ResidentOfficial Publication of the Emergency Medicine Residents’ Association October/November 2019 VOL 46 / ISSUE 5

years ENVISION PHYSICIAN SERVICES HAS GIVEN ME ... THE SUPPORT TO EXCEL AND THE AUTONOMY TO THRIVE

RICH LOGUE, MD, FACEP EMERGENCY MEDICINE

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Visit us at ACEP19 Booth #811 EMRA-fied and Proud 45 Years of Resident-Driven Publications Tommy Eales, DO Editor-in-Chief, EM Resident Indiana University @tommyeales s we celebrate the 45th anniversary of EMRA by Arecognizing 45 exceptional young leaders in the specialty of emergency medicine, it’s worth taking a step back and reflecting on one of the greatest accomplishments of the organization. Of course, we’re talking about EMRA publications. Since its first print-only newsletter iterations, EM Resident has grown into the largest resident-led publication in the country, with nearly 20,000 individual print subscribers and more than 30,000 unique monthly visitors to the online edition. We earned recognition on a national stage this year for our plea to address gun violence in America, winning the highest honors among a pool of entries that included commentary from U.S. ambassadors and massive, influential groups such as the AARP. This publication not only offers a forum for clinical education and sound, cutting-edge, evidence-based rounds of edits and ongoing revisions to discussion of current events in the material. With such a passionate and ensure that the most current evidence is world of emergency medicine, but also talented group, it will be exciting to see reflected. paves the way for the advancement of how far EM Resident will go in the next That vaunted EMRA box you receive the specialty through original research 45 years. when you join the EMRA family is more and scientific discovery. It is a channel Magazines aside, the real magic of than just a few quick-reference guides through which EM’s newest authors can EMRA publications comes in the form of to make every shift easier; it represents develop their skills, find their voices, our popular clinical guides. a collective dedication to lifting up the and contribute a vital perspective to the From the iconic Antibiotic Guide specialty in so many ways. As with EM house of medicine. (a staple in every teaching ED) to new Resident magazine, our clinical library is Far from the early days as a one- offerings like the smash-hit Ortho Guide, built with the help of medical students, person operation, EM Resident now has EMRA owes our great success with these residents, fellows, and faculty all working a high-functioning team of resident and resources to our volunteer authors and together to distill complex, nuanced fellow editors who work together every chief editors, whose dedication to helping concepts into clear, actionable guidance. month to create the magazine in your residents succeed is unmatched. EMRA staff members offer support and hands. Each article we receive undergoes Incredibly, every clinical resource we assistance, and the end result is a collection a rigorous peer revision process that produce starts off as a simple pitch from that helps you become a better doctor. ensures the content is not only up-to-date a passionate EMRA member. Through So, as I conclude my term as Secretary and accurate, but high-yield and easy a series of pilots and drafts, these wild of the Board of Directors and Editor- to read on the go. Our team is lucky to ideas go on to become bedside references in-Chief of EM Resident, I would like to include generous faculty members who used to make life-and-death decisions. express my most sincere gratitude for the donate their time and expert perspective As clinicians ourselves, we understand privilege of working with the incredible on critical topics such as emergency the gravity of this and put every page of authors, editors, and staff that make cardiology and toxicology to ensure that each guide through a painstaking peer EMRA publications world-class. residents are reading the most clinically review process that includes multiple Here’s to another 45 years! ¬

October/November 2019 | EM Resident 1 BREAK INTO YOUR NEXT HEALTHCARE OPPORTUNITY

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TOGETHER, WE HEAL 2 EMRA | emra.org • emresident.org

SCHM2220_Provider_Surfer_EMResident_8p5x11_FIN.indd 1 8/6/19 12:41 PM TABLE OF CONTENTS 4 EMRA FY 2019 Phenibut Overdose: EDITORIAL STAFF Annual Report 28 Coming to an ED EDITOR-IN-CHIEF LEADERSHIP REPORT Near You Tommy Eales, DO Indiana University TOXICOLOGY 6 2019 EMRA Sponsors EDITORIAL TEAM IN APPRECIATION Management of Atrial Brian Freeman, DO 30 Lakeland Health Fibrillation in Hypertrophic 45 Years of EMRA Cardiomyopathy Meghan Gorski, DO 7 EMRA EVENTS Albert Einstein Medical Center CARDIOLOGY Whitney Johnson, MD EMRA at ACEP19 8 UCSF-Fresno Highlights Managing Pediatric 32 Priyanka Lauber, DO EMRA EVENTS Diabetic Ketoacidosis PEDIATRIC EM Lehigh Valley Health Network 9 Honoring EMRA’s Jeremy Lacocque, DO Fall Award Winners 36 Unique Presentation UCSF EMS Fellow EXCELLENCE IN EM of Fracture Blisters Mahesh Polavarapu, MD ORTHOPEDICS Christiana Care Health System 10 EMRA Party @ ACEP19 Jason Silberman, MD EMRA EVENTS 37 What is Aerospace University of Tennessee Medicine? Daniel Bral, DO 11 45 Under 45 SPACE MEDICINE University of Rochester INFLUENCERS IN EM Emergency Medicine MSC Editor 45 Years of EMRA 38 Samuel Southgate 21 in Lao PDR University of Connecticut TIMELINE INTERNATIONAL MEDICINE ECG Faculty Editor Revisiting Acute Do Sports Have an Jeremy Berberian, MD 22 40 Christiana Care Health System Radiation Syndrome Effect on Gang Violence? TOXICOLOGY OP-ED PEM Faculty Editor Yagnaram Ravichandran, MBBS, MD, FAAP Risk Awareness in the Dear Attending... Dayton Children’s Hospital Pediatric ED 24 Clinical Asst. Professor of Pediatrics Interscalene Nerve Block 41 OP-ED Wright State University NEUROLOGY/ULTRASOUND 43 ECG Challenge Toxicology Faculty Editor 26 Multiple Myeloma: INTERPRET AND DIAGNOSE David J. Vearrier, MD, MPH, FACMT, BREAK INTO YOUR NEXT Diagnostic and Treatment FAACT, FAAEM Considerations in the ED 45 Board Review HEALTHCARE OPPORTUNITY HEMATOLOGY Questions EM Resident (ISSN 2377-438X) is the bi-monthly PEER ASSISTANCE magazine of the Emergency Medicine Residents’ Association (EMRA). The opinions herein are those of the authors and not of EMRA or any Looking for a clinical career that helps you go further UPCOMING EVENTS institutions, organizations, or federal agencies. while delivering outstanding patient care? Oct. 24: EMRA Resident Councilor Mixer Oct. 27: Case-Con Poster Competition EMRA encourages readers to inform themselves Oct. 25: Medical Student Meet-Up Oct. 28: Fall Representative Council Meeting fully about all issues presented. EM Resident Oct. 26: Fall Medical Student Forum Oct. 28: EMRA Resident SIMWars reserves the right to edit all material and does not Explore new clinical careers through SCP Health Residency Program Fair, sponsored by Oct. 28: EMRA Party, sponsored by Envision guarantee publication. at scp-health.com/explore Laurel Road Physician Services Oct. 27: EMRA Resolution Review Oct. 29: 20 in 6 Resident Lecture Competition, © Copyright 2019 Oct. 27: EMRA Committee Workshops sponsored by Hippo Education Emergency Medicine Residents’ Association Oct. 27: EMRA Job & Fellowship Fair, Oct. 29: EMRA Airway Stories, sponsored sponsored by emCareers.org, by Vituity Laurel Road, TeamHealth, and Vituity Oct. 30: EMRA MedWAR, sponsored by BTG TOGETHER, WE HEAL October/November 2019 | EM Resident 3

SCHM2220_Provider_Surfer_EMResident_8p5x11_FIN.indd 1 8/6/19 12:41 PM MATT KAUFMAN, MD, FACEP EMERGENCY MEDICINE

Stop by our booth #811 at ACEP19 and talk with our physician leadership ■ Enhanced sign-on bonus at select sites ■ Enhanced referral bonus of $10,000 at select sites ■ Career advancement and leadership opportunities ■ Earn While You Learn Program: Provides senior residents with $2,500/ month while you complete your residency ■ Proud sponsor of the EMRA Party at Club Vinyl

For more information, contact: 877.226.6059 [email protected] EMRA FY 2019 Annual Report Membership: 15,625

90%+ 200+ $3M+ 14% of EM Residents are programs with annually invested revenue growth EMRA members 100% membership into members between 2018 - 2019

EMRA helps you become the EMRA helps you become the EMRA helps EM become the BEST DOCTOR BEST LEADER BEST SPECIALTY you can be. you can be. we can be.

All EM Resident & Student new comprehensive app, new committees Organization, AEROS, created by 1 MobilEM, launching 1 EMRA to foster collaboration winter 2019 3 totalling EMRA and ACEP Health Policy committees new 20 6 Academy Fellows

uide r Care G publications nsgende ra T , MHPE ech, MD stie A. L Chri -Chief Editor-in levue 6 NYU Bel books, reference cards, & awards, scholarships & partnerships to advance our 32 mobile apps grants totalling mission (ACEP, EMF, EMAF, 40+ 9+ NEMPAC, EDPMA, AFFIRM, major EM conferences with EMRA $125,000+ FemInEM, PolicyRx, AMA) presence (ACEP, LAC, CORD, EEM, 6 EDPMA, FemInEM & EmCrit) programs with active AND funded national representation in our regional meetings funded 100+policy-making Representative Council 30+ in collaboration with ACEP leadership 120+opportunities for members oppose further 21,000+ study of AAMC downloads since July 2018 Leadership Academy SVI pilot project 204 fellows SVI Defends 30,000+ EMRA and ACEP the value of residency training on the unique monthly online views EMRA’S ACEP Workforce & PA/NP Scope of and print distribution of UNDER 45 16,000 400+ INFLUENCERS IN EMERGENCY MEDICINE Practice Task Forces nominations received Advocating for residents and faculty in 500,000+ the ACGME’s Program searches of EMRA Match & Clerkship 5,016 Match, Fellowship Match in development members of EMRA’s 20 Committees Requirements References available online October/November 2019 | EM Resident 5 to our SPONSORS FOR A GREAT YEAR!

SEE YOU IN DALLAS AT ACEP20! PHOTO COURTESY OF THE KANSAS CITY STAR Residents meet with surgeon general 45 YEARS OF EMRA Honoring Excellence Emergency medicine has been on a path of excellence and achievement since its inception, and EMRA has been at the forefront of that evolution from its very first meeting in 1974. We are honored to spend this year celebrating where we’ve been and looking forward to where we’ll go in the next 45 years. From the determined work of our original 5-member Executive Committee, EMRA has grown to be 16,000 strong. From hard-fought battles to victories that pierce the fabric of the specialty with new and innovative ideas, EMRA continues to raise the bar and be the voice for emergency medicine trainees around the globe. EMRA helps you become the best doctor you can be, the best leader you can be, and helps EM become the best specialty it can be.

October/November 2019 | EM Resident 7 EMRA at ACEP19 In the 45 years since a dozen residents banded together to represent trainees at organized EM conferences, EMRA’s offerings have grown a bit. We’ll be hosting nearly 100 meetings and events in Denver, and we want you to be there! EMRA Headquarters at ACEP19 Embassy Suites, across the street from the Denver Convention Center Full event details https://emra.org/acep

Highlights of the Week Saturday, Oct. 26 7 am – Noon Medical Student Forum 1:30 – 3:30 pm EMRA Residency Program Fair Sunday, Oct. 27 9 – 11 am Leadership Academy — Supported by Vapotherm 10 – 11:30 am Resolution Review & Public Hearing 12:30 – 5:30 pm EMRA Committee Meetings, including ¬ TEE Workshop, hosted by Critical Care Committee ¬ Pediatric Airway Skills Lab, hosted by PEM, Ultrasound, and Simulation committees ¬ Tox in TV, hosted by Toxicology Committee ¬ Panel discussions, competitions, planning sessions, and more! 12:30 – 5:30 pm EMRA Case-Con Competition, hosted by the Research Committee 5 – 7 pm EMRA Job & Fellowship Fair Supported by emCareers.org, Laurel Road, TeamHealth, and Vituity Monday, Oct. 28 7 am – 12:30 pm EMRA Representative Council and Town Hall ¬ Resolution debate and vote ¬ Election of 5 new EMRA board members

9 am – 3 pm

10 pm – 2 am Supported by Envision Physician Services

Tuesday, Oct. 29 1 – 3 pm EMRA

5 – 7 pm EMRA Airway Stories — Supported by Vituity

Wednesday, Oct. 30 8 am – 5 pm Supported by BTG

8 EMRA | emra.org • emresident.org EXCELLENCE IN EM As EMRA celebrates a 45-year milestone, we draw particular attention to our Honoring EMRA’s Fall 2019 EMRA Award recipients. Their contributions stand out in a field of high achievers, and we are proud to Fall Award Winners honor these dedicated members.

