07 Student and Resident Chapters

Ultrasound Corner............................................ 08-09 On the Cover: “Lightning Strike at page 2

Night” Photo courtesy of Ben Abo

By Richard Limperos

The Fast Track

Issue 8 Fall 2013

An Emergency Medicine Publication

14

20

FACES OF ACOEP

24

RESIDENCY SPOTLIGHT Doctors Hospital

28

WILD MEDICINE

40

CLASSROOM TO CLINIC

PALLIATIVE CARE IN THE ED

By Daniel Turrin

Emergency Medicine Review..................... 10 Rosh Review

Pimpology............................................................. 12

By Danielle Turrin

Visual Diagnosis Question............................ 13

By Cara Norvell

View From the Bottom................................... 18-19

By Brian Lehnhof

Case in Dermatology....................................... 22-23

By Nick Reiss

OMM in the ED................................................... 26

By Brian Ault

By Ben Abo

Tricks of the Trade............................................ 33

By Andy Little

Tech Update......................................................... 33

By Patrick Connolly

A Retrospective Perspective........................ 34-36

By Steven Brandon

Keeping the Message on You...................... 42-43

By Andy Little

By Jay Anderson

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

PRESIDENTIAL MESSAGE - RESIDENT CHAPTER Greetings from the Resident Chapter!

As I wrap up my term as President, and ultimately my residency, I have one overwhelming feeling, and that is of gratitude to this College.

There is no other medical organization in this country who so strongly supports the youth of The College as they traverse through medical school and into residency.

Throughout my 8 years of involvement in the ACOEP I have met many friends, colleagues and mentors; many of which will be relationships that will last a lifetime!

For the past year, all of your national officers have worked relentlessly to improve the foundation of the Resident Chapter, organize national conferences as well as improve the benefits that each resident can experience from the comforts of their own home!

October 5th, 2013 in San Diego will be bitter sweet, as we say farewell to officers who have been involved since they were students, we will also be welcoming a handful of new officers at our annual elections. I look forward to meeting the new crew members and watching the growth of the Resident Chapter as the new team takes over!

I can’t thank each of the Resident Chapter officers enough for the pleasure of working together over this past year! And a special thanks to The College for the honor of representing the ACOEP. Best wishes to all and thank you, from the bottom of my heart, for allowing me to be a part of this college!

Sincerely, Megan (McGrew) Koenig Midwestern University Chief Resident ACOEP Resident Chapter President ACOEP Board of Directors

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The Fast Track

Letter From The Editor

A

s I look back over the last year as an editor of The Fast Track, I realize that my time to shape The Fast Track as a medical student is ending. During

Issue 8 Fall 2013

An Emergency Medicine Publication

my time as editor, I have learned invaluable lessons while sweating over the publication and had a lot of fun in the process. It’s my aspiration that each issue of The Fast Track is relevant and valuable to the reader while being visually appealing, easy to read, readily accessible and pleasantly memorable.

I firmly believe that these goals were achieved through the hard work of our writers, editors and contributors. However, our achievements aren’t measured internally, they are measured by our readers, and there’s no better place for our readers to speak up than at conference.

Last year’s conference in Denver, my first conference, was exciting. I was elated to meet each new face; all while learning about emergency medicine and the ACOEP. Now, I look forward to seeing all of the ACOEP board members that have become my friends and colleagues in San Diego at the fall conference. I also look forward to meeting as many of you, our readers, as possible. I feel like a proud parent each time someone approaches me at conference to say how much he or she has enjoyed The Fast Track, or to share with me a new idea for publication. Perhaps some of you will be the next student editors of

The Fast Track helping to influence the future of this fine publication.

It has been my pleasure to serve as student editor this past year. I consider it an honor and a privilege to have worked with an exceptional group of individuals all of whom I know have bright futures as emergency physicians and members of the ACOEP. I expect that the ACOEP is better for it; I certainly know that I am. Please, if you are at conference, come talk to me. I look forward to meeting you.

Yours, Kenneth Argo OMS-IV

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

Student Events Schedule Saturday - October 5

12:30pm - 12:50pm Welcome with Ashley Guthrie 1:00pm - 2:50pm Advanced Airway Shootout (pg. 32) Hosted by EMCARE and FOEM 3:00pm - 3:50pm Basic Approach to the Poisoned Pt. 4:00pm - 4:50pm How to Find Your Perfect Program 7:00pm - 9:00pm NIght Out with EMP at Hennessey’s Tavern (Gaslamp)

Sunday - October 6

8:00am - 8:50am EM Lecture 9:00am - 9:50am EKG Cases 10:00am - 10:50am The Crashing Patient 11:00am - 11:50am Drinking From the Fire Hose: Online Learing 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 ACOEP Welcome Reception at The Indigo Terrace (Hilton)

Monday - October 7

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8:00am - 10:00am Elections and Student Chapter General Membership Meeting 10:00am - 12:00pm Skills Lab Hosted by Good Sam 12:00pm - 1:00pm Lunch 1:00pm - 1:50pm 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 Remember ALL of our meetings will be held at the San Diego Convention Center **Except Social Events

The Fast Track

Fall Conference, October 5th-7th 2013

ACOEP-RC

Issue 8 Fall 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 ** 10a Insiders Guide to Excelling on the Boards 10:30a Career Panel 11:45 Lunch Sponsored by Team Health 12p-1p Young Physicians Round Table 1p-3p Membership Meeting (Elections) ** 3p-5p Advanced Airway Shootout (See page 32)

Sponsored by EmCare, FOEM 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 8:30p Out with Miami Valley Emergency Services October 7, 2013 9a-2p Chief’s College

Sponsored by Premier Physicians 7p-10p FOEM Gala

** Attendance Required for Re-imbursement

For more information visit www.acoep.org/meetings.htm

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Issue 20132013 Issue86Fall Spring

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!

SOFT TISSUE ULTRASOUND Is there an abscess?

Richard Limperos, MD, RDMS Clinical Assistant Professor of Emergency Medicine, OU-HCOM

Ultrasound Director, Doctors Hospital Emergency Medicine Residency, Columbus, O

page 8

For this article we will discuss how An abscess will appear as a hypoechoic ultrasound can help you determine an (darker) irregularly shaped structure abscess versus cellulitis. Ultrasound is usually in the dermis and hypodermis. useful in determining (Image B) It may if there is a drainable have internal debris, fluid collection. and when you push Cellulitis will have on it you can see a cobblestoning swirling motion of the type appearance. purulence. Lymph (Image A) This nodes and vascular is not specific for structures may look cellulitis but rather similar to an abscess. is the appearance of They should appear any tissue edema. more round and It is important to discreet than an Image A recognize this fact, abscess. Frequent as ultrasound cannot use of color flow can also help you determine what help you differentiate these type of edema you are structures. An abscess visualizing. Edema from should have no color flow, a deep vein thrombosis, where a lymph node will lymphedema, venous have flow in the hilum stasis, fluid overload and (Image C) and a vascular cellulitis will all have structure will have color the same cobblestoning flow through the entire appearance on structure ultrasound.

When scanning an Image B Ultrasound can help you abscess, it is very determine if there is an abscess. important to notice the posterior

The Fast Track

Issue 8 Fall 2013

An Emergency Medicine Publication

Dr. Limperos

Ohio wall. If you cannot completely visualize the posterior wall of the abscess it may require further imaging or surgical consultation to determine its depth and involvement with deeper structures. Ultrasound can also show the proximity of the abscess to other structures. Intravenous drug abusers may have abscesses close to veins and occasionally can have complications such as septic thrombophlebitis . They may also have tenosynovitis from accidentally injecting into a tendon sheath (Image D). With ultrasound you can easily detect these more complicated clinical scenarios.

little downside to trying to incorporate into patient care.  Tayal, Vivek S., et al. “The Effect of Soft tissue Ultrasound on the Management of Cellulitis in the Emergency Department.” Academic emergency medicine 13.4 (2006): 384-388.

Image C

Ultrasound can help determine the need for incision and drainage, identify complications and nearby structures, and detect deeper involvement. This is most clinically useful in borderline cases. Ultrasound is best used to rule in abscesses and is less sensitive to exclude them. Therefore, if you are convinced there is an abscess by your clinical examination, do not use ultrasound to talk yourself out of the incision and drainage. As long as you use ultrasound to detect more abscesses, there is very

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Image D

The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

Emergency Medicine Review with 1. A 23-year-old man with sickle cell disease presents with a penile erection for 5 hours. He complains of severe pain. Which of the following treatments is indicated?

