Talledega nights – Key to Schedule Call for photos! get ER done! recognizing of meetings EMRA’s hyperkalemia and events 2nd Annual Photo Contest

EDITOR’S FORUM NEW FEATURE: CAN’T MISS ECGs EMRA ACTIVITIES AT SAEM EM REFLECTIONS Page 6 Page 31 Page 33 Page 37

June/July 2010 VOLUME 37, issue 3 Resident EMThe Offi cial Publication of the Emergency Medicine Residents’ Association

Vice report Critical decisions – advice to our graduating seniors Angela Fusaro, MD, Carolinas Medical Center, Charlotte, NC, Vice Speaker of the Council s another new class of interns Prioritize your family. Find time to be “Hopefully the Aagonizes over what to wear for their with each of your children for a least a fi rst day of school, our senior residents few minutes each day. You never want Canadians are working are preparing for life in the real world. them to resent your commitment to this on an algorithm for And while they have become accustomed profession. happiness, but in the to dealing with diffi cult decisions in the ED, they might not have considered some Don’t stress about your loans--you can meantime, here is challenging crossroads that lay ahead and will actually pay them off! No matter what your quantity of debt, take that some advice from both in their personal and professional lives. Hopefully the Canadians are working fi rst pay check and spoil yourself. And attending and fellow on an algorithm for happiness, but in spoil those who have helped you survive residency. If you don’t have time to learn residents regarding the meantime, here is some advice from both attending and fellow residents to be fi nancially savvy, seek the advice of how to thrive after regarding how to thrive after graduation. those you trust. And always check in with your lenders--many of us are working in graduation.” Congratulations on completing a long underserved communities and don’t realize journey! that we are eligible for fi nancial incentives. Friends, family, and fi nances One of the biggest decisions you have Choosing your mate is the most important to make is deciding where to live. Your decision of your life. You must always overall satisfaction is based on multi- protect and nurture the sanctity of that factorial criteria, and a big piece of that relationship. Spend uninterrupted time puzzle is geography. You will not stay in with your spouse, and have a retreat or a place if you and your partner are not honeymoon at least every 2 years. continued on page 8 Hurry, sale ends June 30, 2010!

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Contact the ACEP Bookstore by phone, 800-798-1822, ext. 4; or e-mail, [email protected]; or mail your order to ACEP Bookstore, PO Box 619911, Dallas TX 75261-9911. Upcomingevents Table June 3-6, 2010 SAEM Annual Meeting of Phoenix, AZ June 5, 2010 EMRA Representative Council Meeting Contents Phoenix, AZ June 12-16, 2010 AMA MSS / YPS / RFS and House of Delegates Meeting Chicago, IL July 7, 2010 Annals of Emergency Medicine Resident Editorial Board Fellowship Application President’s Message Deadline 4 July 15, 2010 EMRA/ACEP Health Policy Mini-Fellowship Application Deadline Board Update 5 August 12-18, 2010 ACEP Teaching Fellowship Dallas, TX Editor’s Forum 6 August 15, 2010 EMRA Travel Scholarship to ACEP’s Scientifi c Assembly Application Deadline Vice Speaker Report August 15, 2010 EMRA Fall Awards Application 8 Deadline August 15, 2010 EMRA Fall Representative Council Resolutions ACEP Rep Update 10 Deadline August 30, 2010 EMRA Board of Directors Candidate Application Tech Talk 12 Deadline September 10-11, 2010 RRC-EM Meeting Advocacy Corner 15 Chicago, IL Sept 26-30, 2010 EMRA Events at ACEP’s Scientifi c Assembly Las Vegas, NV Clinical Case 16 Sept 28-Oct 1, 2010 ACEP’s Scientifi c Assembly Las Vegas, NV Guest Feature 18 September 29, 2010 EMRA Representative Council Meeting at ACEP’s Scientifi c Assembly Las Vegas, NV Medical Student News 20 October 29, 2010 ACEP Medical Student Professionalism & Service Award Application Deadline October 9-11, 2010 ABEM Oral Certifi cation Exams Talking with Taku 24 Nationwide November 1-8, 2010 Emergency Medicine Basic Research Skills (EMBRS) Meeting EM Pediatrics 26 Dallas, TX November 6-9, 2010 AMA House of Delegates Interim Meeting Resident Life 29 San Diego, CA November 15-20, 2010 ABEM Qualifying Exams Nationwide Resident Research 30

Can’t Miss ECGs 31 Advertisingguidelines EMRA Party 32 Thank you very much for your interest in advertising with EM Resident. As the largest organization to represent the needs of the emergency medicine resident, we are able to reach a unique and important niche of our specialty. EMRA’s mission statement is to promote excellence in patient care through the education EMRA Activities at SAEM 33 and development of emergency medicine residency-trained physicians. It is our belief that this provides the best patient care in an emergency department setting. Money Matters 34 To support our mission and provide the greatest advantage to our residency-trained members searching for jobs, we welcome you to advertise in EM Resident, but require that all positions advertised in our publication be addressed only to board-certifi ed/board-prepared, residency-trained emergency physicians. Board Review Questions 36 For the sake of consistency, the use of the terms “ED,” “emergency department,” and “emergency physicians” are preferable to using “ER” or any such derivation. EM Refl ections 37 Your support is very important to us, and we appreciate your compliance with these guidelines. Please respect this policy and refl ect its sentiment in your advertisements. EM Resident has the right to refuse any Pediatric Pearls 40 advertisement that does not meet these guidelines. Thank you again for advertising in EM Resident. Pitfalls to Avoid 41 To place a classifi ed or display ad in EM Resident, contact Leah Stefanini, 866.566.2492, ext. 3298, e-mail [email protected], or fax 972.580.2829. Information for advertisers can also be found at www.emra.org. Back at You 62 EM Resident is published six times per year. Ads received by July 1 will appear in the August/September issue. EM Resident subscriptions are available only to individuals and institutions that are not considered eligible for EMRA membership as per the EMRA bylaws. For information on how to subscribe please contact Leah Stefanini, 866-566-2492 ext. 3298 or email [email protected].  June/July 2010 3 President’smessage The pulmonary embolism: A historical prospective r. Virchow was among the most prominent presentation, imaging is often required with CT Dphysicians of the 18th century. He angiograms being the most common modality. was a formidable proponent of cell theory The perceived severity of illness, improved in pathophysiology, and is credited with imaging, increased availability of CT scanners, describing many cellular substances including and the medical legal climate in which we myelin and disease processes such as leukemia. practice have prompted a drastic increase in Among his notable claims to medicine was the CT angiogram utilization and irradiation of fi rst description of thromboembolic disease. patients – the affects of which we may see later He coined the terms venous thrombosis and in our careers. Couple this with our perceived pulmonary embolism (PE), describing their acceptable miss rate of zero. But there are relationship in a landmark 1856 publication Edwin Lopez, MD certainly early signs that the pendulum is which preceded any form of medical imaging. Loma Linda Medical Center now starting to swing back the other way. X-ray imaging in fact, was not invented until Loma Linda, CA This is largely driven by concerns regarding President 1895 by Wilhelm Conrad Roentgen. cumulative lifelong radiation, healthcare In keeping with old traditions, Dr. Virchow resource utilization and the cost to society. wore many hats. He was a physician, This surge in CT angiograms has also prompted pathologist, anthropologist and politician the evolution of a collection of clinical “The detachment among other things. But it was his contributions decision instruments, geared to assess clinical of larger to medicine for which he would become most probability and curtail CT utilization. Among or smaller famous, earning him the name of a triad that he the most recognized are the Well’s Criteria fragments did not himself describe – “Virchow’s Triad.” and PERC Rules. Interestingly, there are from the end It includes endothelial damage, altered venous suggestions that they may in fact increase CT of the softening thrombus blood fl ow, and hypercoagulability. which are carried along by utilization leading to more radiation and false the current of blood and Approximately 150 years later and long after positives. his death, the origin of the term “Virchow’s driven into remote vessels. Next is the issue of treatment, which adds yet Triad” remains as elusive as the condition This gives rise to the very another level of complexity. Remember the which it seeks to describe. Furthermore, frequent process on which I oath, “Primum non nocere” or “First, do no despite medical achievements, the overarching have bestowed the name of harm”? The pathophysiology of pulmonary question is now when to pursue the diagnosis Embolia.” emboli has been well described and extensively in patients without clinically signifi cant emboli. Rudolf Ludwig studied since Virchow’s early discoveries. The reasons for posing this question are several Karl Virchow Treatment has similarly evolved and currently and require a brief review in order to better (13 October 1821 – consists of anticoagulation therapy, and understand. 5 September 1902) thrombolysis or embolectomy for patients with First is the issue of CT utilization. Although evidence of marked right heart strain or clinical Virchow’s triad is widely accepted nowadays, deterioration. its clinical applicability for the practicing Recognizing that the risk of anticoagulation physician is limited. The diagnosis of PE is is great and even potentially catastrophic for based on clinical probability and selective our patients, should we pursue subclinical imaging. Probability in turn is a function of patients as aggressively? This refers to patients, risk factors, signs and symptoms. Given that for example, with nothing more than mild the history and physical cannot defi nitively pleurisy. And if so, will the risk from the PE differentiate other causes of similar outweigh the cumulative risk of long term anticoagulation? The jury is still out.

4 EMResident Emergency medicine is a unique specialty in that the critical aspects of our training focus on ruling out serious pathology rather than diagnosing minor ones. There are Board certain diagnoses that are more elusive, of but with potentially catastrophic outcome for the patient if gone unrecognized. directors Pulmonary emboli are on that list and present a clinical challenge for practicing emergency physicians every day. Controversy exists regarding the need to Edwin Lopez, MD Carson Penkava, MD diagnose clinically relevant PE’s vs. all President Secretary & EM Resident Editor-in-Chief PEs, in light of risks and cost to the patient Loma Linda University Medical Center University of Alabama at Birmingham and society at large. This is confounded Loma Linda, CA Birmingham, AL by the lack of description of clinically [email protected] [email protected] insignifi cant PEs.  Nathan Deal, MD Steven Horng, MD President-Elect Technology Coordinator University of Chicago Medical Center Maimonides Medical Center Boardupdate Chicago, IL Brooklyn, NY [email protected] [email protected] • Welcome to Phoenix! If you’re joining us for the EMRA events at SAEM’s Joshua Moskovitz, MD, MPH Kaedrea Jackson, MD, MPH Annual Meeting, please refer to page Immediate Past President/Treasurer Speaker of the Council University of Maryland SUNY Downstate Medical Center 33 for the full schedule of events. Baltimore, MD Kings County Hospital Center Be sure to attend the Annual EMRA [email protected] Brooklyn, NY EM Jeopardy contest, EMRA Resident [email protected] SimWars competition, and of course Eric Maur, MD Angela Fusaro, MD the acclaimed EMRA Party!  ACEP Representative Geisinger Medical Center Vice Speaker of the Council • You’re the reason we do it! Thank Danville, PA Carolinas Medical Center [email protected] Charlotte, NC you for making the 2nd Mid-Atlantic [email protected] Medical Student Symposium & Steven Tantama, MD Residency Fair a huge success! 115 RRC-EM Representative Nathaniel Schlicher, MD, JD students joined us in Baltimore on Naval Medical Center Legislative Advisor April 10th for this FREE event, San Diego, CA St. Joseph Medical Center [email protected] Tacoma, WA featuring fantastic lectures, workshops, [email protected] and more. Be on the lookout for our Todd Guth, MD next regional symposium, it might Academic Affairs Representative Jonathan Heidt, MD just be in your area!  Denver Health Medical Center Director-at-Large Denver, CO Washington University • Vegas, baby! It’s “in the cards” for [email protected] St. Louis, MO you to start planning your trip to [email protected] Vegas for the 2010 ACEP Scientifi c Shae Patyrak Assembly! Visit www.emra.org this Medical Student Governing Council Chair summer for a complete schedule of UT Southwestern EMRA activities.  Dallas, TX [email protected] • Congratulations, Graduates! Whether you’re graduating from residency or EMRAstaff fi nally able to add that MD, DO, or Michele Byers, CAE Alicia Hendricks MPH to your name, we wish you the Executive Director Website Coordinator best! As always, let EMRA know if [email protected] [email protected] there’s anything we can do to make your transitions easier – from school to Leah Stefanini Griffin Achilles residency to fellowships and beyond!  Publications/Events Coordinator Administrative Assistant [email protected] [email protected]

1125 Executive Circle, Irving, TX 75038-2522 Phone: 972.550.0920 Fax: 972.580.2829 www.emra.org

Mission Statement EMRA promotes excellence in patient care through the education and development of emergency medicine residency-trained physicians.

June/July 2010 5 Editor’sforum

Talladega nights – get ER done! nkle sprain. Bronchitis. Flank suffer from traumatic injuries, dehydration, Apain. Seizure. It was a typical rural and even carbon monoxide poisoning. nightshift, except for one thing: my ED was located in the middle of a 2.66-mile During the event, the race teams, racetrack. That’s right—I was working NASCAR offi cials, media, security personnel, and other track workers utilize Talladega Nights! the ICC for their medical care. Race fans For those of you who are not a resident come to the Infi eld Care Center and the in the middle of NASCAR country, Aid Stations in the grandstands with let me tell you a little about what the same complaints one would see in Carson Penkava, MD makes Talladega so special. Talladega the typical city emergency department University of Alabama Superspeedway, located 40 miles east including heart attacks, strokes, injuries, Birmingham, AL of Birmingham, has been thrilling fans burns, seizures, abdominal pain, and Secretary/EM Resident Editor-in-Chief since 1969. With banks at 33 degrees (the dehydration. Probably the only major 2nd steepest in NASCAR) and drivers thing not YET done in the ICC is to reaching speeds of over 210 miles per deliver a baby! hour, Talladega attracts people from all My interest in working at Talladega over the nation. Drawing approximately began with its medical director and my 200,000 people to the biannual event, attending, Dr. Bobby Lewis, who took my Talladega becomes the third largest city friends and me on a tour of the ICC and “Although never much of in Alabama twice a year. the garages during last year’s fall race. a grease monkey myself, I The Infi eld Care Center (ICC) sits at the Granted, I have always been impressed entrance to pit road and right adjacent with his continued enthusiasm for EM couldn’t help but be impressed to the Sprint Cup Garage. Each of the after 32 years of practice, but he seemed to be a different person here. watching the mechanics work 10 beds has its own Philips cardiac monitor, capable of 12-lead ECGs and While walking through the pits, I heard to unload, build and set up a defi brillation. Although unable to order countless workers greet him with a racecar capable of running at labs or imaging, the ICC has all the friendly, “Hey, Dr. Bobby!” Although necessary tools for resuscitation (RSI never much of a grease monkey myself, I over 210 miles per hour.” drugs, chest tubes, diffi cult airway cart). couldn’t help but be impressed watching Two of the beds are set up for critical the mechanics work to unload, build and trauma care to handle any serious set up a racecar capable of running at injuries to drivers or critical illness in over 210 miles per hour. As I watched the infi eld fans. him merrily help workers unload metal barricades, I realized Dr. Lewis had found The track physicians are charged with a way to combine work and a passion— taking care not only of Talladega’s fans, no wonder he was so happy. but also its drivers. During the races, one of the physicians must medically His relationship with Talladega Super clear every driver unable to drive off of Speedway began in 1981 as a physician the track. Although the majority of these on the LifeSaver helicopter, volunteering drivers have no injuries, they occasionally to help with medical transport for the

6 EMResident Editorialstaff  Editor-in-Chief Carson Penkava, MD University of Alabama at Birmingham Birmingham, AL  Executive Director Michele Byers, CAE  Publications Coordinator Leah Stefanini  Medical Student Section Editor Chadd Kraus Philadelphia School of Osteopathic Medicine Philadelphia, PA  Critical Care Section Editor Syed Sameer Ali, MD Penn State Hershey Medical Center Hershey, PA Dr. Lewis giving us a tour.  EM/Pediatrics Section Editors Hans Bradshaw, MD University of Arizona drivers. He became medical director Tucson, AZ at the track 15 years ago as Carraway Charles Gillespie, MD Hospital served as the medical service University of Arizona provider for the speedway and remains in Tucson, AZ that position today.  Visual Editor Melanie Backer, MD In 2002, NASCAR instituted the University of Alabama at Birmingham Medical Liaison program with nurses Birmingham, AL and physicians traveling to all the tracks  Immediate Past Editor where national NASCAR races are held Lisa Bundy, MD to oversee and standardize medical care. University of Alabama at Birmingham Birmingham, AL Dr. Lewis was chosen to be one of the fi ve physicians to help develop the program  EM Resident Editorial Advisory Council Nafis Ahmed, MD and remains in that position today. University of Pennsylvania Philadelphia, PA Dr. Lewis serves as in an example for Paul M. Been, DO anyone wishing to combine emergency Akron General Medical Center medicine with a passion. Whether you Akron, OH Preston Fedor, MD enjoy sports, camping, or music, if it St Lukes Hospital attracts people, there’s an opportunity Bethlehem, PA for event medicine. All it takes is a little Above: Rescue crews practicing extraction David Jang, MD initiative–so go out there and get ER done. during a simulation. New York University New York, NY Residents, start your engines!  Below: High speed drafting. Zac Kahler, MD Carolinas Medical Center Charlotte, NC Charles Khoury, MD University of Alabama at Birmingham Birmingham, AL Taku Taira, MD Stony Brook University Medical Center Stony Brook, NY Arjun Venkatesh, MD Mass. General Hospital/Brigham & Women’s Boston, MA

EM Resident is the bi-monthly magazine of the Emergency Medicine Residents’ Association (EMRA). The opinions herein are those of the authors and not those of EMRA or any institutions, organizations, or federal agencies. EMRA encourages readers to inform themselves fully about all issues presented.

EM Resident reserves the right to review and edit material for publication or refuse material that it considers inappropriate for publication.

© Copyright 2010 Emergency Medicine Residents’ Association

June/July 2010 7 Vicespeaker report Critical decisions – advice to our graduating seniors continued from cover

happy there, despite how ‘perfect’ the job Find your niche within the fi eld. It can be may be. So be honest with yourself about unconventional, but it has to be something what you need in your surroundings. that lights your fi re. There is tremendous pressure on new graduates to excel and Invest in the following: good pens, good make a name for themselves. Don’t do socks, good shoes, and comfortable, yet things just because you think you have to. professional clothes. They’ll be on you more You will be happier if you prevent your hours than you ever planned. Don’t invest in schedule from becoming congested with lots of other stuff for yourself too early. Angela Fusaro, MD meaningless obligations. Carolina Medical Center Don’t sacrifi ce your well being for Charlotte, NC You need to be able to leave work Vice Speaker of the Council money; keep your shift load moderate and at work. Find something cathartic. healthy, especially at the beginning. Don’t Decompress regularly. Find a sleep just equate more work hours with more regimen that works for you. Build a money–that’s a dangerous cycle. reservoir of sleep hours and access that The department reserve when you are tired. Replenish that “Strengthen resource with naps when you can. Always thank your staff and coworkers– your it’s a team effort. Get to know your Keep things in perspective. The literature consultants; it will be easier to work with shows that most EM physicians will only relationship them when you are colleagues rather than stay at their fi rst job for one to two years. with your just a voice on the other end of the line. Your fi rst employment does not have to be your dream job. You do, however, The literature shows that applicants classmates in need to be challenged, or your growth as are more likely to be offered a job in a clinician will be stunted. Make sure the the hope of academic emergency medicine if they practice you choose is not constricted, know how to write a grant. To be able establishing to write a grant, you need mentorship, with no limitations to the types of patients to which you are exposed. and maintaining preferably through a research fellowship. Decide early on what your niche is a supportive Become a citizen of your hospital, and be involved in committees and in the going to be. If you want to be a bench bond with one community. Your personal investment will researcher, it is probably best to take a more traditional path by staying in another in the prevent you from feeling like just another anonymous number. academics and doing a fellowship. future.” However, if you want to be a clinical Strengthen your relationship with your teacher/writer/lecturer, do at least a year classmates in the hope of establishing of private practice at a busy community and maintaining a supportive bond with hospital. It is easier to learn to stand one another in the future. Moreover, your on your own two feet when you are continued contact with residents still in out there alone. You will also get more the training program is a vital repayment practice with procedures and develop and is invaluable to them if done your own style and fi nesse for working constructively and supportively. up patients. It is diffi cult to do this in an

8 EMResident WWelcomeNewel Programcome Reps Congratulations on being selected as your program’s representative. Start the new academic year off right! Find out exactly what your responsibilities are as a Program Representative. Visit academic setting because one of your Protect yourself from tunnel vision. Be www.emra.org and click on the Program primary responsibilities is guiding and prepared to change, and look for the Representative link (under “About supervising residents. opportunity to do so. It takes courage EMRA” tab). Review the short EMRA to admit that you may have misread a 101 Power point presentation and make Listening to your patients is your best situation or taken a lateral step. diagnostic skill. Albeit indirectly at times, sure to update your contact information they will tell you what’s wrong with them. Take time off! This journey is like a online so you can stay current on all Also, you can gain a lot of knowledge by pie-eating contest–even when you are EMRA activities and opportunities. following up on your patients, either in the ‘winning’ all you ever get is more pie. If you are not a program representative, hospital or via phone. There should not be a rush to the fi nish. but are interested in becoming one, talk Take time to enjoy your experience– to your program director or residency Strive to become the local expert in some travel, scrapbook, adopt a street, save the coordinator about representing your topic or disease. spearmint rhino. Do whatever it is that program to EMRA. makes you a complete human being. The Medicine is very diffi cult--be humble. patients will always be waiting for you You can always contact your Sometimes even when you do everything when you return, and you can serve them Representative Council Offi cers, Kaedrea right, outcomes are bad. There are no better if you are happy. Jackson at [email protected] or Angela ‘text book’ cases in real life. Fusaro at [email protected], for Find your version of God. You will more information Practice emergency medicine abroad. It have some very demoralizing days, and will allow you to experience medicine believing in a higher power or purpose We look forward to working with you in a different capacity. Take a sabbatical. will comfort you. Pray or meditate to this year. It gives you a chance to recharge your refresh yourself as you help others. emotional batteries and to see what healthcare is like in a system that is less Fashion speaks volumes and people technology-oriented, and wrought with listen. You will feel more confi dent if you MAKE YOUR less medical-legal complications. present yourself well. VOICE HEARD Never start a new shift somewhere Be prepared to say “yes” to the Call for Resolutions without knowing your airway equipment opportunities that may land in your lap. and where other critical procedure gear Some of them may bring new avenues for Get involved and steer the future success your way. But just as important, may be. of EMRA by writing a resolution. A be prepared to say “no.” Doing a select resolution is a directive for EMRA to Give your new job and environment a few things right, early on, may be take certain action or to form a policy. chance. You just left a place of relative better than getting overextended and These resolutions are discussed and comfort, with an intact social and underperforming on a task. voted on at the EMRA Representative professional framework. It takes a little Council Meeting at ACEP’s Scientifi c And most of all, feel the calling of time to build that anew. Assembly in Las Vegas, Wednesday, medicine, accept your limitations and September 29, 2010. The big picture always place your patients fi rst in any decision. Really.  Set your short and long-term goals (life, The deadline for submissions is August 15, 2010. family, and career) and write them down. Special thanks to Drs. Jayne Batts, This is the fi rst step to reaching them. Stephen Colucciello, Alan Heffner, Jeff For more information on authoring a Revise this list as you mature, but never Kline, JP McBryde, Parker Hays, Robert resolution or to see recent adopted throw away the original. Also, reread your Schafermeyer and all the residents at resolutions, visit www.emra.org personal statements for medical school Carolinas Medical Center for their or email Kaedrea Jackson at and especially residency. They can remind contribution to this article, and more [email protected]. you of who you were, what you held dear, importantly, their guidance of my career and what you still hope to become. in general. June/July 2010 9 ACEPrepresentative update