Joseph F. Waeckerle, MD, FACEP, Christie A. Lech, MD, MHPE CORD AA Travel Scholars Alumni of the Year Brian J. Levine, MD, FACEP, FAAEM Madeline Brockberg, MD | Boston University Jeremy Berberian, MD | Christiana Care Richard M. Levitan, MD, FACEP Medical Center Nathaniel Schlicher, MD, JD, MBA, FACEP Health System LAC Travel Scholars Krystle Shafer, MD Michael Tetwiler, MD, MPH | Harbor-UCLA Faculty Mentor of the Year Laura Welsh, MD Joshua Moskovitz, MD, MBA, MPH, FACEP | Medical Center TRAVEL SCHOLARSHIPS Jacobi Medical Center Airway Lab Scholarship Faculty Teaching Excellence EMRA Congressional Health Robert Allen, MD | SUNY Downstate/Kings Award Policy Fellowship County Kelly Young, MD, MS | Harbor-UCLA Medical Gururaj Shan, MD | SUNY Downstate/Kings Matt Aronson, MD | Advocate Christ Medical Center County Center Mary Bolgiano, MD | Baylor College of Steve Tantama, MD, Military EMRA/ACEP Resident-Fellow Medicine Excellence Award Health Policy Elective Stephanie DeMasi, MD | University of Mia Geurts, MD | Madigan Army Medical Sachin Santhakumar, MD | SUNY Upstate Alabama at Birmingham Center Medical University Ye Jung Ho Ferrabolli, MD | Mount Sinai St. Augustine D’Orta Humanism EMRA/ACEP Medical Student Luke’s Roosevelt Hospital Center Award Health Policy Elective Anne Flower, DO | University of Kentucky Kimberly Chernoby, MD, JD, MA | Indiana Blake Denley | LSU Health Sciences Center Timothy Henderson, MD | Advocate Christ University School of Medicine New Orleans Medical Center Erik Kramer | Yale School of Medicine Clinical Excellence Award Megan Hoffer, DO | Ohio Valley Medical Center David Gregory, MD | Wellspan York Hospital EMRA/EDPMA Scholars Allen Chang, MD | Stanford University Stephanie Huang, MD | Mount Sinai St. FOAM(er) of the Year Hospital Luke’s Roosevelt Hospital Center Joshua Niforatos, MD, MPH | Johns Hopkins Nicholas P. Cozzi, MD, MBA | Spectrum Diana Huynh, MD | Baylor College of University Health/Michigan State University Medicine Be The Change Project Grant Tehreem Rehman, MD, MPH | Advocate Lucinda Lai, MD | Harvard Affiliated Timothy Henderson, MD | Advocate Christ Christ Medical Center Emergency Medicine Residency Yevgeniy Maksimenko, MD | Boston Medical Center International EM Rotation University Medical Center EMRA Simulation Research Grant Scholarship Kevin McGurk, MD | John H. Stroger Hospital William Weber, MD, MPH | The University of Antony Gatebe Kironji, MD, MPH, MSEd | of Cook County Chicago Boston University Medical Center Manuel Bernal Mejia, MD | Advocate Christ Honorary Lifetime Members EDDA Travel Scholars Medical Center Jeremy Berberian, MD Nicholas P. Cozzi, MD, MBA | Spectrum Carl Preiksaitis, MD | Stanford University Arlene Chung, MD, MACM Health/Michigan State University Hospital John C. Greenwood, MD Mitchell Kentor, MD | Advocate Christ Tehreem Rehman, MD, MPH | Advocate Alison J. Haddock, MD, FACEP Medical Center Christ Medical Center Sepehr Sedigh Haghighat, MD Aidin Masoudi, MD | Maimonides Medical Bethany Ruby, DO | University of Arkansas Robert Hsu, MD, FACEP Center for Medical Sciences Zach Jarou, MD Arnab Sarker, MD, MBA | New York Rachel Solnick, MD | University of Michigan Kenneth D. Katz, MD, FACEP, FAAEM, University/Bellevue Medical Center David Toomey, MD | Harvard Affiliated FACMT Natasha Thomas, MD | Harbor-UCLA Emergency Medicine Residency Joseph Habboushe, MD, MBA Medical Center Olivia Zoph, MD | Emory University ¬

October/November 2019 | EM Resident 9 August/September 2019 | EM Resident 39 EMRA’S UNDER 45 INFLUENCERS IN EMERGENCY45 MEDICINE

EMRA’S As EMRA celebrates 45 yearsUNDER of supporting the future of emergencyINFLUENCERS medicine, IN EMERGENCY we recognize45 MEDICINE 4545 Under 45 Influencers in Emergency Medicine (#EMRA45u45).

We’re excited to introduce you to these outstanding young physicians whose EMRA’S contributions embody the spirit of the specialty. WeUNDER can’t wait to experience 45the worldINFLUENCERS they will IN EMERGENCY bring us!45 MEDICINE Let’s peek into the future…

More than 400 applications were reviewed by the selection committee, comprising Steven J. Stack, MD, MBA, FACEP; Zach Jarou, MD; Omar Z. Maniya, MD, MBA; Hannah Hughes, MD, MBA; Ven Subramanyam, MD; Erin Karl, MD; and Jazmyn Shaw. The selection committee was blinded to EMRA and/or ACEP membership status. Care was taken to ensure both a diverse applicant pool and awardee group. For any questions, contact Cathey Wise at [email protected]. Michael April, MD, PhD, MSc, FACEP Uché Blackstock, MD Major, United States Army NYU School of Medicine San Antonio Uniformed Services Health Advancing Health Equity, LLC Education Consortium Addressing inequity in health Decorated veteran Mike care has become the focus April is a United States of Uché Blackstock’s career Military Academy graduate, — as a clinician, an educator, an American Rhodes scholar a public speaker, and the (2005), and an alumnus of founder of Advancing Health the University of Oxford and Equity, LLC. Reaching out and Harvard Medical School. As standing up for those in need Assistant Residency Program is a legacy passed from Dr. Blackstock’s parents Director for Research he not only fosters current (especially her forever role model, her late research but also prepares medical scholars of mother) to her students, colleagues, and the next the future. generation of physicians.

Nicole Battaglioli, MD, FAWM Kimberly A. Chernoby, MD, JD, MA University of Kentucky Indiana University Emergency Medicine ALiEM Chief Resident As outgoing ALiEM Wellness After earning a master’s Think Tank COO, Nicole degree in bioethics from Battaglioli has devoted NYU, Kimi Chernoby became considerable time and the first graduate of the brainpower to defining and combined MD/JD program improving resident wellness. at the University of Florida. Along with being an Assistant In addition to chief resident Professor of Emergency duties at IU, she is serving Medicine, Dr. Battaglioli is the CEO/founder of on the AMA Council on Ethical and Judicial Komorebi Coaching, lover of wilderness med- Affairs and as a trustee for the Indiana State icine, and promoter of super-sheroes, living life Medical Association. She advocates passionately as “an energetic force for good” in EM. for patients’ rights.

Arlene Chung, MD, MACM, FACEP Maimonides Medical Center EM Residency Program Director Nationally recognized She is one of the rare speaker and educator Arlene Chung has championed types whose spirit physician wellness through lectures, teaching, policy shines through in all development, and innovation. She’s editor-in-chief of the the work she does. EMRA Wellness Guide, outgoing Chief Strategy Officer for the ALiEM Wellness Think Tank, chair of the ACEP Well- being Committee, and one of the most effective motivators in medicine.

12 EMRA | emra.org • emresident.org EMRA's 45 Under Influencers in EM Christian Dameff, MD, MS UC San Diego Health Clinical Informatics Fellow Hacker, security researcher, He is a veritable and CyberMed Summit co- founder Christian Dameff is Obi-Wan Kenobi making waves in the world of medical cybersecurity, of health policy and aiming to protect the integrity of medical devices advocacy, a giant and infrastructure. He is a clinical informatician and oft-quoted researcher in the field. who is defining the still-emerging role of Medical Director of Cybersecurity — all while pioneering technology-based innovations.

Cedric Dark, MD, MPH, FACEP Hilary Fairbrother, MD, MPH, FACEP Baylor College of Medicine McGovern School of Medicine Policy Prescriptions® UTHealth – Houston Policy Prescriptions® Hilary Fairbrother is a strong founder/executive editor believer in every individual’s Cedric Dark is a well-known ability to make a difference. presence in health policy It’s how she frames her circles, producing a podcast work in academic medicine, for AAEM, leading the her leadership as chair of EMRA+PolicyRx Health Policy the AMA’s Young Physicians Journal Club, and writing a Section, and her approach regular column for ACEP Now. Called the “Obi- to helping new leaders rise. When not focused Wan Kenobi of health policy,” his work inspires on patients and policy, she’s enjoying life with the next wave of advocates as he demonstrates her husband, toddler, 2 Italian greyhounds, and how to turn theory into action. 3 post-Hurricane Harvey cats.

Carrie de Moor, MD, FACEP Jeremy Faust, MD, MS, MA Code 3 Emergency Partners Harvard Medical School The nation’s 4th-busiest ACEP Now airport (DFW International) As a noted music scholar, made history in 2018 when board president of a it became the first in the Grammy-winning vocal world to have its own ensemble, and worldwide emergency room, thanks to author/editor, Jeremy Faust Carrie de Moor’s Code 3 ER embraces the humanities and Urgent Care. Focusing as a common denominator on “patients, not profit,” she’s at the forefront among all humans. Look to of free standing EDs, urgent care provision, this newly minted ACEP Now medical editor-in- and medical entrepreneurship, standing up chief to frame the specialty’s key conversations for the independent practice of medicine and with evidence, practicality, compassion, and revolutionizing the future of the specialty. inspiration or, depending on the day, sarcasm).

October/November 2019 | EM Resident 13 Alison Haddock, MD, FACEP Baylor College of Medicine ACEP Board of Directors Her power to ACEP Board member Alison Haddock has been a health influence action is policy enthusiast since her days as an EMRA Board strengthened by the member, and she’s instilling the same regard in her way she mentors students and residents at Baylor College of Medicine. rising leaders. As an editor-in-chief of EMRA’s Advocacy Handbook, Dr. Haddock teaches the specialty why advocacy matters — and how to get involved.

Cleavon Gilman, MD Amy Faith Ho, MD Weill Cornell Medical College John Peter Smith Hospital Emergency Medicine Resident Integrated Emergency Services Cleavon Gilman was 12 Fans of “Untold Stories of the when he attended LL Cool ER” will recognize Amy Faith J’s summer camp and Ho as a physician who goes discovered rap music eased the extra mile to answer her his battle with stuttering. patients’ questions and set Fast-forward through their minds at ease. Those school, then a Marine Corps traits serve her well as an deployment to Iraq as a educator, lecturer, podcaster, combat medic, then EM residency, and you and defender of patients’ now find a physician passionate about helping right to equal care. Her influence extends colleagues and patients unburden themselves through national media and direct mentorship in through “scholar rap.” EM.

Alin Gragossian, DO, MPH Paul Jhun, MD Drexel University College of Medicine University of California San Francisco Emergency Medicine Resident Hippo Education Resiliency has a face: In If you thrive on learning less than 12 months, Alin outside the lines in EM, Gragossian went from you’ve likely benefited from being a busy resident Paul Jhun’s work. He is an planning for a critical care award-winning educator who fellowship to being a heart is well-versed in learning transplant recipient. Then, theory — and motivated to mere days before resuming make medical education a “life after transplant” with a return to shifts, her multimedia experience. He believes in death to residency program at Hahnemann University PowerPoint (instead of death by PowerPoint), Hospital disintegrated. And yet, she says, “life is conversational learning, and the power of having beautiful.” someone believe in you.

14 EMRA | emra.org • emresident.org EMRA's 45 Under Influencers in EM Dara Kass, MD, FACEP Alicia Mikolaycik Kurtz, MD Columbia University Mercy San Juan Medical Center FemInEM Founder Real Talk podcast Gender equity — for Spend 5 minutes with Alicia physicians and patients Kurtz and you’ll believe alike — drove Dara Kass to she can change the world. found FemInEM, co-author Spend 10 minutes with her “Olivia Otter Builds Her Raft,” and you’ll know you can, lecture around the globe, too. Such is the gift of this and become a social media natural motivator whose influencer. She campaigns favorite approach to the tirelessly to lift up women in EM. This fearless status quo is to shake it up. Her leadership educator and clinician reached peak fierceness, helped EMRA to level up, and she has as a living donor when her son needed a liver turned that energy toward practice-changing transplant. improvements in health care administration.

Seth Kelly, MD, MBA Aisha Liferidge, MD, MPH, FACEP University of Maryland George Washington University Emergency Medicine Resident Dr. Aisha Liferidge Minority Women Seth Kelly remembers the in Science Foundation patient who pushed him ACEP Board member Aisha out of his business career/ Liferidge is shining a light volunteer firefighter role and on diversity and inclusion into full-time medicine. That through mentorship, same experience — when leadership, and advocacy. he calmed and freed a child She is the director of the trapped in wreckage — is Health Policy Fellowship what propels him toward an EMS fellowship and at George Washington a career in prehospital medicine. Always quick University and CEO of a nonprofit that empowers to highlight teammates and strive for the greater the dreams of future leaders interested in a good, he leads through service. career in science.

Alex Koyfman, MD, FACEP UT Southwestern emDocs FOAMed got a boost What makes him when Alex Koyfman co- founded emDocs, a website an influencer? dedicated to the timely discussion of current Commitment, passion, evidence for practicing humility, integrity, emergency medicine. With a keen interest in resident and and vision – he’s an faculty development, he also serves on ACEP’s Education Subcommittee, writes for Emergency inspiration. Physicians Monthly, and keeps a sharp eye out for future authors.

October/November 2019 | EM Resident 15 Michelle Lin, MD, MPH, MS, FACEP Jessica Mason, MD Icahn School of Medicine at Mount Sinai UCSF Fresno Mount Sinai Beth Israel EM:RAP As Chair-Elect of the Clinical Jess Mason has been Emergency Data Registry seeking better ways to learn Committee, Michelle Lin (and teach) since medical helps direct the largest school, rising from a student qualified clinical data podcaster to Deputy Editor registry in EM. She is also of EM:RAP. She directs the VP of Communications for EM Education Fellowship at the Academy of Women in UCSF-Fresno, influencing Academic Emergency Medicine and has served the educators of tomorrow and pushing the as a fellow and consultant within the Centers for boundaries of med-ed innovation. Within Medicare and Medicaid Innovation (CMS/CMMI) her community, she takes to the airwaves to Seamless Care Models group. promote public health and careers in medicine.