A. Corporeal aspiration B. Intracorporeal terbutaline C. Intravenous phenylephrine D. Phlebotomy

Find more questions like these by visiting roshreview.com

2. A 20-year-old man presents with a rash to the back for 1 week.

He states that the rash started as a single patch and then spread to the rest of his back. Initially, he had a fever but it resolved. The rash is itchy but otherwise, the patient is asymptomatic. What management is indicated?

page 10

A. Antihistamines B. Cephalexin C. Oral corticosteroids D. Topical antifungals

3. A 77-year-old man presents with syncope. He states he was walking to the bus when he felt chest pain, shortness of breath and passed out. The patient has a history of hypertension. Examination reveals dry mucous membranes and a systolic murmur that radiates to the carotids bilaterally. The patient continues to complain of chest pain. Vitals are unremarkable and the ECG reveals left ventricular hypertrophy. What management is indicated?

A. Intravenous fluids and cardiology consultation B. Morphine sulfate and admit to telemetry C. Sublingual nitroglycerin and activation of the cardiac catheterization lab D. Sublingual nitroglycerin and admit to telemetry

4. A 43-year-old woman with breast cancer on chemotherapy presents with a fever to 102째F. She also complains of a cough and generalized fatigue. Physical examination and chest X-ray are unremarkable except for the presence of a mediport. Complete blood count reveals a white blood count of 600 with 30% neutrophils and no band forms. What management is indicated?

A. Administer filgrastim and discharge home B. Draw blood cultures and await results for treatment C. Send blood and urine cultures and start vancomycin and cefepime D. Start levofloxacin and admit for pneumonia Find your Rosh Review Answers on pages 38-39

The Fast Track

SC POE AC

Medical school isnt easy.

Get guidance and insight from residents and attendings now!

Issue 8 Fall 2013

An Emergency Medicine Publication

M RA OG PR OR NT ME

There’s no doubt about it: Medical school is hard. Board examinations are hard. Rotations are hard. And as you’ve been told, your years as a resident will be hard, too. You’re up to the challenge—you made it into med school, you know what the expectations are.

But wouldn’t it be nice if it could be just a little bit easier? If you had an ally to help you navigate the path? If the unknown wasn’t quite so unknown?

Your membership with ACOEP can help. When you sign up for the nation-wide Mentor Program, you will be paired with an experienced attending or resident who will answer your questions, give you advice, and most of all, be honest with you about the perils (and advantages) of life in the emergency department. Imagine how nice it will be to ask honest questions of someone who knows what you are going through and can help guide your way.

You can chose your mentor based on geographic location, specialty, medical school, and communicate with them via e-mail, phone, Skype, or any means that is convenient for you both. This informal relationship isn’t a job interview, and it isn’t an academic advisor. It is an opportunity to learn from someone who knows what you are going through, giving you the extra tools to make the right decisions for your caeer.

For more information visit www.acoep.org/mentor.htm, or contact ACOEP

Member Services Assistant, Jaclyn Ronovsky (312.445.5702/JRonovsky@acoep.org).

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Pimpology 101 The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

Top Things to Know on your EM Rotations Danielle Turrin, DO, MS

It’s 2 AM and EMS brings in a 67 y/o male with chest pain. You note the patient has a history of HTN and is on Lisinopril. Currently his vitals are Temp 99.0F, HR 84, BP 156/72, RR 16, sating 98% on room air. The patient was given 325mg of ASA prior to arrival. The patient looks comfortable and is currently pain free; however he tells you that he had an episode of chest pressure, 7/10, 20 minutes prior to arrival that lasted about 5 minutes.

You place the patient on 2L of oxygen via NC and ordered an EKG and blood work was drawn. The EKG is to the right and the blood work was WNL.

Â

TIMI Risk Score UA/NSTEMI

TIMI Risk Score for STEMI

Estimates mortality for patients with unstable angina and non-ST elevation MI Used as a basis for therapeutic decision making

Estimates mortality in patients with STEMI

Criteria, each worth 1 point. Absence of below criteria yields score of 0.

- Age < 65 +0 points 65-74 +2 points > 75 +3 points - DM or HTN or Angina +1 point - SBP > 100 bpm +3 points - Killip Class II-IV +2 points - Weight < 67 kg (147.7 lbs) +1 point - Anterior ST Elevation or LBBB +1 point - Time to Treatment > 4 hours +1 point

- Age > 65 years - > 3 risk factors for CAD (FHx of CAD, HTN, Hy percholesterolemia, DM, current smoker) - Known CAD (stenosis > 50%) - ASA use in past 7 days = Severe angina (> 2 episodes of angina within 24 hours) - ST changes > 0.5mm - Elevated cardiac markers Assign Score of 0 to 7, which correlates with % risk at 14 days of all cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization - 0 to 1 = 4.7% - 2 = 8.3% - 3 = 13.2% - 4 = 19.9% - 5 = 26.2% - 6 to 7 = 40.9% page 12

Criteria, each with assigned point value

Assign score 0-14, which correlates with % risk for all cause mortality at 30 days - 0 = 0.8% - 1 = 1.6% - 2 = 2.2% - 3 = 4.4% - 4 = 7.3% - 5 = 12.4% - 6 = 16.1% - 7 = 23.4% - 8 = 26.8% - 9 to 14 = 35.9%

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 Cara Norvell, DO

Issue 8 Fall 2013

An Emergency Medicine Publication

Patient is a 15 year old male who presents to the ED after a ATV accident. At the times of presentation he was C-spined and immobilized. He had a chief complaint of bilateral hip pain.

Find your Visual Diagnoses answer on page 37 Do not forget about the BEST way to get around down town San Diego while in town for the conference. The MTS Trolley. It drops off right in front of the conference center with stops at places like Old Town, Little Italy and Gaslamp Quarter.

Visit www.sdmts.com for details.

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

Palliative Care in the Emerg Palliative Medicine: What is it exactly and how does it apply to you as an Emergency Physician?

From the perspective of an emergency physician, the Emergency Department is the toll booth for entrance to the hospital. Most patients come through our doors first before they proceed to the OR, ICU or the inpatient floor. We see the patient initially, make an assessment, employ an intervention and/or initiate a plan of care. Often these patients are ill from infection, trauma, cancer, or advanced age, and decisions made for treatment are important and will determine quantity and quality of life.

Hospice and Palliative Care: What is it and what’s the difference?

Hospice and palliative medicine (HPM) is a medical specialty focused on enhancing quality of life for patients and their families who are facing terminal conditions or critical illnesses. HPM specialists concentrate on managing pain and other symptoms while addressing the whole patient; the spiritual, emotional, and social elements surrounding the patient and their illness. HPM Physicians develop particular expertise in: •Complex symptom management •Psychosocial and spiritual support for the dying

patient and the family

•Assistance with end-of-life decisions and advance care planning •Continuity of care across settings •Home and hospice care •Bereavement care •Interdisciplinary teamwork page 14

Palliation is defined as “making a disease or its symptoms less severe or unpleasant without removing the cause.” This definition mistakenly leads many to believe that palliative care

The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

gency Department

by Danielle Turrin, DO, MS

is for those that cannot be cured. It is my opinion that palliative care represents the implementation and development of a coping mechanism and support system for those dealing with illness. It is for people of any age, and at any stage in an illness, whether that illness is curable, chronic, or life-threatening. In fact, palliative care may actually help you recover from your illness by relieving common symptoms such as pain, anxiety or loss of appetite, as you undergo emotionally difficult and physically uncomfortable medical treatments or procedures, such as surgery or chemotherapy.

The overall goal of palliative care is to improve the quality of life for the patient as well as their families. Palliative care is provided by a team of professionals including a palliative doctor, nurses, social workers, and others. The palliative team works to: •Provide relief from pain and other uncomfortable symptoms.

•Assist patient in making difficult medical decisions.

•Coordinate multidisciplinary care and helps the patient to navigate the health care system.

•Guide patient in making a plan for living well, based on patient’s needs, concerns and goals for care.

•Provide patient and their family emotional and spiritual support and guidance.

Furthermore, studies have shown that palliative care can help to control pain; control common symptoms of serious illness such as fatigue, anxiety, shortness of breath, nausea, depression and constipation; and improve quality of life.

What training do Palliative Care Physicians have?

In order to specialize in Hospice and Palliative Medicine you must complete a fellowship training program. Board certified or board eligible physicians from any one of ten

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

specialties including; Anesthesiology, Emergency Medicine, Internal Medicine, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry, Neurology, Obstetrics and Gynecology, Radiology and General Surgery may apply to a Hospice and Palliative Care Fellowship program. Most HPM fellowships are 1 year in duration, though some have the option of completing a 2nd year focused on research or education.