Trouble brewing in Texas? ecently, the Texas Medical Board through the Board of Certifi cation in Rruled that those physicians who are Emergency Medicine (BCEM) and certifi ed in emergency medicine by the allows its members to declare themselves ABPS/BCEM could advertise themselves “board certifi ed” in emergency medicine to the public as “board certifi ed.” Similar after passing these exams. However, efforts at obtaining recognition are also completion of an emergency medicine underway in other states. residency is not a requirement to sit for the ABPS/BCEM certifi cation exam. EMRA and ACEP continue to stand behind the assertion that the only pathway As outlined on the ABPS Website at http:// Eric Maur, MD to board certifi cation in current times is www.abpsus.org/emergency-medicine- Geisinger Medical Center having completed an emergency medicine eligibility, the requirement to sit for the Danville, PA ACEP Representative residency. qualifying exam is to have completed any ACGME approved residency that includes It’s what we all strive for, the defi ning “substantial and identifi able training in moment of our careers – passing the Emergency Medicine as determined by “…completion boards and fi nally being able to add the Board of Certifi cation in Emergency “board certifi ed emergency medicine Medicine and approved by the ABPS.” In of an emergency physician” to our CV. The American addition, applicants must also meet only College of Emergency Physicians (ACEP) one of the following criteria: medicine and the Emergency Medicine Residents’ residency is not Association (EMRA) both equate board 1. Completed an ACGME or AOA- certifi cation to having passed the written accredited residency in Emergency a requirement and oral portions of the certifi cation Medicine. to sit for the exam administered by the American Board of Emergency Medicine (ABEM) 2. The applicant must have practiced ABPS/BCEM or the American Osteopathic Board Emergency Medicine on a full- certifi cation of Emergency Medicine (AOBEM). time basis for fi ve (5) years AND Only physicians who have successfully accumulated a minimum of 7,000 exam.” completed an ACGME accredited hours in the practice of Emergency residency in emergency medicine can take Medicine AND satisfy either I or II: these exams. i. Completed an ACGME or AOA- To most of us, it seems rather clear. accredited Primary Care or However, ABEM and AOBEM are Anesthesiology residency. not the only organizations providing “certifi cation” in emergency medicine. ii. Be certifi ed in a Primary Care The American Board of Physician specialty or Anesthesiology by an Specialties (ABPS) also offers both ABPS, ABMS or AOA-recognized written and oral certifi cation exams board of certifi cation. 10 EMResident EEMM RResidentsesidents & MMedicaledical SStudentstudents

Emergency Medicine Residents’ Association

3. Graduate Training Program: completed However, times have changed. either a 12 or 24-month Emergency Emergency medicine residencies now JJoinoin Today!Today! Medicine graduate training program exist across the country, and currently Don’t miss out on the benefits of EMRA! approved by the BCEM. Physicians represent the “gold standard” in As a member you’ll receive many completing a 12-month graduate emergency medicine training. This is benefits to help you advance your training program must have practiced perhaps best stated by Dr. Larry Weiss, career in emergency medicine. Emergency Medicine on a full-time Immediate Past President of AAEM, who Membership includes basis for an additional 12 months, said: “The ABPS largely exists to grant Free stuff: Members receive free publications in before or subsequent to completing the board certifi cation to untrained physicians print and online. Plus, receive discounts on products, graduate training program. working in emergency medicine. Most publications and meetings, exclusive access to great Web of the public knows that if someone is content, career and financial planning guides. • EM Resident Recently, the Texas Medical Board ruled board certifi ed, it means they have some • EMRA Antibiotic Guide that those physicians who are certifi ed in advanced training in a specialty. It’s a • EM: RAP and Emergency emergency medicine by the ABPS/BCEM public health issue. Should I be able to Medicine Abstracts could advertise themselves to the public call myself a board certifi ed surgeon • EMRA’s Career Planning Guide • The Medical Student as “board certifi ed.” Similar efforts at if I never completed formal training in Survival Guide obtaining recognition are also underway in surgery? At the core of this controversy • Pediatric EM Practice other states. is whether emergency medicine is a Online • EM Practice Online legitimate specialty.” ...and much more What does all of this really mean? Career planning: EMRA can help you get into the As an emergency medicine There continues to be signifi cant debate emergency medicine residency of your choice, survive resident, how does this affect you? over ABPS/BCEM status, and the debate and thrive during your residency, and succeed after your training with resources to help you land the ideal job. We all know that the physician shortage exists even within the ACEP membership. A simple Google search will yield Clinical & practice tools: Learn about reimbursement is not going to disappear anytime soon. issues, contracts, clinical problems and access case In the meantime, there will continue to numerous comments on both sides of the studies in EM with your membership. And, develop be physicians practicing in emergency issue. life-long skills in advocacy and health policy. departments across the country who Access to www.emra.org: The EMRA Website is full are not emergency medicine residency EMRA and ACEP continue to stand of resources specifically for EM residents & students, trained. Many of these spots are fi lled by behind the assertion that the only pathway including job listings, leadership opportunities, archives of advocacy, clinical, and financial articles. “legacy physicians,” some of the founding to board certifi cation in current times is fathers of our specialty who trained before having completed an emergency medicine Leadership development opportunities: Become residency. active within organized medicine and help shape your emergency medicine residencies were in field. Numerous committee, board and council positions existence or widely available. Yet there are available. For now, buyers beware – in some states are still many more spots that are fi lled Scholarships, grants, and awards: EMRA provides by family medicine physicians, internal “board certifi ed in emergency medicine” several scholarships, grants, and awards that are available medicine physicians, surgeons, and other does not necessarily mean emergency only to EMRA members. specialists who never received any formal medicine residency trained.  Friends & community: Get to know others who emergency medicine training. share your passion for emergency medicine, talk about residency life and plan for a future in this specialty. For more information, please You’ll benefit from many opportunities to develop your It is imperative not to discredit the refer to the President’s Address leadership potential. clinical ability and expertise of some in the April/May issue of EM of these physicians or the value of To join, call 1-866-566-2492, touch 5 experience. Without their vision and Resident and Dr. Angela Gardner’s www.emra.org groundbreaking efforts, our specialty may statement at http://www.acep.org/ never have been born. pressroom.aspx?id=47259.

June/July 2010 11 Techtalk Confi rmation of central lines – bedside adjuncts s I count down the days until I We are commonly taught to inspect the Agraduate from residency, I cannot color and fl ow of the blood coming out of help but wonder whether my training has the introducer needle after disconnecting adequately prepared me for the real world. the syringe. This can sometimes be I run mental simulations of scenarios misleading. Arterial blood can look where “standards of care” break down, venous in the hypoxic or hypotensive and I am left with nothing but my training patient, as can venous blood appear and ingenuity to rescue a critically ill arterial in the aggressively ventilated patient from a poor outcome. patient or those with elevated right heart pressures, as with CHF. Steven Horng, MD Sure, there are certain scenarios that we Maimonides Medical Center all train for: the failed airway, the diffi cult Instead of eyeballing this, compare a blood Brooklyn, NY reduction, the breech delivery. But what gas from the catheter to a standard ABG. Technology Coordinator happens when that rescue technique If they are similar, the catheter is arterial; you’ve trained for doesn’t work or isn’t if they are markedly different, the sample available? What do you do then? To is venous. Additionally, you can use “. . .what illustrate my point, consider the task of manometry to formally investigate blood confi rming a central line placement. fl ow. If you don’t have a CVP pressure happens transducer, you can build a simple when that As emergency physicians, we routinely manometer out of a piece of tubing held place central lines in critically ill patients. vertically and connected to the introducer rescue These lines generally go very smoothly. needle. You can then determine placement technique You get dark red blood on the fi rst stick. by analyzing the fl ow waveform. The guide wire passes easily. Insertion you’ve On top of blood return, clues about is uneventful. Drawback is easy from all placement can be obtained from the guide trained for three ports, and the catheter fl ushes easily. wire itself. If the patient complains of ear Lastly, a post-procedure CXR shows the doesn’t pain or throat tickling or if you palpate catheter in good position. the guide wire tracking upwards in the supraclavicular fossa as you insert the work or isn’t Now, consider the same scenario in wire (fi nger in the fossa technique), you a crashing, severely hypotensive, available? are likely going in the wrong direction. and hypoxic patient with a catheter Conversely, should you elicit PVC’s, What do you placed by a novice trainee who you are you likely have threaded the guide wire supervising. The X-ray system is down do then?” correctly toward the myocardium. Also, for maintenance. The patient is in dire a metal detector can be used to confi rm a need of intravenous intervention now, caudally directed guide wire, since most but you aren’t sure if the catheter is in an have a stainless steel core. acceptable position. I would like to share some adjuncts that you may add to your Besides directionality, the guide wire can verifi cation armamentarium. give you information on position. If you

12 EMResident Congratulations

“I run mental simulations of scenarios where “standards of care” break down, and I am left with nothing but my training and ingenuity to rescue a critically ill patient from a poor outcome.” connect the guide wire to the cardiac should dictate when some of these Rex G. Mathew, MD, FACEP monitor, you will effectively make the adjunct techniques can be considered.  Thomas Jeff erson University guide wire an intra-atrial lead and can Hospital, Philadelphia, PA confi rm placement using ECG guidance References much as you would a transvenous pacer. for the Blue Jay Consulti ng/ 1. Vezzani A, Brusasco C, Palermo S, As the guide wire passes the pericardial Emergency Medicine Foundati on Launo C, Mergoni M, Corradi F. Ultra- Emergency Department refl ection, you will see an increase in the sound localization of central vein amplitude of the p wave. catheter and detection of postprocedural Director of the Year Award pneumothorax: an alternative to chest If you have already removed the guide radiography. Crit Care Med. 2010 Presented on Monday, April 26, 2010 wire, you can fl ush normal saline through Feb;38(2):533-8. at the the catheter and feel for a thrill in the American College of Emergency Physicians distribution of the IJ. Although the 2. McGee DC, Gould MK. Preventing Emergency Department Directors Academy catheter is often diffi cult to visualize by complications of central venous Dallas, TX catheterization. N Engl J Med 2003; ultrasound, the rapid fl ow of saline can 348:1123–33. Blue Jay Consulting and the be used as contrast to delineate the lumen of the catheter using power doppler. Of 3. Ambesh SP, Dubey PK, Matreja P, Emergency Medicine Foundation course, you could always just ultrasound Tripathi M, Singh S. Manual occlusion also applaud this year’s fi nalists the guide wire if it is still available. of the internal jugular vein during subclavian vein catheterization: a Patrick J. Crocker, DO, MS, FACEP Another modality is to inject maneuver to prevent misplacement Dell Children’s Medical agitated-saline into the catheter while of catheter into internal jugular vein. Center of Central Texas simultaneously obtaining a subxiphoid Anesthesiology. 2002 Aug;97(2):528-9. Austi n, TX or apical view of the heart. In this 4. Gebhard RE, Szmuk P, Pivalizza EG, scenario, the agitated saline will work Melnikov V, Vogt C, Warters RD. The William Dalsey, MD, MBA, FACEP as ultrasound contrast. If the contrast accuracy of electrocardiogram-controlled Kimball Medical Center appears within two seconds and shows central line placement. Anesth Analg. Lakewood, NJ lamellar fl ow, the catheter is in good 2007 Jan;104(1):65-70. position. If the fl ow is turbulent, 5. Rath, G.P., Bithal, P.K., Toshniwal, Paul E. Pepe, MD, MPH, FACEP however, the catheter is too deep and G.R., Prabhakar, H. and Dash, H.H. Parkland Health & Hospital System needs to be withdrawn until the fl ow (2009) Saline fl ush test for bedside Dallas, TX is lamellar. If no contrast is seen, or detection of misplaced subclavian vein delayed, the catheter is either arterial or catheter into ipsilateral internal jugular The fi nalists will be honored at the too proximal.1 vein. British Journal of Anaesthesia. Emergency Medicine Foundati on Recepti on 102(4), p.499-502. at Obviously some of these confi rmation ACEP’s Scienti fi c Assembly in Las Vegas, NV 6. Vezzani A, Brusasco C, Palermo S, adjuncts might not be appropriate for Launo C, Mergoni M, Corradi F. www.emfoundati on.org/directoraward every situation. Bedside ultrasound Ultrasound localization of central vein is not universally available and blood catheter and detection of postprocedural (800) 798-1822 x3216 gas results might take longer than you pneumothorax: an alternative to chest can wait. Clinical judgment, patient radiography. Crit Care Med. 2010 circumstances, and operator experience Feb;38(2):533-8.

June/July 2010 13 Thanks to the 2010 Chair’s Challenge Participants

EMRA would like to thank the following Emergency Medicine Residency Programs To view photos of and ACEP Chapters for meeting this year’s “Chair’s Challenge” by sponsoring one or more residents the event, visit EMRA’s to attend the ACEP Leadership and Advocacy Conference in Washington, DC. Facebook Fan page.

Emergency Medicine Residency Programs ACEP Chapters Akron General Medical Center Stony Brook University Hospital Alabama Chapter ACEP Allegheny General Hospital SUNY at Buffalo Arizona College of Emergency Physicians Beth Israel Deaconess Medical Center SUNY Downstate/Kings County Hospital CAL ACEP Boston Medical Center SUNY Upstate Medical University Colorado Chapter ACEP Brown Emergency Medicine UC Irvine Connecticut College of Emergency Christiana Care Health System University of Arizona COM Physicians Christus Spohn - Texas A&M University of California, Davis Emergency Medicine Residents’ Eastern Virginia Medical School University of Florida - Jacksonville Association Emory University University of Kentucky Kentucky Chapter ACEP Georgetown University/Washington University of Louisville Maine Chapter ACEP Hospital University of Michigan Massachusetts College of Emergency Harbor-UCLA Medical Center University of Mississippi Physicians Johns Hopkins Hospital University of Nebraska Medical Center Michigan College of Emergency Physicians Maimonides Medical Center University of New Mexico Missouri Chapter ACEP Maricopa Medical Center University of Rochester Nevada Chapter ACEP Mount Sinai Medical Center University of South Florida New Mexico Chapter ACEP North Shore University - LIJ UT Houston Emergency Medicine New York Chapter ACEP NYU/Bellevue UT Southwestern Medical Center Ohio Chapter ACEP Ohio Valley Medical Center Washington University St. Louis Tennessee College of Emergency Orlando Health West Virginia University Hospital Physicians William Beaumont Hospital West Virginia Chapter ACEP York Hospital Dr. Carol Rivers’ EM Board Review Products are back in publication!

Through an exclusive agreement with EMEE, Inc. Ohio ACEP is proud to announce the continued publication of Dr. Rivers’ nationally recognized Board Review materials

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14 EMResident Advocacycorner

heodore Hesburgh once said, “The but there is one universal truth: it will only Tvery essence of leadership is that you get more limited. Since graduating I have have to have vision. You can’t blow an seen the demands on my time escalate uncertain trumpet.” Have you found your exponentially. But, for the fi rst time in my vision yet? life, I learned to say no thanks. Harvey MacKay once said “Time is free, but it is Many times throughout residency we priceless. Once you have lost it you can fi nd ourselves blindly swimming from never get it back.” Have you lost time to one task to another, trying to keep our leadership without vision? heads above the crashing waves, grateful to survive until the next morning. When Finding vision and the right opportunity to Nathaniel Schlicher, MD, JD opportunities arise, for better or worse, implement it is the greatest challenge. Do St. Joseph Medical Center many young physicians eagerly snap them not simply take the next position, job, or Tacoma, WA up, jumping out of the water in eager assignment given to you if it does not help University of Washington Medical Center anticipation – not realizing it may be meet your vision. Find the route that will Seattle, WA Legislative Advisor the fi sherman’s boat they land in. Often help get you where you want to be in fi ve we follow these assigned leadership or ten years. Do not give up just because opportunities instead of our own vision. the fi rst opportunity does not fi t; you will How many chief residents do you know fi nd your niche. Do not waste time on “. . . seize the that truly lead? How many instead only titles or positions that do nothing for your lead as they are told? dreams and only take away time from the opportunity for a ones you love. It is a signifi cant challenge to fi nd your fresh beginning vision in the rat race of residency before it We now fi nd ourselves at the end of is over. I have been incredibly fortunate to another academic year; new interns this year and have the opportunity to work for you and starting, new attendings minted, the next with the great people of EMRA. It was a step on your own residency journey. Take become the once in a lifetime opportunity, but at fi rst the time this month to fi nd your vision. my vision was clouded. However, after Find your perfect picture for the next year, leader you were settling in I quickly found vision was no next job, next leadership opportunity, meant to be.” longer the problem; it was my time that and your life. Do not wait for someone to was in high demand. Someone wants too hand you the opportunity and substitute much of it, or you have none left to give. their vision for yours. Instead, seize the opportunity for a fresh beginning this year The demands on your time will change in and become the leader you were meant to many ways upon completion of residency, be. Now is the time! 

EMRA would like to welcome these new Osteopathic Emergency Medicine Resident Programs

Lakeland Regional Medical Center Columbia Hospital / St Lucie Medical Center St. Joseph, MI Port St Lucie, FL

Program Director Program Director Michelino Mancini, DO Thomas H. Matese, DO

June/July 2010 15 Clinicalcase It’s no joke History and presentation and has symmetric pupils but he is not ou haven’t even had your morning cooperating with commands and keeps Ycoffee yet when paramedics bring trying to get up from the stretcher. The rest your fi rst patient of the day into the of the physical exam is unremarkable and trauma resuscitation room. “We have an initial FAST exam is negative. unhelmeted cyclist who was just struck by a city bus and knocked off his bike,” Initial thoughts and differential they shout out. The patient complained diagnosis of headache, left shoulder pain and Care of the trauma patient follows a strict left hip pain on scene and has become algorithmic approach in order to identify Todd Guth, MD more agitated and combative during the life-threatening injuries rapidly and takes Denver Health Medical Center transport. They fi nish up their report, “Oh, steps to correct injuries once they are Denver, CO by the way, the patient said that he was a discovered. Based on the severity of the Academic Affairs Representative hemophiliac just before he started to get mechanism of injury and the underlying really confused.” coagulopathy, this critically injured trauma patient is without question going to get You are tempted to laugh out loud for a a full diagnostic trauma assessment. A “...patients moment. They just said, “Hemophiliac.” thorough progression through the ABC’s with moderate That’s funny. Is it April 1st? Surprising of trauma assessment will identify injuries, that they didn’t say that the bus that hit but it is the timely administration of or severe the cyclist was full of hemophiliacs. Now factor replacement, decisive management that would be funny, but this is no joke. decisions, and skillful resuscitation of a hemophilia You look down at the patient and the competent emergency physician that will and significant ecchymosis on the left side of the face allow the patient to be stabilized. appears to be getting bigger right before bleeding your very eyes. The paramedics provide Classic hemophiliacs with hemophilia that kick to your morning that no cup of A have a hereditary X-linked bleeding will require coffee could do, “Yep, he said that he has disorder due to defi ciency of factor VIII emergent severe hemophilia A.” that occurs in 1 in 10,000 live male births. Hemophilia B, factor IX defi ciency, is treatment Physical exam also an X-linked recessive disorder but is On arrival to the emergency department, ten time less common than hemophilia A. with factor the 30-year-old male is getting agitated Given the X-linked genetics of the disease, concentrates to and keeps asking the same questions over males present with disease and females are and over. He has a large stellate laceration almost always carriers. prevent major of his left forehead and a rapidly expanding left periorbital ecchymosis. The clinical classifi cation of both A and morbidity and Vitals are temperature 37.3 C, heart rate B hemophiliacs is based on the severity mortality.” 94, blood pressure 138/72, respiratory rate of the defi ciency with mildly defi cient 21, and O2 saturation 93 percent on 10L patients having fi ve to 50 percent factor facemask. The patient has a cervical collar activity, moderately defi cient patients in place with a left shoulder deformity and having one to fi ve percent activity, and complains of left hip pain when you assess severely defi cient patients having less stability of the pelvis. Neurologically, than one percent of normal factor activity. the patient is moving all four extremities Even in the absence of trauma, severe 16 EMResident Table 1: Factor Replacement Therapy Types of Hemorrhage Desired Factor Level Factor VIII Dose Factor IX Dose: Minor 30 – 50 % 12.5 units/Kg 25 units/Kg Lacerations Mild Hemarthrosis Hematomas Moderate 50 - 75 % 25 units/Kg 50 units/Kg Dental Procedures Epistaxis Hematuria Severe 75 – 100 % 50 units/Kg 100 units/Kg CNS Retroperitoneal Retropharyngeal Severe GI Major Surgery hemophiliacs, such as this patient, are with associated depressed left orbital Factor replacement concentrates prone to have spontaneous bleeding into roof fracture, a small right-sided obtained from donor sources are purifi ed the CNS, the retroperitoneum, joints and pneumothorax, and the aforementioned but still carry risks of transmitting blood muscle compartments. Most importantly clavicular and complex pelvic fractures. borne infection; therefore, the factor for emergency physicians, patients with Despite worsening left eye proptosis replacement of choice when available is moderate or severe hemophilia and and an enlarging periorbital hematoma, recombinant DNA derived products. signifi cant bleeding will require emergent the ocular pressures in the patient’s treatment with factor concentrates to left eye remained normal. After repair In settings where factor replacement is prevent major morbidity and mortality. of the patient’s facial lacerations in not available, cryoprecipitate, whole the ED, he was transferred to the ICU blood and fresh frozen plasma (FFP) Initial management for a nine-day stay in the hospital. can be used. Each bag of cryoprecipitate Due to the patient’s agitation and need While hospitalized, the patient received contains about 100 units of factor, while for additional imaging, the patient was complete factor VIII replacement both whole blood and FFP contain one quickly intubated. Portable X-rays of the for seven days with the size of the unit of factor per 1mL of plasma. Finally, lateral cervical spine, chest and pelvis patient’s intra-parenchymal hemorrhage patients with mild hemophilia A may revealed a displaced left mid-clavicular remaining stable. respond to treatment with desmopressin fracture and comminuted fractures of the (DDAVP) at 0.3micrograms/kg IV every left iliac wing, left acetabulum and left Final thoughts 12 hours. The mechanism through which superior and inferior rami. Immediate Hemophilia, although a relatively DDAVP works is not entirely understood consultation with the blood bank and uncommon disorder, will likely be but likely acts through increasing von hematology confi rmed that the patient encountered by most emergency Willebrand factor. DDAVP can raise was indeed a severe hemophiliac with physicians given the relatively high factor VIII activity level threefold within less than 1 percent factor VIII activity. incidence of complications from the one hour of administration.  Given the likelihood of severe bleeding, disease. Fortunately, indications and 100 percent factor replacement was dosing of factor replacement can be References recommended. A 50unit/kg bolus dose simplifi ed and remembered easily. 1. Tintinall J, Kelen G, Stapczynski, S. of recombinant factor VIII was given Table 1 outlines specifi c treatment Emergency Medicine: A Comprehensive to the patient BEFORE he was taken to recommendations based of the types of Study Guide, 6th edition, 2004, Chapter radiology. bleeding for initial factor VIII and IX 220. replacement in severe hemophiliacs. 2. Marx, J, Hockberger, R, Walls, R. Rosen’s CT scanning demonstrated a left Dosing for factor IX is double that of Emergency Medicine, 7th edition, 2010 frontal lobe parenchymal hematoma factor VIII for all types of bleeding. Chapter 120. June/July 2010 17 Alhambra High school students Guest learn that compressions feature are hard work.