Abhi Mehrotra, MD, MBA, FACEP University of North Carolina Abhi Mehrotra, Vice Many emergency Chair of Operations and Strategic Initiatives at UNC physicians influence EM and chair of ACEP’s CEDR Committee, strives EM regionally, but to improve patients’ lives through health care how many change administration — and a the care of an entire healthy dose of teamwork. Entrepreneurship is high on his list of accomplishments, as is country? research and public service. He has become known for an old email signature: “No act of kindness, no matter how small, is ever wasted.”

Andrew (Andy) Little, DO Rockefeller Acheampong Oteng, EMP of Franklin County/Doctors Hospital MD, FACEP, FGCS EM Over Easy University of Michigan FOAMed star Andy Little Ghana-born and Washington, tackles topics from every D.C.-raised Rockefeller spectrum of EM. When he’s Oteng has built emergency not teaching on shift you can medicine in his native find him planning weekly country one trainee at a time conference at Doctors — starting with global health Hospital, podcasting for the outreach and continuing show EM Over Easy (one through a Fogarty Fellowship he co-founded in 2016), planning regional and supported by the National Institute of General national events, and mentoring the folks from Medical Sciences. He is working to improve care EMRA•Cast. He believes in hard work, accepting throughout sub-Saharan Africa and establish a helping hand, and paying it forward. lasting roots for the specialty of EM.

16 EMRA | emra.org • emresident.org EMRA's 45 Under Influencers in EM Rick Pescatore, DO, FAAEM Salim Rezaie, MD, FACEP Crozer-Keystone Health System Greater San Antonio Emergency Physicians Mullica Hill Advanced Therapies REBEL EM and The Teaching Institute If you’ve ever deconstructed Double-boarded EM/IM Disney movies to form a attending Salim Rezaie differential for the main changed the specialty characters, you need when he founded Rational to compare notes with Evidence Based Evaluation Rick Pescatore. He’s fully of Literature in Emergency immersed in academic Medicine (REBEL EM). His medicine and evidence- contribution to FOAMed based practice (not to mention parenting). With is legendary — as is mentorship: “He let me podcasts, research articles, commentaries, and shadow him (my first EM shifts ever). I didn’t social media, he boldly drives conversation about know I was in the presence of greatness, public health — and pineapple on pizza. because that’s not how he carries himself.”

Ali Raja, MD, MBA, MPH, FACHE Massachusetts General Hospital Harvard Medical School Ali Raja, a world-renowned He is the epitome researcher focusing on ED resource utilization, is of a FOAM the current editor-in-chief of NEJM Journal Watch community influencer, and a frequent lecturer at conferences ranging from often cited on “who to ACEP Scientific Assembly to FemInEM Idea Exchange. His path to medicine follow” lists. also includes time in the United States Air Force, where he was deployed as critical care air transport commander.

Megan Ranney, MD, MPH, FACEP Ryan Ribeira, MD, MPH Brown University Stanford University AFFIRM, Founder SimX Though it was the NRA’s As a clinical instructor, a infamous “stay in your lane” recent AMA board member, tweet that galvanized the a leader in California medical community, Megan organized medicine, and a Ranney has been focused businessman, Ryan Ribeira on gun violence prevention is working to improve since 26 children and staff medicine from nearly members were shot to death every angle. That same at Sandy Hook Elementary School. Following 360-thinking led him to the Las Vegas shooting of 2017 she co-founded found med-ed tech startup SimX, devoted to AFFIRM, and she serves as a positive, uniting high-def virtual training using VR and AR, with presence in the national debate of gun safety. an eye on tomorrow’s advancements today.

October/November 2019 | EM Resident 17 Jeff Riddell, MD Hon. Nathaniel Schlicher, MD, JD, University of Southern California MBA, FACEP EMRA’s Quiz Show and Northwest Emergency Physicians 20 in 6 Resident Lecture of TeamHealth Competition — dreamed When the University of up during Jeff Riddell’s Washington balked at time on the EMRA Board admitting 17-year-old college — illustrate his approach graduate Nathan Schlicher to engaging, dynamic to medical school, he used education. He has become the time (2 whole years) to a well-known lecturer with Essentials of EM get a law degree. He was and ALiEM, while also publishing widely the youngest member of the within the specialty. He encourages a broad State Senate in Washington, president of multiple approach to improving patient care by associations, editor-in-chief of the Advocacy improving the training experience. Handbook, and a tireless voice for patients.

Hon. Jon Santiago, MD, MPH Gillian Schmitz, MD, FACEP Boston Medical Center F. Edward Hebert School of Medicine, Massachusetts Legislature, 9th Suffolk District Uniformed Services University During his final year of Brooke Army Medical Center | UT-San Antonio residency, Jon Santiago As a recipient of EMRA’s unseated a veteran Faculty Mentor of the Year Massachusetts legislator Award, ACEP Board member to become the State Gillian Schmitz is widely Representative from the 9th known as someone willing Suffolk District, becoming to take the time to mentor, one of a handful of EM connect with colleagues, and physicians-turned-lawmakers. He wants to focus advocate for patients and the on recognizing health care disparities in the specialty on every level - making the phrase “I community and working to combat the opioid wouldn’t be where I am without her” common in crisis. many circles.

Jeremiah Schuur, MD, MHS, FACEP Alpert Medical School, Brown University/Lifespan Jay Schuur, chair of She is a truly stellar Emergency Medicine at the Alpert School of Medicine, role model, both for has become a noted force in health policy and quality leadership style and improvement. He led emergency medicine to clinical skills. adopt the Choosing Wisely campaign, and his list of publications and editorial roles scrolls for miles. Equally important are the understanding and guidance he offers his colleagues and students alike.

18 EMRA | emra.org • emresident.org EMRA's 45 Under Influencers in EM Kirstin Woody Scott, MPhil, PhD Harvard Medical School University of Washington visiting scholar Fourth-year medical He is a true student Kirstin Scott has a passion for public health, innovator and research, and policy — and the experience to impact trailblazer, and his all three. She serves on the Liaison Committee on work has national Medical Education, is a visiting scholar at the Institute for Health Metrics implications. and Evaluation, and is a senior research fellow for the University of Global Health Equity in Rwanda.

Rahul Sharma, MD, MBA, CPE, FACEP Ryan Stanton, MD, FACEP, FAAEM New York Presbyterian – Weill Cornell Central Emergency Physicians Medicine Lexington Fire/EMS One of the many ways Rahul Fans of ACEP Frontline Sharma hopes to improve know Ryan Stanton has patient care — in addition to a big voice — which he training excellent physicians uses to tackle the topics under his leadership as Chair EM physicians face in the of Emergency Medicine — is by trenches. He also brings increasing access to that care. medicine to the masses The telemedicine programs he through “The Doc Is In,” a has piloted are directly impacting patients in New TV program airing in 6 markets. His 28 years York, and his ED Express Care Service is held up of media experience inform his service to as a model of the future of medicine. the specialty as he works daily to serve his community via clinical shifts.

Donald Stader III, MD, FACEP Reuben Strayer, MD, FRCPC, Swedish Hospital, CarePoint FACEP, FAAEM Stader Opioid Consulting Maimonides Medical Center The Emmy award-winning EMupdates.com 24|7|365: The Evolution Nearly-native Texan Reuben of Emergency Medicine Strayer trained in Montreal documentary owes its — where “balmy” weather existence to former EMRA helped him focus on President Don Stader, who a flashcard project that has gone on to produce gave rise to the popular the soon-to-be-released EMupdates.com blog. Palliative and serve as editor-in-chief of ACEP’s Current interests (on top 50th anniversary tome Bring ‘Em All. Clinically, of FOAMed) include airway management, he is a national leader in developing guidelines procedural sedation, “sweeping generalizations, to prevent opioid overuse. and jalapeno peppers.”

October/November 2019 | EM Resident 19 Anand Swaminathan, MD, MPH, Scott Weingart, MD, FACEP, FCCM FACEP Renaissance School of Medicine St. Joseph’s Emergency Medicine at Stony Brook EM:RAP, REBEL EM, EMA EMCrit You can’t go more than 2 “Titles and Other Bulldung” clicks in the FOAMed world is the headline for the without running into Anand autobiography page on Swaminathan. REBEL EM, Scott Weingart’s website. It’s EM:RAP, EMA, Life in the Fast vintage for this critical care Lane, emDOCs, Core EM, The specialist and med-ed giant SGEM — he’s contributed to whose podcast, EMCrit, has all of those and more — all become a staple for every while excelling at his “day job” as Fellowship student and practitioner interested in critical Director of both the Clinical Educator and Medical care medicine and resuscitation. Education fellowships at St. Joseph’s.

Seth Trueger, MD, MPH, FACEP Jennifer Wiler, MD, MBA, FACEP Northwestern University University of Colorado JAMA Network Open UCHealth CARE When JAMA Network Open Innovation CenterTM needed a digital media Jennifer Wiler is the lone leader, they sought out EM physician on the HHS Seth Trueger, who reaches committee tasked with 28,500+ people on Twitter as recommending physician- @MDAware, and thousands focused payment models. more as a social media editor She is also Executive Vice for Emergency Physicians Chair for EM at the University of Colorado, a Monthly. While dynamic and entertaining, he professor in the School of Business, and co- is also fundamentally committed to improving founder/executive director of UCHealth CARE patient care through policy, evidence-based Innovation Center, a unique venture that brings practice, and simple common sense. togehter health care and technology innovations.

Arjun Venkatesh, MD, MBA, MHS Yale Emergency Medicine When residents seek you out to help them with mock fellowship interviews and If there were ever an even residency roasts, it’s a sign you have arrived in unsung hero, it’s this academic medicine. Arjun firecracker research Venkatesh fills those roles while leading E-QUAL, a scientist we are proud CMS-funded initiative for quality improvements in more than 1,000 EDs in America. A powerhouse of to call our own. EM policy, he has garnered $6 million+ in funding to improve the specialty nationwide, and his work will impact generations of physicians.

20 EMRA | emra.org • emresident.org October/November 2019 | EM Resident 21 TOXICOLOGY

So I Watched CHERNOBYL… Now What? Revisiting Acute Radiation Syndrome Leslie Crosby, MD physicians ought to be prepared to care and manifest the symptoms of Acute Crozer Chester Medical Center Emergency for the more plausible patient injured Radiation Syndrome. Exposure to less Department from working in an industrial, military, than 1 Gy (1 Gy = 100 rads) is unlikely @LeslieCrosbyMD1 research, or medical setting with known to produce symptoms, whereas greater Laura Roper, MD radiation risks. Alternatively, cases of than 10 Gy is fatal. Exposure to radiation EMRA Toxicology Committee Chair, 2019-2020 Crozer Chester Medical Center Emergency radiation sickness have occurred as a over time increases the risk of eventual 4 Department result of patients unwittingly handling malignant transformation. 2 @LauraBRoper discarded radiation sources. Progression of Illness Dorian Jacobs, MD Pathophysiology of the The prodromal phase of acute Crozer Chester Medical Center Emergency Effects of Radiation radiation sickness occurs within minutes Department, Medical Toxicology Radiation injury is caused by to days of exposure to at least 1 Gy. Introduction deposition of energy in tissues, which During the latent phase, symptoms lthough more than 119 million promotes free radicals and disruption appear to improve or abate for several U.S. residents live within 50 miles of DNA and other cellular structures. days to a month. The manifest phase of a nuclear power plant, most Radiation exposure can occur through lasts from hours to months and features A 3 emergency physicians are unfamiliar with inhalation, ingestion, and transdermal the most severe symptoms. Increasing management of radiation-related injuries, absorption.3 However, body parts and doses of radiation leads to acceleration including mass casualty from nuclear tissues are not affected equally. Rapidly of the timeline such that exposure to accidents.1 Military attacks or natural proliferating cell lines such as intestinal higher levels of radiation can lead to disasters affecting civilian nuclear power mucosa and bone marrow are most immediate prodromal symptoms as well plants are extremely unlikely. However, immediately sensitive to radiation as progression to the manifest phase

