AWAEM AWARENESS JULY-SEPTEMBER 2016 AWAEMAWARENESS

A quarterly newsletter of the current activities of our Academy, an organization of strong advocacy for women in academic emergency medicine

Table of Contents

President’s Column: Gearing Up for a Productive (Academic) Year……..…1

Feature Article: The Nocturnist………………4 President’s Column: Wellness Kit……………6 Gearing Up for a Productive Resident Column: The (Academic) Year Resident Parent……..…7 By Basmah Safdar, MD

Feature Wellness Column: Summer is rapidly coming to an end. For many of you this may My Bucket of Love……11 mean added logistical planning of a school year with kids, interview season or start of an academic year on top of everything Annual Luncheon Table else that you do. It is hard to stay productive with all these balls in Summary: Retirement..…13 the air. This is why I thought it would be a good time to review some of the tips I have gleaned from capable colleagues, mentors Clinical Column: Ultrasound and the non-medical world over the past few years. Guided Nerve Blocks…14 Tips to become more productive at work:

Women in Global Medicine 1. Optimize your stress levels Spotlight Interview: 2. Find your rhythm Dr. Stephanie Kayden……16 3. Make time to relect and recalibrate 4. Build self esteem Direction: To Be A 5. Develop better work-life integration Mentor……………………..19

AWAEM Book Corner….20

Meet the New Members of the AWAEM Team……21

Get Involved! AWAEM Committees 2016-2017..22

AWAEM AWARENESS 1 AWAEM AWARENESS JULY-SEPTEMBER 2016

President’s Column By Basmah Safdar, MD

1. Optimize your stress levels:

Similar to the Starling curve, the Yerkes- Dodson Law describes how stress determines performance (Figure). In essence, increasing stress increases attention, interest and productivity but only up to a certain point Image from Yerkes RM, Dodson JD. The relation of strength of stimulus to after which performance declines. So are rapidity of habit-formation. Journal of Comparative Neurology and there ways you can ind the perfect balance? Psychology. 1908;18(5):459–482 In a recent issue of Harvard Business Review, Fransesca Gino from Harvard Business School shared the following tips to She wears the same pair of socks throughout a better manage stress at work: tournament and ties her shoelaces a a) Exert control over your tasks: particular way. These great athletes use these Contrary to general belief, people who are at rituals almost down to a formula to help them leadership positions experience less stress focus, and to reduce stress levels before high- than people with less responsibilities. This is stake tasks. As emergency physicians we are because people at high-level positions often familiar with the value of rituals with our have more control on their work. For us, this routine use of ACLS and ATLS in high-stress translates into focusing on tasks where you code situations. The key is to form similar can make choices. For instance, deciding rituals before our academic work to help which emails you should answer irst or jump-start the day and stay focused and choosing a speciic time to answer emails as productive. opposed to being tied to your phone all day long. b) Make time to relect on your 2. Find your rhythm: priorities and voice them: According to Ms. Gino, people who experience inauthenticity at I greatly respect individuals who are work experience higher stress. For instance, disciplined enough to follow the timetable when they complete tasks simply to oblige they set for themselves. I unfortunately have a their colleagues as opposed to when they rebellious streak that resists tight structure. themselves believe in the value of their work. As a result, even with the best intentions, I The Solution: Know what your personal sometimes ind it hard to follow a standard priorities are and make a point to voice them. routine. I have adapted by creating a timetable This is particularly dificult for us women and that helps me outline my priorities for tasks needs practice and regular attention. on an annual and then monthly, weekly and c) Use rituals: For anyone watching daily basis. the Rio Olympics, you have likely celebrated Elizabeth Saunders, a life coach, is a big the accomplishments of Michael Phelps. You proponent of inding this inner cadence and may have also noticed how before each race, simpliies it as follows: he walks out to the starting block lost to his a) Set a monthly cadence: headphones’ blasting music, removes his Determine one major task you want to headphones and swings his arms exactly three accomplish that month and go with it. times. Serena Williams uses many rituals to Focusing on more than one often results in help her focus on her game. She bounces her not accomplishing any. Honor the monthly serving ball exactly ive times before the irst commitment and you will build satisfaction serve and two times before her second serve. and self-esteem.

AWAEM AWARENESS 2 AWAEM AWARENESS JULY-SEPTEMBER 2016

President’s Column By Basmah Safdar, MD

b) Find your weekly cadence: sleep, this is hard but essential to stay Clinical shifts, meetings and commitments can productive. Some of the most successful CEOs vary each week. It is useful to have a general spend almost a third of their time doing just sense of your weekly cadence that you can this – it helps them strategize the direction of modify and adapt based on the week. their company and gain eficiency. It helps us Understand what you need to help organize work smarter and not just keep working your week. If you need to, ramp up time at the harder. beginning of the week to plan your weekly I recommend writing down your core commitments, then you may block a chunk of values and priorities. It would help you time midweek to do your creative writing or crystalize your goals into something project and use the end of week to wind functional and attainable that you can refer down. Also schedule in organizational and back to over a period of time. Use visual cues personal restructuring time so you don’t feel to brainstorm – a white board, pencil and guilty about these essentials. paper, stickies, scratch pad on the computer – c) Daily cadence: There is no whatever medium that helps you think. And formula to this. Some folks are most eficient take a picture when you are done. Build in at the beginning of the day and some work time in your schedule to come back to it and best in the middle of the night. It is important see how your monthly, weekly and daily to be honest with yourself. Whatever you do, schedules are aligned with your goals. If you ind the time when you are best focused and have accomplished your goals, you can rejoice keep it open for creative work. the satisfaction that comes with completion of If you are the type who needs processing goals. time, then schedule it in. It is important to give yourself permission to spend time reorganizing when you need it to keep 4. Build your self-esteem: yourself from feeling perpetually guilty. At my institution, we are expected to turn Writing down your priorities serves more in goals and objectives for our academic year than help you become productive. It helps to the Chair. I use it to chart out my essential build your self-esteem and excel in what you projects at the beginning of the academic year. do and distinguish yourself from your peers. A I plan out the different phases of each project recent study by Zoe Kinias from INSEAD by month, highlight the ones that are of (Institut Européen d'Administration des immediate priority and break them down to Affaires – the European Institute for Business weekly tasks. It is probably the best ‘non- Administration) noted that relection on core productive’ time I invest at the beginning of personal values helped women keep a the year. It has helped me multitask when I competitive advantage in business settings. In feel like I am drowning and get paralyzed with a simple study, she studied two cohorts of too many obligations. A small bit at every almost one thousand MBA students. She opportunity keeps my momentum going. prompted one group to relect and write about their core personal values for a few minutes during orientation and the other 3. Make time to relect and group to write about other values (e.g. recalibrate: institutional values). She tracked their performance with grade results at the end of At regular intervals, it is helpful to review the irst semester. The cohort that did not your core values for what drives you, the goals write about core values had a signiicant you are working for, and assess if your efforts gender gap with women performing are moving you toward these goals. Between signiicantly worse than men. For students all the obligations, distractions and lack of