EMRA Local Action Grant provides high school students CPR training rmed with a 2009 Local Action Grant many leading CPR-promoting agencies Afrom EMRA, several University of such as the American Heart Association Arizona College of Medicine (Phoenix and the American Red Cross are beginning Brian C. Geyer, PhD, MSIII Campus) students visited Alhambra High to target Hispanics. CPR trainings are now University of Arizona College of Medicine School in Phoenix in an effort to combat offered in Spanish, and advertisements Phoenix, AZ the documented low rates of bystander are being placed in the Spanish-speaking cardiopulmonary resuscitation (CPR) news media. However, there is a dearth in the Phoenix Hispanic community. of data on the optimal approach to gain A 2008 study performed in Phoenix access to older members of the Hispanic highlighted that Hispanic out-of-hospital community. This is urgent as they are both cardiac arrest (OHCA) patients are 22 more at risk for OHCA and less likely to percent less likely to receive any form of speak English fl uently. bystander CPR during their resuscitation. Studies from Los Angeles reveal an even A recent report from Europe showed bleaker picture, with a Hispanic bystander that once high-school students were CPR rate approximately 50 percent that of Caucasians. CPR is one of the few instructed in proper CPR they were able factors that has consistently been shown to effectively re-teach CPR at home to Travis J. Powell, MSIII others. Importantly, those trained by the University of Arizona College of Medicine to improve overall survival from OHCA. Phoenix, AZ Therefore the medical student team high school students were signifi cantly believed that a novel approach to targeted older, which is the same population that and language-specifi c CPR instruction is most likely to witness or experience could help reverse this disparity and cardiac arrest. The UA medical student increase OHCA survival in Phoenix. team hoped to apply this same creative With the rapid expansion of the Spanish- technique to the Alhambra High School speaking population in the United States, students and their families. 18 EMResident Right: Everyone kept their sense of humor as Elmo was successfully resuscitated by an Alhambra High School student.

Far right: The culmination of each hour of training was a “CPR challenge” where students encouraged their classmates during two minutes of continuous chest compressions.

“Including other community training events, this program has trained 243 high school students to date with more events planned in the future.”

The Alhambra training was held over alternative for those who have not been students to date with more events planned eight hours and involved 192 high school trained and certifi ed in traditional CPR. in the future. With the Alhambra training, students in six class periods. The CPR Furthermore, 911 operators in the Phoenix students were asked to record the number classes were incorporated as part of the area support compression-only CPR during of persons they home trained, their age, required health curriculum and involved OHCA calls by incorporating this technique relationship to the student, and whether the the active participation and support of the in their instructions to bystanders as they training took place in English or Spanish. health and physical education faculty. All wait for the paramedics to arrive. Once the information was collected and four high school grades were represented, analyzed, the UACOM team discovered that with the majority being freshmen. More In the lessons to the high-school students, each student had on average taught at least six than 90 percent of Alhambra students the medical student instructors utilized additional people, resulting in approximately identify themselves as Hispanic, and the pillows covered with t-shirts as the 1,400 people instructed in compression-only majority speaks Spanish at home. Students training dummies. This choice was made CPR as a result of one single community actively participated in the training sessions because it could be easily replicated in the intervention! Importantly, almost one-third that included viewing the training video, student’s home when they were training of the home-training sessions were conducted conducting a question and answer session their family members. The training mantra in Spanish and utilized the Spanish language and then practicing the CPR technique. was simple: Call 911, push hard and feature of the DVD. Almost all of the DVDs push fast! Once each of the students had were returned so that they can be used for During their training the high-school demonstrated profi ciency in compression- future trainings. students were instructed in the only CPR, they were provided with a DVD compression-only CPR technique which produced by the Sarver Heart Center, Thanks to the investment by EMRA this was developed at the University of dubbed into Spanish by the medical project was able to procure DVDs and other Arizona College of Medicine in Tucson. student team, and duplicated with the training materials, creating a sustainable Compression-only bystander CPR has funds from the EMRA local action grant. CPR training program in a traditionally recently been endorsed by the American Including other community training events, neglected population that can be replicated Heart Association as an acceptable this program has trained 243 high school by future medical student classes. While the long-term effects of this intervention requires further study, it is clear that a small and dedicated group of medical students with targeted funding from EMRA has provided a comparatively large section of the community with potentially life-saving skills and a greater understanding of compression-only CPR.

This community service intervention demonstrates that high-school students can be asked to serve as “ambassadors” and bring compression-only CPR into areas that have been historically refractory to CPR education efforts. Group leaders hope that by demonstrating the feasibility of this program, compression-only CPR may some day be Medical Student Emily Shortridge added to the standard Arizona state high- teaches proper shoulder school curriculum.  positioning during the training June/July 2010 19 at Alhambra High School. Medicalstudentnews Food for thought: Refl ecting back and looking forward his is my last article as chair of largest-ever medical student turnout at Tthe Medical Student Governing ACEP’s Scientifi c Assembly, as well Council. Looking back through some as many other projects. Many of them of the past pieces I have written, I move on to outstanding residency seem to draw inspiration from food. programs across the country, while Once I wrote of cafeteria eggs, once a others continue their commitment to projectile potato, once a large burrito… the council in medical school. the list goes on. Perhaps I should have gone into gastroenterology rather than emergency medicine. Upon closer The next Medical Student Governing John Anderson, MSIV scrutiny of prior articles, it is apparent Council and Medical Student Council University of Colorado School of Medicine that the foods were merely props, and have been selected, and I have full Denver, CO the true players were the people beyond confi dence that they will do well Medical Student Governing Council Chair my epicurean musings. These people are to further the interests of medical the ones I would like to thank. students. In the near future, these pages will introduce the new chair, Shae I am lucky to be surrounded by mentors Patyrak, from the University of Texas- “. . . I believe and colleagues who seek excellence Southwestern. She has both the attitude and inspire others to greatness. These the future of and the aptitude to serve the Council; are the type of leaders that emergency our specialty medicine, and frankly, the community plus, her accent is much cooler than in general needs. Given the dedication mine, and she will make Vegas even will be bright of the members of the Medical Student more fun (if that’s possible) for ACEP’s in a time that Council, I believe the future of our Scientifi c Assembly in September 2010. specialty will be bright in a time that most certainly most certainly needs it. They made my Finally, I would like to thank all of the job easy, accomplished a great deal, medical student members of EMRA. needs it.” and even managed to keep me from I appreciate your earnestness and wearing a Yankees hat during last dedication to our specialty. We currently year’s ACEP Scientifi c Assembly in have more medical student members Boston (probably keeping me out of the than ever before, and undoubtedly have local emergency department). Going tremendous student zeal and enthusiasm. above and beyond the call of duty, the Council provided educational resources It is in large part because of people such as the updated “Articles for like you that I believe in emergency Students” section on www.emra.org, medicine. I look forward to seeing you advanced outreach projects to EMIGs all in the future (as colleagues, not as around the globe, helped coordinate the patients). 

20 EMResident Global emergency medicine: Four perspectives from three continents mergency medicine continues to At present there are no structured to further strengthening the practice of Eevolve and grow as a specialty emergency medicine student organizations emergency medicine in the Philippines. around the world. This series presents in the country. It is hoped that through the Most secondary and tertiary hospitals four perspectives on the current state and concerted efforts of the young emergency in the country have basic emergency development of emergency medicine from medicine residents and interested medical facilities and a growing number of which students and young physicians in four students, a formal Emergency Medicine are presently being staffed by trained and unique settings: the Philippines, Rwanda, Interest Group (EMIG) will soon be certifi ed emergency medicine specialists, South Africa, and the Netherlands. established. At present there are at least both in the Metro Manila and provincial seven tertiary hospitals offering structured regions. In some areas with no emergency The Philippines training programs in emergency medicine. medicine physicians, an emergency Adhara Gomez The program is three to four years in department would be run by a family Lazaro, MD length, depending on the institution, with medicine consultant, internal medicine University of the Philippines an additional year of chief residency specialist, or a general practitioner. College of Medicine that focuses primarily on administrative Philippine General Hospital skills. In general, emergency medicine In terms of the EMS systems, a residents are expected to gain expertise nationwide EMS setup is not yet in the recognition, stabilization, and available. In the past management of acutely ill and injured few years however, efforts were made to patients and also do rotations in other organize and sustain community-based Background specialties (e.g., Trauma, OB-GYN, pre-hospital EMS. Emergency medicine in the Philippines Pediatrics, and Medical ICU). started around two decades ago and is one Rwanda of the most promising and fast-growing As of this writing, there are two Zack Ndirima fi elds of medicine. organizations providing accreditation to MD Candidate, 2011 National University of emergency medicine residency programs Emergency medicine training Rwanda Medical School in the country; the Philippine College of Medical students have varying exposure Emergency Medicine and Acute Care to emergency medicine, depending on the (PCEMAC) and the Philippine Society institution where they are enrolled. In the of Emergency Care Physicians (PSECP). case of the University of the Philippines The former was organized by a group of – Philippine General Hospital, emergency doctors from Makati Medical Center, a Background medicine has been well represented in the private tertiary hospital while the latter Rwanda is a developing country in the medical school curriculum such that the was initiated by the University of the heart of Africa. Civil war and armed medical clerks are required to complete Philippines – Philippine General Hospital, confl icts in 1994 left more than 800,000 a two-week rotation in the emergency the largest university-based, government people dead and destroyed most of department. They are expected to have tertiary hospital in the country. a good grasp of the basic concepts and the health care infrastructure. Today, emergency medicine is a very primitive philosophy of emergency medicine, as Emergency medicine practice well as learn the basics of emergency state in Rwanda. The country has feeble management, i.e., resuscitation and To date there have been several graduates emergency medical services and many stabilization of acutely ill patients. of emergency medicine residency training hospitals are only now recovered from Students are also expected to understand programs in the country. An estimate of the ravages of war. But in the past several the emergency triage system, emergency 30-40 trainees would graduate each year. years, there have been many successful department patient fl ow, emergency About half of them opt to go abroad to efforts to improve on its current state, both department patient disposition protocol, work and/or pursue further training while from the state and the private sector. and standard monitoring techniques. the rest decide to stay and contribute continued on page 22

June/July 2010 21 Medicalstudentnews continued from page 21 there are far more patients than available Pre-hospital emergency medicine hospitals. This mismatch in demand and Pre-hospital emergency care Patients arrive to the emergency resources has an adverse impact on the Currently, there are no formal emergency department in three ways: referral by a ability of staff to be adequately trained in services in the pre-hospital setting. The general practitioner; walk-in; or by EMS quick, appropriate action in emergency most common emergency cases are ambulance/helicopter. Paramedics are situations. The physical resources, such related to obstetric emergencies, road frequently the fi rst responders on the as infrastructure, supplies and equipment traffi c accidents, post-traumatic stress ambulance and are authorized to perform are also currently not suffi cient to meet disorders due to recent wars, fi res, and medical procedures and administer the demands of emergency care. Many infectious diseases. The government has medications without consulting a physician emergency-related deaths are could put in place a system of two ambulances in the hospital. Depending on the injuries potentially be prevented if adequate of the patients the help of a Mobile Medical per district hospital. Each district hospital resources were available for emergency care. serves a population of approximately Team (MMT) is called in. The MMT, Recently, more health learning institutes consisting of an anaesthetist or a surgeon, a 150,000 people. However, there are also are being established, and government private ambulance service providers nurse and a driver/pilot, will provide more health budgets have been increased with advanced care to stabilize the patients for that are mainly based in the city health a special focus on improving emergency facilities and at each of the tertiary transport. The 10 trauma centers in the care. Hopefully, these efforts will result in Netherlands provide their own MMT. Every hospitals in the country. The ambulances improved emergency care in Rwanda. range from sophisticated jeeps to ingobyi MMT has a van with fi ve seats, medical (traditionally fabricated stretchers) that equipment and medication, and four MMTs Emergency medicine training for have a helicopter. are ironically called “helicopters,” that doctors and students are used to transfer patients to the nearest Currently, Rwanda has a single medical health care facility. Emergency departments school and there is little formal training Currently, the majority of the nearly two in emergency medicine for students or the In many cases, the best pre-hospital million patients visiting Dutch emergency general practitioners who are graduated measures have involved preventive departments annually are seen by newly from the school. There are no formal programs, such as more stringent traffi c graduated medical students who are training programs, although many medical rules that have decreased the incidence of waiting to be accepted into a residency students are becoming more interested in vehicle crashes by nearly 65 percent in the position, by nurse practitioners, by resident learning about emergency care, and formal past four to fi ve years. Additionally, the physicians of other specialties, and by student organizations will likely encourage ministry of health has put in place a system attending from other specialties. Usually that interest and help in the development of nearly 20 psychotherapists/social residents from other specialties are called of emergency medicine in Rwanda. workers in each catchment area of about to assess a patient with complaints related 20,000 people to serve the mental health to their specialty. This system is currently The Netherlands needs of the community. Community being transformed into the model seen in midwives are too few in number to meet Shiromani Janki other countries, where trained emergency Erasmus MC / University medicine physicians assess, diagnose, treat the need for obstetrical care, and in most Medical Center instances the fi re brigades are not well Rotterdam, the Netherlands and admit or discharge the patients, in organized to assist during emergency President EM Student cooperation with the various specialists. situations with injured patients. Organization EM student organization Emergency departments Because emergency medicine is a new In a country adopting the primary health medical specialty, it is not well represented care system, the quality and availability Background in the medical school curriculum. There are of emergency services improves from the The development of emergency medicine eight medical schools in the Netherlands, community and district health centers to the in the Netherlands began in 2000, with with most teaching fi rst aid, CPR, and tertiary hospitals. However, the fi ve tertiary many landmark achievements in the past AED. Some schools have a dedicated hospitals in the country have greater demand decade, including specialty recognition emergency medicine course ranging from for services than available resources, and in 2009. two to eight weeks, often taught by other 22 EMResident and private that transport patients to Medical Student Professionalism the hospital. Ideally the patient is then and Service Award transferred to the nearest hospital until their condition becomes stable; they are One award available for each medical school OR emergency medicine then referred to another to be treated at the residency program based on selection by school or residency program. appropriate level of care if necessary. The personnel at the hospital which are involved Selection process Application deadline Select one medical student per medical school or October 29, 2010 in caring for the patient are the attending EM residency program for student who: physicians and nurses, although not all of • gives outstanding care to patients in professional/ Awards humanistic manner; • a certifi cate from ACEP the attending physicians have been formally • has active leader service to medical organizations • reception at ACEP’s annual meeting trained in emergency medicine. and community; • any monetary award to be decided at the local • grades and board scores are NOT a requisite level From these experiences, it is safe to say Submission process Announcement Only one nominee per medical school or • publication of names in an ACEP publication. that South Africa has a comprehensive EM residency program. • encourage presentation of award at your system for emergency medicine in Submit name of local award recipient to ACEP medical school’s award ceremony or graduation place, from initial emergency call to using online submission form ceremony. the patient’s admission, and subsequent treatment. However many challenges are still present, including: patients being specialists. With the assistance of Terry and emergency medicine congresses. turned away from treatment by private Mulligan, DO, MPH, FACEP, current Many students also visit the emergency hospitals if they do not have medical aid Chair of the ACEP Section for International department for one-day introductory visits. to pay for treatment; delays in ambulances Emergency Medicine, and together with the By the end of this year we hope to have arriving to injured or ill patients; poor Dutch Society for Emergency Physicians formatted SEHSO’s on every medical communication systems between medics (NVSHA) we have begun to form school and will provide all Dutch medical and physicians located in the hospitals; emergency medicine student organizations students with information and access to and, a general lack of resources to meet all (in Dutch: SEHSO-spoedeisende hulp this new and exciting specialty. of the demands for emergency care. studenten organisatie) for students interested in the specialty. The fi rst SEHSO South Africa Emergency medicine training was established in May 2007 at Erasmus Lesley Tumai for medical students Medical Center Rotterdam. The goal is Kaseke, MSIV Many medical schools have formal to form a national student emergency University of Cape Town, training in emergency medicine, medicine organization by formatting a local South Africa coordinated by an emergency medicine SEHSO at all eight Dutch medical schools President Medical Students’ specialist. For example, at the University Association (2008-2009) that will represent hundreds of Dutch of Cape Town (UCT), Dr. Anne-Marie medical students. So far Erasmus Medical Kropman, an emergency medicine Center Rotterdam and University Medical physician coordinates student training in Center Utrecht have a SEHSO. emergency medicine. Medical students Background are given training in emergency medicine Emergency medicine in South Africa is a The SEHSO goals are: in the 3rd and 4th years of study, learning developing fi eld of medicine, with great • To support the interest in emergency resuscitation protocols for different interest from medical students and the medicine scenarios. Students also ride with community. As many other countries, • To provide interested medical ambulance crews, giving them hands-on South Africa uses the district health students with extra information about experience with medics, and teaching system which has primary, secondary and emergency medicine in addition to the them about the initial management and tertiary health facilities. existing curriculum referral of patients to hospitals. • To support the medical student in making career choices related to Emergency medicine practice Medical student interest groups for emergency medicine From the moment an emergency call is emergency medicine have also been made, the district ambulance services are established and continue to grow across Every two months the SEHSO’s notifi ed. Paramedics are then summoned South Africa. These groups will help to train organize a meeting, consisting of lectures to provide initial assessment and aid to the future emergency specialists in South and/or workshops. Students are also the patient. There are different paramedic Africa and therefore will be critical to the encouraged to join the residency lectures services in this country, both public future development of the specialty here.  June/July 2010 23 Talkingwith

EM perspective on critical care fellowships r. Julie Mayglothling is an assistant What advice do you have for the resident or Dprofessor of Emergency Medicine and medical student who is thinking about going Surgery at Virginia Commonwealth University into critical care and emergency medicine? in Richmond Virginia and is the Fellowship The fi rst step for an emergency medicine Director for the emergency medicine critical resident thinking about critical care is to decide care fellowship. She serves as the president what your eventual practice is going to be. It of the Emergency Medicine Section of the is essential to fi gure out if you want to practice Society for Critical Care Medicine (SCCM). in-patient critical care. I love the fact that I do She completed emergency medicine residency one week per month in the ICU, one week as at NYU/Bellevue Hospital in NYC and a the trauma attending, and six to seven shifts a critical care and trauma fellowship at the month in the emergency department. University of Maryland R. Adams Cowley Taku Taira, MDD Shock Trauma Center. In this interview, Dr. The second step is to decide is whether you Assistant Program Director Emergency Medicine Residency Mayglothling sheds light on the future of like medical critical care or surgical critical Department of Emergency Medicine emergency medicine critical care. care. The patients in each discipline are very Stony Brook University Medical Center different. The patients in medical critical How did you get involved in critical care? care are sick, complicated, and have a lot Like many emergency medicine residents I of co-morbid conditions. Surgical critical had always enjoyed trauma and critical care care patients include trauma, post-surgical, but did not initially consider further training. pancreatitis, vascular surgery, and transplant “I love the fact I started to consider critical care after I patients. There is a lot of different pathology. that I do one mentioned my interest to one of the new You should tailor your training to your clinical trauma surgeons at Bellevue. This trauma interests and the patient population you want to week per month surgeon had just completed his fellowship at work with. Shock Trauma and said that there were in the ICU, one several emergency medicine physicians in his What are the different types of critical care week as the class. fellowships? What are the differences? There are four main types of critical care trauma attending, He encouraged me to consider further training. fellowships. After looking into the fellowship I found that and six to seven it had everything I was looking for: a mix of The fi rst are anesthesia programs. These shifts a month in critical care and trauma, a welcoming attitude are mostly focused on surgical critical care, towards emergency physicians, and freedom to based out of the SICU, and are mostly one the emergency pursue my interests. year. Examples of anesthesia based critical care programs that have accepted emergency department.” Since then the opportunities for emergency medicine residents are Massachusetts General medicine residents interested in training in Hospital, Johns Hopkins, and the University of critical care have expanded greatly. At the Washington. time I was applying, there were maybe fi ve to six programs that had accepted emergency The second type of fellowships is a surgically medicine applicants. Now, there are over 20 to based program. These are also one-year 25 institutions that take emergency medicine programs that combine both surgical critical residents. care and trauma care. These programs train 24 EMResident Scissors...