22 EMRA | emra.org • emresident.org within hours to days. This accelerated BIODOSIMETRY baseline CBC with differential and sequence is almost uniformly fatal. A detailed history, including the platelet count and repeat every 2-3 Management source of radiation, the distance from hours for the first 48 hours to continue to monitor for declines in lymphocytes. CONSULT SPECIALISTS the source, and how the patient was Obtain type and screen for HLA typing, As soon as possible, recruit the help exposed, is critical to determine the in case transfusions are required. of your designated hospital radiation course of treatment. Time to onset of Obtain routine urinalysis and basic safety officer and toxicologist. symptoms can help estimate the exposed metabolic panel to determine baseline The Radiological Assistance dose of radiation. Severity of exposure renal function. Swab body orifices to Program of the U.S. Radiation can be estimated based upon time to determine whether internal exposure Emergency Medical Management emesis; survival is inversely related has occurred. Collect 24 hour sample (REMM) has a 24-hour hotline available to radiation dose. Emesis that occurs of urine for 4 days for radionuclide at 202-586-8100, which offers greater than 4 hours after exposure identification.12 specialized assistance and reporting. typically predicts a more mild course of Supportive care and resuscitation The U.S. Department of Energy sequelae. Emesis within 2 hours predicts at least 3 Gy dose of radiation. Clinicians should include antidiarrheals, fluids, Radiation Emergency Assistance electrolytes, non-NSAID analgesics, typically closely follow the absolute Center/Training Site (REAC/TS) is also and burn care. Radiation experts may lymphocyte count, since it predictably available to assist 24/7 at 865-576- recommend cathartics, gastric lavage, correlates with the amount of exposure 1005. and activated charcoal if ingestion is to radiation in a dose-dependent Colleagues from radiology, suspected. Any surgical intervention manner. Though less frequently used hematology-oncology, trauma surgery, should occur within 36 hours of in clinical practice, the gold standard and burn centers may provide additional exposure.3,14,12 for biodosimetry is the lymphocyte expertise in these cases. Any blood products administered chromosomal dicentrics assay. The DECONTAMINATION should be leukoreduced and irradiated. assay requires a culture of 48-72 hours Personal protection equipment Internal contamination treatment is to yield results and may be ordered should include disposable scrubs determined by the specific radionuclide through the Radiation Emergency with taped seams, shoe covers, hats, contaminant. For instance, if the patient Assistance Center/Training Site.8,9,10 The masks, and goggles. Staff should wear a was exposed to radioiodines, potassium REMM App has useful decision tools for personal dosimeter to monitor exposure. iodide should be administered within quickly estimating exposure of radiation 3 The goal of decontamination is to reduce 4-6 hours of exposure. If estimated based upon time to emesis, lymphocyte the level of contamination to twice the exposure is greater than 2 Gy, consider kinetics, and chromosomal dicentrics level of background radiation or until human leukocyte antigen testing in assay. subsequent attempts fail to reduce the anticipation of future pancytopenia level of contamination by less than 10%, Treatment management. Consult radiation or according to consultant guidance.4 Manage ABCs first. Treatment of experts and hematology to determine if Removal of clothing should reduce life-threatening conditions has priority granulocyte colony stimulating factor the level of external contamination by over treatment of radiation-related is indicated and the recommended 12 90%.7 Residual radiation contamination injuries.11 As soon as possible, obtain regimen. ¬ is then evaluated by passing a Geiger counter at a constant distance from TAKE-HOME POINTS the skin over the entire body. Residual contamination is then removed by gently • Radiation injury promotes free radicals and disruption of DNA and other cellular cleaning the skin and hair with soap and structures warm water to avoid damaging the skin. • Rapidly proliferating cell lines such as intestinal mucosa and bone marrow are Cover any open wounds to prevent most immediately sensitive to radiation further contamination via runoff. • Recruit help as soon as possible from local and national institutions, including Irrigate abrasions and puncture your toxicology service, radiation safety officer, REMM and REAC/TS. wounds with saline. Lacerations may • Decontaminate require excision if standard irrigation is • Download the REMM app to estimate the amount of radiation exposure ineffective. Wounds containing impacted • Important diagnostic tests are CBC with differential repeated every 2-3 hours for radioactive shrapnel require special the first 48 hours to continue to monitor for declines in lymphocytes, type and care in order to avoid healthcare staff screen, urinalysis and basic metabolic panel exposure. At times, amputation may • Treat with supportive and symptomatic care including antidiarrheals, IVF, replete be required to adequately remove the electrolytes, non-NSAID analgesics, and burn care source of radiation from the penetrating • If blood products are administered, they should be leukoreduced and irradiated. wound.4,6

References available online October/November 2019 | EM Resident 23 NEUROLOGY/ULTRASOUND

It is important that we consider the risks of this procedure and appropriate patient selection.

Risk Awareness in the Interscalene Nerve Block Heather Roesly, MD anesthetic is infiltrated around the nerves. the benefits of the procedure are being Denver Health This procedure has been shown to be of promoted, the risks of the procedure have Emergency Medicine Residency particular utility in shoulder reductions in not been fully explored in the emergency Spencer Tomberg, MD Emergency Medicine/ the ED, with multiple studies illustrating medicine literature. Sports Medicine Physician decreased emergency room length of Interscalene nerve blocks were Denver Health Medical Center stay with the use of regional anesthesia developed for analgesia prior to shoulder nterscalene nerve blocks have recently compared to procedural sedation.1 While surgeries. As emergency physicians have been popularized as a technique to this is an important finding, especially broadened their skill sets with ultrasound Ifacilitate shoulder reductions in the among emergency physicians working in (US)-guided regional nerve blocks, the emergency department. The procedure overcrowded EDs with long wait times, procedure has become a tool available in involves recognizing the brachial 5th, 6th, it is important that we consider the ED. When performed under direct and 7th roots of the brachial plexus where the risks of this procedure and real time visualization, there has been an they lie between the anterior and middle appropriate patient selection prior increase in its success rate in the hands scalene muscles on the inferior/anterior to popularizing its use, just as we have of less experienced physicians, and there neck. After the 5-7th roots are visualized, done with procedural sedation. While has been a significant decrease in the

24 EMRA | emra.org • emresident.org potential risks of the procedure.2 diaphragm. This is thought to be more back and shoulder pain and varying levels Traditionally, interscalene blocks directly correlated with anesthetic volume of functional impairment.6 Traditionally, are performed under US guidance in and cranial spread of anesthesia along the injury to the scapular nerve was avoided the emergency department. This should muscle fascia rather than secondary to by the use of muscle stimulation/ only be considered after complete direct injury.3 twitching, which is not usually utilized in neuromuscular examination of the Several studies have shown decreased the emergency department. This makes extremity, as regional anesthesia will pulmonary function in the majority awareness and US identification all the limit any further assessment after of patients post-interscalene blocks, more important so this structure can be administration. A complete view of the suggesting that phrenic nerve paralysis avoided. brachial plexus should be obtained in the can be an expected consequence of this Long Thoracic Nerve procedure.4 interscalene position with administration There was no observed The long thoracic nerve (LTN) of anesthetic performed under in-line difference in this rate in comparison innervates the serratus anterior and is of the anterior or posterior US-guided visualization until envelopment of the derived from the 5th and 6th cervical roots. approach. It is postulated that decreasing brachial plexus is identified. Choice It runs in close proximity to the DSN as volumes of anesthetic may decrease this of anesthetic agent varies given the described above, but is generally deeper, effect.4 different length of actions; however, usually between the 6th and 7th cervical use of shorter-acting anesthetics seems While this may not have a huge role in roots within or close to the middle scalene to make sense in the setting of a short otherwise healthy individuals, it can have muscle. Injury of LTN can also contribute procedure with limited post-procedural drastic effects on ventilation in patients to a chronic pain syndrome with serratus pain. Prior to anesthetic administration, with already limited pulmonary function. anterior palsy. This can impair shoulder it is important to identify all important Its effect on obese patients, those with elevation and can lead to impingement nearby structures to ensure these are syndromes.6 avoided during the procedure. As emergency It is important to consider all structures near the brachial plexus Vasculature physicians have The addition of US guidance and when performing interscalene Doppler imaging has greatly assisted broadened their skill blocks. One Korean study showed that during a standard US-guided posterior in the identification of vasculature in sets with ultrasound the area. Prior to administration of brachial plexus block approach, the anesthetic, it is important to identify the (US)-guided regional DSN was encountered as much as 60% carotid artery and the internal jugular of the time, and the long thoracic nerve nerve blocks, the 7 vein. These are often out of the in-line was encountered up to 21% of the time. view as they are more medial structures, procedure has While this finding was identified under nerve stimulation and may overestimate but should be identified prior to initiation become a tool associated risk of injury, it is important to so that the performing physician can consider this as a very viable complication be aware and comfortable with their available in the ED. of the procedure, even under US location. These should be avoided guidance, especially when the nerves are throughout the procedure, not only to hypoventilation, and those with primary not identified prior to performing the decrease risk of bleeding or vessel injury, lung disease (especially with oxygen procedure. but also to ensure against inadvertent requirements) must be considered prior The utility of interscalene blocks in intravascular injections of anesthetic to the procedure. shoulder reductions is being recognized which can have a dose-dependent direct Dorsal Scapular Nerve in the emergency department. It is cardiovascular toxic effect. Although phrenic nerve injury is important to be clear of surrounding Phrenic Nerve a well-known and respected possible neurovascular structures and to While the phrenic nerve is often a complication of interscalene blocks, understand potential complications considered structure in this area, its the long thoracic and dorsal scapular of this procedure prior to adopting vicinity cannot be appreciated enough, nerves are less often discussed. The it. Vascular structures should always especially when considering potential dorsal scapular nerve (DSN) supplies be identified and avoided under US candidates for this procedure. As the innervation to the levator scapulae and guidance. Potential patients should be phrenic nerve courses along the brachial rhomboid muscles. It is derived from screened for underlying pulmonary plexus on its path to innervating the the 5th cervical nerve root and can be disease prior to the administration of diaphragm, consideration of its paralysis identified via US at the 6th cervical root anesthetic as phrenic nerve paralysis or injury must be emphasized. Paralysis level, usually as a hyperechoic structure can be an expected complication of the of the phrenic nerve secondary to within the middle scalene muscle.5 procedure. Being able to recognize the anesthetic administration or direct Injury can lead to a chronic pain DSN and LTN can help avoid damage to injury can lead to hemiparalysis to the syndrome in these patients, with upper these important structures. ¬

References available online October/November 2019 | EM Resident 25 HEMATOLOGY Multiple Myeloma

ED management of multiple myeloma should focus on medical stabilization and symptomatic relief. However, there are potential complications that require special consideration.

Diagnostic and Treatment Considerations in the ED Daniel Patino-Calle, MD is positive for distention. He also has Discussion University of Connecticut bony tenderness over the lumbar Multiple myeloma (MM) is a cancer of Shawn London, MD, FACEP spine. Digital rectal exam reveals plasma cells that results in the production Program Director guaiac negative brown stool and University of Connecticut of abnormal antibodies (ie, paraproteins), normal rectal tone. Laboratory studies Emergency Medicine Residency which accumulate in the bone marrow are significant for creatinine 15.9 mg/ and other vital organs. MM accounts Case Presentation dL, calcium 13.4 mg/dL, hemoglobin for 1-2% of all cancers and results in 65-year-old male with a past 4.7 g/dL, and total serum protein 10.3 approximately 106,000 deaths per year medical history of peptic g/dL (normal range 6 – 8.3 g/dL). A worldwide.1 It is known as a cancer of the ulcer disease presents to the skeletal survey performed in the ED A elderly, with a median diagnosis age of 66 emergency department with 2 months demonstrates scattered lytic lesions of generalized weakness, constipation, and an L1 compression fracture. The years. The precise etiology is unknown, and weight loss. Initial vitals include patient receives resuscitation with but an increased incidence has been temperature 98.7 degrees Fahrenheit, intravenous fluids, analgesics, and linked with environmental exposures heart rate 111, blood pressure 191/88, 2 units of packed red blood cells. including agricultural pesticides, sheet and oxygen saturation 98% on room air. Nephrology and hematology are metal, and wood dust.2 On physical exam, he appears cachectic consulted and the patient is admitted Patients will often present with non- and ill-appearing. He has evidence of with a presumed diagnosis of multiple specific symptoms such as weight loss, conjunctival pallor. His abdominal exam myeloma. fatigue, generalized weakness, and bone

26 EMRA | emra.org • emresident.org 3 pain. A definitive diagnosis is rarely made In patients with bladder dysfunction, a C.R.A.B. SYMPTONS in the ED but there are certain features bladder ultrasound can be performed to • Calcium Elevation of the disease that should raise your assess for post void residual (PVR). PVR • Renal Insufficiency level of suspicion. The classic tetrad of >50 mL (may be up to 100 mL in age > 65 • Anemia hypercalcemia, renal failure, anemia, years) is considered abnormal. MRI of the • Bony Lytic Lesions and bony lytic lesions are important spine is the diagnostic modality of choice components of the diagnostic criteria. and prompt neurosurgical consultation calcium levels should be obtained as non- Total serum protein is a nonspecific is required in patients with suspected ionizing calcium can bind to paraproteins, marker but an elevated level may suggest epidural involvement.4 resulting in a falsely elevated number. MM in the appropriate setting. In order Renal Failure Intravenous fluid hydration, adequate to make a formal diagnosis, the presence Acute kidney failure is a common analgesia, and cardiac stabilization of paraproteins must be confirmed via complication and poor prognostic indicator should be the priority in the ED. serum, urine, and/or bone marrow biopsy. in patients with MM. Renal dysfunction Diuretics can be considered but only in This is often not an appropriate or feasible is caused by precipitation of paraproteins patients with clear evidence of volume test to perform in the ED, so it is usually within the distal tubules as well as direct overload. In severe cases, bisphosphonates performed by the admitting medical team. toxic effects to the proximal tubules and and calcitonin can be administered with Management glomeruli. Adequate fluid hydration, guidance from nephrology.3 correction of electrolyte derangements, ED management should focus on Hematologic Complications and early consultation with nephrology are medical stabilization and symptomatic Bone marrow infiltration can paramount. Some patients may arrive to relief. However, there are potential result in a wide array of hematologic the ED in extremis and will require dialysis complications that require special abnormalities. Leukopenia and antibody on initial presentation.3 consideration. dysfunction can increase the risk of life- Spinal Cord Compression Hypercalcemia threatening infections. Chemotherapeutic Although a rare occurrence, bony Hypercalcemia is primarily caused intervention further exacerbates infiltration of the spinal column can by local osteolysis triggered by malignant immunosuppression leading to sepsis. result in vertebral fractures, spinal cord plasma cells. Patients will present with Patients should be treated accordingly compression, and rapid progression symptoms of hypercalcemia: abdominal with fluid hydration and broad-spectrum to paralysis. Patients with a known or cramps, nausea, vomiting, constipation, antibiotics. Thrombocytopenia and presumed diagnosis of MM who complain and fatigue. Associated nephrocalcinosis anemia are also common, and patients of back pain should undergo a thorough (calcium deposition in kidneys) and may require appropriate transfusions evaluation to assess for neurological dehydration further aggravates the overall to maintain hemodynamic stability. deficits. If cauda equina is being decline in renal function. Characteristic EKG Finally, hyperviscosity syndrome can considered, assessment of rectal tone, lower findings include QT shortening, AV blocks, also occur secondary to aggregation of extremity reflexes, and sensory deficits of QRS widening, and occasionally Osborn paraproteins within blood vessels. Patients the perianal area should be documented. waves. Prior to initiating treatment, ionized can present with neurological symptoms ranging from a headache to a stroke. The paraproteins can also lead to coagulation pathway disruption which can result in spontaneous bleeding from mucous Comes in the The heart of membranes. Treatments of choice include door with ... the diagnosis plasmapheresis and chemotherapy.3 Non-specific Paraproteins symptoms such as Case Conclusion confirmed via serum, weight loss, fatigue, During the patient’s hospital course, urine, and/or bone generalized additional diagnostic testing was performed, marrow biopsy weakness, and bone which revealed a predominance of IgA in pain the serum and a bone marrow aspirate with 97% clonal plasma cells, confirming the diagnosis of multiple myeloma. He received intravenous bisphosphonates for Diagnostic hypercalcemia and an additional two units of check points First steps of packed red blood cells for persistent anemia. Hypercalcemia treatment in ED He was started on chemotherapeutic Renal failure Stabilize the patient medications that consisted of and provide Anemia symptomatic relief cyclophosphamide, dexamethasone, and Bony lytic lesions subcutaneous bortezomib. He remains hemodialysis-dependent. ¬