Fellowship training focuses on the following elements: •Communication •Ethical and legal decision making •Pain in cancer and non-cancer patients •Management of non-pain symptoms •Medical co-morbidities and complications in populations with life threatening diseases •Neuro-psychiatric co-morbidities in populations with life-threatening diseases •Psychosocial and spiritual support •Death and dying •Bereavement support for the family •Quality improvement and research methodology in populations with advanced illnesses •The hospice and palliative approach to care •Interdisciplinary team work Upon the completion of a 12 month fellowship training program, fellows will have completed several clinical experiences and satisfied established educational goals leaving them uniquely qualified to navigate difficult situations involving illness, death, dying, and page 16

end of life care.

The Fast Track

Hospice and Palliative Care as a Continuum There is a specific type of palliative care – called hospice – for people for whom a cure is unfortunately, no longer possible and who likely have six months or less to live. Hospice

Issue 8 Fall 2013

An Emergency Medicine Publication

care, like palliative care, can be provided at the patient’s home, at a hospice facility, a hospital or a nursing home. Hospice care is about giving the patient control, dignity and comfort so as to have the best possible quality of life during the time the patient has.

Hospice care also provides support and grief therapy for patients’ families.

It’s important for patients and their families to understand that at a certain point, “doing everything possible” may no longer be helpful. Sometimes the burdens of a treatment outweigh the benefits. For instance, an aggressive treatment might give you another month of life, but make you feel too ill to enjoy that time. Palliative doctors can help you assess the advantages and disadvantages of specific treatments.

Hospice care can help you continue treatments that are maintaining or improving your quality of life. If your illness improves, you can leave hospice care at any time and return if and when you choose to.

What Does This Mean to you as an Emergency Physician?

You have the ability to make a difference and take your role in patient care one step further.

Take it upon yourself and find out what your hospital has to offer in the way of Palliative Care and be aware of all of the resources you have available to you to give your patient’s the best treatment possible. If Hospice and Palliative Medicine is something you have an interest in check out the HPM website for a list of accredited fellowship programs.  Resources: www.aahpm.org; www.palliativedoctors.org

Are you into POLITICS? Want to make sure your in the know about issues that face you as an osteopathic physician?

Then check out the Grassroot Osteopathic Advocacy Link, by visiting www.osteopathic.organd search GOAL

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

The View From The Bottom: An Interns look at how things really were and are..... ii

page 18

By Brian Lehnhof, DO

I will never forget the story told by the chair of surgery at my medical school. The story involved a complex and complicated surgical case that he was scrubbed in on as a medical student. The case took numerous unexpected turns for the worse, and after much chaos ended up in a salvaged outcome. Following the case he mentioned to the surgeon how exciting it was, and how he enjoyed being scrubbed in. The frazzled but wise surgeon looked at him and introspectively said: “I suppose the view of the ride depends on your seat in the bus.” The surgeon had led the team through the difficult case; his shoulders bore the heavy responsibilities. As a medical student, the responsibility was to observe and this provided a drastically different vantage point.

It was not that long ago that I was riding in the back of the metaphorical “bus” enjoying the view. Then one day in the heat of the Phoenix summer, I walked across a stage as my name was called and I became a doctor. Suddenly I was expected to move from the comfort of the backseat of the bus and take the wheel. It was my turn to drive. This is the process for which medical education prepares us. We develop our skills and knowledge in step-wise fashion.

Similarly, responsibilities are placed upon us in a step-wise manner. If it were not so, we would all crumble under the pressure. This is particularly true as emergency medicine physicians. We are called upon to take control in dire circumstances. Becoming comfortable in this capacity is achieved through the steps of the medical education hierarchy.

My objective with this column is to share some of my journey from the back of the bus to the driver’s seat. I hope to share some insight that might benefit my colleagues in making their own journey a little easier or smoother, as I share my “View From the Bottom” of the medical hierarchical ladder.

On the first day of internship, I walked into the same ED that I did as a MS-IV. The difference about this shift was what was expected of me. Succeeding as a medical student meant obtaining good histories, doing thorough exams, deriving exhaustive differentials and finally not screwing it up when presenting to the attending. These things still matter now as an intern, but there is more than getting a good grade, getting a SLOR and solidifying a residency spot. The pressure I now feel is to be the physician that my patients expect me to be. Fortunately the majority of my patients did not know of my inexperience on that first day, but I did. The difference between their unwarranted confidence in me and the lack of confidence I had in myself is what pushed me, and still pushes me, to live up to their expectations of me. I would venture to say that the majority of patients do not know what happens July 1st in teaching hospitals across the country. In fact, I imagine a large population of our patients do not even realize what a “teaching hospital” is. Patients come into our emergency departments expecting to be healed. They expect us all to be excellent physicians.

If I could travel back in time to my medical school rotations, I would push to apply myself more in my role as a member of the care team. It is easy to hide under the low expectations of the title “medical student”, and defer to an attending or resident. I unfortunately too often said, “I’m just the medical student” and let the responsibility and

The Fast Track

TAKE Advantage of the OPPORTUNITY you have before YOU... opportunity pass me up. While this was the easier path, it was also the path that did not engage me in the experience that was occurring around me. It did not teach me anything.

It is the sum total of the small lessons that ultimately shape us into what we become.

These lessons come from successes and failures, but either way it requires engagement to obtain the experience. The lessons we learn as we watch from the periphery are some of the quickest to leave our ever-crowded craniums. It has now become my quest to put myself out there and engage myself in as many opportunities as I can. This is not a smooth or painless process. It has caused me to give completely wrong answers in lectures, get torn apart by a trauma surgeon at ATLS training, utterly fail at procedures, and much more. All of these things could be avoided by stepping back and taking shelter in the neighboring crowd of residents. For me this vulnerability is what makes me better. I have learned just as much from wrong answers, botched procedures and incorrect diagnoses as I did from the times I got it right.

My plea to medical students and my fellow interns is that you will take advantage of the opportunity you have before you. Put yourself in situations that make you engaged.

There is no better place to learn and solidify your skills and knowledge than when your pride is vulnerable and exposed. The expectations for our performance only go higher each day of our career. Now is the time to make the experiences that solidify you. I guarantee that you will retain more from something you are engaged in than if you are sitting back as an experience occurs around you. Being right or wrong is not the issue, it is being engaged that makes the process a success.

For the medical students that are in audition rotations, now is the most critical time to put yourselves on the line. The object of residency is to be trained. No program expects to find someone that is perfect and ready to fly solo. They are looking for someone to train.

One of your best assets can be your ability to be taught. Engaging yourself in didactics and on your shifts in the ED will show that you want to be taught. Volunteer to interpret an EKG in didactics. There will be lots of things you miss, but I promise you will retain more than the student next to you. Write your own encounter notes and have attendings or residents review them. Do whatever it is that you feel you need to work on. This does not show your weaknesses; rather it is showing your desire to become stronger. There are going to be plenty of students sitting quietly on both sides of you. Seize this opportunity to show desire to learn and to also become better as a result.

Regardless of where we are in our career today, we are going to keep facing difficult situations. The primary aspect that we can control is the attitude with which we approach these obstacles. I am learning that for me, the best approach is to step up and try my best as often as possible. My hope is that I will succeed in flawless form each time, but no matter the degree to which I stumble, the mere experience of engaging will add something to who I am and what I ultimately become +

Issue 8 Fall 2013

An Emergency Medicine Publication

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

The faces of th

Our student chapter officers from William Carey. Paul Cooper OMS II, Susan Walker OMS II, Derek Hunt OMS II, Kathryn Finch OMS II, Alex Gauthier OMS II

photo courtesy of the ACOEP Student Cahpter

photo courtesy of Kathryn Finch

Residents from Marrietta Mem

Ohio residents enjoy a break while at a State Wide RPAC in Columbus, Ohio

page 20

photo courtesy of Andy Little

Allison Shingler-Weiss DO and practicing trauma proced

The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

he ACOEP

photo courtesy of Jessie Schaberl photo courtesy of Ben Abo

d Tanner Gronowski DO dures during a lab

Residents from Kent enjoying a day off at the links

photo courtesy of Leigh Hylkema

photo courtesy of Brian Lehnhof

morial enjoying a day at a ropes course

Residents at Mount Sinai in Miami Florida pose for a picture on a warm Miami day

Residents and students during a Haz Mat day at UPMC Hamot in Erie Pennsylvania

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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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

A Case in Dermatolog

by Nick Reiss OMS IV

An 80 year old female presented to her primary care physician for examination of a small warty lesion on her right cheek. She was referred by an emergency physician who recently repaired a laceration of her left hand.