What is the impact of the recent American Board of Emergency Medicine (ABEM) surgeons and emergency medicine and the American Board of Internal physicians together. The best known Medicine (ABIM) agreement on critical of these programs are Maryland Shock care training? Trauma and Saint Luke’s Hospital in Recently, ABEM and ABIM agreed that if Bethlehem, PA. an emergency-medicine-trained physician does an ACGME approved two-year- The third type of program is the multi- medical critical care fellowship they will disciplinary program. This type of be board eligible for critical care. I did a Paper... program gives you the widest exposure surgical critical care fellowship and enjoy to different areas of critical care. The surgical critical care, but to this date, there program at Pittsburgh is the best-known is no board pathway if you do anesthesia multi-disciplinary program. The program or surgical critical care from emergency at Pittsburgh is ACGME approved for medicine. Rock-solid medicine, anesthesia, and surgery. The fellows are from medicine, emergency There is an opportunity to be board savings! medicine, surgery, and anesthesia—all certifi ed through the European Society for of whom do the same rotations. The Intensive Care Medicine, but you are not emergency medicine-critical care board eligible in the U.S. Presently, many fellowship is either one or two years. critical-care-trained emergency physicians are practicing in hospitals where board certifi cation is not an issue. The future The last type of program is emergency Announcing a new member medicine based. These tend to be is uncertain—lack of board certifi cation programs that have arisen from could become a barrier in the future and benefi t for EMRA members. people like myself who have done may push one towards seeking a training emergency medicine and critical care pathway that would allow for board Now EMRA members can save an certifi cation. and then started fellowships at their average of 52% off manufacturer’s own programs. These fellowships are usually two years and are both Can you talk about the opportunities list prices on all purchases at Offi ce surgically and medically based but with for residents to be involved in emergency an emergency medicine focus. The best medicine critical care on the national Depot. 150 items are discounted level? known of these types of programs are up to 90% — including printer Indiana University, North Shore LIJ, and There are three main bodies: the EMRA Virginia Commonwealth University. Critical Care section, the ACEP Critical toner, paper, pens and all the things Care section, and the SCCM EM Critical What is your general sense of the job Care section. There is a lot of overlap, but you need the most. opportunities for people coming out of these groups work to promote emergency critical care training? Are institutions medicine critical care. Most critical care supportive or welcoming to have emergency physicians are active in at least physicians who split their time between one of these groups. the emergency department and the ICUU? We have a paper coming out in Academic The physicians involved in these groups Emergency Medicine. We surveyed all have a wealth of knowledge and experience Visit www.emra.org/offi cedepot.aspx of the physicians who have done an that can be useful for residents who are to start saving today! emergency medicine and an accredited considering fellowship training. Whatever Or call critical care fellowship. We found that question a resident might have, if we didn’t 1-866-566-2492

2/3 practice emergency medicine, 2/3 know the answer, we would be able to at least for more information. practice CC, and 40 to 45 percent of them get you in touch with someone who did. practice both emergency medicine and critical care. These physicians practice Any last comments? in a variety of settings—community, I cannot imagine my job being any better academics, and level one trauma than it is. I did a four-year residency and a centers. Some even split their time one-year fellowship, but it was worth the between multiple institutions, with the long hours and the sacrifi ce because this opportunities to do so increasing annually. job is everything that I could want.  EMpediatrics Pediatric suicide History and presentation from the ligature may lead to laryngeal n 11-year-old male was found edema or fracture. Patients may have Ahanging by a leather belt around tenderness over the larynx, hoarse voice, his neck in a closet, 20 minutes after an stridor or be in respiratory distress. argument with his parents. On initial EMS Fiberoptic intubation should be considered evaluation, he was unconscious, apneic, in awake, stable, and cooperative patients. and pulseless. A surgical airway may be required in unresponsive or unstable patients if direct CPR was initiated, and an intraosseous laryngoscopy is unsuccessful. Emily Grover, MD line was placed. After a dose of University of Arizona College of Medicine Cardiovascular status is dependent upon Tucson, AZ epinephrine, the cardiac rhythm revealed ventricular fi brillation, prompting the time until rescue. Blood vessels in defi brillation and further CPR. After the neck and head are affected as venous intubation, repeated defi brillation, and obstruction and arterial spasm decrease interventions with epinephrine, lidocaine blood fl ow to the brain. Arrhythmias and cardiac arrest may occur. Skin “According to and atropine, the patient developed return of spontaneous circulation. fi ndings can include ecchymosis of the the Centers for neck, petechiae on the neck and head, or Epidemiology hemorrhages in the eyes. The carotids Disease Control may be damaged, so imaging should be According to the Centers for Disease considered. Resuscitate cautiously with and Prevention Control and Prevention (CDC), suicide fl uids because these patients are at high is the fourth leading cause of death in the risk for cerebral edema and ARDS. (CDC), suicide is U.S. among children ages 10 to 14, behind the fourth leading accidental injury, malignant neoplasm When treating a patient after a hanging, and homicide. The CDC categorizes cause of death in maintain cervical spine stabilization. hanging as a type of suffocation, which The classic Hangman’s Fracture, or C2 the U.S. among has accounted for 63 percent of suicides traumatic spondylolisthesis, results from committed by 10 to 14 year olds and has children ages forced hyperextension and distraction of seen a sharp rise among young females the neck and is almost always an unstable 10 to 14…” since 2001 (Figure 1). Breaking the data fracture (Figure 3). Risk of cervical spine down by race and ethnicity shows that injury increases with large dropping American Indians and Alaskans across all distances, so Hangman’s Fractures are age groups have the highest rate of suicide rare in suicidal hangings. In patients in the U.S. (Figure 2). Certain native who survive the initial airway insult subgroups, such as youth (ages 10 to 24) of hanging, morbidity and mortality of the White Mountain Apache Tribe in generally are a consequence of cerebral Arizona, have a strikingly high rate (80 hypoxia. percent) of death due to hanging2. Once the patient has been stabilized, other Treatment interventions may include consultations When treating a patient after a hanging, with ENT, neurology, neurosurgery, airway management may present a psychiatry and social services. Patients signifi cant challenge, as direct trauma should be monitored closely for airway

26 EMResident Figure 1 Figure 2 Figure 3 Trends in suicide rates among Percentage of suicides among Hangman’s fracture females 10-24 years, by persons ages 10-24 years, by mechanism, U.S., 1991-2006. race/ethnicity and mechanism, U.S., 2002-2006.

Source: Tintinalli JE, Kelen GC, Stapczynski JS: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 6th Edition: www.accessemergencymedicine.com Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

obstruction, pneumonia, ARDS, blood self-destructive behavior, and current References pressure instability, arrhythmias, mental stressors. The survey offers non-mental 1. Centers for Disease Control and status changes, and seizures. Other self- health professionals the means to rapidly Prevention, National Center for Injury infl icted injuries such as toxic ingestion assess the major facets of suicide risk in Prevention and Control. Web-based should also be considered. children. Injury Statistics Query and Reporting System (WISQARS) [online]. (2005) Prevention Case conclusion [cited 2010 April 17]. Available from Hanging does not require expensive or On arrival to the emergency department, URL: www.cdc.gov/ncipc/wisqars specialized equipment, and lethality the patient was hypotensive with a is high. Consequently, this may be an non-sedated Glasgow Coma Scale of 2. Mullany B, Barlow A, Goklish N, appealing method for suicide among the three. He had no gag-refl ex, absent Larzelere-Hinton F, Cwik M, Craig pediatric and adolescent populations, corneal refl exes, and equal, nonreactive M, Walkup JT. Toward understanding as fi rearms and poisons are generally pupils. Therapeutic hypothermia was suicide among youths: results from more diffi cult to access. Cultural and initiated. After admission, an EEG the White Mountain Apache tribally religious factors may also infl uence the showed decreased cerebral activity. mandated suicide surveillance system, mechanism an individual uses to commit Computed tomography showed loss of 2001-2006. Am J Public Health. 2009 suicide. brain gray-white matter distinction, but Oct;99(10):1840-8. no c-spine fracture, vascular injury, or 3. Tintinalli JE, Kelen GD, Strapczynski One suicide screening tool implemented intraventricular hemorrhage. JS: Tintinalli’s Emergency Medicine: in a pediatric emergency department A Comprehensive Study Guide, 6th was evaluated in a small, cross- The ICU course included treatment for Edition. sectional study in 2001. Among the labile blood pressures with pressors, 14 screening questions, four questions trauma-induced diabetes insipidus with 4. Horowitz LM, Wang PS, Koocher GP, showed signifi cant predictive value vasopressin, and impending herniation Burr BH, Smith MF, Klavon S, Cleary of suicidal risk when compared to with mannitol. The patient was declared PD. Detecting suicide risk in a pediatric an extensive questionnaire. The four brain dead after extensive, independent emergency department: development of items assessed were: present suicidal examinations by the intensivist and a brief screening tool. Pediatrics. 2001 behavior, past suicidal ideation, past neurologist.  May;107(5):1133-7.

June/July 2010 27 AN ABOVE AVERAGE APP FOR THE ABOVE AVERAGE PHYSICIAN

EMRA Antibiotic Guide by Salibad the Sinner – Version 1.0.1 – Jan 22, 2010 “Excellent format and interface.” Best of Class by Sardamann – Version 1.0.1 – March 23, 2010 “As an Infection Preventionist Easier than and a Microbiologist I find Sanford it an incredible source by Geekstrap – Update of information. Flow is “It’s easier to navigate very logical and essentials and the suggestions are readily available. actually seem more Perfect work.” in line with actual practice.” EMRA ABX GUIDE or Download through your iPhone App iTunes account on Apple.com Residentlife

Dead emergency medicine resident running: Finding balance while training re you as excited about going to work today as our lives also leads to erosion in our performance Ayou were on your fi rst day as an intern? When at work. As interest in work declines, so goes our we start residency, we are fi lled with an incredible performance –no matter the time spent on work amount of energy, involvement, and engagement; activities. The attraction we once felt for residency however, it seems that for many of us this excitement may be replaced by avoidance, isolation, and dread tends to fade and may be replaced by exhaustion of working another shift. and cynicism. This process does not happen all of a What are the consequences of not properly sudden, but is a gradual and insidious process that balancing your life? For many residents the answer may take over if we are not aware. may be simply a loss of enjoyment in their work. The main culprit in this transition is frequently For other residents, more irreversible outcomes erosion in the balance in our lives. As physicians, such as divorce or inability to complete residency Jonathan Heidt, MD we are trained in a manner that leads almost may result. Other residents may turn to alcohol or Director-at-Large inevitably to this loss of balance. It is vital to substance abuse as a means to manage their stress. Washington University be aware of this transition in order to avoid St. Louis, MO Once you recognize that balance has been lost, irreversible consequences. The ACEP Wellness what should you do? First, it is important to Book has a chapter on burnout, which highlights recognize that there are multiple areas in life that several reasons while physicians are at such great require attention: risk for this transformation: 1. Physical balance – i.e., stay in shape! Physical “We are given the 1. Medicine monopolizes our whole identity fatigue can lead to mental and emotional fatigue. incredible privilege 2. Establishment of an overdeveloped sense of 2. Relationship balance – connect with old friends responsibility with whom you lost touch during the marathon and responsibility 3. Feeling entitlement to respect of your training. Refocus your attention to 4. Expectations not to display vulnerability your family – including your spouse. Our of helping patients including sadness family members are usually our greatest when they are at 5. Work intensity supporters, and it is important to show them 6. Disruption of circadian rhythms that appreciation. their sickest, but 3. Community balance – remember that there is a The transition from medical school to residency in order to provide world outside of the hospital. Be involved with is a time of great excitement and trepidation. As groups outside of the hospital. Be involved with you progress through residency, however, have the best possible volunteer activities, church groups, hobbies, etc. you noticed a change in your personality or in the 4. Work balance – work towards being the care, we must first personality of your colleagues? As we lose balance best possible physician you can become, but in our lives, our personal relationships begin to be healthy and remember there is a limit to the amount of work suffer. One common complaint that residents have that one person can reasonably accomplish. is that they miss the time they spent socially with content.” their fellow residents. Instead of viewing their Residency is a time of great excitement and classmates as friends, they begin to see others with development. We are given the incredible privilege mistrust for “using sick call too much” or “refusing and responsibility of helping patients when they are at to help out by trading that shift.” their sickest, but in order to provide the best possible care, we must fi rst be healthy and content.  For residents with families, the relationship with their spouse is also frequently stressed. While References you may view the amount of time you spend on 1. Vickman, Larry MD MHA FACEP. ACEP Wellness residency activities as being your responsibility Book for Emergency Physicians. “Burnout.” Pp 22 – 27. and commitment towards personal success, your 2. ACEP Practice Resources. “Avoid Burnout by spouse may feel that you have placed work as a Managing your Stress.” http://www.acep.org/ priority over family life. The loss of balance in practres.aspx?id=22722

June/July 2010 29 Residentresearch

Asking the research question: How to develop an original hypothesis sking an original research question comes advanced projects directed at building your area Amore naturally than you may think. In of expertise. Simply put, doing a well-defi ned fact, if you are a resident or medical student in project on 3rd metatarsal fractures could make emergency medicine, you do it every day. Every YOU the department expert! time you ask yourself or a colleague “why do we do this?,” “why don’t we do that?,” or “upon It is important to realistically assess the time and what evidence are we basing our approach?,” resources required to answer your question from you have created a research question. start to fi nish. Part two of the EMRA Research Committee series, in the December/January 2010 The fi rst step in developing your idea is to issue of EM Resident, highlighted the importance Jesse A. Borke, MD comprehensively review the literature available of building a student-mentor relationship to help NY Presbyterian Hospital on the topic. If there is “too much to read,” then defi ne a realistic timeline for each project step New York, NY your question may be too broad. The next step is from IRB approval to publication. Team building to develop a testable hypothesis. Make sure your is an integral part of emergency medicine, and question is narrow enough to yield meaningful emergency medicine research is no exception. results. Understand (and be prepared to explain) You should not hesitate to bring others into exactly how answering your question would your project if they complement your skills and change or reaffi rm your clinical practice. contribute to the overall outcome of the project. The next step is to select a study design suited Emergency medicine is the most diverse to your question. Selecting the correct design specialty in the house of medicine–it touches can make executing your project much easier, every other specialty from infectious disease to while selecting the incorrect design can result gynecology to sports medicine. The specialty in a fatally fl awed approach. The type of study is still in its infancy, however, and that means design will depend primarily on the question Brian C. Geyer, PhD, MSIII the sky is the limit for emergency medicine you ask and the resources you have available. University of Arizona research. As you develop your clinical skills, College of Medicine A good resource is: Rennie D, Guyatt G, eds. Phoenix, AZ Users’ Guide to the Medical Literature: A you will be exposed to numerous original ideas Manual for Evidence-Based Clinical Practice. and have the opportunity to select from a vast array of research questions. One relatively painless way to start is with a retrospective chart review. Institutional Review You may fi nd it more rewarding to study a topic Board (IRB) approval is usually relatively easy in which your program has readily available to obtain for chart reviews, as there is no direct expertise. Identify the content area experts in contact with patients, and data collection is your department and seek them out. Of course, much easier since you are analyzing existing if your interests take you in a novel direction, data. What would such a project look like? How it is perfectly acceptable to seek appropriate about reviewing all of the patients admitted support and carve out your own niche. through your emergency department with sepsis The most important thing to remember is to see if an association exists between time to this: only study a topic about which you are fi rst antibiotic and survival to discharge? passionate. Following this advice will make the Your initial conclusions from a retrospective process easier, enhance the quality of your results study can build the hypotheses for future and keep you fulfi lled. Now get to work!  30 EMResident Can’tmissECGs Figure 1 Key to recognizing hyperkalemia Case presentation until the ventricular rate improves. This patient 42-year-old man presents to your did, in fact, receive atropine, transcutaneous A emergency department complaining of pacing, and was then started on a dopamine severe malaise and postural lightheadedness. infusion without any improvement in his heart He has a history of long-standing hypertension rate. The laboratory then called the emergency though admits to being non-compliant with department to report a “panic” potassium level medications. His VS are notable for a HR in of 7.7 mEq/L (normal value 3.5-5.0 mEq/L). the 30s and a BP of 80/40. He is listless but arousable and oriented. The exam is otherwise Hyperkalemia is the most common deadly unremarkable. Nurses obtain an ECG and electrolyte disorder that we encounter in the present it to you (Figure 1). What is your emergency department. The traditional teaching Amal Mattu, MD, FACEP diagnosis and treatment? regarding ECG fi ndings of hyperkalemia Program Director includes peaked T-waves, widening of the Emergency Medicine Residency Associate Professor of Emergency Medicine Discussion QRS complexes, fl attening and eventual loss University of Maryland School of Medicine The ECG demonstrates a slow regular rhythm of the P-waves, ventricular dysrhythmias, and Baltimore, Maryland with a ventricular rate of approximately 30. The a sine-wave appearance of the rhythm as the narrow QRS complexes and absence of P-waves patient approaches cardiac arrest. However, are suggestive of a junctional rhythm, although bradydysrhythmias are common in cases of severe “Unfortunately, the rate is slower than a typical junctional escape hyperkalemia as well—slow atrial fi brillation, rhythm (usually 40-60 beats/min). Another slow junctional rhythms, slow junctional many physicians notable feature is the presence of tall, peaked rhythms, and advanced AV blocks are all potential T-waves in the anterior leads. This T-wave manifestations of severe hyper-kalemia. fail to recognize morphology is typical of hyperkalemia. The peaked T-waves of hyperkalemia are most notable Unfortunately, many physicians fail to hyperkalemia in in the precordial leads, as noted in this case. recognize hyperkalemia in the setting of these bradydysrhythmias because they are not the setting of these When this patient initially presented to often taught. Further confounding the care of the emergency department, the health care these patients is the fact that ACLS treatment bradydysrhythmias providers focused their attention on the patient’s algorithms for unstable bradydysrhythmias heart rate and hypotension. Typical Advanced frequently fail in these cases because these because they are Cardiac Life Support (ACLS) protocols dictate patients are often severely acidotic. Atropine, that unstable bradydysrhythmias should vasopressors, and even transcutaneous pacing not often taught.” be treated with atropine, transcutaneous or may be ineffective in the setting of severe transvenous pacing, and vasopressors such as acidosis. epinephrine or dopamine in a sequential manner for Case Resolution see page 39

For other great ECG’s cases, check out these resources by Dr. Mattu, available at the ACEP Bookstore. ECGs for the Emergency Physician Part 1–Gives you ECG fi ndings that form the core knowledge necessary for accurate ECG interpretation. ECGs for the Emergency Physician Part 2–Surpasses the basics and has two sections for intermediate and advanced levels of diffi culty. Electrocardiography in Emergency Medicine–When seconds count, you have to understand the subtleties of ECG fi ndings to prevent missed Amal Mattu, MD, FACEP Amal Mattu, MD, FACEP Amal Mattu, MD, FACEP diagnosis and this book covers those fundamentals and so much more. William Brady, MD, FACEP William Brady, MD, FACEP Jeffrey A. Tabas, MD, FACEP Robert A. Barish, MD, FACEP June/July 2010 31 You think Phoenix is ... the

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7340 East Indian Plaza Scottsdale, AZ 85251-3571 (480) 970-1112 EMRAEMRA Activitiestivitie s at the 22010010 SAEMSAEM AnnualAnnual MeetingMeeting June 3-5, 2010 JW Marriott Desert Ridge Resort & Spa 5350 East Marriott Drive • Phoenix, AZ 85054 Thursday, June 3, 2010 1:00pm-5:00pm EMRA Board of Directors Meeting Pinnacle Peak #1 Friday, June 4, 2010 8:00am-9:00am EMRA Technology Committee Pinnacle Peak #2 8:30am-9:30am ACEP/EMRA Offi cers Meeting Pinnacle Peak #1 8:30am-11:30am EMRA Board of Directors Meeting Pinnacle Peak #1 10:30am-11:30am ABEM/EMRA Offi cers Meeting Pinnacle Peak #1 11:30am-1:00pm EMRA Leaders Luncheon (invitation only) Blue Sage (JW Marriott) 1:00pm-1:30pm EMRA Committee Chair Orientation Desert Suite #1 1:00pm-2:00pm EMRA Regional Representative Meeting Desert Suite #6 1:00pm-3:00pm EMRA Medical Student Governing Council Meeting Desert Suite #4 1:00pm-5:00pm EMRA Resident Sim Wars Competition Grand Saguaro Ballroom West 1:30pm-3:00pm EMRA Health Policy Committee Meeting Desert Suite #7 1:30pm-3:00pm EMRA Critical Care Committee Meeting Desert Suite #8 1:30pm-3:00pm EMRA International Committee Pinnacle Peak #2 2:00pm-3:00pm EMRA Conference Committee Orientation Pinnacle Peak #1 3:00pm-4:00pm EMRA Reference Committee Public Hearing Grand Canyon Ballroom #2 4:00pm-5:00pm EMRA Reference Committee Work Meeting Pinnacle Peak #2 4:00pm-5:30pm EMRA Research Committee Meeting Desert Suite #8 5:30pm-6:30pm EMRA Spring Awards Reception Grand Saguaro Ballroom East Saturday, June 5, 2010 8:30am-9:00am EMRA Rep Council Welcome Breakfast & Registration Grand Saguaro Ballroom West 9:00am-12:30pm EMRA Rep Council Meeting/Town Hall Grand Saguaro Ballroom West 12:30pm-1:30pm EMRA Rep Council / Resident Luncheon Grand Saguaro Ballroom West 3:00pm-5:00pm EMRA Board of Directors Meeting (Committee Updates) Desert Suite #3 5:30pm-7:00pm EMRA National EM Jeopardy Contest Grand Sonora Ballroom H-K 9:30pm-2:00am EMRA Party Axis/Radius 7340 E. Indian Plaza, Scottsdale, AZ Moneymatters

Staying on top of your game mergency medicine residents are appears that the next development involves Efamiliar with change. To stay on a signifi cant change in the way student top of your game, you must juggle shift loans are to be structured. As a result of the schedules, training, patient care, income recent bill signed into law by the President, limitations, practice opportunities, debts, the government will be the fi rst lender for expenses, budgets, families, and numerous all student loan programs, with the goal other situations. As you balance your of using the +/- 4.5 percent interest spread personal and professional lives, I want to (difference between their actual borrowing take this opportunity to provide you with rate and your loan interest rate) to fund the an update of the most recent changes in new healthcare bill. It is likely that there M. Shayne Ruffi ng the fi nancial community, as they relate to will be increased incentives to practice in CLU, ChFC, AEP you. The following information is current various areas that the government sees as as of April 15th, 2010. critical. I am not yet confi dent enough of the provisions to provide advice in this Savings rates regard, but I encourage you to contact your For the most part, savings rates (money lender and fi nd out what this means for you markets, CD rates, savings accounts) are personally. less than inspiring. This is not a reason to move that money into something else like Disability insurance gold. Keep your cash savings in savings Always in a state of change, the disability and remember that it is for emergencies industry continues to provide increasing and fi nancial confi dence. opportunities for emergency medicine residents. These are the most recent Because of member benefi ts, many credit movements in that industry: unions have the most competitive rates at the moment for these cash assets. Residents are now able to purchase up to $7,500 of monthly specialty-specifi c/ Another source of good cash yields is own-occupation coverage and lock in in permanent life insurance contracts. the ability to increase by up to another Some of the guaranteed accounts in these plans are paying in excess of 5.0 $7,500 in the future. You must be within percent, although there are restrictions and six months of completing training to be considerations involved in using such an eligible for this benefi t. asset as your savings account. There are four companies with specialty- specifi c contracts through age 65 or 67. Student loans It was just a year ago that the Higher Three of the four major disability Education Act took effect and upended companies now limit the amount of DI residents’ cash fl ow across the country. It a resident can get if they have a signed