References available online October/November 2019 | EM Resident 27 TOXICOLOGY

PHENIBUT OVERDOSE Coming to an ED Near You

Megan Hoffer, DO Ohio Valley Medical Center PHENIBUT: WHAT IS IT? Michael Tranovich, DO Phenibut (β-phenyl-γ-aminobutyric acid) is a GABA analogue that was first Richard Houck, DO introduced in Russia in the 1960s. Its primary use in Russia has been as an Ohio Valley Medical Center anxiolytic and nootropic medication. The toxidrome of phenibut most closely Department of Emergency Medicine resembles that of medications in the benzodiazepine class, but its effects are poorly studied apart from limited case reports.1

fter listing a few common home medications, a young, reasonably healthy patient recently reported that he used a supplement called phenibut for anxiety. During the Ainterview, he was quite anxious with pressured speech. A few minutes later, he became acutely hypotensive and unresponsive. He received a standard workup for altered mental status, which was essentially negative aside from marijuana on a drug screen. Revisiting his medication list, a quick search of phenibut showed that it was not a supplement but a resurrected Russian medication now available over the counter.

28 EMRA | emra.org • emresident.org What does an overdose look analog. Baclofen has been used to Can phenibut be detected on like? treat muscle spasticity, and despite laboratory studies? All documented case reports its similar structure, does not have Two case reports have confirmed the demonstrate somnolence or significant anti-anxiety effects. Baclofen diagnosis using gas chromatography- unresponsiveness as the primary has poor crossing of the blood brain mass spectroscopy, but the diagnosis presenting symptom with otherwise barrier due to an additional chloride in the ED must typically be made unremarkable laboratory workup. Case moiety which makes its crossing clinically, as phenibut is not detected 8 reports from Australia and more recently stereoselective. This may be why in commercially available urine the U.S. have demonstrated significant baclofen does not have the same drug immunoassays.2,11 The benzene toxicity and withdrawal symptoms, some marked anxiolysis that phenibut has, ring of phenibut may interfere with of which have required intubation and but still may have neurotoxicity in high methamphetamine testing on urine ICU care.2-6 doses. Phenibut is able to cross easily, drug screen, so an unreportable so it is able to have effects in the central methamphetamine screen might hint at Learning from Australians — nervous system. something we’re all familiar the diagnosis. with Why are Phenibut overdoses Be wary of supplements Phenibut came to media attention on the rise? Phenibut is a controlled substance in Australia following a well-publicized Phenibut has recently grown in internationally, but available in the U.S. phenibut overdose in seven college popularity in the United States for online for around $20. Patients are students. In February 2018, the its anxiolytic properties and its easy frequently unaware of the dangerous Australian Department of Health made availability without a prescription. implications of supplements purchased phenibut a Schedule 9 substance, Tolerance has been noted to develop online or over the counter. For medications citing “reports of anxiety, insomnia, quite quickly, and this leads to and supplements not controlled by the hypertension, hyperhidrosis, psychosis, escalation of the dose to achieve the Food and Drug Administration, consumers 9,10 tachycardia, widening of QRS complex, desired anxiolytic effects. This gives frequently rely on anecdotal online reviews as well as CNS depression, delirium, the drug significant abuse potential and clever marketing. Many young patients seizures — potentially requiring and increases the risk of toxicity from do not follow with primary care doctors intubation and ventilation.”7 unintentional overdose and withdrawal. and instead self-medicate for many Additionally, it has been demonstrated physical or mental conditions. For a young How does it work? that patients may experience significant patient with anxiety, this will seem like an Phenibut’s clinical effects may withdrawal symptoms, including easy solution, and it may alleviate their be better understood in light of two 9,10 agitation and even psychosis. symptoms. However, there is a reason that well-studied medication classes: it has not been approved by the FDA for use benzodiazepines and anti-spasmodics. How can a phenibut overdose be treated in the ED? as a medication in the U.S. — development Clinical effects similar to With the information currently of rapid tolerance makes it a poor choice benzodiazepines available, Phenibut overdoses or for any long-term applications, especially Both benzodiazepines and phenibut phenibut withdrawal should be treated when superior medications are available. exert their effects by activating GABA the same way that benzodiazepine In the U.S., over-the-counter supplements receptors in the central nervous system, overdose or withdrawal is treated-- are commonplace, but in the emergency which results in the anxiolytic effects typically with supportive measures. department we must be increasingly alert experienced with both medications. Depending on the severity of symptoms and aware of those supplements which are Phenibut is identical to GABA with the and any changes in vital signs, this likely to cause clinical effects. addition of a benzene ring. This allows may range from observation alone Back to the patient it to cross the blood brain barrier more to intubation and monitoring in the After an unremarkable workup and easily and bind to GABA receptors in B intensive care unit. The half-life of fluctuating responsiveness in the ED, he the central nervous system.1 phenibut in plasma is 5.3 hours.1 In was admitted to the intensive care unit, Structurally similar to baclofen most case reports, patients have been treated supportively, and able to be safely Phenibut’s structure most closely admitted to the intensive care unit for discharged home two days later after resembles baclofen, another GABA monitoring. making a full recovery. ¬ Phenibut, first introduced in Russia in the 1960s, has recently grown in popularity in the United States for its anxiolytic properties and its easy availability without a prescription.

References available online October/November 2019 | EM Resident 29 CARDIOLOGY Management of Atrial Fibrillation in Hypertrophic Cardiomyopathy Vase Bari, MD Case Western Reserve University/MetroHealth/ Cleveland Clinic Foundation B. Bryan Graham, DO Cleveland Clinic Foundation 46-year-old female presents by EMS with tachycardia and Ahypotension. En route the patient received two rounds of adenosine with no improvement. On initial assessment, the patient is somnolent but arousable and protecting her airway. The first set of vital signs reveals a blood pressure of 70/30 and the monitor shows atrial fibrillation with a rapid ventricular rate between 160 to 180 bpm. The patient receives a 1 L bolus of normal saline without significant improvement of her heart rate or blood pressure. The decision is then made to perform a synchronized cardioversion. She is sedated with REPRINTED WITH PERMISSION FROM YOUNG L, SMEDIRA NG, TOWER-RADER A, LEVER H, DESAI MY. etomidate and an initial 150 J biphasic ©2018 CLEVELAND CLINIC FOUNDATION. ALL RIGHTS RESERVED shock is delivered without any change in rhythm. A second shock at 200 J is 1 delivered, which is again unsuccessful. intramural coronary arterioles. Left Broadly, patients will present with Further chart review reveals that the ventricular (LV) hypertrophy is a defining symptoms related to heart failure, chest patient has a history of hypertrophic characteristic of HCM. Depending on the pain and dysrhythmias. Dyspnea, chest cardiomyopathy with severe left specific morphology, patients can develop pain, and syncope with exertion should ventricular outflow tract obstruction. one or more of the following: LV outflow raise suspicion for HCM particularly in tract (LVOT) obstruction, diastolic younger patients with a family history Hypertrophic Cardiomyopathy dysfunction, myocardial ischemia and of early sudden cardiac death. Physical Hypertrophic cardiomyopathy (HCM) 2 mitral regurgitation. LVOT obstruction exam findings can be non-specific and is a genetically determined autosomal is caused by systolic anterior motion of associated with the degree of LVOT dominant disorder that causes abnormal the mitral valve against a hypertrophied obstruction. A systolic murmur that development of cardiac myocytes and septum. increases with valsalva and going to an upright position from supine is KEY POINTS suggestive of HCM. While management of HCM can be ● Approximately 20% of patients with hypertrophic cardiomyopathy will have atrial complex and based on several factors, fibrillation. initial therapy in symptomatic patients ● HCM patients in AF with RVR are at high risk for hemodynamic collapse as a result of decreased filling time, worsened LVOT obstruction and decreased is focused on reducing the LVOT cardiac output. obstruction and reducing myocardial ● In a hemodynamically unstable HCM patient with AF, in addition to performing oxygen demand. This is done by synchronized cardioversion, ensure that the patient has adequate preload. optimizing preload and through the use ● Phenylephrine can be used to augment blood pressure after fluid resuscitation, of negative inotropic agents such as beta but positive inotropic drugs should be avoided. blockers, nondihydropyridine calcium ● Amiodarone can be considered in atrial fibrillation refractory to electrical channel blockers, and disopyramide. cardioversion. Further down the algorithm are invasive measures such as pacemakers, automatic

30 EMRA | emra.org • emresident.org Atrial fibrillation is 4-6 times more common in HCM patients than in the general population, and it carries an eightfold increase in the risk of stroke. implantable cardioverter-defibrillators atrial fibrillation, there is a loss of atrial Case Resolution (AICDs) and septal myomectomies, which kick, which subsequently reduces preload. Cardiology is consulted and comes are beyond the scope of this discussion.5 In combination with a high ventricular emergently to the bedside. The patient is Here we will focus on dysrhythmia as a rate, there is a decrease in cardiac output given an additional 2 L of normal saline. complication of HCM. secondary to a reduction in LV filling A 150 mg bolus of IV amiodarone is given Atrial Fibrillation in HCM time. This physiologic response becomes followed by a continuous infusion rate of Atrial fibrillation (AF) is the most life-threatening in the setting of baseline 1 mg/min. Following this, a third shock common dysrhythmia, both in the general end-diastolic dysfunction as in HCM. is delivered at 200J which successfully population and in patients with HCM.3 It is imperative to ensure that preload converts the patient to sinus rhythm. Her However, atrial fibrillation is 4-6 times is optimized by giving IV fluids and if blood pressure and mental status improve. more common in HCM patients than the needed, phenylephrine. Positive inotropic She is started on a heparin drip and general population. Approximately 20% agents such as dopamine, dobutamine transferred to the cardiac intensive care of HCM patients will go on to develop and norepinephrine should be avoided. unit. During her hospital course, an AICD AF.3 AF is an independent predictor An unstable patient with HCM and is placed for primary prevention of sudden of all-cause mortality in HCM and AF with RVR still requires electrical cardiac death. Subsequently, she undergoes carries an eightfold increase in risk of cardioversion, but it may fail if preload a septal myectomy, mitral valve repair with stroke.3 Barring contraindications, all is not addressed. If the patient is still papillary muscle reorientation, pulmonary HCM patients with AF should receive refractory to electrical cardioversion, vein isolation, and placement of left atrial anticoagulation. amiodarone can be administered. The appendage clip. She is continued on her Patients with HCM and AF who go into dose will be 150 mg IV bolus followed by beta blocker and anticoagulation. rapid ventricular response are particularly a continuous infusion at 1 mg/min. If at Acknowledgements high risk for hemodynamic collapse. This this point, the patient is still refractory, Special thanks to Thomas Noeller, MD; is in large part due to preload dependence cardiology should be emergently Lauren Gustafson, MD; and Dhruv in the heart with HCM. In the setting of consulted for further management. Amratia, MD, for their feedback. ¬ Because every project is one rusty nail away from the ER. You’re there for them, we’re here for you.