She had no complaints on presentation. She denied pain, swelling, or discharge from the wound site. She explained that she had the lesion for several years, and that it grew steadily over that time. She denied pain, but stated that occasionally it itched. She reported bleeding on several occasions, provoked by scratching. She denied recent illnesses, infections or contact with sick people or animals. She experienced no changes in weight, and denied using new soaps, detergents, or facial products. She

had no recent travel history.

Her medical history included hypertension, diabetes, hyperlipidemia, and atrial fibrillation, for which she takes Coumadin, 2mg twice daily. Her other medications include Metformin, Glyburide, Lisinopril, Lasix, Simvastatin, Labetalol, and Norvasc. She had no allergies and no surgical history.

Her vital signs were within normal limits, and she was in no apparent distress. She had a 3 cm laceration on the palmar aspect of her left hand with 3 clean, dry nylon sutures in place. There was no discharge or sign of infection, and the wound appeared to be healing well. She had a round, 0.8cm papule on he right cheek with central fissuring.

The patient was taken off her Coumadin and directed to return to clinic in 2 days for a shave biopsy.

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The skin below the lesion was erythematous with sharp margins. The lesion was sent for examination by pathology and the report returned several days later. The pathologistâ&#x20AC;&#x2122;s report noted findings consistent with

The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

gy squamous cell carcinoma in situ, arising in a seborrheic keratosis. The patient was referred to dermatology for further excision of the lesion with wide margins.

Her healing is being followed regularly for any recurrence of the lesion.

Seborrheic keratoses are the most common benign tumor in older individuals. Although no specific etiologic factors have been identified, they occur more frequently in sunlight-exposed areas. They often described as having a “pasted on” appearance. Seborrheic keratoses are usually asymptomatic, and although generally not associated with malignant transformation, they should be monitored for changes in symmetry, size, and color, especially when occurring in isolation.

The sign of Lesser-Trélat is the association of multiple eruptive seborrheic keratoses with internal malignancy.

Most commonly, the sign is observed with adenocarcinoma, especially of the gastrointestinal tract; however, an eruption of seborrheic keratoses may develop after an inflammatory der-

matosis (eg, eczema severe sunburn).

Treatment may involve close observation, topical medication, or surgical removal. As with all skin lesions, any suspicious appearance should prompt removal and biopsy because, as with the case above, malignant transformation can never be 100% ruled out.

Although a medical issue more appropriately dealt with in the outpatient setting, emergency physicians should not fail to refer patients for outpatient follow-up of any signs and symptoms suspicious for more sinister pathology. References: www.aad.org/dermatology-a-to-z/diseasesand-treatments/q---t/sebhorrheic-keratoses

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

Residency

Spotlight

Doctors Hospital is a teaching hospital unlike any other. Located on the west side of Columbus, Ohio, we offer an experience that allows trainees to see a large variety of pathology, all while living in one of the nations best cities.

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The Fast Track

Issue 8 Fall 2013

An Emergency Medicine Publication

“YOU WILL COME OUT OF THIS RESIDENCY WITH ALL OF THE SKILLS AND CONFIDENCE NEEDED TO RUN ANY EMERGENCY”

Photos provided by Tanner Gronowksi and Leigh Hylkema

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

OMM In The ED

More Relevant Than We Realize

by Brian Ault, DO

A T

56 year-old female presented to the ED. She is a very thin woman who appears much older than her stated age, and is sitting in front of me, she has tachypnea, diaphoretic, and with right sided chest pain.

he more I talked with her, the more I believed that she was not having cardiac chest pain. I was able to draw out of the history that the pain began suddenly, after a coughing fit, and the patient stated that she was presently being treated for bronchitis. During my exam, I diagnosed a right-sided rib dysfunction, precisely in the location of her chest pain. Over the next few minutes her symptoms resolved with osteopathic manipulative treatment to the area. She then exclaimed, pleased but perplexed, “How did you do that?” This result did not completely absolve my concerns, but certainly helped. She stayed in my ED, slept comfortably through her cardiac workup (all negative), and I gladly discharged her home. This type of experience was what I had envisioned as part of my osteopathic emergency medicine career. Unfortunately, this type of experience is few and far between.

W

e all entered osteopathy for our commitment to the osteopathic philosophy and the desire to positively effect our patients’ lives with osteopathic manipulative medicine, and to continue to do so through whatever specialty we might enter, right? Probably not. I realize that it is likely that my passion in this arena is not the norm. After all, I was one of those crazy folks who felt compelled to spend an extra year as an osteopathic manipulative medicine fellow, learning and teaching osteopathy for a total 5 years of medical school. I realize that many osteopathic emergency medicine physicians do not quite understand nor feel the need to use osteopathic manipulative medicine. For those physicians, my argument to you is this: In a time of political, social, and “customer service” paradigm shifts, osteopathic manipulative medicine in the ED is worth your time, and I challenge you to take a few minutes to make a difference and to be different; your patients may even thank you.

M

aking a difference is ofte n our medical school interviews, we all faithfully recited the pominutes; I think you’ll find litically correct response, “I want to be an osteopath so that I can treat the whole person.” While a very noble ideal, that philosophy is not exactly a founding tenant of emergency medicine, and in reality (dare I say it), would probably be a hindrance to your practice if taken as a purist. But osteopathy is not an all or nothing practice, and the tools we have learned in our medical education can be not only relevant, but powerful in the resolution of patient complaints and the total patient experience.

I

D

espite fears related to the impending Affordable Care Act, and dramatic reductions taking place throughout hospitals nationwide, we are in a time of growth in osteopathic medical education. Examples of this growth are the 39 osteopathic medical schools, expanded from 27 in just the past seven years (the time that has passed since I entered medical school).

So, osteopathy is growing, patients want everything, and the foundation of osteopathic education has not changed, therefore, OMM should be everywhere, right? The answer, as I see it, is “sort of”. There are cer-

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tainly more DOs than ever, and we are present in every renowned teaching hospital. However, we as a group seem oddly hesitant to use our skill.

W

e as physicians live by the onus to “first, do no harm”. But, let’s be honest, society expects us to fix any and all problems that a patient presents. We are emergency physicians; We certainly must have an answer for why our patient’s tongue has been itching for months, and now at two in the morning on a Saturday night it seems imperative that she find out why. If we are to effectively manage the variety of ailments thrown our way, we should be driven to use all of our available tools. Of course, we all (myself included) love the adjuncts: a new airway toy, a fancy new drug, the use of ultrasound to help determine COPD v CHF, or the iPhone to provide peripheral brain support.

So why do so many of us shy away from OMM on cases where it makes sense? It is cheap, always available, part of our training, and best yet, fits well into the “do no harm model,” as virtually free of side effects.

Issue 8 Fall 2013

An Emergency Medicine Publication

F

urther, if you have not realized it yet, your practice is at least partially customer service driven. I am not endorsing that you order an MRI for the person who asks, but I am suggesting that more than ever, the atmosphere, and happiness of the patients is a real concern, beyond providing great/safe care. In my experience, patients treated with OMM are more likely to report a positive experience in the ED as opposed to patients treated solely with allopathic methods.

S

o what does OMM in the ED look like? In my practice, I touch every patient. I examine, recognize, and use their somatic dysfuncen only a matter of a couple tions to guide my care. d the investment well worth it.

Am I going to treat every patient I see with OMM, absolutely NOT! Do I think about it? You bet. During my exam when I find an area that could be part of the problem, I diagnose and treat briefly, which may or may not reduce the complaint.

Regardless, this does not alleviate me from my duties as an ED physician to investigate the case in its entirety, using any other tests or tools that are appropriate. But I use my OMM treatment as a tool to support my medical decision-making. I am not advocating trying to revive someone in a code with external rotation of the temporal bones, as described in our historical literature. However, I am challenging you to, for example, treat the ribs and diaphragm in a shortness of breath patient for better chest wall compliance, while waiting for your neb treatments to arrive. Treat the back/neck/head pain patients to help them exit your department with less medication use. Treat extremities with strains and any other part of the body that you can get your hands on to speed healing and increase functionality.

O

steopathy is a part of your medicine; dose wisely and frequently, even in minute intervals as you re-evaluate. This may be the only patient of your day to thank you for your time. Making a difference is often only a matter of a couple minutes; I think you’ll find the investment well worth it. 

ded by Brian Ault

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

Wild Medicine: Striking Distance

By Benjamin Abo, DO “Rampart from Medic 142. Be advised inbound to your facility with a 32 year-old male struck by lightning <garble garble garble> five minute E.T.A” Medic 142 from Rampart, your signal cut out. Did you say struck by lightning? <crackle crackle crackle> Medic 142 from Rampart, do you copy? <crackle crackle crackle>

known to travel many miles from a cloud to where – or whom – it strikes.