34 EMResident “As a result of the recent bill signed into law by the President, the government will be the first lender for all student loan programs.” contract that will have group long term need it, you can cancel or potentially sell • Deposit all EM-related income disability benefi ts – Obtain disability it to a settlement company. into that corporate account and pay insurance before you sign your yourself a salary or “owners draw” contract!! Buy Term – There are a lot of good from those funds reasons to buy permanent life insurance. • Run all business expenses through Conversion options can often provide Not many of them make sense during that corporate account and all great benefi ts if you have a medical residency. In the early years of your history and are unable to purchase training or practice, buy lots of term individual expenses through your individual disability coverage or have insurance for pennies on the dollar and individual account medical history that would lead to an direct your other cash towards paying • Hire an outside practice manager or undesirable contract. Consult your GME off debt, building savings and funding bookkeeper to maintain all of your or human resources department for retirement. contracting, billing, coding, and information. If you have a signifi cant reimbursements and to maintain your medical history, it is critical that you do Retirement strategies this before you fi nish your training! bank accounts. The Roth IRA continues to provide signifi cant tax leverage for residents. **The EMRA Disability Program Learn the difference between a SEP IRA, provides you with an independent Tax Tip – If you have been max-funding 401(k), and defi ned benefi t plan and analysis of the most competitive your Roth IRA during residency and will structure the optimal program that allows contracts in your state and recommends soon lose the ability to do this due to you to make the largest contribution to the most competitive plan, doing increased income, consider max-funding all the work for you! For more your own retirement.  info: complete the EMRA survey a non-deductible traditional IRA. In the at www.integratedwealthcare.com/ year 2010, you can convert any funds Shayne Ruffi ng, CLU, ChFC, AEP is fi nancialeducation. ** in that IRA into your Roth IRA (paying the creator of the Confi dent Transition taxes on any gains) and ultimately end Plan™ for medical residents, the Physician Disability Income Analyzer™ Life insurance up being able to get two or three more years of Roth funding! Consult your tax and the Physician’s Financial The life insurance marketplace is advisor or fi nancial planner for planning Navigator™. Shayne specializes in interesting. Term insurance is still very strategies. executive benefi t planning for physicians competitive, but permanent plans have and medical practices. He can be seen increases in costs to adjust for Independent contractors reached at 800.225.7174, or via e-mail longer life spans. I believe that the trend at [email protected] or on the web If you are pursuing a position as an will be to continue increasing rates over at www.IntegratedWealthCare.com. time. independent contractor, the following may be helpful in getting started and Shayne is an Financial Advisor offering Insurance Tip – This is a good time to staying organized: Securities and Advisory Services “warehouse” insurance. Buy a lot more • Establish yourself as an actual legal through NFP Securities, Inc., a Broker/ than you need and lock in a low premium entity such as an LLC or S-Corp Dealer, Member FINRA/SIPC and now, while in your most healthy and • Establish a separate checking account Federally Registered Investment lowest-age bracket. In the future, you in the name of the entity and also get Advisor. The Benefi t Planning Group will already have coverage; if you don’t a credit card in that entity name is not an affi liate of NFP Securities, Inc.

June/July 2010 35 PROVIDED BY PEER Q VII &A

PEER VII is ACEP’s Gold Standard BOARD in self-assessment and educational review for emergency physicians. EMRA members can purchase REVIEW PEER VII at a signifi cant discount at www.acep.org/bookstore. Abdominal & Gastrointestinal Disorders For a complete reference and answer explanation for the questions below, visit www.emra.org.

1. A 46-year-old woman presents with constant abdominal 4. A 53-year-old man with cirrhosis presents with pain with associated nausea that started 8 hours earlier. a 12-hour history of diffuse abdominal pain. She appears nontoxic and is lying still on the bed. Physical examination reveals a positive fl uid Blood pressure is normal; pulse rate is 95, respiratory wave, mild diffuse abdominal tenderness, and rate is 16, and temperature is 37.8°C (100°F). Physical a temperature of 38°C (100.4°F). Paracentesis examination is remarkable for RUQ and epigastric reveals 2,000 WBCs/microliter and 280 PMNs/ tenderness to palpation without rebound or guarding. microliter. Which of the following is the most Laboratory test results reveal elevated ALT, AST, and appropriate management? alkaline phosphatase, normal lipase and total bilirubin, A. Administer oral antibiotics, and discharge and a negative urine hCG. The next most appropriate home management step is: B. Culture ascitic fl uid, and treat if cultures are A. Acute abdominal series positive B. CT scan C. Order triple-contrast abdominal CT to look for C. General surgery consultation causes of abdominal pain D. Oral cholecystography D. Perform RUQ ultrasonography to look for E. RUQ ultrasonography cholecystitis E. Start cefotaxime 2 g IV q8h, and admit 2. Which of the following statements regarding ingested foreign bodies is correct? 5. A 54-year-old man with a history of “alcoholic A. All children with a suspected foreign body ingestion liver disease” presents with frank hematemesis, should undergo x-ray a blood pressure of 80/40, pulse rate of 110, B. Ipecac can be used safely to dislodge a button battery and respiratory rate of 26. After assessing and in the esophagus managing the airway, which of the following is C. Meat tenderizer can be used safely to dissolve an most likely to provide defi nitive treatment? impacted meat bolus A. Blood products D. Most common site of esophageal foreign body B. Emergent endoscopy with sclerotherapy entrapment in pediatric patients is the thoracic inlet C. Normal saline 1 L bolus IV E. Objects longer than 5 cm and wider than 2 cm should D. Sengstaken-Blakemore tube be removed before they pass through the stomach E. Vasopressin 3. A 40-year-old man presents with severe chest and neck pain. He is otherwise healthy but says that he “threw up 1. Answers

really bad” 6 hours earlier at a tailgate party. The neck Want More E pain is made worse by swallowing and by fl exing his 2. PEER VII questions? E

neck. What is the appropriate next management step? 3.

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A. Broad-spectrum antibiotics VII Sampler, and help ACEP test a new learning strategy called 4. B. Endoscopy spaced education. In return for your feedback on a short survey E C. Laboratory testing, to include lipase that will be sent out midway through the program, you’ll get a 5. B D. Soft-tissue neck x-ray total of 40 PEER VII questions delivered daily via e-mail. E. Treatment with H2 blockers

36 EMResident EMrefl ections EMRA’s 2nd Annual PHOTO CONTEST A call for photos: Send us your best shots! “A great photograph is one that fully expresses what one feels, in the deepest sense, about what is being photographed.” – Ansel Adams

If you’ve been inspired lately to capture images from an away 2010 CATEGORIES rotation, the changing of the seasons, or the sights of your city, Nature & Wildlife we want to see! Send entries to [email protected] by Travel & Landscapes Art Photography July 20, 2010. Indicate a title for your photo, your name, School/ Portraits Program/Hospital, and the category in which your photo belongs. Sports & Events Miscellaneous One winner and one runner-up from each category will be selected and displayed in the Submissions will be judged by our October/November issue of EM Resident. editorial staff along with award winning photojounalists: Lisa Bundy, MD, and Giuliano De Portu, MD. A few of the 2009 Winners ART PHOTOGRAPHY 1st PLACE WINNER The City from the Gate | Julio Manuel De Peña-Batista, MD st PORTRAITS 1 PLACE WINNER Kendall Regional Medical Center, Miami, FL Young Warrior | Jason Hamel, MSIV Loma Linda University School of Medicine, Loma Linda, CA

NATURE RUNNER-UP ART PHOTOGRAPHY Cheetah with Prey RUNNER-UP Natalie Anne Ayres, MD, MS Spring Refl ection Carolinas Medical Center Sarah Medeiros, MPH, MSIV Charlotte, NC David Geffen School of Medicine Los Angeles, CA

June/July 2010 37 EMrefl ections Letter to the Editor Dear EMRA Leadership, I received my EM Resident publication in the mail last night, and I feel that I must comment on one of the articles – “Consultant’s Corner: Orthopedics Observation.” While I found that the piece did provide some useful information and suggestions for EM physicians, there are aspects of the article which I feel do not have a place in a publication that is aimed at EM residents. Specifi cally, I take exception with Dr. Sutherland’s comments that “...if your workup is inadequate, if you don’t know something you should, or if you forget something, own up to it, apologize, and take it when the consultant reams you out.” I do not think that I am alone in teaching my residents that unprofessional EMRA 2010 behavior such as “reaming out” a colleague is never acceptable, and I fi nd it troubling that a publication which Spring Award Winners should be supporting EM residents is instead advocating for the acceptance of such behavior. It is widely accepted (and Academic Excellence Award well published in the medical literature) that environments Jason Heiner, MD in which intimidation, fear of questioning the actions of Madigan Army Medical Center colleagues within the medical environment, and a lack of Alexandra Greene Medical Student Award collaboration contribute to and often lead to medical error. Claire E. Broton Most hospitals (including the one in which I work), as well as SUNY Upstate Medical University the Joint Commission, have taken very strong stands against ‘disruptive physicians,’ and behaviors such as “reaming out” Assistant Residency Director of the Year a resident are not acceptable in any circumstance. Albert B. Fiorello, MD, FACEP I suspect that EMRA and EM Resident did not intend to University of Arizona advocate for the acceptance of unprofessional behaviors such as the one described in the article. Unfortunately, I fear that Dedication Award some residents may interpret the article in this fashion. Julie M. Sullivan, MD Christiana Care Again, I fi nd your publication to be outstanding and EMRA a fantastic resource and advocate for EM residents. In the Robert J. Doherty Teaching Fellowship Scholarship future, I hope that you might carefully consider instances in Glen E. Michael, MD which aberrant behavior by some of our medical colleagues University of Virginia is portrayed and accepted. Jean Hollister EMS Award Thank you for your time and attention. Timothy P. Chizmar, MD Sincerely, University of Maryland Jeff Schneider, MD, Residency Program Director Local Action Grant Department of Emergency Medicine Jerry Bodily Boston Medical Center University of Colorado-Denver Boston University School of Medicine Response: Thank you for your thoughtful review of our Residency Coordinator of the Year publication and for taking the time to bring this to our Sherrill Mullenix attention. Allow me to start by agreeing with you Christiana Care wholeheartedly. Our new “Consultant Corner” section was meant to educate and facilitate interactions with consultants. Residency Director of the Year We certainly do not want to promote anything that creates Douglas Mark Char, MD, FACEP animosity between services nor do we feel that it is acceptable Washington University to “reaming out” a resident. We support functional, professional and amicable interactions between consulting SAEM Travel Scholarship services and we sincerely regret that this oversight took place. Tom Becker We are now taking a look at our guidelines for guest authors University of Heidelberg, Germany and will be paying particular attention to this section. This publication has made great strides over the years thanks to Cynthia Santos the help of numerous authors (residents, attendings, fellows, Cornell University medical students). Your feedback is key and it helps us keep our publication where it needs to be. Ayan Sen, MD Thank you kindly for your comments. Henry Ford Hospital Edwin Lopez, MD President, Emergency Medicine Residents’ Association

38 EMResident EMRA elections will be held during ACEP’s Scientifi c Assembly in Las Vegas, Nevada, September 29, 2010 for the following positions:

 President-Elect: Candidates for President-Elect must make a three-  ACEP Representative: This two-year year commitment to EMRA. The fi rst year serving as President-Elect. position requires signifi cant travel and The second year in the term is as the President. The third and fi nal year is interaction with a number of leaders in spent as Immediate Past President/Treasurer. emergency medicine. In addition to the regular duties of an EMRA Board member, you will  Vice Speaker of the Representative Council: This two-year term attend all ACEP Board of Directors meetings, with the fi rst year serving as Vice Speaker and the second as Speaker, serve on the ACEP Steering Committee, assists Speaker as Parliamentarian for the Representative Council, acts and be primary liaison with EMRA as director of all Representative Council taskforces, and is the EMRA Representatives serving on ACEP Committees. Delegate to the AMA Resident and Fellows Section at the annual and interim AMA meetings.  RRC-EM Representative: The Residency Review Committee for Emergency  Legislative Advisor: Candidates for Legislative Advisor must make a Medicine (RRC/EM). The EMRA RRC/EM two-year commitment to EMRA. Position is responsible for coordinating representative serves a two-year term. This and running the Residents and First-Timers Track at ACEP Leadership position serves in three different roles: 1) and Advocacy Conference. Generating and updating the EMRA EMRA Board of Directors member, 2) RRC Emergency Medicine Advocacy Handbook. As well as helping foster representative, and 3) Liaison to ABEM. resident advocacy.

For full position descriptions please visit www.emra.org. If you are interested in running for a position, please email your CV, a statement of interest (200 words or less), letter of support from your residency director, and a photo (jpeg format) to [email protected] by August 30, 2010. EMRA will post statements and photos received from candidates on the EMRA Website. Nominations from the council fl oor will also be accepted.

Can’t miss ECGs Alphabet Soup Benjamin Lawner, DO, University of Maryland continued from page 31 Case resolution Once the diagnosis of hyperkalemia was discovered, the health care providers gave the patient 1 gram of calcium gluconate, 88 mEq of sodium bicarbonate, and 10 units of regular insulin (with dextrose) intravenously. The patient quickly converted to normal sinus rhythm with a rate of 110 and a normal blood pressure. The dopamine infusion was discontinued, and the patient remained stable. His laboratory studies were consistent with acute renal failure. He was admitted to the hospital and received urgent hemodialysis. 

June/July 2010 39 Pediatricpearls Risk management pitfalls for treating children who ingest potentially toxic substances From the March 2010 issue of Pediatric Emergency Medicine Practice. Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice and Pediatric EM Practice issues, go to www.ebmedicine.net/emra, call 1-800-249-5770, or email [email protected].

1. “But they looked so good!” recommendations regarding the 8. “All caustics are the same.” length of observation time are based Children may not demonstrate the There are numerous caustics on on the available evidence. It is better signs and symptoms commonly seen the market, and the astute health to be too conservative and avoid in adults that may warn of impending care provider should not only be adverse outcomes in young children cardiovascular decompensation. It is concerned about local tissue damage, as we await more comprehensive imperative that health care providers but also about systemic effects from studies. closely monitor the vital signs and such agents (i.e., hydrofl uoric acid). mentation of potentially poisoned 5. “They are not moving, so they are 9. “The patient’s oxygen saturations children. not seizing.” on a 100 percent non-rebreather 2. “It was an herbal product, and Certain toxins can cause non- are 98 percent, so he does not need herbals are natural and safe.” convulsive status epilepticus, such to be intubated.” as with organophosphates toxicity. If A number of herbal products can Adequate evaluation of the patient’s non-convulsive status epilepticus is be deadly to children even if small neurologic status, ventilatory suspected, an electroencephalogram quantities are ingested. “Natural” status, and gag refl ex should guide should be obtained. cannot be equated with safe. the need for intubation. Too often 6. “Charcoal must be administered to clinicians may be complacent about 3. “We monitor all overdoses for four every overdose patient.” the patients at risk for aspiration hours.” and carbon dioxide narcosis when Charcoal does not need to be Numerous toxins require monitoring a patient’s oxygen saturation is administered in every case of for longer than four hours, such as adequate. poisoning. In fact, there are the sulfonylureas and sustained- contraindications to charcoal 10. “We do not need an x-ray to release calcium channel blockers. administration such as the ingestion confi rm the position of the 4. “The literature recommendations of caustics and hydrocarbons. nasogastric tube position; just are too conservative regarding the push the charcoal.” 7. “Ipecac is a mainstay of length of observation time.” prehospital treatment.” The administration of charcoal prior Studies pertaining to pediatric to confi rmation of tube position Prehospital administration of syrup 75 toxicology are limited. Many by x-ray is a dangerous practice. of ipecac is no longer recommended Charcoal aspiration can lead to in the routine management of marked respiratory diffi culty and poisoning. signifi cant long-term sequelae.76,77 Proper placement of the nasogastric tube should be confi rmed prior to administration of charcoal. 

40 EMResident Pitfallstoavoid Risk management pitfalls for oncologic emergencies, part II From the March 2010 issue of Emergency Medicine Practice. Reprinted with permission. To access your EMRA member benefi t of free online access to all EM Practice and Pediatric EM Practice issues, go to www.ebmedicine.net/emra, call 1-800-249-5770, or email [email protected]. 1. “Although this cancer patient said he it certainly occurs with solid tumors soluble than uric acid in the blood, had a fever at home today, he doesn’t as well, especially in metastatic and facilitating its urinary excretion. Because have one here. Plus, results of his chest therapy-sensitive cancers. The high of rasburicase’s high cost, however, it radiograph are normal, his urine is 36 percent mortality rate associated should be given only after discussion clean, and his physical examination with solid tumor TLS can be partially with the oncologist. doesn’t show any infection. I’m going attributed to the lack of anticipation and 8. “The patient has hypercalcemia, most to send him home.” delayed recognition of TLS following likely due to hyperparathyroidism or Patients with neutropenic fever often chemotherapy.45 another metabolic problem. I’ll give have subtle or no signs of infection other 5. “The patient did not have a recent her some fl uids and tell her to avoid than the fever, and only about 30 percent history of chemotherapy. I didn’t think milk and other calcium-containing have an infectious cause identifi ed by the TLS could occur without it.” products, and she’ll be ready for time of hospital discharge. Neutropenic If a patient has electrolyte abnormalities discharge and outpatient follow-up in fever results in high morbidity and in the setting of an underlying the next two to three weeks.” mortality if not treated aggressively malignancy, one should consider TLS Hypercalcemia occurs in a quarter of and early. Additionally, neutropenic in the differential diagnosis. Patients cancer patients, and half die within a individuals who are afebrile in the ED with a large tumor burden can present month after diagnosis of this metabolic but report fevers at home need to be with TLS even in the absence of complication. More than a third of all evaluated and treated just as aggressively antitumor treatment (e.g., chemotherapy, hypercalcemic patients presenting to the as those who have a fever in the ED. radiotherapy, surgery, endocrine therapy, ED have a malignancy. In patients with 2. “I read EM Practice, so I knew that corticosteroids). mild hypercalcemia, it is important to this leukemic patient who recently stress the need for close follow-up to 6. “This patient with TLS has a received chemotherapy needed ensure adequate screening for potential creatinine value of 2.4 mg/dL, so I am antibiotics promptly. It looked like she cancer. going to gently hydrate him to avoid had a urinary tract infection, so I gave volume overload.” 9. “This patient doesn’t have her sulfamethoxazole-trimethoprim Most patients with TLS are hypercalcemia. Her calcium level is right away!” intravascularly depleted and will require only 9.5 mg/dL.” Prompt and appropriate antibiotic aggressive volume resuscitation to Although the total calcium level administration is fundamental in the prevent signifi cant kidney injury and may appear normal in the laboratory treatment of patients with neutropenic severe electrolyte abnormalities. An results, a serum albumin level or an fever. Except in very rare instances, abnormal serum creatinine value in a ionized calcium level is needed to more broad IV antimicrobial coverage patient with previously normal renal accurately assess the true degree of (e.g., cefepime, imipenem, piperacillin/ function is a red fl ag that kidney injury hypercalcemia. Remember that for tazobactam) is necessary. is imminent if fl uid resuscitation is every 1 g/dL decrease in albumin, the 3. “I’m not worried about neutropenic not aggressive. Aggressive IV fl uid corrected calcium level should increase fever because the patient’s ANC is administration is the cornerstone of by 0.8 mg/dL. 800 cells/μL, which doesn’t meet the treatment for TLS, so large volumes 10. “She has breast cancer, and now she’s criterion of less than 500 cells/ μL for a of fl uid must be given to induce forced here with hypercalcemia. To lower diagnosis.” diuresis unless the patient is clinically her calcium level, she needs some Although an ANC of < 500 cells/ fl uid overloaded or has congestive furosemide ASAP.” μL is what most physicians recognize heart failure. Loop diuretics exacerbate hypokalemia, as neutropenia, another defi ning 7. “Intravenous fl uid is really the only which is present in approximately characteristic is an ANC of < 1000 cells/ signifi cant treatment for TLS.” half of patients with hypercalcemia of μL with a predicted nadir of < 500 cells/ Although IV fl uids are very important, malignancy. Additionally, most patients μL over the ensuing 48 hours. rasburicase is a very effective and with hypercalcemia of malignancy are 4. “I thought TLS only occurred in increasingly common adjunctive signifi cantly volume depleted. Unless patients with leukemia.” medication for TLS. It works by volume overload is already a concern, Although TLS is much more common converting uric acid to allantoin, a furosemide should be held until the with lymphoproliferative malignancies, substance that is fi ve to ten times more patient is euvolemic.  June/July 2010 41 The 5th Annual

Emergency Medicine AAnnalsnnals ofof Qualifying Exam EmergencyE Medicine Review Course

Resident Editorial Board PREPARING FOR THE WRITTEN BOARDS Fellowship Appointment In New York City October 13-15, 2010 A 3-day

The Resident Fellow appointment to the Editorial Crowne Plaza, LaGuardia Airport intensive study in Emergency Board of Annals of Emergency Medicine is designed 104-04 Ditmars Boulevard East Elmhurst, NY 11369 Medicine to introduce the Fellow to the peer review, editing, and publishing of medical research manuscripts. Its Convenient to LaGuardia and Kennedy Airports, this purpose is not only to give the Fellow experience that comprehensive review for Emergency Medicine physicians will enhance his/her career in academic emergency preparing for the qualifying exam in Emergency Medicine medicine and in scientifi c publication, but to develop will provide a maximum of 31 hours of instruction over a skills that could lead to later participation as a peer 3-day period. Physicians interested in board recertification reviewer or editor at a scientifi c journal. It also provides or continuous certification will find this course particularly a strong resident voice at Annals to refl ect the concerns helpful. Topics will be presented in lecture format, encom- of the next generation of emergency physicians. passing the core curriculum distributed by the American Board of Emergency Medicine (ABEM). Please visit Annals’ Website at www.annemergmed.com For course information, please contact: for a copy of the complete application. Rick Hostnik, Assistant Director Due date is July 7, 2010. Office of Continuing Medical Education Questions should be directed to Nancy Medina, CAE, North Shore-LIJ Health System Editorial Director, Annals of Emergency Medicine, at [email protected] 516.465.3263 (3CME) 800-803-1403, ext. 3221, or by e-mail to [email protected]. www.newyorkemboardreview.com

Register today for Ohio ACEP’s

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42 EMResident

4to8weeksinGhana (allexpensescovered)ȱ The sidHARTe program will cover all costs related to the rotation, including international travel. Details to follow upon acceptance.