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October/November 2019 | EM Resident 31 PEDIATRIC EM

A SUGAR RUSH Managing Pediatric Diabetic Ketoacidosis Cindy D. Chang, MD Case 1 all day and breathing heavily. The patient’s Chair, EMRA Pediatric A 4-year-old girl presents to the ED with vitals are T: 39, BP: 75/40, HR: 145, RR: Emergency Medicine Committee 40, O2 sat: 91%. On exam, you notice the Harbor-UCLA Medical Center nausea and vomiting. The family notes that @cdichang for the past week the patient has been more patient is lethargic, tachypneic, and not Jessica L. Chow, MD, MPH tired than usual and having decreased responding to painful stimuli. Chair-elect, EMRA Pediatric appetite. She has had 3 days of runny nose, Case 3 Emergency Medicine Committee cough, vomiting, and abdominal pain. Her A 15-year old girl with history of diabetes UCSF-San Francisco General Hospital vitals are T: 38.7, BP: 95/60, HR: 123, @jesslchow on an insulin pump presents to the ED RR: 35, O2 sat: 97%. On exam, you notice Ilene Claudius, MD with vomiting and a syncopal episode. She Associate Professor, that the patient is sleepy-appearing, but was at a family party when she collapsed. Emergency Medicine arousable. Her abdomen is soft without There was no head trauma or seizure-like Director, Process and focal tenderness. She is tachypneic and activity. Over the past 2 days, she had Quality Improvement Program taking deep breaths. Harbor-UCLA Medical Center been intermittently vomiting with some Case 2 abdominal discomfort and had told her A 14-month old toddler presents to the ED mother her blood sugar readings ranged with fever. His dad reports that the patient between 150-250 mg/dL. The patient’s vitals has had fever, cough, and vomiting for one are: T: 37.5, BP: 100/67, HR: 120, RR: 32, week. Today, the patient has been sleeping O2 sat: 98%. On exam, you see a talkative

32 EMRA | emra.org • emresident.org teenager with a soft, non-tender Signs and Symptoms the following in a patient with diabetes abdomen, an insulin pump in the lower The presentation of a child in DKA can (Table 1). abdomen, and no signs of trauma. Her be very insidious, especially those less than The severity of a patient with DKA can urine pregnancy test is negative and 5 years of age who tend to present with a be determined by a measurement of the her EKG shows sinus tachycardia. delayed diagnosis of severe DKA. Polyuria venous pH and their serum bicarbonate 5 and polydipsia may not be appreciated at (Table 2). Epidemiology and Clinical signs of dehydration tend to Pathophysiology this age. Initially, the diagnosis of DKA may be delayed or missed in infants or toddlers be inaccurate, hence markers such as an Diabetic ketoacidosis (DKA) is presenting with concurrent infections such elevated blood urea nitrogen (BUN) or a severe complication of diabetes. as pneumonia or bronchiolitis, causing elevated hematocrit can be helpful. Approximately 30% of children in the duration of their symptoms to be even Management and Treatment the United States present in DKA at longer and putting them at risk of severe The most important goal in DKA the initial time of diagnosis of type 1 acidosis, dehydration, and altered mental treatment is to restore the body’s glucose diabetes, and commonly present in status. They may present with increased regulation back to normal and replace this state to the ED.1 Although less irritability, weight loss, and physical signs the losses. It is not as simple as giving common, DKA may also occur in of hypovolemia. A severe Candida diaper an insulin bolus because dehydration children with type 2 diabetes. DKA rash can be a leading clue towards a and a child’s sympathetic activation tends to be precipitated by factors such 3 diagnosis of diabetes. may interfere with insulin absorption. as concurrent infection, particularly if Children older than 5 years old tend It’s also critical to address any possible the patient is affected by vomiting and to present with polyuria, polydipsia, and precipitating factors that may have dehydration. It may also be precipitated vomiting that leads to dehydration. They caused a patient to go into DKA. This may by missed insulin doses or social factors can also present with weight loss. Many include infection, medications, drugs or such as alcohol or illicit drug use. may have non-specific symptoms such as alcohol, or missed insulin doses in known In DKA, insulin deficiency leads nausea, vomiting, and abdominal pain that diabetics. to hyperglycemia. Without insulin, could be misinterpreted as appendicitis. The management of DKA involves the cells and tissues are unable to take up Children may also exhibit hyperpnea as a following 3 steps:6 and use blood glucose as an energy compensatory effort to counterbalance their 1. Correct dehydration: Average source. Instead, adipose tissue gets ongoing metabolic acidosis. water losses in children with DKA are broken down into free fatty acids that On exam, children may show signs around 70cc/kg.7 When calculating are converted into ketoacids by the of dehydration such as decreased skin fluids, children with mild to moderate liver, causing a metabolic acidosis. The turgor and dry mucous membranes. If DKA and those with severe DKA presence of high extracellular hydrogen severely dehydrated, they may exhibit should be assumed to have 5-7% ions causes potassium to shift out of tachycardia, decreased capillary refill, dehydration and 7-10% dehydration, cells into the blood. Potassium is lost and potentially hypotension. A careful, respectively. The amount of fluids due to hyperglycemia driven osmotic thorough examination should be done to to give to a pediatric patient in diuresis, causing patients to develop find a possible inciting cause that may have DKA is very controversial given the a depletion of total body potassium.2 precipitated this event. concern of precipitating cerebral Overall, a counterregulatory hormonal According to the International Society edema.8 In general, an initial IV stress response occurs with subsequent for Pediatric and Adolescent Diabetes fluid bolus of 20cc/kg of 0.9% worsening insulin resistance, (ISPAD) 2018 consensus statement,4 normal saline should be given. The hyperglycemia, and hypovolemia. DKA is defined by the presence of all of goal of initial rehydration is not euvolemia, but to maintain adequate Biochemical Criteria of DKA TABLE 1. perfusion of end organs. When Laboratory Features the patient is hemodynamically Hyperglycemia ● Blood Glucose >200 mg/dL stable, judicious replacement of the Metabolic Acidosis ● Either remaining fluid deficit should be ▪ Venous pH <7.3 given over 24-48 hours in addition ▪ Serum bicarbonate <15 mEq/L to maintenance fluids. A recent Ketosis ● Either large randomized controlled trial ▪ Beta-hydroxybutyrate ≥3 mmol/L from the Pediatric Emergency ▪ Moderate to large urine ketones Care Applied Research Network (PECARN) showed that neither the TABLE 2. Severity of DKA in Children rate of fluid administration nor the Features Mild Moderate Severe sodium chloride content of IV fluids Venous pH 7.2 to <7.3 7.1 to <7.2 <7.1 significantly affect neurological Serum bicarbonate (mEq/L) 10 to 15 5 to 9 <5 outcomes in children with DKA

References available online October/November 2019 | EM Resident 33 PEDIATRIC EM

during treatment or after recovery.9 PEARL However, it must be noted that the range What needs to be monitored and how often? of IV fluid protocols used in the study Continuously: Vitals, intake and output may have been too narrow to notice a Every hour: Glucose (while on insulin), neurologic examinations (including cranial difference. nerves) 2. Correct hyperglycemia: Continuous Every 2 – 4 hours: Electrolytes and venous blood gas IV insulin infusion should be administered at 0.1 unit/kg/hr. No “bolus” or loading PEARL dose is necessary. When the serum glucose What are the signs of cerebral edema and how can it be treated? reaches 250 mg/dL, dextrose should be The most concerning complication from treating DKA is cerebral edema. Clinically added to the IV fluids and insulin should significant cerebral edema occurs in up to 0.9% of DKA episodes in children, with a be continued until the ketoacidosis mortality rate of 20-25%.10,11 Though rare, children less than 5 years of age with severe completely resolves. Insulin infusion may DKA are at the highest risk of developing cerebral edema, often due to delayed be discontinued once the serum anion gap diagnosis. It is most commonly found in children with severe acidosis or hypocapnia. is 12 ± 2 mEq/L or beta-hydroxybutyrate The key is to treat early. Suspicious signs and symptoms include bradycardia, is ≤1 mmol/L, venous pH >7.3 or serum headache, vomiting, incontinence, fluctuating level of consciousness, posturing, bicarbonate >15 mEq/L, blood glucose decreasing GCS, abnormal pupillary response, and abnormal respiratory patterns <200 mg/dL, and the patient is tolerating (Cheyne-Stokes, grunting). Treatment of cerebral injury consists of avoiding hypoxia oral intake. and hypotension, and immediately giving mannitol at 0.5-1 g/kg IV over 15 minutes. 3. Correct electrolyte abnormalities: This can be repeated in 30 minutes. Hypertonic 3% NaCl at 2.5-5 mL/kg is only Serum sodium should correct by 1.6 reserved as a second line intervention due to one retrospective study that showed mEq/L for every 100 mg/dL decrease higher mortality rates in patients treated with hypertonic saline versus mannitol.12 in glucose. Children with DKA have total body deficit of potassium, despite PEARL levels appearing to be normal or increased initially. Insulin infusion Should a Head CT scan be done to confirm cerebral edema prior to stimulates intracellular uptake of treating? potassium, putting the patient at No. Cerebral edema is a clinical diagnosis with high morbidity and mortality. risk of hypokalemia. If the patient is Treatment should not be delayed. In addition, cerebral edema may not be visualized hypokalemic (below 3.3 mEq/L), 40 on initial imaging and may only be apparent hours to days later after neurological mEq/L of potassium at least should decline. Imaging may be helpful to find other etiologies for altered mental status, be given and insulin therapy should but if there is high suspicion for cerebral edema, treatment should be initiated be delayed as long as possible until immediately. potassium levels increase closer PEARL to a normal range. If the patient is normokalemic (3.3-5.3 mEq/L) and Should fluids be withheld for fear of causing cerebral edema? voiding, 20-30 mEq/L of potassium Administration of IV fluids should not be withheld due to concerns of causing should be added to the IV fluid cerebral edema, especially if the patient looks clinically dehydrated. Fluids should maintenance infusions while patient be adjusted to maintain a normal blood pressure to optimize cerebral perfusion in is started on an insulin drip. If the all DKA patients with or without concerns for cerebral edema. patient is hyperkalemic (above 5.3 PEARL mEq/L), potassium should be withheld in the initial fluids. Potassium should What if the ketoacidosis does not improve despite insulin and IV be replaced with both potassium fluids? phosphate and either potassium chloride Look for another cause of persistent metabolic acidosis such as sepsis, or possibly or potassium acetate to reduce risk of incorrect preparation/administration of the insulin infusion. hyperchloremic metabolic acidosis.2,6 PEARL Insulin also stimulates intracellular uptake of serum phosphate leading to Should pediatric patients with DKA receive bicarbonate infusion to hypophosphatemia, putting the patient correct for acidosis? at risk for rhabdomyolysis, muscle No. Bicarbonate infusions have been associated with increased risk of cerebral weakness/paralysis, and hemolytic edema and worsening hypokalemia. The rapid correction of acidosis can also anemia, hence it should also be decrease the stimulus for hyperventilation and lead to increased carbon dioxide in aggressively repleted. Mild hypocalcemia the brain causing a decrease in cerebral pH as carbon dioxide crosses the blood- and hypomagnesemia can occur as well, brain barrier.11,13 In very rare situations, bicarbonate can be considered, especially if requiring monitoring and repletion as the child is in severe acidosis, hemodynamically unstable, hyperkalemic, or about to needed. go into cardiac arrest.4

34 EMRA | emra.org • emresident.org Case 1 Conclusion ICU for further monitoring and titration set close to the rate that the patient was Your patient’s fingerstick blood sugar of an insulin regimen for newly diagnosed breathing at prior to being intubated to level reads 456 mg/dL and you draw a diabetes. compensate for metabolic acidosis. The set of blood and urine samples, while Case 2 Conclusion patient is then transferred to the ICU. After starting her on IV hydration. Her pH You suspect a critically sick child one repeat dose of mannitol, continued is 7.1 with a high beta-hydroxybutyrate and bring him to a resuscitation room. hydration, electrolyte repletion, and result, and positive urine ketones. You He gets IV access and his fingerstick improving blood sugar levels, the patient is hear crackles on lung examination and glucose is >400 mg/dL with a blood gas extubated after 2 days, with a normal MRI the chest x-ray shows a right middle lobe showing pH 6.9 and a bicarbonate of <5. scan. He is diagnosed with type 1 diabetes infiltrate concerning for pneumonia. After You immediately start fluid resuscitation, and transitioned to subcutaneous insulin an initial bolus of IV fluids, your patient empiric antibiotics, and an infectious therapy. appears more alert, has not vomited, work-up given your concern for septic Case 3 Conclusion and is watching clips of Baby Shark on shock with his fever and hypotension. After further interviewing, you find her family’s cell phone. You start her on You are initially worried about meningitis the patient had lied to her mother about antibiotics, maintenance fluids, and an as a cause of his altered mental status, her blood sugar ranges at home, for fear of insulin drip. However, 2 hours later, you but recall cerebral edema complications needing to go to the hospital. On her blood find that your patient’s repeat blood sugar in DKA. He is having more difficulty tests, she had a blood glucose of 649 mg/ drops to 220 mg/dL. At this time, you breathing and worsening lethargy with dL, a pH of 7.1, and a potassium level of add D10 to your maintenance fluids while unimproved blood gases, and you have 3.0 mEq/L. You turn off her insulin pump continuing the insulin drip given that the growing concern for herniation. You and start her on potassium repletion and gap has not closed. The glucose levels talk to the family about a definitive IV fluids without dextrose. Each hour, her continue to drop to 150 mg/dL, so you airway and start mannitol. You prepare glucose checks and blood gases improve, decrease the insulin drip next. One hour to intubate with the understanding that and she gets started on 1.5 x maintenance IV later, you find your patient is more shaky the apneic pause during intubation may fluids with dextrose and an insulin infusion and sleepy with concerns for symptomatic worsen his acidosis. Fortunately, you at 0.1 units/kg/hour. She is transferred to hypoglycemia. You stop the insulin drip for visualize the airway without difficulty and the ICU. The patient’s insulin pump was 10 minutes and then restart at a lower rate rapidly intubate him. You ensure that interrogated and found to be dysfunctional with more dextrose. She is admitted to the the respiratory rate on the ventilator is and her insulin pump gets switched. ¬