AWAEM AWARENESS 3 AWAEM AWARENESS JULY-SEPTEMBER 2016

President’s Column By Basmah Safdar, MD

who wrote about their values, the gender gap c) When on vacation, turn your was eliminated. email off completely Three weeks before their inal exams, the d) Designate space at home to work group that wrote about personal values had – this may be an ofice or part of another less self-doubt than the other cohort when room. It is useful to separate your relaxation asked. The authors noted that people strive to space from your work space. feel respected and to have meaning for their e) Carve out time for yourself lives and for their efforts. Without these core regularly – it may be short but use it values being at the forefront of their efforts, exclusively for yourself. It could be for they may feel devalued and feel self-doubt exercise, music, a book or some ritual that that interferes with their performance, works for you to relax and helps you keep particularly women who often feel a your rhythm. stereotypical threat. By reafirming their personal values, they are better able to This list of pointers is by no means all- counter the stereotypical threat that most inclusive but should be a good starter for women face at work. By bringing core values conversations within your own circles. As to their forethought, people felt more valued women and as emergency physicians we are and worthwhile. great at learning and adapting. If you have found more tips that are helpful, we are always looking for new energy, ideas and 5. Develop better work life input. Please share these experiences with us. integration or balance? Finally, as you may have noticed, we are Whether we call it balance or integration, using the same strategies at AWAEM to be another key message I have heard time and more effective as a team. All summer we have again is to better manage work at home. This been busy inding time to relect, setting our is harder done than said, especially for us priorities and planning out the year as we ind emergency physicians. We are used to our cadence. You have read about some of working 24/7 and often do the same for non- these elements through our monthly clinical work. While some advocate never communication on the listserve. We will bringing work home, I personally ind this continue to update you on our progress and goal unattainable. I have, however, found hope to share some success stories in the some strategies that help contain the stress upcoming months. that comes with bringing work home. Thank you a) Designate time for home life – Basmah guilt free. b) Better manage your phone: turn off the email notiication on your phone and restrict your email checks for speciic times of the day.

join the conversation: #AWAEM

AWAEM AWARENESS 4 AWAEM AWARENESS JULY-SEPTEMBER 2016 Feature Article: The Nocturnist By Angela Smedley, MD, University of Maryland School of Medicine, Baltimore, MD

a three year old who just wanted a The move into night shift wasn’t a mother to count on. slow drift for me; it was an avalanche. At That wasn’t the only bonus. I could nurse thirty, heavily pregnant with baby #2, my son and put him to bed before work. fresh out of residency, I was growing At four months (blessedly better than the literally and iguratively. My shifts rotated 5.5 weeks for my irst, a residency baby), erratically from 7-3’s to 2-10’s to 4-12’s to he was a serious sleeper, generally 7-3’s to overnight 11-7’s and back again. sleeping ten to six. I could sneak in breast Although that irst trimester nausea and pumping in the quiet physician lounge vomiting had resolved, napping remained one time during the night before the elusive with a two-year-old with a full evening doc left (a step up from the diaper wandering after me. None of this scattered residency trauma locker room was unexpected; it was just the way it pumping sessions under the hum of was. The craziness of shifting hours and luorescent lights). Then my son would adjusting schedules were what my take cereal from my husband in the husband and I had grown used to. Not so morning (with frozen breast milk) and I much my two and a half year old. She could nurse once I got home. If running was the loose rock that started the whole late, I pumped in the car on the way home avalanche. (don’t ask). I had a fabulous day-time nanny, who would bring him up to me to Before settling on night shift my scattered nurse or give him a bottle while I slept absences increasingly worried my blissfully through the day. Plus, I could daughter. She was never quite sure if put that feisty three-year-old to bed – she’d see me again before a story and bathe her, read her a bedtime book. bedtime. That uncertainty was Better still, no tearful goodbye before problematic when she started preschool. walking out in the quiet darkness to the Drop offs were a leg clinging car. In the morning I’d see her before pre- extravaganza; she loved school once school and she knew that I’d be there sitting at a table with a crayon or snack, when she brought me her drawings and but hated leaving me, uncertain if I’d be hugs after school. there folding laundry or just gone when she got home. She was an easy baby and This worked so well that I continued for a great kid, but starting preschool and baby #3. I gradually learned over the sharing time with a new baby brother years that when I sacriiced sleep, I would were enough to push her to plot ways to get sick and the drive home from work undo our lives. would happen in a trance; then my house of cards teetered, felt precarious. If I was When I went back to work after 4 months going to continue to work this “backward of maternity leave (by that I mean unpaid day,” this schedule that is the opposite of time off…but that’s a story for another most people’s, I accepted that I had to put time), we decided to try sticking to one some routines and structures in place to shift to solve the uncertainty problem. keep myself healthy. It’s the only way one The only shift available for that plan? can do nights over the long term and lead 11p-7a. It turned out that’s the only shift a balanced and healthy life—only limited most prefer to pass on. While it’s things can give. In addition to my sleep, I apparently disastrous for personal health committed to exercise (though it’s far too (according to a number of reports, studies easy to skip it and stay in bed, begging off and rumors), it turned out to be great for because of being “too tired”- yep, I’ve done that). I go to the gym or boot camp