PROGRAM PURPOSE sidHARTe PROGRAM INFORMATION To provide clinical training, process improvement, The sidHARTe Program consists of the following hands-on bedside teaching, and supervision of components: clinical service delivery, using United States 1. Supervising clinical service delivery at trained emergency physicians at district level either Kintampo District Hospital or hospitals in Ghana. Mampong District Hospital 2. Training of health staff which includes: PROGRAM OBJECTIVES physicians, medical officers, midlevel With the support of GE Foundation and in providers, nurses and midwives collaboration with the Ghana Health Service, we 3. Health systems process improvement have developed a pilot project to provide technical with the Ghana Health knowledge transfer at Kintampo and Mampong Service and other programs District Hospitals for 3 years, using United States 4. Monitoring & Evaluation trained emergency physicians. (external evaluation)

ELIGIBILTY PROCESS Emergency Medicine Resident Physicians must be in their third or Please email CV immediately with possible travel dates. You will fourth year of training at an accredited US program in Emergency receive application materials on receipt of email. Medicine by July 2010. Physicians are later asked to submit two letters of recommendation Emergency Medicine Attending Physicians who are board prepared addressed to Rachel Moresky, MD, MPH, FACEP. or board certified in EM are also welcome to apply.

Please send all information to our Senior Program Officer, Beth Rubenstein, MPH, MBA via email at: [email protected].

R EACH YOUR POTENTIAL Columbia University Medical Center / New York-Presbyterian Hospital International Emergency Medicine Fellowship

2 Year IEM Fellowship with MPH Application Deadline: November 1st Send completed applications to: Rachel T. Moresky, MD, MPH, FACEP Email: [email protected] More information visit: http://www.nypemergency.org/fellowships/int_eme.html?name1=International+Emergency+Medicine+Fellowship&type1=2Active

June/July 2010 43 Publications available online at www.emra.org/emra_bookstore.aspx

Sepsis Card

2009 Edition: Chris Coletti, MD and John Powell, MD 2006 Edition: Dave Farcy, MD Severe sepsis affects more than 750,000 patients and claims more than 210,000 lives each year in the U.S. It is the second leading cause of death in non-cardiac ICU patients and the 10th overall cause of death. The rate of severe sepsis is expected to rise to 1 million cases a year by 2010 as the population ages. Early therapy influences outcome. Utilizing the Surviving CAREER Sepsis Campaign Guidelines improves morbidity and can decrease mortality by 25%. Angus DC, et al. CCM 2001(29)7 Hotchkiss RS, et al. NEJM 2003, (348)2 SSC: survingsepsis.org Martin GS, et al. NEJM 2003 (348)16 Dellinger RP, et al. CCM 2008 (36)2 PLANNING Infection Defined as a pathologic process caused by the invasion of normally sterile tissue, fluid or body GUIDE cavity by pathogenic microoganisms. FOR EMERGENCY MEDICINE Sepsis Defined as a suspected or documented infection and 2 or more of the following variables: s 4EMPERATUREª#ª& ORª#ª& s (EART2ATEBPM s 2ESPIRATORY2ATEBREATHSMIN s !CUTELYALTEREDMENTALSTATUS s (YPERGLYCEMIAGLUCOSEMGD,ORMMOL, INTHEABSENCEOFDIABETES s 7"# MM3 MM3 ORIMMATUREBAND FORMS Severe Sepsis Defined as acute organ dysfunction, hypoperfusion or hypotension before fluid challenge. Organ system dysfunction must be remote to the site of infection with the exception of pulmonary criteria. GUS M. GARMEL, MD 2ND EDITION Cardiovascular s (YPOTENSION3"0MM(G -!0MM(GORAN3"0DECREASEMM(G Pulmonary s "ILATERALPULMONARYINlLTRATESWITHANEWORINCREASED OXYGENREQUIREMENTTO MAINTAIN3P/ s !CUTELUNGINJURY 0A/&I/INABSENCEOF0.!ASSOURCE 0A/&I/WITH0.!ASSOURCE Renal Contract Issues s !CUTEOLIGURIA5/MLKGHRFORHRSDESPITEADEQUATEmUIDRESUSCITATION 2009 EEMRAMRA s #REATININEINCREASEMGD,FROMBASELINE for emergency physicians Hemotologic 2nd Edition s #OAGULATIONDYSFUNCTION).2OR044SECSABSENTANTICOAGULANTUSAGE s 4HROMBOCYTOPENIAPLATELETCOUNT MM3) Joseph P. Wood, MD, JD Hepatic/GI NTIBIOTIC UIDE s (YPERBILIRUBINEMIATOTALBILIRUBINMGD, A G Editor in Chief Systemic s (YPERLACTEMIAMMOL,MGD,

Sepsis-Induced Tissue Hypoperfusion BrianBiaJ JJ.. LevinLevine, LLevineevinee iMDeMDe, MD $ElNEDAS SEPSIS INDUCEDPERSISTENTHYPOTENSION3"0MM(G A-!0 Editor-in-ChiefEditor-in-Chief EmergencyEmergency MedMedicineicine ResResidents’idents’ AssocAssociationiatio ORORA3"0DECREASEMM(GFROMBASELINE OR LACTATEA 3"0 DECREASE  MM(G FROM BASELINE OR  LACTATE MGD, OR OLIGURA EMRA 33EPTIC3HOCKIS3EPSIS )NDUCED4ISSUE(YPOPERFUSIONNOTRESPONDEPTIC 3HOCK IS 3EPSIS )NDUCED 4ISSUE (YPOPERFUSION NOT RESPONDINGTOTOMLKG Christiana CareCare Health SSystemystem ccrystalloidrystalloid bbolusolus

$ERIVEDFROMTHE,EVY-- ETAL$ERIVED FROM THE ,EVY -- ET AL CMM 2003 (3)4 OsbornOsborn TM,TM, et al. AEMM 2005 (46)3 Dillenger RP, et al. CCM 2008 36(3) EMERGENCY Emergency Medicine’s MEDICINE Top Th e MMedicaledical SStudenttudent Pediatric SSurvivalurvival GuideGuide Clinical Problems

A ComprehensiveComprehensive GuideGuide ttoo Th e SSpecialtypecialty Dale Woolridge, MD, PhD

Edited by Kristin E. Harkin, MD, FACEP and Jeremy T. Cushman, MD, MS A Rapid Pocket Reference and Teaching Tool EMRA Publications Emergency Medicine Advocacy Handbook Contract Issues for Emergency Physicians, Emergency Medicine’s Top Pediatric Nathaniel R. Schlicher, MD, JD 2nd Edition Clinical Problems, 1st Edition In this clear, well-thought-out handbook, Dr. Schlicher and the chapter Joseph P. Wood, MD, JD Dale Woolridge, MD, PhD authors outline the essential advocacy issues surrounding emergency Invaluable for any emergency physician entering into an employment or The pediatric version of top clinical problems features the same design medicine today. Not just for the politically-minded, this resource is independent contract agreement to provide medical services on behalf and format as its cousin. Is a must have pocket reference and teaching useful for the student, resident, physician, healthcare worker, patient or of a hospital or group. What you don’t know can really hurt you! tool for all EM physicians, especially during pediatric rotations. concerned citizen to help understand the important issues affecting all Reviewed by Ann Emerg Med 2009; 53; 165 900230 / List Price $25.95 aspects of emergency care. 900110 / List Price $49.95 ACEP Member Price $23.35 • EMRA Member Price $15.95 900290 / List Price $25.95 $ $ Published 2008; 336 pages; Soft Cover 4 x 6 $ $ ACEP Member Price 44.95 • EMRA Member Price 29.95 ACEP Member Price 23.35 • EMRA Member Price 15.95 Published 2007; 92 pages; Soft Cover 5.5 x 8.5 Published 2009; 96 pages; Soft Cover 5.5 x 8.5 Emergency Medicine Bulk pricing available; order online at www.emra.org Emergency Medicine: The Medical Student Chief Resident Survival Guide Survival Guide, 2nd Edition Christian Arbelaez, MD, MPH; Kavita Babu, MD 2009 EMRA Antibiotic Guide, 13th Edition Kristin E. Harkin, MD; Jeremy T. Cushman, MD, MS Joy Martin, MD; Matthew Miles, MD Brian J. Levine, MD The most comprehensive guide to the specialty of emergency medicine Written specifically for EM chiefs by EM chiefs, this straightforward, A quick reference guide to antibiotic use in the emergency department. written specifically for medical students. Familiarize yourself with all practical guide is designed to help aspiring and current chief residents Organized alphabetically by organ system, followed by sections on aspects of emergency medicine including lifestyle and wellness, careers, succeed as young physician leaders. Details the role of Chief Resident as “Special Topics” to make reference quick and easy for a particular training, research, fellowships, subspecialties and much more. Leader, Clinician, Educator, and Administrator. disease process. Color coded. Reviewed by Ann Emerg Med 2009; 53; 165 Reviewed by Ann Emerg Med 2007; 49; 830 900030 / List Price $25.95 900120 / List Price $25.95 900190 / List Price $34.95 $ $ ACEP Member Price $23.35 • EMRA Member Price $15.95 ACEP Member Price $23.35 • EMRA Member Price $15.95 ACEP Member Price 31.45 • EMRA Member Price 19.95 Published 2008; 96 pages; Soft Cover 4 x 6 Published 2007; 280 pages; Soft Cover 5 x 9 Published 2006; 96 pages; Soft Cover 5 x 9 Career Planning Guide for Emergency Medicine, Emergency Medicine’s Top ABX Guide 2009 for Pocket PC and Palm OS 2nd Edition Clinical Problems, 2nd Edition Robert Blankenship, MD; Brian Levine, MD Gus Garmel, MD Gary Katz, MD, MBA; Mark Moseley, MD, MHA A necessity for any physician, resident, medical student, or other health A new and improved pocket reference and quiz tool. Each chapter care professional who rotates in the ED. Select antibiotics based on organ Get help organizing and understanding the many complex issues system and diagnosis. Virtually every type of infectious disease is covered starts with critical actions and then logically expands with disease- concerning emergency medicine careers. Topics include career for outpatient management and for patients needing admission. With possibilities, CV’s, interview tips, contract negotiations, benefits & more. specific information. The design simulates the format of an everything you love about the printed guide included, plus the ability to Reviewed by Ann Emerg Med 2009; 53; 292 emergency medicine oral or written board exam. search, it’s fast, easy to use, and accurate! 900080 / List Price $29.95 900100 / List Price $25.95 Palm OS-900210 • List Price $25.95 ACEP Member Price $26.95 • EMRA Member Price $19.95 ACEP Member Price $23.35 • EMRA Member Price $15.95 Pocket PC 900200 • List Price $25.95 Published 2007; 104 pages; Soft Cover 5.5 x 8.5 Published 2008; 218 pages; Soft Cover 4 x 6 ACEP Member Price $23.35 • EMRA Member Price $15.95 Pocket Reference Cards Pediatric Qwic Card EMRA Sepsis Card EMRA Airway Card Dale P. Woolridge, MD, PhD 2009 Edition: Chris Coletti, MD and John Powell, MD; 2006 Edition: Dave Farcy, MD A handy pocket reference for intubation of neonates to This comprehensive quick reference card has pertinent information Everything you need to know about improving outcomes for septic patients in adults. Includes helpful information on drips, tube placement from proper dosages, vital stats by age, pearls, to RSI. The perfect the emergency department available in this newly revised pocket reference and Glasgow Coma Scale. A must-have in the emergency accompaniment to the new pediatric family of publications from EMRA. guide. This comprehensive review of sepsis treatment recommendations was department for patients of all ages! developed by the EMRA Critical Care Committee. 900240 / List Price $12.00 EDED partners with national 900180hotel / Listchain Price $12.00 900220 / List Price $12.00 $ $ ACEP Member Price $10.80 • EMRA Member Price $7.00 to boost patient satisfaction.ACEP Member Price 10.80 • EMRA Member Price 7.00 ACEP Member Price $10.80 • EMRA Member Price $7.00 Published 2008; Folded; Laminated 4 x 7 Published 2005; Laminated Card 3 x 5.5 Published 2009; Laminated Card 4 x 7 Folded/8 x 7 flat EMERGENCY MEDICINE RESIDENTS’ ASSOCIATION Get a career consult... Faster than you can get an on-call specialist!

It’s your emergency medicine career and you need answers STAT! EM Career Central has been redesigned to connect you with more jobs in less time.

Visit EMCareerCentral.org now to:

• Find The Right Jobs: Look for hundreds of emergency medicine • Sign Up For eNewsletters: Employment best practices and job tips are positions by location, keyword and company name. as close as your inbox. • Get Job Alerts: Register for e-mail about jobs that match your skills • Find Career Advice: Access the latest tips to help you land the and interests. right position. • Connect At Events: Use our improved Conference Connection™ • Tie It All Together: Upload your existing CV or build a new one, and feature to see who’s attending ACEP’s Scientific Assembly and easily keep track of job applications. EMRA’s Job Fair.

And if you’re hiring, there’s something for you too. The newly redesigned EM Career Central is attracting lots of attention from qualified applicants. Take advantage of the additional traffic and put more jobs in front of the right candidates.

Are you ready for a career consult? See what’s new – at EMCareerCentral.org today! 46 EMResident Classifiedadvertising

Multiple States, Alabama, Louisiana & Greenville) or coastal regions (Wilmington, Arkansas Delta near the Mississippi River. Pennsylvania: Full Time Directorships and Myrtle Beach). Make the right move for All within approximately one hour’s drive FT/PT Physician opportunities. Hospital your family and your career! What’s of Memphis; Helena, Forrest City and Physician Partners seeks qualifi ed candidates important to YOU is what matters to US… Newport offer the comforts of small town for immediate opportunities. ED volumes excellent compensation, sign-on & tuition living with big city amenities nearby. The ranging from 8K to 40K. Candidates bonuses, paid malpractice w/ tail, fl exible outdoors enthusiast will enjoy the scenic should be residency trained BC/BP in EM scheduling and great team support. Contact natural beauty and mild climate of northeast with ACLS, ATLS and PALS with recent ED Edie McDuffi e, MBA: (800) 291-4020 ext. Arkansas, perfect for year round activities. experience. What’s important to YOU is what 4268; emcduffi [email protected] or visit What’s important to YOU is what matters to matters to US…excellent compensation, www.hppartners.com/emra.  US… attractive compensation packages, sign-on and tuition bonuses, paid paid malpractice with tail, fl exible malpractice with tail, fl exible scheduling and Arizona, Fort Mohave: Located in the scheduling and great team support. Contact excellent team support. Contact Jimmique Colorado River Basin near the state lines of Deanna Maloney: Toll Free at 866-maloney Jones-Guthrie: (800) 815-8377 ext. 2262; California and Nevada. Valley View Medical (866-625-6639); fax your CV to (972) 562- [email protected] or visit Center sees 20,000 patients in the ED. This 7991; email [email protected] or www.hppartners.com/emra.  60-bed facility has all major specialty back- visit www.hppartners.com/emra.  up. EMS with helipad and 24 hr. lab and Multiple States, North Carolina & radiology. Situated in a growing community, California, Carmichael: Sacramento South Carolina: You have the training Valley View is proximate to Lake Havasu and is one of California’s most livable cities, and skills; we have the locations! The Laughlin, Nevada. Contact Bernhard Beltran and Mercy San Juan Medical Center Carolina’s offer one of the most desirable at 800-359-9117 or [email protected].  affords easy access to all that the area lifestyles in the country. Full Time/Part offers including a wide variety of housing, Time Physician opportunities available in Arkansas, Multiple Cities: Hospital excellent schools, plus recreation in Lake 12 & 24 hour shifts. ED Volumes ranging Physician Partners welcomes you to explore Tahoe, Napa Valley and more. Modern from 20K to 50K. Enjoy working in the fantastic opportunities available in facility is a Level II Trauma Center and metropolitan areas (Chapel Hill, Raleigh, beautiful northeast Arkansas! Rich in host to full specialty back up and support Greensboro, Winston-Salem); mountain history and heritage, the cities of Helena, services, providing for excellent care to regions (Asheville, Boone, Black Mountain, Forrest City and Newport lie within the 66,000 emergency patients per year. Enjoy

June/July 2010 47 Building Long-Term Partnerships in Emergency Medicine Classifiedadvertising

a dynamic EM practice with broad pathology, family practice resident rotations and active EMS. Contact Bernhard Beltran at 800-359-9117 or [email protected]. 

California, Sacramento: Methodist Hospital of Sacramento is a respected community hospital that treats 49,000 emergency patients per year. Soon to be granted Level II Trauma Center designation, the hospital is host to a Family Practice Residency Program affi liated with USC, and residents rotate through the ED. Active in EMS, the facility is also a training site for EMT students. High quality lab and x-ray, with diagnostics including NMR, CT and nuclear medicine. Location provides for easy access to many desirable residential areas and all that the city has to offer. Contact Bernhard Beltran at 800-359-9117 or [email protected]. 

California, Sacramento: Mercy General Hospital is a 300-bed, urban community hospital that is one of the busiest, most highly- OPPORTUNITIES AS BIG AS TEXAS! regarded tertiary cardiovascular referral centers for Northern CA and the west coast. 36,000 emergency patients are treated annually, ESP is a democratic physician-owned group with over and are supported by a full specialty medical staff of over 900. 23 hospital partners across Central and East Texas. State-of-the-art imaging includes 64-bit spiral CTs/MRI/color With compensation models to maximize income, Doppler plus bedside ultrasound in the ED. The location provides fair scheduling, paid malpractice, mentoring/leadership for easy commutes from the area’s most desirable communities and Emergency programs and Partnership opportunity, we truly recreation options. Contact Bernhard Beltran at 800-359-9117 or have our physicians’ best interests at heart! Service [email protected].  Partners For further information on joining this dynamic team contact us at 888-800-8237. California, San Andreas: Mark Twain Hospital serves Calaveras and Alpine counties in the Sierra foothills between Yosemite and www.eddocs.com Lake Tahoe. Made famous by Mark Twain, Calaveras County is

Looking for a rewarding career Pennsylvania’s Leader in Emergency Medicine

opportunity in emergency medicine? ERMI is Pennsylvania’s largest emergency medicine physician group and is part of the prestigious University of Pittsburgh Medical Center, You just found it. one of the nation’s leading integrated health care systems. ERMI is a physician-led company that offers unmatched stability, and a host of other advantages:

• Multiple sites in western Pennsylvania/Pittsburgh area • Suburban, urban, and rural settings • Coverage averages less than two patients per hour • Excellent compensation and benefits • Employer-paid occurrence malpractice with tail • Employer-funded retirement plan • CME allowance • Equitable scheduling • Abundant opportunities for professional growth

For more information about joining Pennsylvania’s emergency medicine leader, contact Robert Maha, MD, at 888-647-9077, or send an e-mail to [email protected]. Quantum One Building ERMI 2 Hot Metal Street Pittsburgh, PA 15203 Telephone: 888-647-9077 apartofUPMC Fax: 412-432-7490 EOEEOE

48 EMResident Classifiedadvertising 133 miles east of San Francisco in the Gold Country. The annual volume of 10,000 has a high acuity level and admission rate. This is a modern hospital with an excellent nursing staff and specialty back-up. The hospital recently received a JCAHO rating in the top 3% of all hospitals in the country. 12- or 24-hour shifts and a manageable workload provide for a high quality of life and plenty of free time. Contact Bernhard Beltran at 800-359-9117 or [email protected]. 

California, Southern: EMERGENCY MEDICINE. Outstanding opportunity for Emergency Medicine in Southern California. Partnership opportunity in growing area and dynamic medical community. Emergency Physicians Medical Group is seeking Physicians to join our group at Community Hospital of San Bernardino. The current ED sees approximately 44,000 pts./yr. “With Hospital Physician Partners, Emergency Physicians’ Medical Group (EPMG) has been providing you’re not treated as part of a machine. outstanding partnership opportunities since 1973. EPMG offers a Physicians are respected as individuals premium hourly rate plus, democratic governance, open books, and with unique wants and needs.” excellent compensation/bonus plus shareholder status after one year. Compensation package includes comprehensive benefi ts with funded Jack Field, DO pension (up to $28,175 yr.), CME account ($5,000/yr.), family medical/ – Partnering Medical Director dental/prescription/vision coverage, short and long term disability, life insurance, malpractice and more. Contact Bernhard Beltran directly at 800-359-9117 or 800.828.0898, email [email protected] EPMG 4535 Dressler Rd. NW, Canton, OH 44718. 