References available online. October/November 2019 | EM Resident 35 ORTHOPEDICS

Unique Presentation

of Fracture Blisters FIGURE 1 Will Hockett broken, loose rocks. She was unable extremity, while controlling swelling Oregon Health & Sciences to ambulate, and without cell phone via gentle compression.5 Distal pulses University Medical School reception, she waited on the trail until a should be quickly checked prior to Class of 2020 runner was able to activate search and application of any splint materials Delvin Akins Oregon Health & Sciences rescue. She arrived at the ED 18 hours to achieve a baseline assessment University Medical School after sustaining her injury. of circulation. Space between the Class of 2021 Search and Rescue used a Structural extremity and the splint should be Craig Warden, MD, MPH Aluminum Malleable (SAM) splint filled with padding to help immobilize Oregon Health & Sciences University around the ankle directly on top of the injury and potentially reduce racture blisters are tense vesicles, the patient’s sock and secured the swelling. The splint should provide or bullae that result from a loss of splint with an ACE wrap. The splint support proximal and distal to the site Fintegrity at the dermal-epidermal stabilized her injury as she rode a mule, of injury. Circulation, motor response, junctions secondary to increased a commonly used method of transport and sensation should be rechecked interstitial pressure following trauma.1,2 in this region, 8.5 miles along the trail after application of splint materials and Fluid accumulation combined with the to an ambulance. At the rural ED, the adjusted if there is a change from their risk of venous stasis following vessel wilderness splint was removed, showing initial examination. damage contribute to the formation several tense blisters, the largest Fracture blisters carry an increased of these blisters. Fracture blisters can measuring 5 x 9 cm. risk for infection and are best left intact. present as clear-fluid, or blood-filled Discussion They complicate surgical management, and no clear consensus exists on when to lesions, thought to be dependent on the The blisters were initially thought to 3 surgically repair. When fracture blisters extent of dermal-epidermal separation. be secondary to inadequate placement of are present preoperatively, there is a The most common sites at risk for padding under the SAM splint and shear higher incidence of postoperative wound fracture blister formation are the skin forces of the splint material on the skin. infection.2 overlying the foot, ankle, tibia shaft, tibial Further inspection, however, showed A detailed skin assessment 4 plateau, and elbow. these to be consistent with fracture should be documented and relayed to Case blisters in their common anatomic your consulting orthopedic surgeon. A 70-year-old female presented to the locations (Figure 1). Outcome emergency department after a 16-hour The SAM splint was a suitable The ankle was reduced in the ED wilderness evacuation for a trimalleolar treatment in this situation, but there are and the patient was transferred the next fracture and posterior dislocation of the several important tips to remember for day to a tertiary center. Orthopedics right ankle. prehospital injury immobilization. All completed an open reduction internal The patient was backpacking when splints should be well-padded, as bulky fixation and required a wound vac to she fell while descending an area of dressings can aid in immobilizing the assist with blister management. ¬

36 EMRA | emra.org • emresident.org SPACE MEDICINE What is Aerospace Medicine? Emily Stratton, MD members are like a close family, with WANT MORE INFORMATION? SUNY Upstate Medical University yearly scientific meetings hosted by ü Join the new ACEP Aerospace AMSRO Vice President its largest organization, the Aerospace Acting Vice President, ACEP Aerospace Medicine Medicine Section! (First meeting is at Medical Association (AsMA). There is Section ACEP19: Monday, Oct. 28, 10-11:30 am, even a section for students and residents: ave you ever wondered what kind of Denver Convention Center Rm 604) Aerospace Medicine Student and Resident doctor supports the United States ü Visit asma.org space program? Who monitors the Organization, with scholarships and H mentoring events. ü Do a clerkship with NASA (even if health and wellbeing of astronauts on the you’re an attending)! asa.gov/feature/ International Space Station and stands at Origins aerospace-medicine-clerkship the ready for their launch and return? Who This specialty has been around helps to plan the upcoming Lunar and for many years, and the term “space Mars missions alongside engineers, pilots, medicine” was first used in the late 1940s Why should this interest me? and other brilliant scientists? This is the during the Mercury and Gemini missions.3 These doctors not only often work field of Aerospace Medicine. Currently, there are 4 accredited U.S. clinically, such as in the ED, they also With the White House asking residency/fellow­ship programs for help support the future of space travel Congress for an additional $1 billion Aerospace Medicine: through research and operations. for an accelerated lunar program,1 ● U.S. Air Force Residency in Aero­ Additionally, they are crucial to the entire this is definitely an exciting time to be space Medicine at Wright-Patterson aviation industry. involved with the field of Aerospace Air Force Base in Dayton, OH Because Aerospace Medicine is a Medicine. Also, with the birth of the ● U.S. Army/Navy Residency in subspecialty of Preventive Medicine, commercial space flight industry, Aerospace Medicine in Pensacola, FL the field works to avoid disease/ there is an even greater need for highly ● University of Texas-Medical Branch emergencies. This is not always a familiar trained Aerospace Medicine physicians. in Galveston, TX concept to emergency physicians. Yet However, this subspecialty is not just ● Mayo Clinic in Rochester, MN it can be an invalu­able skill to learn about space medicine; these physicians Participants also often receive a how to prevent bounce-back patients to the ED. In fact, Aerospace Medicine also care for the health of pilots and Master of Public Health (MPH) degree physicians often decide fitness for duty, flight crewmembers. Many also study with board certification. Aerospace while traveling and working in austere the physiology of microgravity on the Medicine fellows can hail from any environments to prevent accidents and human body and how it can help to fight specialty, but according to current keep the pilot (or astronaut) as fit as conditions here on Earth (for example, the recommendations from one of the possible for the mission. In the same NASA Twins Study with Scott and Mark civilian programs, fellows must be a U.S. way, Aerospace Medicine physicians Kelly2 and the evaluation of increased citizen with an MD or DO degree with do mishap investigations and toxin intraocular pressure in space assessed by clinical residencies (typically in Internal exposure analysis if an emergency does an ultrasound located on the International Medicine, Family Medicine, or Emergency occur. Additionally, they work with Space Station). Medicine) — although other residencies engineers to create an efficient system The Aerospace Medicine specialty can be considered on a case-to-case basis. for launches and descent. They also focus on performance maximization through optimal sleep scheduling, task Squeezing time in to prepare assignment and delegation, wellness your residents for the Oral activities, and functional downtime to make use of crew time in the most Board Exam Experience? efficient manner possible. This is applicable to the shift work in the ED. CORD’S Member Exclusive eOral software Aerospace Medicine works with other is the solution you’re looking for! fields to prevent emergencies through ü Access to 35 cases with monthly updates disaster preparation, specific crew ü Unlimited users training, and kit design. Given these connections to the ED ü Same platform used by ABEM and the need for Aerospace Medicine Learn more at cordem.org/eOral physicians in the future, this is definitely an interesting specialty to look into after graduating from an EM residency. ¬

October/November 2019 | EM Resident 37 INTERNATIONAL MEDICINE

A NEW BEGINNING Emergency Medicine in Lao PDR Anouphet Yentavanh Dr. Mouavang Xiapao joined well-suited for their symptoms. As Mouavang Xiapao the residency EM providers, we have to act fast to Thepbandith Sydavong stabilize patients in order to save a EM Residents in Lao PDR from Xaysomboun human life. This, to me, is a priceless n 2017, the inaugural Lao Provincial experience and I believe that every emergency medicine residency Hospital, located hospital in Laos should have an EM Iwas born from a collaborative in the northwest specialist on staff. project between the Lao portion of the What would you like University of Health Sciences; country. physicians in other countries Lao Ministry of Health; central to know about Laos and about hospitals in the capital, Vientiane; Why did you choose a career in emergency medicine in Laos? and the NGO Health Frontiers. medicine? Health care professionals in These residents and their I chose medicine because I enjoy Laos, especially in the ED, hurry to colleagues are working incredibly being a doctor and being able to restore assist patients. However, there is no people back to their lives after physical hard as they prepare to take national standard of care: doctors and injury and disability. I enjoy treating both on the immense challenge and hospitals have different approaches adults and children alike and ultimately to most everyday cases. There is responsibility of being the first will endeavor to keep on learning. emergency medicine specialists a lack of standardized protocols, What do you like best about guidelines, or training available. This in Lao PDR when they graduate in working in the ED? sometimes means that they take the 2020. It is an incredibly exciting EM doctors are the first to receive same approach towards all patients time for the field of emergency and examine patients. We are the ones to for all diseases rather than manage medicine in Lao PDR. decide whether their condition is severe them appropriately according to their or mild and what kind of assistance is specific diagnosis.

38 EMRA | emra.org • emresident.org Dr. Anouphet Yengtavanh traffic, and industrialization need to be Dr. Thepbandith Sydavong joined the residency paralleled by a developing and improving worked in the ED program from healthcare system. Emergency medicine of Setthathirath and emergency management are critical Tahteng District to this process. Hospital, a Hospital in Sekong What is the most difficult part of central hospital in province, which EM training? Vientiane Capital, is located in the Medical training in Laos is faced before she was southeast part of with all kinds of difficulties such as a chosen for the EM the country. It is one lack of equipment, a lack of specialized residency. of the poorest, most ethnically knowledge and lessons, linguistic Why did you choose a career in diverse, and most sparsely difficulties, and doctors being unaware of reliable sources of knowledge. medicine? populated provinces in Laos. What do you like best about I enjoy providing health care services Why did you choose a career working in the ED? to patients who come in to receive them. It is challenging work and there is a great in medicine? Emergency medicine is highly need for trained personnel. There are I think that robust healthcare and challenging because it is an area of work medical expertise are essential to national which has to cater to patients of all kinds. insufficient numbers to meet healthcare development. Many Laotian citizens As a doctor, I recognize the importance demands. It makes me feel proud and reside in rural areas of the country and of the emergency department and often happy each time I play a part in this. need care that specialist doctors provide. parallel it to the military: a fence to How do you think EM will However, at the moment, specialists do protect a country. improve patient care in Laos? not travel to visit patients residing in What would you like physicians The ED is right on the front-line of rural areas. Speaking as a rural doctor in other countries to know about the hospital, so every day our ED meets myself, I consider it to be important that EM in Laos? people in all kinds of conditions, from multi-ethnic people receive coverage I would like them to know about the minor to severe. Therefore, if the ED nationwide. Thus, I studied medicine to solidarity and unity we share as a work- works systematically and uniformly, be a part of this development. family — solidarity where everything we are able to act fast in diagnosing the How will emergency medicine takes place peacefully — and the mutual patient and performing the treatment improve patient care in Laos? respect we have for each other. I believe in time. This reduces mortality and Specialized emergency care at this this helps us as coworkers during difficult morbidity rates and the need for inpatient time is lacking, but it is essential as Laos times. However, we still lack knowledge, treatment. is in the process of relieving itself of equipment, and expensive medications, What would you like physicians its status as a least developed country all of which remains a problem in Lao in other countries to know about (LDC). The rising population, vehicular medical facilities. Laos and about Emergency Medicine in Laos? Laos is a developing country with Residents and their colleagues are a high demand for health care to working incredibly hard as they prepare adequately cater to the needs of the to take on the immense challenge and population. Emergency care is important responsibility of being the first emergency and challenging for all our hospitals, medicine specialists in Lao PDR. as the supply of trained personnel and necessary emergency equipment are often insufficient. This leads to delays in diagnosis and treatment and significant morbidity. The lack of EM specialists also makes education difficult for EM residents like myself. If you would like to support Emergency Medicine in Lao PDR, we are looking for financial contributions and volunteers. More information can be found on the Health Frontiers website: www. healthfrontiers.org. ¬

October/November 2019 | EM Resident 39 OP-ED Do Sports Have an Effect on Gang Violence? Dustin Harris, MD the South Side of Chicago witnessed 391 in activities outside of school.4 EMRA Sports Medicine Committee Chair shootings, 103 murders, 1,227 vehicle A secondary finding was the effect Sports Medicine Fellow 2 thefts, and 1,017 aggravated batteries. of positive or negative outlooks on Stanford-O’Connor Hospital It’s difficult to find Chicago’s specific school environment. If a student had dle hands are the devil’s crime rates when it comes to teenagers. a positive outlook on his or her school playthings.” These words pass But rates of teen arrests in the United environment, that would decrease rates through my mind while I am on the “I States have steadily increased for murder of risky or delinquent behavior.4 The sideline — a football game in progress in and nonnegligent manslaughter, from majority of the previous population were front of me. The Phillips Academy High 2.2/100,00 persons in 2012 to 2.7 in upper middle class. One could argue the School football team was doing what they 2017.3 Instead of increasing the results could not be directly translated to usually do: winning. Just several city number of police units and the teens from a more impoverished area. blocks down the street you would find the number of years in mandatory Another study in the early 2000s, University of Chicago Medical Center, a sentencing, could there be a benefit out of the University of Michigan, found Level I trauma center that can average in sports programs? Sports often similar results in a more diverse sample multiple gunshot wound victims a night. provide a positive influence on students, of students. Rates of major crime and The field where the football team play is so it is easy to make the assumption not a stone’s throw from the old Ida B. that they would have a positive effect on school suspension were lower in schools Wells Homes housing community where crime. Are there studies showing sports with higher rates of sports participation 5-year-old Eric Morse was murdered after have a positive impact on teen crime? while controlling for school location 5 being held outside a 14-story window by In 2008, a study from Northeastern and student:teacher ratios. The trend 10- and 11-year-old boys. University College of Criminal Justice over the several-year study was that as The city of Chicago is no stranger looked into the effects of church and rates of sports participation increased, to crime. Its homicide rate consistently non-school activities like sports on a converse decrease occurred in major ranks among the highest in the United delinquent behavior (such as violent crime and school suspension. Lastly, States.1 But a disproportionate amount acts like carrying a weapon or fighting). a large meta-analysis published in of crime emanates from the South Side There was a significant decrease in 2016 analyzed 51 studies with more of Chicago. In 2018, according to the delinquency rates among the 1,400 than 130,000 adolescents and found Chicago Police Department statistics, teens studied who participated no significant difference in juvenile delinquency among those who did or did not participate in sports.6 Even when separated by gender or by team sports, the results were not significant. Multiple studies did show a positive effect, but the significance did not have enough power to outweigh other studies. Regardless of study findings, no one is arguing against the positive effects of sports. They increase bonding, promote following rules, and can offer positive mentorship. It’s possible the data might change if certain sports that may increase aggression were separated from studies. Also, in neighborhoods without access to other after-school programs, sports may actually have a significant effect. More research can still be done, and I hope to look further into this topic in the future. ¬