AWAEM AWARENESS 5 AWAEM AWARENESS JULY-SEPTEMBER 2016

Feature Article By Angela Smedley, MD

or run or hike or whatever I can several addiction plague the ED patients that times a week. Sometimes those make us their home). We mourn each endorphins are the only thing that keep regular lost to the elements, accidents, me going. I have had to make peace with drugs and alcohol. This feeling of family a diet that can support the backward is just one more part of what keeps me sleep and waking. To avoid the temptation “on” nights. to eat my way through the kitchen when arriving home in a sleep deprived fog of Of course, that’s just me. Different night leptin/ghrelin axis confusion, I have had shift types have various reasons for their to limit or cut out my trigger foods – schedule. For some, there is a pay cheese (sigh), sugary stuff and processed differential that makes a difference in foods. That helps me, anyway. how many shifts they work. For others, there is a trade off in number of shifts. Nights aren’t for every temperament - but One of my greatest beneits has to do with don’t ask me to deine what personality my ability to pick my schedule with works best. Like many who work nights, I lexibility. We are double covered on am somehow always tired enough to nights, so even though we have a few full sleep so I try to be good to myself. In time night physicians, I am able to pick other words, I’ve stopped ighting it— the nights of the weeks I work and the instead I listen to my body and am a ones I’m off. This has been a game generous friend, napping when it is clear I changer as my children grew up and had need to. When we are tempted to skip crazy (hockey, soccer, etc.) schedules of sleep; over time, the body undeniably their own. I had the ability to adjust my punishes us. I can almost be guaranteed a schedule to meet the crisscross schedules cold or headache if I start skimping on of academics, sports all those sleep to get more done. My father’s extracurricular activities - I hardly missed favorite axiom, “You can catch up on all anything. the sleep you missed after you are dead,” turns out to be an inaccurate accounting Now my oldest (18) has started college, of reality. That “supermom” thing? As the middle child (15) is starting his my kids would say, “No, just no.” sophomore year of high school and my Despite the drawbacks of being up all baby (13) is headed into eighth grade. My night, there is deinitely a chemistry and reasons to stay on night shift remain camaraderie to the night shift that is hard compelling. While it probably seems like I to explain. It is just as busy (or busier), should admit now to being a night owl, it yet there are fewer people, less chaos and would be more accurate to say I am more less noise. The business of the day has of a fox in a crowded suburb, drawn to the receded; the consulting docs are gone, the night because of events out of my control, ancillary staff is limited and the yet somehow inding a way to make it my administration miraculously evaporated. own. The nursing, ancillary and physicians form an alliance in their goal to get things caught up and accomplished. We operate independently and yet fondly together. Many of the patients we see are oddly our regulars; we feel at once protective of them and frustrated with their various situations (homelessness, lack of resources, psychiatric illness and

AWAEM AWARENESS 6 AWAEM AWARENESS JULY-SEPTEMBER 2016 Wellness Kit By Jeannette Wolfe, MD, and Amy Leuthauser, MD

Hi wonderful ladies, we know how hard you all work so wanted to create a little something special just for you. The result is our new handcrafted monthly AWAEM wellness kits. In it you will find lots of little ways to refuel your spirit and recharge your battery. Just click away to find a new meditation, yoga pose, yummy recipe or Saturday night movie.

Enjoy and thank you for all you do for our patients and your families,

Jeannette & Amy

Meditation 5 minute- find your breath meditation

Yoga Pose calming child's pose

Hospital Snack high protein snacks

Special Recipe yummy pancakes

Artsy Movie Moonrise Kingdom

Mini Indulgence ecofriendly fresh flowers (from a company that even provides child care!)

“I need to listen well so that I hear what is not said.” –

AWAEM AWARENESS Thuli Madonsela 7 AWAEM AWARENESS JULY-SEPTEMBER 2016 Resident Column The Resident Parent - chaos, challenges, and unforeseen benefits By Kelly Quinley, MD, Emergency Medicine Resident, PGY-IV, Highland Hospital, Oakland, CA

“Do I detect a gravid uterus?” He gestured toward my abdomen, eyebrows raised, judging. I was meeting to discuss residency applications and my future career with one of the administrators who was high up in the academic milieu of the medical school. And yes, if you’re reading this and this robotic question makes you feel awkward, or [insert a more negative emotion], all I can say is this man’s comments were more disturbing in person. I was a fourth year student, 30 years old, and left that meeting with a sinking feeling that perhaps the emergency medicine programs I was applying to would have similar sentiments about having children as a resident to those this man likely did. Apart from the anxiety that comes with applying to residency at baseline, I was broke out in laughter. My fears eased up that already illed with other fears that after month as being pregnant at Highland Hospital the stork dropped off the baby (if only it was clearly viewed as a normal part of life. No actually happened that way…), my judgments. All acceptance. Just one of many childless friends would write me off as a reasons that my irst choice residency program “mommy” only, an alien of sorts, quickly changed. uninterested in all future adult contact. Now I started to seriously fear that Residency interviews started two weeks residencies would question my dedication after my son was born. I was breastfeeding, and to their program given that I would have a given that the residency interview experiences child at home. Too late now. normally lasts an entire day, I had to email ahead to awkwardly ask every program if they could I was six months pregnant when I accommodate my needs for at least two 15 completed a sub-internship at an outside minute breaks and a private place to pump. One hospital, which in all honesty I chose thinking it program offered a pumping space of a single stall would be my second choice for residency, so in without counter space in a multi-stall old dusty case the program director frowned upon my bathroom with no lock. Another program sent me “gravid uterus,” I then might have a blank slate at to a supposedly unused ofice, but 3 minutes in a my irst choice institution. I strived to show that man suddenly knocks on the door, obviously my impending motherhood could not distract me perturbed, “I know what’s going on in there. Can or impede my ability to be a focused resident. you just hand me my laptop?” On a cross-country One night a cardiac arrest case came in, I jumped light, I had to pump in the airplane bathroom. on the chest, the room became quiet and as I When I exited 20 minutes later, there was a line focused on depth of my compressions, I hear a six people deep, all with glaring looks equally desperate voice yell, “Can someone please relieve annoyed as suspicious, as if I had been building a the pregnant medical student?!” Four people bomb in the bathroom. These anecdotes aside, as lined up in a lash. And I almost inappropriately a testament to perhaps how far this ield has