Let’s get physical. Most electrical injuries are caused by alternating current (AC), but lightning is made of direct current (DC). A single bolt of lightning has a massive amount of current weighing in at a range of 30,000 to 110,000 amperes; compare this to the usual threshold of transcutaneous pacing of a healthy human being 80mA (0.08 amperes).

Of course, unlike electrical injuries caused by AC, lightning currents are only applied for 10100 milliseconds. Lightning injuries are basically classified by the path taken to the person – direct strikes, contact injuries, side splashes, or ground currents. Direct strikes are quite rare, as opposed to side splashes making up a third of lightning injuries and ground current which accounts for nearly half.

It is probably pretty safe to say that everyone reading this has experienced at least one view of the allpowerful lightning that commonly accompanies thunderstorms. It is also probably a fair statement that at least a majority picture cartoons from our childhood (ok… or adulthood) where someone is struck by lightning and Following the path immediately turn into Nerve < Blood < Muscle < Skin < Fat < Bone of least resistance as a barbecued crisp. It is previously mentioned surprising to realize how many of our thoughts and ideas that we have grown also occurs within the human body, and this is important to remember when considering electrical to learn about lightning and lightning injuries are injuries as different body tissues have varying actually quite incorrect. Given the above scenario, resistances. Those with less resistance will tend to what would you expect? What would you want to know? What would you prepare? Resuscitation room have more electrical damage, and the tissue types and maybe a code team? A body bag? Trauma team in order from least to greatest resistance are the for a burn victim? In this inaugural installment of the following: nerve < blood < muscle < skin < fat < bone . quarterly Fast Track Wilderness Medicine, we will skim the surface similar to Lichtenstein “burns” of some of the myths and facts of lightning injuries and Myths vs. Shocking Truths management.

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Back to the basics with current events

How confident are you with your knowledge of lightning injuries?

Lightning and thunderstorms are basically created by vertical updrafts of air that cools and condenses into cumulonimbus clouds as it is pushed upwards.

The cooling at altitude of this warmer air causes a separation of electrical charge within the cloud that eventually leads to the genesis of lightning.

Lightning will follow the path of least resistance, which is not always a direct line. Lightning has been

Myth #1: For every second between the flash and thunder, the storm or lightning is a mile away. Let us consider even under perfect conditions, the speed of sound vs. the speed of light. In reality, it is more like five seconds per mile, then you add in things that would distort

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the travel of sound such as vegetation, cityscape, motors, hills, and wind. The latest consensus from the Wilderness Medical Society gives a Class 1C recommendation to simply stay indoors if you can even hear thunder, and otherwise wait 30 minutes.

Myth #2: The most common cause of death from lightning injuries is secondary to burns. First, you should know that a majority of lightning strike victims actually survive, although usually they have permanent disabilities or injuries. The classic mechanism of sudden death from lightning is simultaneous cardiac and respiratory arrest.

This makes sense to us emergency medicine people since the person is basically being defibrillated.

Myth #3: A patient struck by lightning is fried and most likely dead. Death is actually rare, so long as a victim survives the initial lightning strike. It is estimated that for every fatality from lightning, there are 10 casualties.

Myth #4: If a group of people is struck by lightning, standard triage applies with those in cardiac arrest being tagged black. As previously mentioned, the classic mechanism of sudden death is simultaneous cardiac and respiratory arrest â&#x20AC;&#x201C; we basically have short-circuited the human body. Now usually in the form of sinus bradycardia, cardiac automaticity kicks in and precedes recovery of the respiratory system.

Since the respiratory center (medulla) remains paralyzed even though there has been return of spontaneous circulation (ROSC), a second cardiac arrest can occur. As ROSC precedes resolution of respiratory arrest, a patientâ&#x20AC;&#x2122;s ventilation should be supported as soon as possible. This is the basis of reverse triage where, in groups of victims, a patient is given priority among lightning victims if they lack vital signs or spontaneous respirations.

en Abo and Andy Little

Myth #5: OK, even though a majority survive, all victims are considered high risk and require a significant workup. How the cardiovascular and nervous system are effected by a lightning strike can vary from benign temporary parasthesias

to sudden death. Based on the latest consensus from the Wilderness Medical Society, high-risk patients should receive a screening ECG and echocardiogram. High-risk indicators include suspected direct strike, loss of consciousness, focal neurologic complaint, chest pain or dyspnea, pregnancy, cranial burns or leg burns or burns >10% TBSA. Those suffering a direct strike or those with an abnormal screening, cardiac markers excluded, should be admitted for telemetry monitoring for at least 24 hours.

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An Emergency Medicine Publication

Myth #6: That ferning pattern known as the Lichtenberg figure requires extensive burn care or at least a burn consult.

This transient pattern is pathognomonic of a lightning strike, but is not actually a burn. It usually shows up within an hour and typically resolves on its own within a day. Interestingly, histologic changes cannot even be seen.

Myth #7: If someone is awake but paralyzed form a lightning strike, it can be considered keraunoparalysis and so no imaging will be required. Keraunoparalysis is a transient paralysis after a lightning strike that has been well documented in a number of case reports. Signs and symptoms include pulseless, pallor, cyanosis, or motor or sensory deficits in affected extremities.

While it typically resolves within several hours, it is important to know that it can mimic two major things: cardiac arrest and spinal injury. For this reason, it is important to assure cardiac arrest and to maintain immobilization until imaging can rule out spinal cord pathology should there be persistent neurologic deficits.

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The Fast Track

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Issue 8 Fall 2013

Staying strikingly current with those burning questions on how our bodies conduct themselves…

Yes, I went there… and anyone that knows me probably is not all that shocked. Seriously though, you can now see a little more that there is more than just burns and cardiac arrest.

Let’s add to this thought – if a majority of lightning strike victims actually survive, what do we do for them? What can we warn them about? I will leave this as some food for thought, and as an appetizer, know that there are varied temporary or permanent morbidities associated with lightning injuries. Some psychological like my mother’s phobias of loud noises and sudden flashes… and many physiological like loss of hearing and permanent nerve pains.

Being an avid lightning enthusiast, and not wanting to give away my entire lecture about it, I’ll end here this preview of an ongoing column regarding wilderness medicine topics. Upcoming topics include OMT in the wild (complete with a true case study) and dealing with the pressures of treating barotrauma.  References Link MS, et al. Electrical therapies: Automated external defibrillators, defibrillation, cardioversion, and pacing (Part 6). 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S706-19.

Cooper MH, R. Mechanisms of Lightning Injury Should Affect Lightning Safety Messages. Lightning Detection Conference. Orlando, Florida; 2010.

Cooper MA. Electrical and lightning injuries. Emerg Med Clin North Am. 1984 Aug;2(3):489-501.

Taussig HB. “Death” from lightning and the possibility of living again. Am Sci. 1969 Autumn;57(3):306-316.

Cooper MA. Lightning injuries: prognostic signs for death. Ann Emerg Med. 1980 Mar;9(3):134-138.

Cooper, MA; . (Feb 10, 2012). Lightning Injuries. Medscape. Retrieved August 17, 2013 from http://emedicine.medscape.com/article/770642-overview#a0156.

Taussig HB. “Death” from lightning and the possibility of living again. Am Sci. 1969 Autumn;57(3):306-ˇ16.

Davis, C., Engeln, A., Johnson, E., et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Lightning Injuries. Wilderness Environ Med. 2012 Sep;23(3):260-269.

Resnik BI , Wetli CV . Lichtenberg figures . Am J Forensic Med Pathol . 1996;17:99–102 Driscoll P , Wardrope J . ATLS: past, present, and future . Emerg Med J . 2005;22:2–3

Its never to early to start thinking about Spring Conference in Scottsdale, AZ April 22nd-26th, 2014. Visit www.acoep.org/meetings for more details about pricing page 30

and how to register.

Issue 8 Fall 2013

Tricks of the Trade

The Fast Track

An Emergency Medicine Publication

By Andy Little, DO

Removing Insects from Ears: 1. Make sure the patients tympanic membrane is intact.

2. If it is intact, place the patient in the lateral recumbent period with affected ear up.

3. Lavage the patient ear with 2% viscous lidocaine; this not only kills the insect but it anesthetizes the patients ear for the procedure.