Connecticut, New London: Lawrence & Memorial is on the coast near Mystic and sees 40,000 pts./yr. and an affi liated freestanding ED seeing another 30,000 +/yr. Level II Trauma Center has supportive medical staff/back up. EMP is an exclusively physician owned/managed group UÊ-ˆ}˜‡"˜Ê œ˜ÕÃià UÊ/Ո̈œ˜Ê,iˆ“LÕÀÃi“i˜Ì Uʏi݈LiÊ-V i`Տˆ˜} UÊ*>ˆ`Ê >«À>V̈ViÊÜˆÌ Ê/>ˆ UÊÀiiÊ"À>Ê,iۈiÜÊ œÕÀÃi UÊÀiiÊ Ã Emergency Medicine Opportunities Our private practice group currently manages WISCONSIN: and staffs 21 emergency departments in Milwaukee Area Wisconsin and Illinois. Our respected, well- Sheboygan established emergency medicine group offers Kenosha Appleton/Oshkosh qualified, ABEM/AOBEM certified and EM Beaver Dam residency trained physicians the opportunity to >̈œ˜Üˆ`iÊœLÊ-i>ÀV Green Bay join us in a variety of practice settings. WWW.HPPARTNERS.COM/EMRA Marinette Eau Claire Infinity HealthCare offers an outstanding Chippewa Falls compensation and benefit package including Wisconsin Rapids retirement plan and a distributed ownership Door County structure that provides for each physician employee to have shared equity. There are unlimited opportunities to engage in ILLINOIS: Rockford administrative / leadership roles in the hospital Libertyville setting and within Infinity HealthCare. Evanston For detailed information please contact: Mary Schwei or Johanna Bartlett, Email: [email protected] Toll free: 888-442-3883 Fax: 414-290-6781 111 E. Wisconsin Ave, Suite 2100 Milwaukee, 800-815-8377 WI 53202 [email protected] www.infinityhealthcare.com

June/July 2010 49

Classifiedadvertising

with open books, equal voting, equal profi t St. Louis. Eight Universities and Colleges are sharing, equity ownership, funded pension, within one hour. Hospital Physician Partners

full benefi ts and more. Contact Steve Rudis, seeks qualifi ed candidates for immediate The Emory/Centers for Disease Control MD ([email protected]), Emergency opportunities. Full Time and Part Time EM and Prevention (CDC)

Medical Toxicology Fellowship Program Medicine Physicians, 4535 Dressler Rd, NW, Physicians for 27K volume ED with 10 ED Canton, OH 44718. 800-828-0898 or fax beds. Outstanding physician and mid-level Panama, Kenya, Bangladesh, Ethiopia, Mexico, 330-493-8677.  coverage. Must be BC/BP in Emergency Nicaragua and the Ukraine….. Medicine. ACLS/ATLS and PALS required. These are just a few of the places where our Georgia, Multiple Cities: Adel, Blairsville, What’s important to YOU is what matters Medical Toxicology Fellows have traveled while investigating outbreaks of chemical-associated Blue Ridge, Cochran, Dahlonega, Eastman, to US…attractive compensation packages, illness, mass poisonings, and environmental health Ellijay, Fort Valley, Hartwell, Hawkinsville, sign-on & tuition bonuses, paid malpractice threats. These outbreaks and investigations have Hiawassee, Monticello, Madison, Reidsville, w/ tail, fl exible scheduling and great team included: Royston and Sylvania. Seeking Full-Time support. Contact Molly Smith: (800) 877-5520 x Suspected cholinesterase inhibitor poisoning Directorships and Full-Time and Part- ext. 6301; [email protected] or visit among children Time Emergency Medicine Physicians. www.hppartners.com/emra.  x A mystery illness characterized by severe ED volumes range from 5,000 to 16,000. hepatic dysfunction Qualifi ed candidates should be residency Maryland, Leonardtown: MEP, a privately x Mass poisoning from diethylene glycol trained Board Certifi ed/Board Prepared owned Emergency Medicine physicians contaminated cough syrup in Emergency Medicine with recent ED group, is seeking ambitious, experienced x Potential occupational exposures to manganese experience. Current ACLS, ATLS and BC/BP Emergency Medicine Residency- x Aflatoxicosis from contaminated maize PALS certifi cation required. What’s Trained Physicians to join the MEP team at x And others…. important to YOU is what matters to US… St. Mary’s Hospital (SMH) in Leonardtown,

This two-year program offers you affiliations with rewarding compensation packages, sign-on MD. MEP offers an exceptional productivity the Emory University School of Medicine, CDC, the bonuses, paid malpractice with tail, fl exible based compensation plan, a $40,000 sign-on Agency for Toxic Substances and Disease Registry scheduling and excellent team support. If bonus and a comprehensive benefi ts package (ATSDR), and the Georgia Poison Center. The Georgia is on your mind and you’re ready including malpractice with tail coverage. Total Georgia Poison Center is among the 5 busiest poison centers in the United States and receives to discover the true hospitality of the South, compensation package of over $310,000. more than 90,000 calls per year. As an Emory/CDC while partnering with the best, come see what SMH is a full-service hospital with a newly Medical Toxicology Fellow you will: awaits you. Contact Lori Sullivan: (800) 815- designed and renovated 27-bed ED, with a 8377 ext. 2410; [email protected] or patient volume of 45,000, a 6-bed Fast Track, x Participate in the toxicological evaluation, visit www.hppartners.com/emra.  and a collegial feel. Leonardtown offers a management and bedside care of patients at five Atlanta-area metropolitan hospitals relaxed waterfront lifestyle only 50 miles x Provide expert toxicological guidance and Illinois, Chicago area and Kankakee: from the sophistication of Washington, DC. consultation for the Georgia Poison Center EMP manages EDs at 4 community teaching Qualifi ed candidates should contact Amy- x See a wide variety of environmental and hospitals seeing 30,000 – 50,000+ pts./yr. with Catherine McEwan at 301-944-0049, or e-mail occupational cases of illness through the Level I and Level II trauma center designation CV to [email protected].  Grady Toxicology Clinic and EM residency teaching options. We are x Learn from a diverse faculty that includes more an exclusively physician owned/managed Maryland, Eastern Shore: Maryland than 10 board-certified medical toxicologists group with open books, equal voting, equal Emergency Medicine Network (MEMN) x Work and train with international Medical profi t sharing, equity ownership, funded is a well-established group that currently has Toxicology Fellows and Pharmacy Clinical pension, full benefi ts and more. Contact Steve opportunities for talented BC/BP emergency Toxicology Fellows as well as mentor/teach Rudis, MD ([email protected]), Emergency physicians seeking staff positions within medical students and rotating residents Medicine Physicians, 4535 Dressler Rd, NW, Maryland. Opportunities are available in our x Have protected time to moonlight and maintain Canton, OH 44718. 800-828-0898 or fax two Eastern Shore communities that enjoy your primary clinical skills within and/or outside of the Emory system 330-493-8677.  excellent public and private schools, family- x Participate in international and domestic centered activities, shopping, and gourmet chemical-associated outbreak and public Illinois, Kankakee: EM position restaurants. Choose this beautiful setting for health investigations available at Riverside Medical Center. its close proximity to the Chesapeake Bay x Receive formal training in epidemiology, The 40,000 annual visit ED is located and the Maryland/Delaware beach resorts. statistics, scientific writing, medical management 60 miles south of Chicago and has 36 Enjoy boating and water sports all not far of both biological and chemical casualties, public hours of physician coverage per day/11 from the excitement of metropolitan life in health risk assessment, laboratory science, and hours mid-level FastTrack coverage. Baltimore and Washington, DC. Employee more Candidates must be BC/BP EM. EPMG status with excellent compensation package For more information please contact: offers paid family medical benefits, paid including shift differential and incentive Brent Morgan, M.D. malpractice, incentive bonus system, plan. Malpractice insurance provided. Please Director, Emory/CDC Medical Toxicology Fellowship flexible scheduling, and much more. forward CV and letter of interest to Susan Georgia Poison Center Contact Andy Roy at 800-466-3764, x329 Kamen at [email protected] or via fax 50 Hurt Plaza SE, Suite 600 or [email protected].  410-328-8028. Phone 410-328-1859 for Atlanta, GA 30303 additional information.  (404) 616-6651 Illinois, Mt. Vernon: Excellent opportunity [email protected] www.emory.edu/em/fellowships_toxicology.html awaits you in Southern Illinois. Mt. Vernon is Michigan, Battle Creek: BC Emergency a small city rich in history and close to Medicine physician sought for democratic

50 EMResident Classifiedadvertising XCELLENCE group in 50,000 volume ED. Excellent package offers shareholder status at one year with no buy-in! Benefi ts include pension, family medical plan, CME, incentive income, malpractice, more. Stable group with outstand-ing physician retention record. Contact Kim Seeking Full-Time Emergency Physician Rooney, Premier Health Care Services, (800) 726-3627, ext. 3674, Saint Peter’s Hospital [email protected], fax (937) 312-3675.  Albany, NY Emergency Medical Associates (EMA) is a democratic, physician-owned and governed group of practicing emergency physicians. We offer early, full, and equal partnership, Michigan, Brighton: Brand new free-standing ED to open Summer which attracts the finest career emergency physicians. Our physician satisfaction and 2010! Seeking staff physicians and Associate Medical Director. BC/BP retention rates are among the highest in the industry. 442-bed community teaching hospital EM and residency trained for clinical and director with administrative Annual emergency department volume 51,000 patients services. Brighton is rated one of the best school districts in the state of 60 hours of physician coverage and 40 hours of midlevel Michigan by the US Department of Education. 20 minutes north of Ann practitioner coverage per day Arbor. 25,000 annual visits and 42 hours of provider coverage daily. Solucient ranked St. Peter's Hospital a top-100 cardiovascular hospital for nine years (the only hospital in New York State and only one of five nationally Employee status with excellent benefi ts. Please contact Nancy Ely at to earn the award for nine or more years) 800-466-3764, x337 or [email protected].  HealthGrades ranked the cardiac program at St. Peter's Hospital a 5-star program and listed it as the #1 hospital in New York State for heart surgery 3 consecutive years Michigan, St. Joseph: EM positions available at 43,000 visit St. Peter’s has been designated a Magnet hospital for consistent excellence in nursing services ED in St. Joseph, MI and 20,000 visit ED in Niles, MI – both near The Albany area offers excellent public and private schools and year-round outdoor recre- beautiful Lake Michigan. Mid-level coverage provided daily. BC/ ational activities. Albany is home to a wealth of cultural offerings and activities, including several renowned museums, theaters, fine dining and sporting events. It is also centrally BP EM. DO emergency medicine residency starting 2011. ED located and within easy driving distances to New York City, Boston, and Montreal. Albany is renovation completed Feb 2010. EPMG offers paid family medical also a very short drive from the Adirondacks, the Berkshires, the Catskill Mountains and the renowned Saratoga Springs. It offers all the amenities of a larger city in a beautiful scenic benefi ts, incentive bonuses, fl exible scheduling, paid malpractice, and affordable setting combining the best of both city and country living. 401(k), and more. Please contact Andy Roy at 800-466-3764, x329 The Sign of Excellence in Emergency Medicine® or [email protected]. 

Michigan, Tawas: EPMG is seeking BC/BP EM physicians for a 15,000 annual visit ED located in Tawas City, Michigan. 12- hour shifts. Tawas City is located on the beautiful shores of Lake 877.692.4665 x1134 Fax 888.467.4692 Huron. EPMG offers paid family medical benefi ts, Rx, vision, [email protected] www.EMA-ED.com

EMERGENCY MEDICINE POSITIONS Caritas Christi Health Care, New England’s second largest health care system, is seeking Emergency Medicine Physicians to join Caritas Emergency Medicine, a network Allen Hospital’s state-of-the-art ER is of more than 70 Emergency Medicine physicians, in its six hospitals located in Boston, Brockton, Dorchester, Fall scheduled to open in 2009, housing an all- River, Methuen and Norwood, Massachusetts. new Emergency Department and we want you to be part of the excitement. 250 Bed Regional Center This dedicated group is physician-governed offering an above market compensation package including a with a wide range of specialities: comprehensive benefits package, with both 403b and 457 tax deferred retirement plans. Allen offers: Currently, two hospitals have resident rotations, and a third • Exceptional earning potential hospital is to become a satellite facility of an Emergency • A highly trained and caring nursing staff Medicine Program in 2009. Applications are now being • A support staff that’s second-to-none accepted for full, part time, and per diem staff positions. • A vision for the future of healthcare 0U[LYLZ[LKHWWSPJHU[ZZOV\SKZ\ITP[H*=HUKJV]LYSL[[LY[V! Discover the combination of big-city career Mark Pearlmutter, MD opportunities with small-town charm, right here Chair and Vice President, Network Emergency Services at Allen. For more information, c/o: [email protected] Katie Warren, Physician Dev. or call 617-562-7717 800-553-0877 [email protected] We are happy to provide additional information. Visit: allenhospital.org Visit us on the web at www.CaritasChristi.org

June/July 2010 51 Virginia Classifiedadvertising dental, life, LTD, fl exible scheduling, 401(k), paid malpractice, and much more. Please contact Carrie Dib at 800-466-3764, x336 or [email protected].  Emergency Physicians of Tidewater (EPT) is a progressive, democratic group serving 7 hospitals Mississippi, Multiple Cities: Great College Towns in Mississippi! Hospital Physician Partners welcomes you to explore the fantastic in the Virginia Beach/Norfolk area. The practice opportunities available in the cities of Booneville, Oxford and includes level 1 and 2 trauma centers, as well as Columbus! Located just 85 miles southeast of Memphis, TN, Oxford diverse community settings. EPT provides faculty is home to the University of Mississippi (affectionately known as Ole Miss) and boasts a cost of living below the national average. Oxford has for and directly supervises an EM residency been listed among the “Best 100 Small Towns” by USA Today; one of program. Great niche opportunities in U/S, EMS, Time magazine’s “7 Great Places to Retire;” and is a Money magazine’s top six “Best Places to Retire.” Come join the Baptist Memorial Health administration, tactical medicine, forensics, and System in Oxford, Columbus or Booneville and work in a state-of-the- hyperbarics. Well-staffed facilities. Competitive art emergency department. What’s important to YOU is what matters financial package leading to full partnership and to US… attractive compensation packages, sign-on bonuses, fl exible scheduling and great team support. Contact Deanna Maloney: Toll Free profit sharing. Great, affordable coastal area with at 866-maloney (866-625-6639); fax your CV to (972) 562-7991; email moderate year-round temperatures and beaches [email protected] or visit www.hppartners.com/emra.  minutes away. Only EM BC/BP candidates ac- Missouri, St. Louis & Dexter: The Gateway to the West has it cepted. Send CV to Emergency Physicians of all! Jazz, Blues, Baseball, Arts & Culture, History, Urban Life and Wide Open Country Spaces. Hospital Physician Partners seeks Tidewater, 4092 Foxwood Dr., Ste. 101, Virginia qualifi ed physicians for immediate opportunities. FT/PT EM #FBDI
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Nathan Schlicher, MD, JD, is one of four early career physicians to receive a 2010 AMA Leadership Award. A member of the EMRA Board of Directors as a Legislative Advisor, he was the youngest graduate from the University of Washington Law School at age 19. He completed his residency at Wright State University.

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“With TeamHealth, you have the feel of a local group with access to the resources of a national platform. I have equal treatment among colleagues, too. Even as a young physician, I am given opportunities for involvement, and TeamHealth has the structure to allow me to pursue activities, my interests in advocacy for emergency medicine, and my family life.”


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Tail, 12 Hour Shifts, Flexible On-Line BP in EM with recent ED experience, Competitive compensation and bonus Scheduling, Full Support Administrative ATLS, ACLS and PALS. New graduate program offered. Contact: Megan Evans, Teams, State Licensing assistance and candidates will be ABEM certifi ed within Physician Recruiter, 1-800-394-6376, Relocation Bonus packages. What’s 5 years of residency completion. This is an [email protected] or fax CV to important to YOU is what matters to US… independent contractor position and we offer 631-265-8875.  Contact Catherine Marvez: (800) 815-8377 access to Financial Services, Guaranteed ext. 2252; [email protected] or visit Board Preparation Courses, Competitive North Carolina, Charlotte: EMP is www.hppartners.com/emra.  Compensation, Sign-On Bonus, Shift partnered with 6 community hospitals Bonus Pay, Holiday Bonus Pay, 10 Hour in Charlotte, Lincolnton, Pineville and Nebraska, Omaha: BP/BC EM physician Shifts, Double MD Coverage, Double MLP Statesville. A variety of partnership sought for stable group at suburban ED. Coverage, Paid Malpractice with Tail, opportunities are available in urban, Excellent package with shareholder Flexible On-Line Scheduling, Full Support suburban and smaller town settings with opportunity at one year plus family Administrative Teams, State Licensing EDs seeing 8,000-70,000+ pts./yr. EMP is an medical plan, employer-funded pension, assistance and Relocation Bonus packages. exclusively physician owned/managed group malpractice, expense account and more. As What’s important to YOU is what matters to with open books, equal voting, equal profi t Nebraska’s largest city, Omaha provides US… Contact Catherine Marvez: (800) 815- sharing, equity ownership, funded pension, both metropolitan amenities and friendly, 8377 ext. 2252; [email protected] or full benefi ts and more. Contact Steve Rudis, Midwestern charm. Contact Kim Rooney, visit www.hppartners.com/emra.  MD ([email protected]), Emergency Premier Health Care Services, (800)726-3627, Medicine Physicians, 4535 Dressler Rd, ext. 3674; e-mail [email protected]; fax New York, Brooklyn: The Chair of EM at NW, Canton, OH 44718. 800-828-0898 or (937) 312-3675.  Lutheran Medical Center (LMC), Brooklyn, fax 330-493-8677.  NY is seeking full-time emergency New Mexico, Albuquerque: Live, Work medicine physicians. LMC is a Level I North Carolina, Kinston: Located in the and Play in the Land of Enchantment. Trauma Center and a designated stroke center of eastern North Carolina, Kinston is Hospital Physician Partners seeks qualifi ed center. With an annual volume of 66,000, less than 60 miles to the east are some of the physicians for immediate opportunities. LMC offers a wide range of major clinical most beautiful beaches of the Carolina coast FT/PT EM positions available with ED programs, a cutting edge 30-bed rehab unit and 35 miles from Greenville. 200-bed full- volumes ranging from 22K to 32K. and 476 acute beds. Candidates must be BC/ service community hospital treats 41,000 ED Candidates will be residency trained, BC/ BP EM and have current EM experience. pts./yr. Outstanding partnership opportunity

AboutAbout GundersenGundersen LutheranLutheran

Gundersen Lutheran is a dynamic top-rated healthcare organization based in scenic La Crosse, Wis. At Gundersen Lutheran, we serve Emergency Medicine: La Crosse,Wis. residents of western Wisconsin, southeastern Minnesota and northeastern Iowa. Our healthcare system is anchored by one of the BC/BPBC/BP inin Emergency Emergency Medicine. Medicine. Join Join a talented a talented and and largest multi-specialty group practices and a teaching hospital with Level II Trauma Center. Specialty outreach, telemedicine, distance learning, experiencedexperienced team team that that handles handles approximately approximately 30,000 30,000 visits digital imaging and other services link Gundersen Lutheran with regional visitsperper year. Aboveyear. Abovemarket marketsalary and salary benefits and package benefits to clinics, hospital affiliates and practitioners in a 19-county service area. packageinclude loan to include forgiveness. loan forgiveness. La Crosse is a historic, vibrant city of more than 50,000 people nestled between bluffs and the legendary Mississippi River. La Crosse boasts We support a safe, healthy and drug-free work a historic downtown and riverfront, a host of festivals and annual environment through background checks and controlled substance screening. EOE/AA/LEP celebrations, some of the best outdoor recreation, excellent schools including three universities, affordable housing in safe neighborhoods, an endless variety of live entertainment and breathtaking beauty, making this a great place to call home.

Contact Jon Nevala, manager, medical staff recruitment, at (800) 362-9567, ext. 54224, or email [email protected] Visit online at gundluth.org

June/July 2010 53 OUTSTANDING EM OPPORTUNITIES IN NY Classifiedadvertising

✓ Earn up to $165/hour (depending on the site) includes equal profi t sharing, equity ownership, funded pension, ✓ Programs for Residents: availability varies—ask for details open books, full benefi ts and more. Contact Steve Rudis, MD, • Home purchase assistance • Early signing stipend ([email protected]), Emergency Medicine Physicians, 4535 Dressler Rd, NW, Canton, OH 44718. 800-828-0898 or fax 330-493-8677.  ✓ Career development/advancement opportunities ✓ 11 different sites to choose from with volumes ranging from North Carolina, Morehead City: Located in a sound-side seaport, 12K to 40K Morehead City is a thriving, growing community. Modern, 21,000 sq ft ED sees 40,000 ED pts./yr. Outstanding partnership opportunity ✓ Many sites are commutable from the New York City metro area includes equal profi t sharing, equity ownership, funded pension, open books, full benefi ts and more. Contact Steve Rudis, MD MedExcel USA, Inc. offers unparalleled opportunities for EM residents ([email protected]), Emergency Medicine Physicians, 4535 Dressler looking to practice in the Northeast. From low volume rural EDs to Rd, NW, Canton, OH 44718. 800-828-0898 or fax 330-493-8677.  state of the art urban trauma centers MedExcel USA, Inc. provides physicians with a wide variety of potential practice settings. An North Carolina, New Bern: Respected 313-bed regional medical extremely competitive compensation package includes a base salary, center located at the intersection of the Trent and Neuse Rivers just modified RVU and profit sharing. off the central coast. 74,000 ED pts./yr. Outstanding partnership opportunity includes equal profi t sharing, equity ownership, funded MedExcel USA, Inc. is a quality-driven physician owned emergency pension, open books, full benefi ts and more. Contact Steve Rudis, medicine management group. We offer many innovative programs, MD ([email protected]), Emergency Medicine Physicians, 4535 including a “no-Wait ED” and a “Pain Sensitive ED” as well as Dressler Rd, NW, Canton, OH 44718. 800-828-0898 or fax unparalleled career opportunities and professional development. We 330-493-8677.  offer a nurturing, physician friendly environment in which to develop your future. Career development opportunities are available for those Ohio, Barberton: SUMMA Health System-Barberton Hospital interested in an administrative career track. is a full-service community hospital in southern suburban Akron with 44,000 ED visits/yr. Outstanding partnership opportunity For additional information, includes equal profi t sharing, equity ownership, funded pension, contact Mark Douyard at open books, full benefi ts and more. Contact Steve Rudis, MD 800-563-6384 x.258 or ([email protected]), Emergency Medicine Physicians, 4535 Dressler [email protected] Rd, NW, Canton, OH 44718. 800-828-0898 or fax 330-493-8677. 

NOT TO HAVE ONE.

EmCare is committed to giving you the freedom to balance the medical career you've worked for with the lifestyle you deserve.

You save lives. EmCare helps you have one. Every day, we provide physicians and advanced clinical practitioners the ability to practice high quality medical care, backed with administrative support and flexible scheduling, so you can balance your personal goals with professional attainments. With opportunities at more than 450 client hospitals in 40 states, practicing medicine with EmCare can help you have the career – and the life – you’re seeking.