AWAEM AWARENESS 8 AWAEM AWARENESS JULY-SEPTEMBER 2016

Resident Column By Kelly Quinley, MD

come (I of course have minimal perspective), prove that it can be done, and done well. I have most programs were overwhelmingly fantastic had to breast pump in bathroom shower stalls, and accommodating. Numerous residencies even radiology suites, in the car driving across the Bay sent their breastfeeding attendings to casually Bridge in trafic. The program was incredibly check on me and see how I was doing, which supportive of pumping during a shift, but nothing opened the door for great non-medicine related can take away the inherent stress of the 20 conversation during the interview trail. minute pump getaway as a resident, which goes a little something like this…here are the thoughts I began residency with a 6 month old and actions involved: baby. This has made these past three years the “Oh man, I’m 2 hours past time already, most grueling, exhausting, and sweetest of my 35 department is busy, shoot. Oh no, my engorged years. Luckily it turns out that the sleep debt from chest is telling my hypothalamus and pituitary a newborn is excellent preparation for emergency that I don’t need this milk, my supply is going to medicine residency. Challenges have included plummet, I already feel like a bad mom, I’m never long days and childcare coverage. There have home. Ok, I’ll make time. Find the attending, tell been countless days on trauma surgery, ICU or him I’m going to pump, go to the pumping room, ortho call where I have left before the little man hurry, four new unseen patients, stop to check the was awake, come home after he’s in bed, or was board, no chest pain or scary vitals, ok I’ll be back at the hospital for over 24 hours in a row and in 20. Unlock the room, hook up (takes 3 min and didn’t see him awake for multiple days. The the assembly of a thousand small pieces), let thoughts that kept me going at those times were down, whew! Thank god, ok, hurry up and eat that it has to be good for children to see their while pumping because there is absolutely not mothers work hard outside of the home, as well enough time for me to both pump and take 10 inside. We found a nanny who was lexible to minutes to eat later, ok, bottles half full, stufing come in early or spend the night months I had to my face. Overhead I hear the call, “Level 1 trauma, be at the hospital at 5am and my husband was 3 minutes, airway resident needed.” [Expletive]. traveling. I’m the airway resident. [Expletive again]. Unhook. Just spilled some of the milk, [repeat I had my second boy in the middle of my expletive]. Oh wait, where is my hand gel, trying second year. I was too busy to pay as much not to give CRE and MRSA to my 9 week-old, attention to this pregnancy as the irst, I just put where is the [expletive] gel, ok, found it. Unhook my head down, wore double-lead when I had to the pump, damn, I’m leaking, throw breast pads assist the orthopedic surgeon in the OR, and used in, no way I’m going to get back to pumping the my belly for extra leverage when called into the rest of this out before the shift is over. I open the ER at 3am to reduce an open trimalleolar door, sprint to the trauma bay, try to be subtle fracture. Honestly said, that’s about all I can about holding the breast pads on with the back of remember from pregnancy number two. my forearms while I run through the department. Cringe. I forgot to put the breastmilk in the The bigger challenge was breastfeeding fridge.” The trauma patient arrives. and pumping at work as an R2. Every pumping session meant my board went to hell, as stepping Residency. Parenting. These are the two out for 20 minutes is no small thing on a busy hardest jobs I’ve ever had, and I am doing them at night shift. I was just getting my sea legs running the same time. But it’s not all hardships and half of the department, wanting to be fast (and complaints. Having my own small humans has good, of course), wanting my colleagues to think I provided some unforeseen beneits, and I think it belonged in this residency, and my program has helped me become a better doctor. It has directors to know that having a newborn wasn’t made me love other people’s children more, I am going to slow me down. I also felt a strong sense more patient with pediatric patients and their of responsibility for future resident mothers to parents, especially the parent who brings in a

AWAEM AWARENESS 9 AWAEM AWARENESS JULY-SEPTEMBER 2016

Resident Column By Kelly Quinley, MD

febrile, well appearing child that we all know you attendings or residents who have ever held doesn’t need to be in the ER. Adult tantrums, no the base call phone or attended to your fellow big deal. Vomit, diarrhea, I’m totally bored. For resident’s patients while she was pumping, I’m the dificult adult patients, when I’m about to thanking you on behalf of the resident mothers, loose my cool internally, I remind myself that this your generous help has been critical and needed person was once a cute, clean, innocent little in a dificult time in your colleagues’ lives, and I person, who has just gone through innumerable promise your help is appreciated more than we hardships I may never have to experience, and I can possibly convey. We simply could not juggle can recollect myself. My relationship with residency and parenting without you. emotional and psychotic patients has changed. One day I deescalated a threatening, hyper-verbal So residency continues. Whew, it’s my manic patient, and a colleague looked at me and irst weekend day off in 4 weeks, I got home from said, “Whoa, you’re good.” I guess I deescalate swing shift at 1am last night. Went to bed at 2am. irrational 2 year-olds all the time, I have a lot of The clock says 6am. I hear the bedroom door practice. squeak open, I squint open my eyes but make sure I don’t look like I have my eyes open, and I How constantly crazy life is at home barely see the top of a curly head of hair over the makes me love my job more and makes me want edge of the bed, it bounces my way, I close my to come to work, as often it’s easier to be in the eyes, I hear the footsteps get closer, two small ER where I get to have adult conversations. hands grab my face, and I hear, “Mama! The sun’s Having kids has taught me to embrace chaos. I do wakin’ up, wake up! Let’s go watch the sunrise.” possess the stereotypical doctor type-A control- Actual quote. Can’t say no to that. I get up, the freak gene, but as a parent, you have to go with sleep debt continues to grow, but I’m illed, and the low. Saliently for an EM physician, it’s made I’m going to take that with me and rock my swing our chaotic job easier as I’m simply used to shift this evening. disorganization, and can’t afford to sweat the small stuff. After that dificult day at work, I go home and put my face in the necks of my small, soft, loving boys, and it’s the best medicine around. However, I’m resolved to the likelihood that I’ll be struggling with the thoughts that I’m never giving 100% to my job, or 100% to my children, for the rest of my career. I simply don’t have 200% time and attention.