4. Wait 20-30 seconds for the insect to die (this also allows time for the ear to be completely anesthetized).

5. While pulling the ear up and posteriorly in adults and down and posteriorly with kids, flush the ear with normal saline irrigation (10-20 ml) or until the insect â&#x20AC;&#x153;bubbles outâ&#x20AC;? and then irrigate with an additional 10-20 ml prior to sitting the patient up.

Reference: http://emedicine.medscape.com/article/763712-overview#a11

Are you looking to get involved in the political process? Want to meet face to face with your Senator and US Representative in Washing D.C.?

Then consider joining the ACOEP and the AOA at DO Day on the Hill 2014 on thursday March 6th, 2014. www.osteopathic.org/inside-aoa/events/Pages/do-day-on-capitol-hill.aspx page 31

Advanced Airway Shootout The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

Presented by the ACOEP Resident Chapter Sponsored by EmCare, FOEM October 5th2013 1-3pm Students 3-5pm Residents

We will have multiple stations, each with its own twist on airways. From beginners to difficult. We also will have representatives from the following companies there to showcase their adavanced airway products. These include:

GlideScope Co-Pilot Intubrite Storz Vividtrac

Ambu

Airtrag

KingVision

McGrath

So please make sure you stop in to try out the products and speak to the reps at this one of a kind airway experience Special thanks to EmCare for making this event possible. For more information about what EMCARE has to offer visit www.emcare.com page 32

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Tech Update with Patrick Connolly, DO Hello one and all and welcome to the first Semi-Annual TECH Report. We are here to introduce the latest software, websites, and gadgets for the Emergency professional.

Issue 8 Fall 2013

An Emergency Medicine Publication

“The simple and sleek interface of Pedi-STAT makes accessing most pertinent information a snap.“

QxMD is a brilliant little healthtech company. Its products have been featured in The New York Times and Emergency Physician Monthly to name a few. They collaborate with researchers at major research and medical institutions to bring inexpensive, slick and useful apps to the Iphone and Android markets.

Pedi-STAT is a must have for any emergency resident or student. Authored by ESP physician James Kempema MD FACEP, Pedi-STAT is your rapid reference for resuscitation of the pediatric patient in the ER. The simple and sleek interface of Pedi-STAT makes accessing most pertinent information a snap. Search by Age, Weight, Length, or just use the App’s Broselow Color Guide. In a word the app is “Seamless”. At $2.99, this app packs a punch of pediatrics at a puny price! Check out some of the features below or search Pedi-STAT by QxMD on Youtube for tutorial.

• Rapid results for airway interventions including endotracheal tube sizes, depth, intubation medication dosages, ventilator settings, and sedation • Cardiac resuscitation data including weight specific dosages for resuscitation medications, cardioversion, and defibrillation • Access to age and weight specific pediatric equipment including foley catheters, airway management, chest and NG tubes, peripheral and central line sizes, and more

Screen shot of Pedi STAT on the iPhone

• Seizure medication dosages • Reference of age specific normal vital signs • Procedural sedation dosages including single dose meds and infusions, as well as reversal agents

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The Fast Track

An Emergency Medicine Publication

Issue 8 Fall 2013

A Retrospective

Perspective

by Steven Brandon, DO I have often heard people compare the residency interview process to dating. In both processes you are trying to find your right “match”, and both can be agonizing, emotionally trying and expensive. This courtship starts as one party expresses interest; you nervously send them an application and hope they send you an interview invite. Then they (sometimes) reciprocate with an invitation to interview, aka; your first date.

You go on this first date and everyone wears nice clothing, and is cordial and friendly with each other. Then after the date you go home and wonder if they liked you. Should you call them?

If so how long should you wait? Maybe just send a text or email? Or do you play it cool and wait to hear from them, after all you don’t want to seem too eager or desperate. Ah, the insecurities of dating, I mean applying to residency. Okay, let’s get back on topic.

One of the biggest questions of the application process is how much, if any, contact a student should have with a program after their interview.

We have all heard stories of that persistent student who contacted a program frequently and was rewarded a residency spot, as well as other equally Do not tell every program they are your number one program. persistent students who annoyed the program and were not even ranked. So what should you do?

In preparation for writing this I have contacted a handful of Program Directors (PDs) throughout the country from both big and small programs to get their opinions on the subject and will supplement my thoughts with some of what they said.

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The first rule is that there is no rule. All of this will vary by program and you all need to do your best to feel out the situation to determine what is appropriate. One PD even asked and was amazed at the extreme variations in opinions shared amongst the core faculty within their program.

So most of what I say here is opinion based on

many collective experiences, but hardly a rule. I would generally say that positive and appropriate contact can potentially help, maybe help them decide between you and a similar candidate.

However, a poorly worded email or note can do much more harm and even drop you off of a rank list. Most of the PDs with whom I spoke told me about applicants who have sent a note or thank you that had incorrect information or the wrong names in them, you can imagine how that effected the applicant’s chances of matching. In general, it is not expected that you will have any contact with a program after your interview. So most of this is stuff you do not have to do, but all of you Type-A’s out there just can’t help yourselves so I’ll continue. #1 Rule, honesty This was a universal sentiment of everyone. Do not tell every program they are your number one program. Most of them know it is a lie, and I’m pretty sure you are not really supposed to talk about specifics of your rank list with programs in the first place. I also wouldn’t tell someone they are at the bottom of your list either. If you feel the need, just tell them you liked the program and that it is definitely one that you are considering. Also be honest if asked about applying to the allopathic match, just say that some of the ones you are considering are also allopathic programs. Really this topic is not supposed to be brought up, but it often is. All PDs have been burned by students saying their program was their top ranked, so they will appreciate the honesty and it will not hurt your chances if they do not think they are your number

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one. Not even Zach Morris was smooth enough to concurrently convince multiple girls they were his number one, so don’t think you can either.

Thank You Letters

Issue 8 Fall 2013

An Emergency Medicine Publication

Of everything I will talk about this is the only thing you HAVE TO DO. This is a common courtesy of any interview you do for the rest of your life, and it is expected. Many programs will include this, and any other emails or letters, in your files. Try to mention something pertinent from the interview day, This is too important to let something dumb like that ruin your chances. perhaps a topic you spoke about. Try not to be generic. PDs receive tons of these letters and can easily spot a lack of sincerity. And, again, do not use the wrong information, PD name or program name. This is too important to let something dumb like that ruin your chances. To help with this, write all of you thank you notes the day of the interview so you do not get things mixed up. You should write a thank you to the PD, as well as anyone who interviewed you. I realize that can be a lot, but just do it. Also send a thank you to the Program Coordinator. They put in a lot of work arranging your interview, and they all have a lot more power at a program than you might realize. Additionally, most students do not send a thank you to the coordinator, so this can make you stand out in a good way. In our increasingly digital world, there is the question or whether to send a hand written card or an email. I would say the content of the note and the fact you send one is most important. That being said, every PD with whom I spoke said a hand written letter or card is better. I agree with this. If it is important to you, put in the extra effort.

Return or Follow-Up Visits Many of you have likely heard that if you return to the program after your interview for a second look or “follow-up” visit, you can increase your chances of matching. I do not think this is true, and most of the PDs agreed with me. In fact, I had a friend in medical school that did second look visits to five different programs and didn’t get into any of them. That being said, these visits can be beneficial. Keep in mind that you are “visiting” someone while they are supposed to be working, and you will inevitably be in the way. It is different than when a student rotates in a department, because then there is a structure for how they help in the ED. Considering that, I would not do a return visit that lasts more than 3-4 hours.

Obviously different situations can provide different expectations for time spent, but you most of all do not want to over-stay your welcome. Most programs are very open to you coming back for a second visit, just be respectful of what you are asking of them. And be energetic. If you do go there and just sit in the corner or are not very personable, it will hurt your chances of matching. As with all things in this process, these visits can hurt you a lot more than they can help. Return visits are most beneficial for you to see the department in which you might spend the next four years. If you are trying to decide between programs this can provide you with a lot of insight as to how the program feels when they are not in interview mode, remember they put their best face forward on those days just like you do!

Basically my recommendation for these visits is to do them if it is convenient and will not cost too much money. For example, if you have to fly out to Michigan for an interview, you could take that opportunity to visit another program in the same area that you interviewed at a few weeks prior. I would definitely not make a trip of any distance with the sole purpose of doing a return visit to a program, it is a waste of time and money.

Phone Calls Unless there is a specific reason to call a program after an interview, don’t do it. You will be wasting their time.