Join the nation’s leading provider of emergency care. For a complete listing of EmCare's career opportunities, visit www.EMCARE.com or email [email protected]

54 EM10-EM-824_EMResident Resident_AprilMay.indd 1 2/10/10 12:07 PM Classifiedadvertising

Ohio, Cambridge: Southeastern Ohio and 12 other specialties. The ED is treating not deducted from outstanding clinical Regional Medical Center is a 177-bed, full- approximately 67,000 patients per year. compensation. Contact Kim Rooney, service facility and Level III Trauma Center Outstanding package includes partnership, Premier Health Care Services, (800) 726- treating 34,000 ED pts./yr. Outstanding open books, full benefi ts package and more. 3627, ext 3674, [email protected], fax partnership opportunity includes equal profi t Contact Dan Phillips, MD, FACEP (937) 312-3675.  sharing, equity ownership, funded pension, ([email protected]), Emergency Medicine open books, full benefi ts and more. Contact Physicians, Ltd. 4535 Dressler Rd, NW, Ohio, Lodi: Fully accredited 30-bed hospital Steve Rudis, MD ([email protected]), Canton, OH 44718. 800-828-0898 or fax with acute and skilled care facilities is Emergency Medicine Physicians, CV to 330-493-8677.  part of the Akron General Health System. 4535 Dressler Rd, NW, Canton, OH 44718. Brand new 12-bed ED has 12 private rooms 800-828-0898 or fax 330-493-8677.  Ohio, Columbus: Choose city or small- including cardiac and trauma. 11,000 ED town living 25 minutes NW of Columbus. pts./yr. with 12 and 24 hr. shifts. Outstanding Ohio, Cincinnati: EM Physician Excellent opportunity in 22,000 volume partnership opportunity includes equal profi t opportunity with Democratic group north ED with fast-track. Enjoy the advantages sharing, equity ownership, funded pension, of Cincinnati. Newer hospital with state- of a democratic, physician led group open books, full benefi ts and more. Contact of-the-art expanded ED. Annual volume including equity ownership and incentive Steve Rudis, MD ([email protected]), of 63,000 with 61 physician and 24 MLP opportunities, malpractice, family medical Emergency Medicine Physicians, hours daily. Terrifi c package includes family plan, CME, employer-funded pension and 4535 Dressler Rd, NW, Canton, OH 44718. medical plan, employer-funded pension, more. Contact Amy Spegal, Premier 800-828-0898 or fax 330-493-8677.  expense account, malpractice, incentive plus Health Care Services, (800)726-3627, shareholder opportunity with no buy-in; ext 3682, [email protected] fax Oklahoma, Tulsa: Modern 800+ bed Contact Kim Rooney, Premier Health Care (937) 312-3683.  community hospital hosts new (7/08) Services, (800) 726-3627, ext. 3674; allopathic EM residency program and [email protected].  Ohio, Lima: Outstanding package with sees 77,000 ED patients per year. Broad democratic group. Level II, 57K volume pathology, high acuity, modern facilities Ohio, Columbus: Doctors Hospital is a ED has separate pediatric ED and hospitalist and supportive environment. Outstanding 256-bed teaching facility representing all support. Features shareholder status without partnership opportunity includes equal profi t major specialties and hosting Osteopathic buy-in, loan repayment, pension, family sharing, equity ownership, funded pension, residency programs in Emergency Medicine, medical, more. Full benefi ts included and open books, full benefi ts and more. Contact

Join Us As We Grow!

A Unique Ownership Opportunity

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June/July 2010 55 XCELLENCE

Take Your Career in Emergency Medicine to New Heights

Emergency Medical Associates (EMA) has been a leader in the industry since 1977. Our unique structure of full, early, and equal partnership for all our physicians is the perfect equation to help you reach your career goals. As a partner in EMA your opportunities for professional growth are limitless. You can run an ED, participate in clinical research, sit on various policy or governance committees, become a member of the Board, or even the CEO. Anything is possible for EMA partners.

EMA has 2 outstanding opportunities located in New York: St. Peter's Hospital — Albany, New York 442-bed community teaching hospital Annual ED volume of 51,000 patients Academic appointment available through Albany Medical College HealthAlliance of the Hudson Valley — Kingston, New York New state-of-the-art ED to open 1st quarter 2010 Newly merged entity of Kingston Hospital, Benedictine Hospital, Margaretville Hospital Annual ED volume of 50,000 patients Upstate New York offers a wonderful quality of life including low-cost living, high-quality education, a thriving art and theatre scene and endless year-round recreational activities. Whether you like boating, rock climbing, hang gliding, skiing, hiking, mountain biking, or golfing, the Catskill and Adirondack Mountain regions offer all this and more!

Join one of the most highly respected Emergency Medicine groups in the nation.

The Sign of Excellence in Emergency Medicine®

877.692.4665 x1134 Fax 888.467.4692 [email protected] www.EMA-ED.com

56 EMResident Classifiedadvertising

Steve Rudis, MD, ([email protected]), Pennsylvania, Pittsburgh: Alle-Kiski outstanding compensation/benefi t Emergency Medicine Physicians, 4535 Medical Center in Natrona Heights is package includes paid malpractice with Dressler Rd, NW, Canton, OH 44718. currently building a brand new ED to see tail, employer-funded retirement plan, 800-828-0898 or fax 330-493-8677.  36,000 emergency pts./yr. The Western paid health insurance, CME allowance, Pennsylvania Hospital-Forbes Campus sees and much more. EM board-certifi cation/ Pennsylvania, Northwestern: Join 45,000 EM pts./yr. in Monroeville. Both preparation required. Contact Dr. Robert Pennsylvania’s Leader in Emergency are proximate Pittsburgh’s most desirable Maha at 888-647-9077 / Fax 412-432-7480 Medicine. UPMC Northwest is Emergency residential communities. Outstanding or e-mail at [email protected]. EOE  Resource Management’s newest site. partnership opportunity includes equal profi t UPMC Northwest is a state-of-the-art sharing, equity ownership, funded pension, Pennsylvania, York: Memorial Hospital facility located in Seneca, PA, halfway open books, full benefi ts and more. Contact in York is host to a respected osteopathic between Erie and Pittsburgh. The ED Steve Rudis, MD, ([email protected]), EM residency program and sees 40,000 sees approximately 30,000 patients with Emergency Medicine Physicians, 4535 annual ED visits. Enjoy equal equity excellent coverage. The surrounding Dressler Rd, NW, Canton, OH 44718. ownership/partnership and a high quality community is situated in the foothills of 800-828-0898 or fax 330-493-8677.  of life. Outstanding package includes the Allegheny Mountains, offering a great partnership, open books, full benefi ts and lifestyle with plentiful outdoor activities Pennsylvania, Pittsburgh: Join more. Contact Dan Phillips, MD, FACEP and a low cost of living. We offer an Pennsylvania’s Leader in Emergency ([email protected]), Emergency Medicine outstanding compensation/benefi t package Medicine. UPMC Passavant Hospital is Physicians, Ltd. 4535 Dressler Rd, NW, including: paid malpractice insurance located in an affl uent suburban area with Canton, OH 44718. 800-828-0898 or fax with tail, employer-funded retirement plan, excellent housing and schools, and is CV to 330-493-8677.  paid health insurance, CME allowance, a short commute from the amenities of and more. Board certifi cation/prepared in Pittsburgh. The newly expanded ED sees Tennessee, Multiple Cities: Hospital EM. Contact Dr. Robert Maha at 888-647- 35,000 patients annually with 39 hrs of Physician Partners welcomes you to 9077/Fax 412-432-7480 or e-mail physician coverage and 20 hrs of mid- explore the fantastic opportunities [email protected]. EOE  level provider coverage daily. An available in the beautiful state of

Emergency Medicine Opportunities

ÌPartnership ÌOwnership ÌLeadership ÌHealth and Retirement Opportunities Programs ÌManagement Support ÌLocal Autonomy

Visit us at www.cepamerica.com or Call Recruiting at 800.842.2619

ARIZONA CALIFORNIA GEORGIA ILLINOIS OREGON TEXAS WASHINGTON CEP America—A national entity established by California Emergency Physicians Medical Group

June/July 2010 57 CHOOSE YOUR FUTURE . . . CHOOSE GHEP [email protected]

Ince ntive Bon uses www.ghep.com

Semi annual profit sharing www.ghep.com [email protected] www.ghep.com [email protected]

(888) 239-7924 (888) TOLL FREE: (888) 239– 7924 (888) 239– 7924 Greater Houston Emergency Physicians www.ghep.com [email protected] www.ghep.com www.ghep.com

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CHOOSE YOUR FUTURE . . . CHOOSE GHEP

58 EMResident Classifiedadvertising

Tennessee. Whether you are looking for a Hospital is a Level I Trauma Center and slower pace in a rural setting, or a rapidly county teaching hospital with an annual growing major city suburb, Hospital census of 90,000 and academic affi liations Hartford, Connecticut Physician Partners has a Tennessee with UT Southwestern and UNT. Criteria: location just right for you. As the ABEM certifi ed or eligible. Position offers EMERGENCY MEDICINE origination point for the Music City Star attractive benefi ts and compensation while PHYSICIAN East Corridor Commuter Rail, Lebanon, Fort Worth offers character, charm and Tennessee provides easy access to the entertainment that will not disappoint. A prestigious healthcare downtown Nashville Riverfront for fine Contact Katie McPike, CPC at 214.712.2072 system located in Hartford, dining, shopping, entertainment, etc. while or [email protected] for more Connecticut has an offering the comforts of small town living. information. Email: katie_mcpike@emcare. opportunity for 4 BC/BP Other locations include southwest and com. Websites: www.jpshealthnet.org, Emergency Medicine south central Tennessee. What’s important www.emcare.com.  physicians to join a growing to YOU is what matters to US… attractive team to staff a newly built compensation packages, paid malpractice Virginia, Blacksburg: Seeking full- 70 bed ED to open March with tail, flexible scheduling and great time BC/BP EM physician for 26,000 2011. Saint Francis Hospital team support. Contact Deanna Maloney: visit ED located just 40 miles south of and Medical Center is a Toll Free at 866-maloney (866-625-6639); Roanoke. Level III trauma center. Great Level 2 trauma and tertiary fax your CV to (972) 562-7991; email work environment. EPMG offers paid [email protected] or visit family medical benefi ts, incentive bonus referral center with 70,000+ www.hppartners.com/emra.  system, paid malpractice, 401(k), fl exible visits per year. scheduling, and much more. Please contact

Texas, The successful candidate Amarillo: Full-Time Emergency Ruth Ann Sheets at 800-466-3764, x332 or Staff Physician - Northwest Texas [email protected].  may be eligible to hold an Healthcare System, located in Amarillo, academic appointment at is a 489-bed acute care medical center with West Virginia, Bluefi eld: EM physician the University of Connecticut a Level III Trauma Center, 24-bed ED and opportunity with democratic group. School of Medicine. 5-bed Fast Track serving approximately This 36,000 volume ED is on the WV/ 45,000 patients annually. With 48 hours of VA border. Excellent coverage of 36 We would like one of the 4 physician coverage daily and extra MLP physician hours plus 20 PA/NP hours daily. to be a BC/BP toxicologist coverage, the facility is seeking additional Benefi ts include shareholder opportunity, to augment the toxicology coverage through the hire of a full-time, family medical plan, malpractice, pension, program. BC EM physician with a high guaranteed incentive income. Scenic location with hourly rate and IC status. Enjoy the beauty appealing sports/recreational opportunities. Hartford, located in central of the Palo Duro Canyon, quality Contact Rachel Klockow, Premier Health Connecticut, is a vibrant educational system, gardens and delectable Care Services, (800)406-8118, e-mail community in the midst of restaurants in Amarillo. Contact Terri [email protected], fax (954) 986- significant growth with a Harper at (800) 362-2731, ext. 2742 or 8820.  wide range of city or upscale [email protected].  suburban living choices, West Virginia, Ronceverte: Live a laid- access to first-rate schools, Texas, El Paso: Full-time Emergency back lifestyle while enjoying the beautiful cultural activities, and the best Staff Positions - Sierra Providence change in seasons. Historical community Health Network, located in El Paso, Texas, situated on the gently fl owing Greenbrier of New England’s country and seeks emergency physicians for its River. Friendly people, quaint district and coastal environments with easy affi liated hospitals: Providence Memorial affordable housing. Hospital Physician access to New York and Hospital, Sierra Medical Center, and Sierra Partners seeks qualifi ed candidates for Boston. Providence East Medical Center. Criteria: immediate opportunities at Greenbrier BC EM, residency trained in emergency Valley Medical Center. Full Time and To obtain further details, medicine. Enjoy a high compensation plan, Part Time EM Physicians, 22K ED volume, please call Christine Bourbeau, IC status and living in a major metropolitan state of the art facility treating moderate Director of Physician area with access to New Mexico skiing and acuity cases. Must be BC/BP in EM and may Recruitment at 800-892-3846 hiking. Learn more by contacting apply for 12 hour shift coverage starting or fax/email your CV to Terri Harper at (800) 362-2731, ext. 2742 at 7a and 7p with mid-level coverage 860-714-8894. or [email protected].  ten hours daily. Candidates must have completed residency and hold ACLS/ATLS/ E-mail address: Texas, Fort Worth: John Peter Smith PALS. What’s important to YOU is what [email protected] Hospital in Fort Worth is seeking an matters to US… scheduling fl exibility, Emergency Medicine Associate Residency paid malpractice w/ tail and supportive Visit our Website at Director, Ultrasound Director and academic leadership. Contact Debra Baumel: www.saintfranciscare.com faculty positions for its newly accredited (800) 815-8377; [email protected] EM residency program. John Peter Smith or visit www.hppartners.com/emra.  EOE-AA-M/F/D/V

June/July 2010 59 Classifiedadvertising

West Virginia, Weirton (near Pittsburgh, PA): Weirton Medical Center affords easy access to desirable residential areas and amenities in WV and PA. The ED treats 40,000 patients annually. Outstanding partnership opportunity includes equal profi t sharing, equity ownership, funded pension, open books, full benefi ts and more. Contact Steve Rudis, MD ([email protected]), Emergency Medicine Physicians, 4535 Dressler Rd, NW, Canton, OH 44718. 800-828-0898 or fax 330-493-8677. 

West Virginia, Wheeling: Full time position available at 36,000 visit ED located just one hour from Pittsburgh. Wheeling Hospital was recently named among the top 10 best hospitals in the nation for quality healthcare. BC/BP EM. EPMG offers paid family medical benefi ts, paid malpractice, 401(k), fl exible scheduling, incentive bonuses, and more. Contact Tynia Arnold at 800-466-3764, x335 or [email protected]. 

UÊ-ˆ}˜‡"˜Ê œ˜ÕÃià West Virginia, Wheeling: Ohio Valley Medical Center is a 250-bed community teaching hospital with a brand new-ED under UÊ/Ո̈œ˜Ê,iˆ“LÕÀÃi“i˜Ì construction. AOA approved Osteopathic EM and EM/IM residency Uʏi݈LiÊ-V i`Տˆ˜} program. Enjoy teaching opportunities, full-specialty back up, active EMS, and two campuses seeing 28,000 and 24,000 pts./yr. UÊ*>ˆ`Ê >«À>V̈ViÊÜˆÌ Ê/>ˆ Outstanding partnership opportunity includes equal profi t sharing, UÊÀiiÊ"À>Ê,iۈiÜÊ œÕÀÃi equity ownership, funded pension, open books, full benefi ts and more. Contact Steve Rudis, MD, ([email protected]), Emergency UÊÀiiÊ Ã Medicine Physicians, 4535 Dressler Rd, NW, Canton, OH 44718. 800-828-0898 or fax 330-493-8677. 
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ÀŽ>˜Ã>Ã Ê œÀˆ`> Fee for Service ED Opportunities in Ê iœÀ}ˆ> Southern, Central and Northern California Ê ˆÃÜÕÀˆ * * * * * * * * Ê œÀÌ Ê >Àœˆ˜> Near S.F. Bay Area, San Diego, Sacramento, Ê " ˆœ Mendocino, San Joaquin & Sonoma Valleys, Ê /i˜˜iÃÃii Turlock, Merced, Redding; including many Coastal, Mountain & Wine Country Destinations!

"˜ˆ˜iÊœLÊ-i>ÀV EXCELLENCE IN EMERGENCY MEDICINE WWW.HPPARTNERS.COM/EMRA Currently serving 23 clients in Southern, Central & Northern California and Texas!

Excellent Benefits! Stock Options! Fast track to Shareholdership!

Contact: VEP Recruiter Email: [email protected] Phone: (925) Call-VEP (925-225-5837) 800-815-8377 [email protected] Visit us at www.valleyemergency.com

60 EMResident Classifiedadvertising

Wisconsin, Eau Claire: Outstanding Physician Assistant partners and a high to: Johanna Bartlett or Mary Schwei, opportunity for ABEM (or AOBEM) quality nursing and support staff. Please Infi nity HealthCare, 111 E. Wisconsin Ave, certifi ed/EM residency trained physicians direct inquires to: Mary Schwei or Johanna Suite 2100, Milwaukee, WI 53202, to join a well-established, top quality Bartlett at Infi nity HealthCare Inc; ihc- Toll Free 888-442-3883, email: group in an exciting practice setting. careerops@infi nityhealthcare.com, 111 E. ihc-careerops@infi nityhealthcare.com.  Infi nity HealthCare has assumed the ED Wisconsin Ave, Suite 2100 Milwaukee, WI management and staffi ng responsibilities 53202 fax (414)290-6781 or at the toll free Wyoming, Cheyenne: Join a dynamic at Sacred Heart Hospital in Eau Claire, number 1-888-442-3883.  emergency physician team in beautiful, Wisconsin. A college town, Eau Claire is historic Cheyenne, Wyoming. Frontier a major metropolitan center in northwest Wisconsin, Wisconsin Rapids: Emergency Physicians (FEP) is seeking an Wisconsin, surrounded by lakes and Partnership Opportunity. Infi nity energetic and enthusiastic team member, HealthCare a well-established recreational areas within a short distance a physician who is board certifi ed/board to Minneapolis, MN. This represents Emergency Medicine group with over prepared in emergency medicine. He or a truly outstanding opportunity for 30 years of experience in staffi ng and she would fi ll a position at Cheyenne qualifi ed candidates to participate in the managing emergency physician practices Regional Medical Center, which hosts a reorganization of a quality EM boarded invites you to join us in a new exciting level II trauma center, operated by FEP, physician practice while joining a highly practice at Riverview Hospital. Located regarded group, Infi nity HealthCare. on the banks of the Wisconsin River; that sees about 35,500 patients a year. Excellent compensation and comprehensive this area provides an outdoor recreational FEP offers a competitive salary, benefi ts, benefi t package including the exceptional playground for camping, hiking, skiing and partnership opportunities. Interested benefi t of distributed ownership/equity. The and fi shing. Centrally located it is within physicians should send a cover letter and a practice is 25K patients/annum & growing, a few hours from Milwaukee, Madison copy of their curriculum vitae by email to tertiary neuroscience capabilities, Level and the Twin Cities. Comprehensive [email protected] or by mail to SERIO III Trauma Center & Paramedic Medical package includes competitive salary Physician Management, Attention: Teresa Control Center with group responsibility for and incentive compensation, in addition Long, 1241 W. Mineral Ave., Suite 100, the Paramedic Training Center, an effi cient outstanding benefi ts, retirement plan and Littleton, CO 80120. Or, call Dr. Mike physical plant with UC/Fast Track area, equity participation. Please direct inquiries Means at (307) 633-7550. 

XCELLENCE

EMERGENCY MEDICINE PHYSICIANS The Kingston Hospital Ochsner Health System in New Orleans is seeking additional Kingston, NY residency trained and board-prepared/certified EMERGENCY Administrative and Staff Positions Available MEDICINE PHYSICIANS to join our expanding 40-physician Emergency Medical Associates (EMA) is a democratic, physician-owned and governed group of practicing emergency physicians. We offer early, full, and equal partnership, department. which attracts the finest career emergency physicians. Our physician satisfaction and retention rates are among the highest in the industry. Ochsner Health System is a physician-led, non-profit, academic, New state-of-the-art ED to open January 1, 2010 Annual ED Volume – over 50K multi-specialty, healthcare delivery system dedicated to patient 50 hours of Physician Coverage care, research, and education. The system includes eight 24 hours of Associate Practitioner Coverage hospitals and 35 health centers throughout Southeast Louisiana. 24 hours of Clinical Information Manager (Scribe) coverage Hourly rate + incentive bonus Ochsner employs 750 physicians in 90 medical specialties and Equity Bonus Plan sub-specialties and conducts approximately 300 ongoing clinical Excellent Benefit package (medical/dental/disability) research trials annually. We offer a generous and comprehensive 401(k) and Defined Benefit Plan benefits package. We also enjoy the advantage of practicing in a Malpractice Insurance The city of Kingston is located in the historic Hudson Valley region of New York State, favorable malpractice environment in Louisiana. Please visit our approximately 2 hours north of NYC. Kingston offers its residents a wonderful quality of life including a low-cost of living, high-quality education from pre-K through college, website at www.ochsner.org. a thriving art and theatre scene and endless recreational activities. Within minutes of Kingston you will find world-renowned rock climbing, hang gliding, skiing, hiking, New Orleans is one of the most exciting and vibrant cities in mountain biking, public/private golf courses and more!

America. Amenities include multiple universities, academic The Sign of Excellence in Emergency Medicine® centers, professional sports teams, world-class dining, cultural interests, renowned live entertainment and music.

Please email CV to: [email protected], Ref. # AEMEDP09 or call 800-488-2240 for more information. EOE. 877.692.4665 x1134 Fax 888.467.4692 [email protected] www.EMA-ED.com

June/July 2010 61 back at you save on life so you can SPLURGE on SUMMER Summer 2010 is full of possibility. Whether you’re saving for a quick weekend getaway or planning a cross-country relocation, we’re guessing you could use a few extra dollars to make it a summer to remember. So, instead of paying full price for the things you might normally be using, make sure you’re taking advantage of the benefi ts you already get from EMRA!  NEW!! 50% off of Pepid for residents and students during the month of June (20% off for alumni members!)  Special rates on Auto, Home and Renter’s insurance through Liberty Mutual.  NEW!! Offi ce Depot discounts of up to 90% on offi ce supplies you need most.  14% off of Sprint PCS phones and service; 15% off of Nextel phones & service.  Free subscriptions from Critical Decisions in Emergency Medicine, EB Medicine titles, and EMA & EM:RAP audio and video downloads. Eat this “It’s not that!© kind

Chocolate bars: get a 100 Grand (190 calories) of fun instead of a Snickers (280 calories) Chips: Baked Lays Potato chips (110 calories) instead of Sun Chips (210 calories) to do the Cheesy snacks: Goldfi sh crackers (140 calories) instead of Cheez-its (180 calories) Cookies: Mini Chips Ahoy cookies (140 calories) instead of impossible.” Famous Amos chocolate chip cookies (240 calories). Fruity snacks: Welch’s Fruit Snacks (195 calories) instead of Skittles (250 calories) Walt Disney http://health.yahoo.com/experts/eatthis/38410/best-amp-worst-vending-machine-foods/

62 EMResident June/July 2010 63 PRSRT STD U.S. POSTAGE PAID Emergency Medicine Residents’ Association BOLINGBROOK, IL 1125 Executive Circle PERMIT NO. 467 Irving, Texas 75038-2522 972.550.0920 www.emra.org

Love where you work.

Emergency Medicine Physicians partners with dozens of emergency And where departments in locations ranging from small communities to major metropolitan areas. Do you enjoy cultural or outdoor recreation activities? Would you like to live on the water? Tell us what qualities you live. you’re looking for and we’ll let you know about locations that meet your needs. If you’re looking for a democratic organization, equal equity, competitive benefits and a schedule you make your first year, you’ll feel right at home at Emergency Medicine Physicians. Visit emp.com today.

Opportunities across the USA.