As the “non-traditional” student becomes ever more traditional, and more students come to medicine as a second, third or even fourth career, the resident parent will only become more common. I tell all students, including men and those not planning on having children, that they should note which programs have residents with kids, as the administration’s support of families likely indicates they support their residents’ lives outside of the hospital. It’s a great litmus test. For you mother (and father) attendings who have both supported your parent residents, and have paved the way and had it tougher than my generation, thank you for priming the pump. For

AWAEM AWARENESS 10 AWAEM AWARENESS JULY-SEPTEMBER 2016 Feature Wellness Column: My Bucket of Love By Maria O’Rourke MD, and Vicken Y. Totten, MD MS

attentive to psychosocial issues. These As female physicians, patients see us unique strengths in communication have as nurturers. If we have children, our kids allowed me to develop another great tool expect unbridled love and support. We that has improved the toughest patient raise, encourage, and provide for our interaction. I call it “the power of choice”. children. We feed them as infants and watch them grow, nurtured by our bodies Balancing dificult patients and life and surrounded by our love. While we stressors as a female physician requires never experience the same closeness or many tools. While we need to ill our emotional attachment to our patients, we toolbox with a wide variety of can appreciate that they expect many of instruments, I’d like to describe another the same things from us as our children speciic skill I’ve developed, which has do. Our patients expect understanding, improved even my toughest patient warmth, security, and patience. interactions. This tool has not only given me a popular reputation with the nurses, In my 12 years as an EM doctor, irst but it has also allowed me to enjoy the as an US Army Doctor during Operation most dificult patients, the ones that used Iraqi Freedom, then in civilian academic to cause me the most stress. and community settings, I have worked to become an expert in my specialty. I’m 50 Here’s an example: years old now and my approach to the I was paged to a room where a emotional demands of my life and my dificult patient, with an extensive cardiac patients has matured. I’ve trained myself history, was still complaining of chest to leave the stress of work at my front pain after three nitroglycerins and a dose door when I come home after a shift. I’ve of morphine. His repeat EKG was thought about how best to rebound from unchanged. The nurse was frustrated by a particularly dificult case. his frequent demands and wanted to know if we should give him additional I developed a tool; my “bucket of love”. medicine before he got admitted. She I reach into a stockpile of emotional suspected he was drug seeking and that reserve that I intentionally save for his pain was not real. When I arrived, he whenever I encounter a particularly was anxious, annoyed, and still stressful situation, such as a needy complaining of pain. He was sitting with patient. Although this method isn’t his arms crossed, a half-eaten sandwich foolproof (Who has any emotional reserve and juice box at his bedside. I offered him after 7 shifts in a row?), having a a blanket and sat down. I introduced deliberate emotional savings account myself and asked him how he was doing, helps me remain compassionate for even then I listened. I really listened. I thought the most draining patient encounters. “What does this patient really need?” All pain, physical or not, requires Many women have come before me acknowledgement. I told the patient and paved the way to welcome more exactly what was going to happen--I nurturing relationships in the emergency would come back in 10 minutes, I would department. In fact, compared to their repeat the EKG, I would address his pain male counterparts, female physicians and when he was pain-free, he would go encourage patients more to take an active upstairs to the admission bed awaiting role in their care, are less verbally him. For each of my patients, I do this in a dominant during conversations and more way that makes them feel validated and as

AWAEM AWARENESS 11 AWAEM AWARENESS JULY-SEPTEMBER 2016

Feature Wellness Column By Maria O’Rourke, MD and Vicken Y. Totten, MD MS

if they are an important member of the Adjusting my mentality and focusing medical team. on what the patient needs made a difference for me at work by increasing Patients appreciate when their the number of positive patient choices and preferences are integrated interactions I experienced. It decreased into the treatment plan. The choices don’t my stress during shifts. When I worked in even have to be major. Sometimes even a Combat Support Hospital in Kuwait the ‘choiceless choice’ helps- I use this during Operation Iraqi Freedom, I had to one on my kids, too. “Do you want to do accept that I would lose many your homework before or after the battles. Soldiers came in every day and dishes?” (You will do the dishes, and your night, many mangled, some dead, and homework. You have a choice of the some we weren’t sure would survive. I order.) or, for this patient, “Here is a learned not to internalize those losses; I blanket. The repeat EKG was ine. Do you had to approach each case individually, want more nitroglycerin now or after you without the emotional baggage of are admitted?” previous patients. I have brought that understanding to my work in academic Why the change in approach? Your and community EM. patients, just like your children, want to feel heard and understood. They want to Navigating a career in Emergency be nurtured. By listening to your patient, Medicine as a female physician is a bit like you may be able to resolve an escalating playing chess. Occasionally, you situation, to everyone’s satisfaction. In my may feel like a pawn, knocked out early previous example, I was able to leave that and feeling dejected, but remember, the situation feeling that I successfully did my board will re-set and you can start again job and helped my patient. next shift. I continue to search inside myself and ind the courage to move forward.

AWAEM AWARENESS 12 AWAEM AWARENESS JULY-SEPTEMBER 2016 Annual Luncheon Table Discussion Summary: Thoughts and Advice from the “Retirement Planners” By Susan Watts, MD

The accommodations for ‘older’ physicians recommended by ACEP and others DO work to help keep valuable senior faculty healthy. A little extra time goes a long way toward reducing fatigue and aiding with recovery from a long shift. Time to sit and eat; time to take a bathroom break; time to sit down and chart; extra time to recover from overnight shifts.

At some point, the ED shifts become too physically and/or mentally demanding. When is the appropriate time to walk away from clinical practice? What are the options? Those in academic centers may be able to shift to increased administrative or educational duties to offset fewer ED shifts. For others the best option may be to take a non-clinical, but still medically related, job; with an insurance company for instance. These kinds of changes may result in reduced income however. So see your inancial advisor. When can you afford a decreased income?