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Issue 8 Fall 2013

Other Emails + Other than hand-written thank you cards, I think most contact you initiate after an interview should be by email. Here are a few pointers on those: + Be careful not to try and force an email conversation with a PD with the purpose of increasing your contact with them by increasing the number of emails you exchange. Program Directors are very busy, especially during this time of year. If you have legit questions there is no problem, but be respectful of their time. + Keep these emails brief. One PD said, “Remember that I am an ER doctor, my attention span is like a 3rd-grader; make the letter short”. + Spell check. That is it. + If you interviewed early in the season, I think it is appropriate to send a follow up email in late November or early December. Just simply saying that you liked the program and are still interested.

You can even say that you just wanted to touch bases since it has been two months, or however long, since your interview or last contact. + The one other email I feel is appropriate is what I call an “update email”. This should be done if there are any new things that occur that are not on your ERAS application. Examples could include: you published an article, received an honor grade in your core EM rotation, or have a new letter of recommendation (only if it is really good and from another PD). Good reasons do not include: you got married, traveled abroad (even if doing medical work), joined a new club at school, or got a new puppy.

Update emails should only be for very significant things a PD might use in considering your application. + Spell check again. You don’t want to look stupid.

So in summary: be honest and respectful, do hand written thank you cards, it’s okay to send a follow up email near the end of the season, send appropriate update emails, and only do follow up visits if they are convenient.

Good luck all you fourth years, I hope to see you all in San Diego this fall!

There are still tickets available for the FOEM Gala held on Monday October 7th. Contact swhitmer@acoepo.org

for more details on how to attend. page 36

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Visual Diagnosis Answer

with Cara Norvell, DO

Issue 8 Fall 2013

An Emergency Medicine Publication

As you can see above the patient was diagnosed with a right posterior hip dislocation and a left pelvic fracture.

After multiple failed attempts to reduce the dislocation the patient was taken to the OR for operative reduction.

Dont forget that ALL of our conference events will be held at the San Diego Convention Center (except for nightly Social Events).

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The Fast Track

Review Answers An Emergency Medicine Publication

Issue 8 Fall 2013

page 38

Question 1: Answer: A. The patient presents with priapism, a urologic emergency that should be relieved emergently with corporeal aspiration. Priapism describes engorgement of the corpora cavernosa due to either low-flow (more common) or high-flow states. Low-flow priapism is due to decreased venous outflow and is commonly seen in sickle cell disease and leukemia.

A number of medications can also cause this disorder. High-flow priapism is generally painless and results from excessive inflow of arterial blood or spinal trauma. Management should be expeditious as prolonged priapism can result in fibrosis and erectile dysfunction. Cavernosal aspiration and irrigation with phenylephrine is the most effective treatment modality. A dorsal nerve block should first be performed followed by aspiration from the corpora cavernosa until the penis detumesces. This can be followed by phenylephrine irrigation into the corpora.

Patients with persistent priapism or underlying sickle cell disease or leukemia should be considered for admission. Terbutaline (B) may be given orally or intramuscularly (not intracorporeal) for priapism and has a 33% response rate. Intravenous phenylephrine (C) is not effective in management. General phlebotomy (D) will not fix priapism because it does not reverse the underlying decreased venous outflow.

Question 2: Answer: A. This patient presents with pityriasis rosea and should be treated symptomatically with antihistamines as the condition is self-limiting. Pityriasis rosea presents as scaly, salmon colored, oval papules or plaques 1 â&#x20AC;&#x201C; 2 cm in diameter on the trunk and proximal extremities.

It usually presents in children and young adults.

Classically, the diffuse rash is preceded by a herald patch 1-week prior. This lesion is larger (2-5 cm in diameter) than the others that form. Patients may also initially have fever, malaise or lymphadenopathy early in the course of the disease. The diffuse form of the rash has a Christmas tree-like distribution following the cleavage lines of the skin. Pityriasis rosea is a self-limiting disease but may take 8-12 weeks to completely resolve. The causative agent is unknown although a virus is suspected (HHV 7). There is no specific treatment for the disease and so care should be directed at relieving symptoms, most commonly itching, with antihistamines. Cephalexin (B) is a first generation cephalosporin with activity against many streptococcus and staphylococcus species, which are not implicated in pityriasis rosea. Oral corticosteroids (C) have not been shown to reduce symptoms or duration of pityriasis rosea.

Although tinea infections are on the differential diagnosis for pityriasis rosea, a fungal etiology has not been shown to be causative of the disease and topical antifungals (D) do not play a role in treatment.

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Question 3: Answer: A. The patient presents with syncope and a systolic murmur radiating to the neck, which suggests the presence of critical aortic stenosis. Management should focus on restoring preload and cardiology consultation. Aortic stenosis is the most common cardiac-valve lesion in the U.S. A normal aortic valve has an area of 3 cm2. Reduction by 50% causes significant obstruction and critical aortic stenosis occurs with a valve area < 0.8 cm2. As the disease progresses, left ventricular hypertrophy develops to maintain cardiac output. Patients often are asymptomatic until aortic stenosis has progressed to severe or critical levels. At this point, they often develop angina (due to increased demand and decreased supply), exertional syncope (fixed cardiac output), and congestive heart failure (diastolic and systolic dysfunction). The classic physical examination finding is a crescendo-decrescendo, systolic ejection murmur that radiates to the bilateral carotid arteries. Additionally, carotid pulses may be both diminished and delayed. Once patients develop symptoms, survival is markedly reduced unless the valve is replaced. 50% of patients with angina die within 5 years, 50% with syncope die within 3 years and 50% with dyspnea die within 2 years. Immediate medical management should focus on restoring preload with fluids or blood transfusion if significant anemia is present. The only definitive treatment is valve replacement. Patients with symptomatic aortic stenosis exhibit an extreme sensitivity to vasodilators. Sublingual nitroglycerin (C & D) treats typical anginal symptoms by vasodilation leading to decreased preload and decrease cardiac work load. In aortic stenosis patients, this vasodilation can precipitate worsening symptoms. Morphine (B) causes vasodilation through histamine and is also contraindicated.

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Question 4: Answer: C. This patient presents with neutropenic fever and requires culture of typical infectious sources and broad-spectrum antibiotics. Fever can be caused by a number of etiologies in cancer patients including inflammation, medications, antimicrobials, transfusions and tumor necrosis.

Most fevers occurring in cancer patients are infectious in origin (55-70%). Neutropenia is defined as an absolute neutrophil count (ANC) <500 cells/mm3 (or < 1000 cells mm3 with predicted decline to <500 cells/mm3) and is calculated by multiplying the total WBC count by the percentage of neutrophils and bands. Neutropenic fever is an oncologic emergency and is defined by neutropenia along with a single oral temperature > 101째F or a temperature of 100.4째F for at least 1 hour. All of these patients should be managed presuming that they have a serious bacterial infection regardless of the presentation. A thorough physical examination should be performed looking for an infectious source but spontaneous bacteremia is common. Common sites include urine, chest, skin and blood and cultures should be obtained.

Patients with chronic indwelling catheters should have a culture sent from this site. Broad-spectrum antibiotics covering the most likely pathogens should be started. An antipseudomonal penicillin with an aminoglycoside or a fourth generation cephalosporin are commonly started. Vancomycin should be added in patients with possible methicillin resistant Staphylococcus aureus (MRSA). This includes patients with recent hospitalizations and indwelling catheters or severe illness. Untreated neutropenic fever has a high mortality rate (~ 20%). Filgrastim (A) is used by oncologists to boost the white blood cell count in patients undergoing chemotherapy but has a delayed onset of action and will not treat a serious bacterial infection. All patients with neutropenic fever should have antibiotics started and waiting for culture results (B) delays care. Although the patient has symptoms concerning for pneumonia, levofloxacin (D) is not broad enough to cover the likely pathogens that may be present in neutropenic fever.

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Issue 8 Fall 2013

Transitioning From Classroom to Clinic

As medical students make the switch from the classroom to clinical rotations, they are immersed into an environment that requires immediate adaptation. The typical routine of covering one body system at a time and exploring it in its entirety is replaced with real patients who have multiple issues simultaneously. The standard multiple choice exam is still a part of the evaluation process, but now grades are also dependent on subjective assessments performed by residents or attendings evaluating us in the clinical environment. The flexible schedule and classes of the first two years give way to long work days often starting early in the morning and not complete until late in the evening.

The importance of shifting your frame of mind and practices as you transition from the classroom to clinical rotations is evident by the sheer number of books, blogs, and journal articles that offer advice to students making this step. My particular hospital system requires their students to read, 250 Biggest Mistakes 3rd Year Medical Students Make and How to Avoid Them, by Samir Desai and Rajani Katta. It is my hope that the following advice will help students starting rotations to ensure they have the best clinical experience possible.