Whatever your speciic life situation is, it is useful to think of retirement as another periodic reinvention of yourself. This happens to us every 5-10 years, and retirement is just the next one. But it takes a plan and practice to taper off from work, just like any other learning situation. If your goal is to travel in retirement, you have to practice traveling now. You have to learn how to block out the time on your calendar and learn how to relax once you get there. Since we’ve been driven by external forces for so long (patients in the waiting room; manuscript revisions due yesterday), we have to practice going at our own pace. A ‘mental health sabbatical’ can be very helpful way to practice for retirement. Take time to just sit and think. Find ways to be creative. And stay connected to a group of supportive friends!

AWAEM AWARENESS 13 AWAEM AWARENESS JULY-SEPTEMBER 2016 Clinical Column: Ultrasound Guided Nerve Blocks By Devjani Das MD, RDMS Guest Author: Margaret Zielinski MD, PGY III, Northwell Health-Staten Island University Hospital, Staten Island, NY

Ultrasound-guided nerve blocks allow for Overview of Ultrasound Technique the safe and effective delivery of anesthesia A high frequency linear transducer (7.5-15 to patients who require a painful procedure MHz) is typically used for this procedure as in the emergency department. While it allows better visualization of superficial emergency physicians frequently turn to structures. Draw up 10-30cc’s of 1% procedural sedation to provide pain control lidocaine in a syringe. Consideration can be during difficult reductions and dislocations, given to using mepivicaine or bupivicaine if it is a time-consuming process that requires longer anesthesia is required. Begin by hemodynamic monitoring and additional cleaning the skin and injecting local nursing support. Nerve blocks provide a anesthesia to create a skin wheal at the promising alternative in the busy emergency proposed site of injection. With the setting. Nerve blocks can deliver adequate transducer held in a transverse orientation, analgesia for patients who may not tolerate introduce the needle approximately 0.5cm in general sedation and can be directed to the a sagittal plane relative to the base of the area where analgesia is required, reducing transducer (Figure 3). This allows full the overall amount of medication needed as visualization of the needle and needle tip well as the patient’s length of stay in the from the moment it enters the skin. Identify department1. the nerve and direct the needle to the distal nerve border. Prior to injecting anesthetic, Ultrasound identification of the Nerve draw back on the syringe to confirm the The nerve fascicle can be identified on needle has not entered vasculature. Inject the ultrasound as a hypoechoic structure with anesthetic, which can be visualized as a surrounding hyperechoic septae, spread of anechoic fluid around the superior representing the perineurium (Figure 1). border of the nerve. Redirect the needle tip Begin the exam from a known anatomic in a direction where the fluid has not landmark near the nerve. Once the nerve is reached with the goal of engulfing the nerve visualized, it should be traced by scanning in the anesthetic fluid. distally and proximally to note any structural abnormalities. The nerve should Femoral Nerve Block be located in a position where it can be The femoral nerve is a common location for accessed by the anesthetic needle but is nerve blocks. Femoral nerve blocks provide sufficiently distant from any vasculature. analgesia for hip fractures, proximal and Remember to use color flow doppler to mid shaft femur fractures, patellar injuries, differentiate vasculature from neighboring and hip dislocations. A femoral nerve block structures. will provide analgesia to the entire anterior thigh and most of the femur and knee. The femoral nerve travels inferior to the inguinal ligament, lateral to the femoral vasculature and superficial to the psoas muscle (Figure 2). To perform a femoral nerve block, place the patient in the supine position and locate the anterior superior iliac spine and inguinal crease. Place the linear probe in a transverse position parallel to the inguinal crease and insert the needle in a sagittal plane directly Figure 1: Identifying the Nerve underneath the linear transducer (Figure 3). Identify the artery, vein and femoral nerve. (Image: http://nerveatlas.ucsf.edu/ulnar.html#)

AWAEM AWARENESS 14 AWAEM AWARENESS JULY-SEPTEMBER 2016

Feature Wellness Column By Devjani Das, MD and Margaret Zielinski MD

Scan the artery to ensure it is located proximal to the bifurcation of the profunda femoris artery.

Figure 4: Median Nerve at the Elbow

(Image: http://usra.ca/medelbow.php) visualized medial to the artery (Figure 4). Insert the needle medial to the probe using a sagittal approach and inject anesthesia to Figure 2: Locating the Femoral surround the nerve. Nerve2 Enter the skin with a lateral-to-medial in- plane approach. Advance the needle Conclusion carefully, targeting the fascia iliaca Ultrasound-guided nerve blocks can be overlying the iliopsoas muscle. Once performed at a variety of anatomic locations beneath the fascia, aspirate to confirm depending on the specific needs of the placement and then inject 10-20 mL of patient. Although identifying anatomic anesthetic. landmarks may initially pose a challenge, with practice and increased familiarity with technique, it is sure to become a valuable tool for the emergency physician.

References 1. Stone MB, Wang R, Price DD. Ultrasound-guided supraclavicular brachial plexus nerve block vs procedural sedation for the treatment of upper extremity emergencies. Am J Emerg Med. 2008;26(6):706-10. 2. Tirado A, Nagdev A, Henningsen C, Figure 3: Femoral Nerve Block2 Brekon P, Chiles K. Ultrasound-guided procedures in the emergency department-needle guidance and localization. Emerg Med Clin Median Nerve Block North Am. 2013 Feb;31(1):87-115. Median nerve blocks are useful for painful 3. Bhoi S, Chandra A, Galwankar S. procedures of the hand. The nerve can be Ultrasound-guided nerve blocks in the blocked at the elbow, forearm and wrist. The emergency department. J Emerg Trauma Shock. median nerve leads to the anterior 2010;3(1):82-88. interosseous nerve distal to the elbow and a 4. Lawande AD, Warrier SS, Joshi MS. nerve block here allows for improved Role of ultrasound in evaluation of peripheral paralysis. To identify the nerve, place the nerves. Indian J Radiol Imaging. 2014;24(3): probe in the antecubital fossa over the 254-258. brachial artery and the nerve will be

AWAEM AWARENESS 15 AWAEM AWARENESS JULY-SEPTEMBER 2016 Women in Global Emergency Medicine: Spotlight Interview with Dr Stephanie Kayden By Megan Rybarczyk, MD

subspecialty of Stephanie Kayden, MD, MPH, is Chief of International the Division of International Emergency Emergency Medicine and Humanitarian Programs in the Medicine Department of Emergency Medicine at (IEM) and, in Brigham and Women’s Hospital (BWH) in Boston. She is an Assistant Professor at completing the Harvard Medical School and the Harvard Harvard IEM T.H. Chan School of Public Health. fellowship, I Dr. Kayden is Director of the International found a way to Emergency Department Leadership combine my Institute, which has trained hundreds of interests in ED leaders from over 30 countries in ED Emergency administration and management. She also Medicine and directs the Humanitarian Studies humanitarian Initiative of the Humanitarian Academy at response. By Harvard, which trains professionals in working with a range of humanitarian humanitarian aid and disaster response organizations, Ministries of Health, and hospitals around the world. Dr. Kayden also serves I gained a lot of experience during fellowship in as Program Director of the International Emergency Medicine Fellowship and the growing Emergency Medicine (EM) abroad. Global Women’s Health Fellowship at BWH. While doing this work, it became clear that EM in many countries suffered from a leadership and Dr. Kayden has worked to improve management gap. Because of this, my colleague emergency medical systems and Phil Anderson and I started the International humanitarian response in more than 25 Emergency Department Leadership Institute countries in Europe, Asia, Africa, the (IEDLI) in 2009. IEDLI is a week-long training Middle East, and Latin America. program for EM leaders throughout the world in ED administration. To date, more than 400 individuals from more than 30 countries have What is your focus and interest within been trained. Global Emergency Medicine (GEM)? I have also worked to develop programs such as the Humanitarian Response Intensive Course My focus in GEM is two-fold: first, to improve (HRIC) and other courses at the Humanitarian day-to-day emergency care in collaboration with Academy at Harvard—all to develop the hospitals, universities, and Ministries of Health; humanitarian profession and to train GEM and second, to improve humanitarian response leaders throughout the world. through educational projects and training programs for responders throughout the world. In summary, what started out as deployments and projects has developed into a focus on education What drew you to GEM as a career, and how and training programs concentrated on the did you get to where you are today? development of EM and humanitarian professionalization. I always knew I wanted an international career. Near the end of residency, I discovered the

AWAEM AWARENESS 16 AWAEM AWARENESS JULY-SEPTEMBER 2016

Women in Global Emergency Medicine: By Megan Rybarczyk, MD

What have been some of the challenges of Has a career in GEM impacted your working in GEM? Are there any specific to decision regarding marriage/partnership being a woman? and children/family, and, if so, how?

There are two main challenges that most GEM No and no. However, I will say that choosing a academics face: funding and academic promotion. supportive partner is one of the most important Because there is little NIH funding for GEM things you can do to make a GEM career work, we often seek funding from private sources successful, even more so if you decide to have and foundations. These grants are often much children. Traveling back and forth to the field is smaller than NIH funding, and many do not cover hardest when you have young children (and at salary support or shift buy-down. As a result, some ages impossible). But from what I have seen, those who work in GEM often have long hours in it can be relatively easy, actually, to be based the field and then return to double shifts at home. abroad—as long as one’s partner can do so—when children are of preschool age. Childcare and Another problem is that our research data is often household help can be very affordable in many more difficult to gather (think household-level countries. I have known some colleagues who assessments) than, for example, large data sets prefer to be based abroad with their kids. that are easily available in the US. It might take a month or more of field work to collect a data set What advice do you have for women who are that yields only a couple of papers. When we do pursuing or who are interested in pursuing a publish, it is often in partnership with academic career in GEM? colleagues abroad who are working to build up academic Emergency Medicine in their respective For those still in residency, your top priority countries. Therefore first authorship is often— should be to become a good EM clinician. and ethically should be—shared. Although we do continue to learn clinical skills throughout our career, the rate of learning drops All of these issues can make GEM researchers sharply after you leave residency. So make sure appear less academically efficient than our peers you use your electives to solidify clinical skills first with US-based research. Unfortunately, though before choosing to travel abroad. some of hardest working people I know are GEM researchers, it is sometimes does not look that That said, it is helpful to gain global clinical way on paper. Thus, institutional support for experience in residency. If you do a clinical academic promotions in GEM can be tough to rotation abroad, be sure observe the health care get. structure while you are there. Do not just notice what is lacking, but why it is lacking. Many Regarding the second question, I think there are people think of simple solutions to perceived challenges to being a working woman in many problems, like donating an electrocardiogram industries. Because GEM involves travel, women (EKG) machine to a clinic or hospital that does must juggle time away and time at home while not have one. But they fail to wrap their head usually being a bit busier than our non-GEM around why that facility does not have an EKG peers regardless of where we are. This is especially machine in the first place, if it is appropriate for difficult for those with a partner or with young them to have one, or, if it is really a need, how to children. provide supplies and maintenance for the donated machine.

AWAEM AWARENESS 17 AWAEM AWARENESS JULY-SEPTEMBER 2016

Women in Global Emergency Medicine: By Megan Rybarczyk, MD

In your personal life, if you have a partner, begin Any final thoughts? by sharing your plans with him or her and talk about what your global career will look like. If Anyone working in GEM should remember that your partner is nervous about your traveling, take you cannot copy and paste what you know from trips with him or her to show them what it will be EM in the US into the global context. While the like. EM fund of knowledge is similar throughout the world, EM care delivery systems are often very Finally, you should decide what space you want different. Good GEM work requires that you take GEM to fill in your life and your career. If you the time to build relationships, conduct want it to be a small part, you might take a few assessments, foster collaborations, and adapt your weeks a year to go to the same place with the teaching to a local context in a sustainable way. same organization. Just about anyone can do this; Seek advice from the GEM community or go to however, ensure that it is a good program that is the IEM fellowship website sustainable and that it really serves the needs of (www.iemfellowships.com) to reach out to the population. fellowship directors or other GEM practitioners.