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As a medical student new to the clinical setting, it is easy to take a backseat and not be involved in patient care to the maximum extent. This may be the result of the preceptor not being the greatest educator or maybe that the student is too passive in learning through their interaction with patients. Medicine is a unique profession because students, residents, and attendings will at some point in their career be involved in teaching a younger generation. Quality teaching attributes are difficult to come by so it is critical that the student take learning into their own hands when they find themselves in this situation. Students will often find themselves in situations where the patient is presenting with symptoms or a disease state that they have covered numerous times that day. The passive approach of sitting back and

waiting to hear the treatment or antibiotics that the attending physician will prescribe instead of being an active contributor to the conversation will come back to hurt the student at the end of the 4th year when programs are looking for students who are motivated and involved in the care of their patients.

One statement that I found particularly useful in preparation for rotations was, try to learn something from each and every patient. This can be a challenging process for new students as they shift from the preset objectives used during the first two years to having to define their own learning goals as they move from rotation to rotation. The family members of patients are also excellent learning resources for students as they can provide a different perspective to the disease or illness. Family members are in a position to recognize changes or other complaints that the patient may not remember or just neglect to mention because they do not believe it is important.

The significance of professionalism is something that is heavily stressed from the time medical students first receive their lab coats. These behaviors are even now more crucial now that patients are involved and students are working in environments where there are a significant number of extra people around. I once heard the analogy that the hospital is just like a small town, meaning news tends to spread fast between staff. The best practice would be to assume that preceptors can hear every conversation students are having and that includes discussions with other medical students. If ever discussing an attending or other medical staff in a negative manner, it would be easy for someone else in the hospital to overhear that conversation and share that information. Preceptors have an incredible amount of power as they are the ones primarily responsible for completing the end of rotation evaluations, determining whether the student passes, honors, or will have to remediate. It is also important to consider each preceptor as

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Jay Anderson OMS III OU-HCOM

someone who may be writing a future letter of recommendation for residency applications. This is even more important for students who have yet to decide which area of medicine they want to practice in.

The other thing to consider is that physicians talk and they will often solicit information from others to determine if students deserve a particular evaluation. It would be in the studentâ&#x20AC;&#x2122;s best interest to work hard, be interested and motivated each time they work no matter who they are working with.

It is impossible to mention professionalism without addressing HIPPA and the potential violations students could encounter while on rotations. HIPPA violations are one of the easiest ways for students to find themselves in serious trouble. Violations are considered major events and will be reported to your dean of students, potentially evening being included on the studentsâ&#x20AC;&#x2122; record. A great deal of caution should be taken when in the hospital or clinic to limit discussions about patients to clinically relevant information and only discuss this information in secure areas.

Elevators, cafeterias and hallways are three locations where it would be easy for patients or family members to overhear conversations.

When a discussion must take place it is important to leave out any unique patient identifiers, like name, room number and specific disease states.

Medicine is a field with continuously changing information and the best way to stay up to date and keep such a large amount of data fresh is to read nightly. When starting a new rotation try to identify students who have already completed it and find out what text books they found beneficial. The recommendation I have heard is attempt to do this for one hour each night. That may seem like an impossible task on certain rotations where the days in the hospital can last up to 12 to 14 hours. Developing and sticking to this routine has produced immediate results for me as I can contribute more clinical knowledge and I am able to get more out of each experience. Fourth year students at my hospital suggested carrying around a small

ed by Andy Little

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notebook to jot things down as the day goes along.

This is great way to have a list of things to read up on throughout the day during down time. I try to recognize all the medications patients are taking and write down the ones I am unfamiliar with to look up later. Journals articles are another excellent resource for quick reading throughout the day to stay current with current information and research.

As physicians and students it is also important to be aware of the information that patients are seeing in the press and nightly news broadcasts. One great resource I have found for this is the AMA Morning Rounds, an e-mail generated every morning covering medical news by the American Medical Association. This is one of my favorite resources because I can easily glance over them on my phone before morning rounds start. The format is mobile phone friendly with the major headlines and important information but also provides links to the more detailed articles.

After completing two years of lecture based medicine, rotations are truly a breath of fresh air as students are now able to see for the first time why they applied to medical school. The transition period is something that each student has to deal with as they learn to adjust to fixed schedules, long hours, and endless readings. All of this hard work is made easy by the gratification that being with patients brings. During rotations it is also important for students to make sure they are keeping a good balance between their social and family lives. This is no easy task and expect there to be a new transition period at the start of each rotation but a doctor that does not take care of thyself, will not be able to take care of patient+ References: Desai, Samir Katta, Rajani.250 Biggest Mistakes 3rd Year Medical Students Make and How to Avoid Them. 2nd ed.

Houston, TX: www.MD2B.net

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Issue 8 Fall 2013

Keeping the Message on You with Andy Little, DO

N

ot long after I started as a resident, I was sitting at my program’s weekly didactics and looked around to see a group of students dressed in their Sunday best for

interviews, and I knew “I had arrived.” As I felt a great appreciation for not having to go through that process again, my mind took me back to stories told by fellow residents along with my own experience with applying to residencies and the match. Now, as I speak with students rotating through my program and students I converse with by phone or email, I recall interactions I had with residents throughout the country. In considering who I am and how I got here, it has come to my mind the true impact the answer to a simple question can have when it comes to the future of a student. It has made me realize that although the application process is different from the perspective of students and residents, there should be one commonality: for both parties the focus should be keeping the message on you.

S

tudents, this time of year is the most important three to four months of your medical school career. Between rotations, studying for the step 2’s, applications,

and interviews, this time represents why and how you have come so far: to match in the specialty of your choice. This time will play a pivotal role in where you will train as a resident next July. When you rotate, there will be other students on the rotation with you, be nice to them, work with them, but most of all, worry about how you perform and how you carry yourself. There is nothing like watching a student ruin their chances at a program by spending time and effort trying to compare themselves with their competition. Know that there will be things you are bad at, that you will make mistakes, and that it is ok. Take responsibility for your deficiencies and don’t blame someone else.

Show that you are willing to be and can be taught. Work on it, strive to be better, show that you are willing to work towards making yourself better.

E

ach of your applications are filled with great attributes, but despite your best efforts, almost all of you will have a blip, a question mark, something that will lead to a tough

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question. Again, keep the message on you. Be honest about owning up to your faults and

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you deflect the blame or choose not to address the issue. This principle also applies to your strengths. Be willing to take praise, speak highly of yourself. Always be aware that

Issue 8 Fall 2013

deficiencies. You will go farther and improve your likelihood of being considered than if

there is a fine line between this and arrogance, and once you know where that line is, please feel free to let me know.

F

or residents, we have a great responsibility. Students listen to what we have to say and we are the face of our programs. I remember talking with residents about their

programs, and other programs and being utterly surprised by what came out of their mouths. If I mentioned a program I was applying to other than the one I was at, more often than not I received an overwhelmingly negative response. I still do not know what the purpose or basis of these responses were. Was it to deter me from applying to those programs? To in some way show me that they knew what was best for me? Looking back, what this did was put a bad taste in my mouth about their own program and decreased my desire to work with negative people. I found myself moving those programs down my rank list, and in some cases off my list altogether.

S

o to residents who may be reading, when students ask about programs, keep the message on you. We don’t know what any particular student may or may not be

looking for, what program is perfect for them. We need to spend more time talking about how our programs would be right for them. If I do say something about another program it is usually, “I have a friend who is at that program and loves it,” or “If you have questions about that program I can get you in touch with someone who is there.” This will demonstrate to prospective students that you are confident in your program and that rather than tear down another program you would prefer students get information from a good source.

S

o as interview season gets into full gear, whether you are a resident or a student, approach this time with honesty and positivity. We are all in this game together trying

to find the best fit for each of us as residents and as co-workers. We all deserve to find a program and co-residents that will suit us and fulfill all of our particular needs, and our best chance at this is to be ourselves, be open to new opportunities and honest about your strengths and weaknesses as a person and as a program. Good luck everyone!

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Will you join us?

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Issue 8 Fall 2013

In Scottsdale, AZ, April 22nd-26th for Spring Conference 2014. For more information see the ACOEP booth at the Scientific Assembly in San Diego October 5th-9th.

ACOEP Resident and Student Chapter 142 East Ontario Street Suite 1500 Chicago, Illinois 60611 page Phone: 312.587.3709 44 Fax: 312.587.9951 E-mail: bthommen@acoep.org

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