If you make GEM central to your career, I would highly recommend a fellowship in IEM as well as a Masters in Public Health (MPH) that will give you the necessary research skills as well as the networking opportunities that are essential for a career in GEM. The MPH portion of your training should be focused on research design, health care management, monitoring and evaluation, budgeting and accounting, program management, and teaching methods.

Overall, you must be entrepreneurial about your GEM career to balance your time, to develop and sustain projects, and to assemble funding sources. It is a common misconception among trainees that academicians have a relaxed schedule. This is definitely not the case in GEM. You probably work more hours and do more juggling than many of your academic colleagues.

Those changing career paths into GEM should remember that it is not too late for a fellowship or an MPH (GEM research often requires different skills than other research). An MPH can be done part time, or, if that still does not work in your schedule, there are several short courses out there to help you build your research skills, even later in your career.

AWAEM AWARENESS 18 AWAEM AWARENESS JULY-SEPTEMBER 2016 Direction: To Be a Mentor By Michelle D. Lall, MD, MHS, FACEP Connect! @LallMichelle

To be a practicing woman in EM is amazing; to be a mentor is priceless.

I have been fortunate to have had many mentors in my career, including a number of amazing women. Although I’ve thanked them all before, they deserve far more than my gratitude; they’ve inluenced my life and career in more ways than I can ever express with words. But, most importantly – by following their lead – I have developed the courage and skills to become a mentor myself.

I can vividly recall how my earliest mentor, Dr. Gloria Kuhn, kindly taught me the proper way to auscultate a patient’s lungs during my second year of medical It has been my privilege to be a part of my school. Little did I know what a giant in mentees’ lives, as well, and I strive to emergency medicine she was. provide them with the guidance and Approachable and available, she has encouragement that my mentors have continued to provide me with guidance given me. If you’re early in your career, I and support for the past 14 years – a debt challenge you to ind a mentor – and I cannot repay. thank one. And, when the time comes, I ask you to become a mentor and pass I’m also grateful to my contemporary peer the torch. There is perhaps no better way mentors, with whom I continue to work to ind or become a mentor than by and grow. These parallel mentoring connecting with AAWEP, AWAEM, and relationships may be informal and AAMC. Networking, collaboration, and often go both ways, but their power mentorship, which often go hand in hand, cannot be underestimated. My give these groups momentum and play a colleagues at Emory continue to push me huge role in their continued growth. The out of my comfort zone, and – when doing women in these organizations have raised so – offer me unwavering support. the bar for all of us through their courage, dedication, and commitment to bridging To all the women of AAWEP and AWAEM, the gender gaps that still exist in thank you for your courage, dedication emergency medicine. and commitment to women in Emergency Medicine. These groups are truly incredible and without them we will not bridge the gender gaps that still exist in medicine and we need to ensure that these groups keep momentum and continue to grow. Networking, collaboration and mentorship often go hand in hand and are key components to these groups.

AWAEM AWARENESS 19 AWAEM AWARENESS JULY-SEPTEMBER 2016 AWAEM Book Corner: We Should All Be Feminists by Chimamanda Ngozi Adichie by Devjani Das, MD, Northwell Health-Staten Island University Hospital

What does the word “feminism” mean in this modern world? That is the question at the heart of the much-accomplished author, Chimamanda Ngozi Adichie’s personal essay, which, coincidentally, is an adaptation of her TEDx talk of the same name. Adichie eloquently provides a narrative of her life through personal anecdotes of her childhood experiences in Nigeria and then her experiences as an adult woman, both in Nigeria and the United States. She expounds on the importance of recognizing that the issue of gender rights needs to be addressed not just towards the question of human rights, but speciically what it means to be a woman in society. Her ability to highlight gender issues in more traditional societies where women have for centuries been expected to act a certain way and are often viliied and blamed for crimes committed towards them is both moving and eye opening. Approaching such serious topics with both humor and insightfulness makes this quick read both engaging and entertaining for all. Adichie beautifully illustrates why feminism should not be considered a dirty word, but rather one that should be applied to all humans, regardless of gender. If you have not read any of her other wonderful books to date, this is a great introduction into why she is one of the most celebrated writers today. Even if you don’t have the time to read this short essay, check out her TEDx talk of the same name (https://www.youtube.com/watch? v=hg3umXU_qWc).

What Do You Think? @ddasmd

AWAEM AWARENESS 20 AWAEM AWARENESS JULY-SEPTEMBER 2016

Meet the New Members of the AWAEM Team!

Nicole Cimino-Fiallos, MD

Emergency Medicine Resident, PGY3

University of Maryland Medical Center

Maite Huis in ’t Veld, MD

Emergency Cardiology Fellow

University of Maryland Medical Center

Danya Khoujah, MBBS, FAAEM

Assistant Professor, Emergency Medicine

University of Maryland School of Medicine

AWAEM AWARENESS 21 AWAEM AWARENESS JANUARY-MARCH 2016

AWAEM Committees for 2016-2017 Get involved!

If you are interested in helping with any of these committees, as a member or leadership role, please e-mail Basmah Safdar at [email protected].

We need people like you to keep AWAEM a success!!

Awards Chair: SAEM Meeting Initiatives/Didactics Chairs: Esther Choo, MD & Karen Jubanyik, MD Rebecca Barron, MD, Evie Marcolini, MD & Wendy Woolley, DO

E-Communications Chairs: Global EM Chair: Danya Khoujah, MBBS, Nicole Cimino-Fiallos, MD Pooja Agrawal, MD MPH and Maite Huis in’t Veld, MD

Senior Faculty Task Force Chair:

Membership Chairs: Ciara Barclay-Buchanan, MD & Jessica Schmidt, MD Resident Initiative: Allison Houston, MD

Wellness Chair: Regional Mentoring Chair: Jeanette Wolfe, MD Neha Raukar, MD

Research Chair: Tracy Madsen, MD

AWAEM AWARENESS 22