40 EMRA | emra.org • emresident.org OP-ED

Parth Gandhi, DO Christiana Care Health System @parthsgandhi Instagram: the doctorsapron Dear attending, oday you looked at me with a face that begged the question, “Are you TOK?” Yes, attending — yes, I am… because of you. Attending, I have been a doctor for only a few weeks and I’m still nowhere near the level of skill and competency I’d like to be at. I still walk from one side of the hospital to the other with a confused look as I try to navigate the hallways. When the clerk asks me, “Are you the DOCTOR taking care of the patient in room 6?” I sheepishly respond with, “Yes, that’s me.” As the consultant asks me more questions about the patient, I Dear nervously shuffle through my notes as I try to provide an answer. However, as I go through my shifts I remember your words Attending... — “This is normal” — and finally, after PHOTO BY RENEE FERNANDES, WITH PERMISSION FROM PARKLAND HEALTH & HOSPITAL SYSTEM all this time, I’m starting to believe you. I’m trying my absolute best, dear “Maybe I’m not an imposter.” get to the cafeteria, and I still trip over attending. Some days I believe I’m smart Dear attending, you amaze me every my words when talking to consultants. and capable, while other days this is day with your poise and clinical acumen. Luckily for me, though, I have an not the case. There are days when I still You show me every day what hard work attending who doesn’t do any of these struggle to find the right order in an EMR and dedication can amount to. Keeping things and is willing to teach me. that seems harder to decipher than The this in mind, I try to shape my behavior I doubt there will ever come a day Da Vinci Code. I hear you asking the and ultimately in a sense, I try to emulate when I will not need you at all, because fourth-year student questions and I hear you. As a medical student, I looked at the even when I’m all grown up, I’ll think that student rattling off answers with a residents I worked with as being light back to the lessons you’ve taught me confidence that I’m sure I once possessed. years ahead of me. Now, as a resident, I and use them to guide my approach in Where did all that information go? don’t feel light years ahead of my former treating patients. My only hope is that Did I lose it all? Am I really this... self. You, however, remind me every day through my failures I can grow and slowly bad now? These are just some of the that I am. After all, you’ve been where I learn to not be terrible. After all, dear questions that plague me. am — you’ve done what I’m doing. You attending, you’ve taught me that if you Dear attending, I’ve been dealing with know better than anyone else what I am could get through it, then so can I. these insecurities for quite some time now feeling and because of this, you know I know you said I will do all these — but you’ve been there to reassure me that this is all just a part of the process. exactly what to say to me when I’m my things by myself, but I do not believe The first time I walked into a patient’s own worst critic. this is true. I have the support of all my room I found myself hesitating as I So, I write this letter to you and for upper-year residents, ED personnel, and introduced myself. As I peered over my you, dear attending. I promise to wake up co-interns. shoulder, I saw the imposter sitting there every morning with a reinvigor­ated drive And so, dear attending, to answer mocking me. Thoughts of inadequacy to become better, smarter, and more your question: “Am I OK?” Although I and self-doubt rushed into my mind capable. I know now that my struggles still look lost the majority of the time — as I reassured my patient. I came out are not just mine — they are ours. You Yes I am. I still have doubts and fears, but of the room wanting to rule out every have shown me that we are on a journey certainly they are not as overwhelming likely diagnosis and prove to you that I together and only by lifting each other as what I felt in the beginning of July, am someone who has considered all the up can we continue to move forward. and if I keep working hard, and if you possibilities. To my surprise, and to that Although I don’t feel quite that confident keep inspiring me the way you have been, of the imposter’s, you agreed with me. yet, I am starting to realize I am in fact I have no doubt that one day I will be That day I gained a little more confidence not terrible. It’s true; I still struggle with able to make you proud of the capable and finally smirked and said to myself, the EMR, I still take the long way to attending I will become. ¬

October/November 2019 | EM Resident 41 Are you prepared? Physician’s Evaluation and Educational Review in Emergency Medicine PEER questions and Personalized learning Visual learning aids answer explanations are Continually updated content % PASS “closest to the boards.” Claim-as-you-go CME credit 100% 95RATE Money-Back “I have used the PEER series for both my initial board certification and my ConCert. I have never been Guarantee* a great test taker, but the practice, layout, and questions helped me feel ready for test day. PEER is an integral tool in the preparation process.” – Ryan Stanton, MD, FACEP Subcribe today at acep.org/PEER

Not affiliated with ABEM The American College of Emergency Physicians is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The American College of Emergency Physicians designates this enduring material for a maximum of 150 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. *If you buy a PEER subscription, use it to study, but don’t pass your board exam, ACEP will refund your money or give you another year of PEER for free.

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42 EMRA | emra.org • emresident.org ECG CHALLENGE ECG Challenge Benjamin Golden, MD Jeremy Berberian, MD Christiana Care Health System Associate Director of Resident Education, @bgolden19 Dept. of Emergency Medicine Christiana Care Health System @jgberberian

CASE. A 22-year-old male with a history of sickle cell disease is brought to the ED by police after he was found altered and naked outside on a rainy night. What is your interpretation of the following ECG? See the ANSWER on page 44

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October/November 2019 | EM Resident 43 ECG CHALLENGE ECG Challenge

J Waves (Osborn waves) This EKG shows a normal sinus rhythm with a ventricular rate of 80, a normal axis, and early R-wave transition in the precordial leads. There is diffuse T-wave flattening and some baseline artifact that makes calculating the QTc difficult, but it prolonged when measured in V2. J waves, also called Osborn waves, are present in leads V2-V6 and the inferior leads. J waves are positive deflections at the terminal junction of QRS and beginning of the ST-segment takeoff resembling a dome or hump.1 They are often seen in the hypothermic patient and the amplitude and duration have been shown to correlate with the degree of hypothermia. They are most commonly seen in the inferior (particularly lead II) and lateral precordial leads but can be seen in any or all leads depending on the degree of hypothermia. In 1953, Dr. John Osborn described J waves as an “current of injury” concerning for impending ventricular fibrillation in the setting of hypothermia.2 Although J waves had been reported before this in hypercalcemia and hypothermia, the J wave became known as the Osborn wave as a testament to his work. There is no consensus on which name to use, and some use Osborn wave when seen with hypothermia and J wave in all other settings. Despite Dr. Osborn’s research, the association of J waves with life-threatening dysrhythmias in the hypothermic patient is unclear. As well, the presence of J waves is not pathognomonic for hypothermia. J waves can be seen with hypercalcemia,3 cardiac ischemia, and CNS injury (eg, SAH). There is even a case report describing J waves in the setting of Todd’s paralysis.4 Accordingly, the presence of J waves on an ECG warrants a broad differential diagnosis, including environmental exposure, cardiac ischemia, electrolyte abnormalities, and neurologic pathology.

LEARNING POINTS

ECG Findings in Hypothermia General Features • Findings most commonly seen at < 32°C EKG Features • Bradydysrhythmias — Atrial fibrillation with slow ventricular rate — Sinus bradycardia with 1st degree AV block — Junctional rhythms • Prolongation of PR, QRS, and/or QT intervals • J waves (also called Osborn waves) — Positive deflection at the terminal junction of QRS and beginning of the ST-segment takeoff (see Figure) — Most commonly seen in the inferior and lateral precordial leads Clinical Significance • Amplitude and duration of J waves typically correlate with the degree of hypothermia • J waves can also be seen with hypercalcemia and intracranial hemorrhage

Case Conclusion The presence of J waves made us concerned about hypothermia, and the patient’s core temperature was found to be 29.5°C. His workup was notable for multiple traumatic injuries. The patient was placed on a rewarming protocol and transferred to the Surgical ICU for further management of his traumatic injuries.

For more on the J wave, please see pages 55-56 of the EMRA EKG Guide. ¬

44 EMRA | emra.org • emresident.org PEER Board Review on IXsale! Questions

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For complete answers and explanations, visit the Board Review Questions page at emresident.org, under “Test Your Knowledge” at emresident.org Order PEER at acep.org/peer .

1. A 64-year-old man presents with gradual onset of swelling in his face, a cough, a headache, shortness of breath, and, that morning, blue lips. When asked, he says that he smokes “not quite two” packs of cigarettes per day. Which test will most likely reveal the diagnosis? A. Brain MRI with diffusion-weighted imaging B. Chest CT with contrast C. Lower-extremity Doppler ultrasonography D. Lumbar puncture and CSF cell count

2. When managing an acute aortic dissection, which medical therapy should be initiated first? A. Esmolol B. Nicardipine C. Nifedipine D. Nitroprusside

3. Which statement regarding Bordetella pertussis infection is correct? A. Blood cultures are an effective means of identifying patients with active disease B. Identifying disease in infants is difficult because apnea can be the only symptom C. Previous infection confers lifelong immunity for subsequent infection or disease D. Treatment to prevent infectivity is most effective during the paroxysmal phase

4. Which statement about the metabolism of ethanol is correct? A. Approximately 20 mg/dL is eliminated per hour in nontolerant individuals B. Cytochrome P450 is responsible for the majority of metabolism C. Elimination occurs predominantly by renal metabolism D. It is characterized by zero-order kinetics at lower concentrations

5. Which structure is best evaluated for traumatic injury using noncontrast CT? A. Pancreas B. Small bowel C. Spine

D. Stomach ¬

1. B; 2. A; 3. B; 4. A; 5. C 5. A; 4. B; 3. A; 2. B; 1. ANSWERS

October/November 2019 | EM Resident 45 CLASSIFIED ADVERTISING Emergency Medicine CALIFORNIA Ventura: Newly constructed hospital and ER department functioning since December 2018. Practice with a stable ER group on the central coast of California and only 70 miles from LAX. Positions available in two facilities for BC/BE emergency Central Wisconsin— physician. Main facility is a STEMI Center, Stroke Center with Stevens Point on-call coverage of all specialties. This is a teaching facility with Wisconsin Emergency Medical Services Associates, SC residents in Family Practice, Surgery, Orthopedics and Internal (WEMSA) is seeking BC/BE Emergency Medicine Physicians Medicine. Admitting hospital teams for Medicine and Pediatrics. to staff the new Aspirus Free Standing ED in Stevens Point, 24-hour OB coverage in house and a well-established NICU. WI (with some cross coverage and onboarding completed at Annual volume is 48K patients with nearly 70 hours of coverage Aspirus Wausau Hospital in Wausau, WI). daily and 12 hours of PA/NP coverage. All shifts and providers Aspirus Stevens Point Emergency Department (Free Standing) ü New, state of the art facility opened July 2018 have scribe services 24/7. Affiliated hospital is a smaller rural ü Over 6,000 visits in first year facility 20 minutes from Ventura in Ojai. Malpractice and tail ü 12 hour shifts (rotating day and night) coverage is provided. New hires will work days, nights, weekends ü 12 shifts per month ü As volume increases, Advanced Practice Providers will be recruited and weekdays. Come work with a well-established high caliber to assist group with expected volume growth potential at our new facility. Aspirus Wausau Hospital Emergency Department Enjoy the life style of a beach community yet outside the hustle ü Level II Trauma Center with all specialties available of the LA area. Please send a resume to Alex Kowblansky, MD, ü Average of 30,000 – 35,000 visits per year ü Efficient ED working closely with Hospitalists and Specialists FACEP, at [email protected]. ü 18 bed Emergency Room ü 8 or 9 hour shifts INDIANA ü Advance Practice Provider support South Bend - Memorial Hospital of South Bend. Stable, Aspirus Wausau Hospital and Aspirus Stevens Point are 30 minutes Democratic, 23 member group seeks additional BC/BE apart. (Travel between is easily accessible.) Come join an experienced Emergency Physicians. 60K visits, Level II Trauma Center, double, and collaborative group in a new endeavor at Aspirus! To learn more and apply, contact Jamie Dahl, Physician Recruiter, at 1-800-792- triple and quad physician coverage, also micro-hospital opening 8728 or e-mail a copy of your CV to [email protected]. fall 2019. Equal pay, schedule and vote from day one. Over Sorry this is not a visa eligible opportunity. 400K total package with qualified retirement plan; group health and disability insurance; CME reimbursement, etc. Favorable Indiana malpractice environment. University town, low cost of living, good schools, 90 minutes to Chicago, 40 minutes to Lake Michigan. Teaching opportunities at four year medical school and with FP residency program. Contact Joseph D’Haenens at [email protected]. TEXAS THE CAREER YOU DESIRE. THE LIFE YOU DESERVE. Leading Edge Medical Associates, an affiliate of American Rewarding opportunities available in: Physician Partners, is a growing, dynamic group of all EM- Board-Certified physicians who enjoy a full range of clinical California, Illinois, Kansas, North Carolina, opportunities in a vibrant, small city set among the beautiful Ohio, Texas & West Virginia! forests and lakes of Northeast Texas. We offer competitive Ask us about our: compensation and excellent full benefits. We are known for • Sign-on Bonus • Residency Stipend developing strong EM leaders. All our physicians work in a • Leadership Development variety of clinical ED settings, ranging from a higher volume trauma center to lower volume departments, all with a Founded in 1981, VEP Healthcare is a democratic, provider- positive work culture. LEMA offers the best of community EM owned physician organization. VEP provides work-life with opportunities to teach residents as well. We constantly balance and a path to ownership after just 150 hours strive to exceed the expectations of our patients, physicians, of service. and hospital partners. Our physicians work well together Visit Us at Booth #1008 as a team, value each member’s input, and enjoy a level of to win 50% off ACEP 2020 and Please contact: meet VEP leadership & recruiters! integrity, honesty, and trust that make this innovative group 925-225-5837 [email protected] one-of-a-kind. Contact: [email protected] Attn: www.vephealthcare.com Suzy Meek, MD. October 27 - 30

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October/November 2019 | EM Resident 47 SEEKING EMERGENCY DEPARTMENT PHYSICIANS The busiest ED in North Carolina, and one of the top 15 busiest in the nation, treats 95k adult and 35k pediatric cases annually in its 92 beds. We are currently seeking residency trained BC/ BE emergency physicians to work in the 75 bed adult ED. This ED serves a high acuity patient EXPECTING TO BE EXCITED population with 28% annual admission rate. There are over 90 AND CHALLENGED? hours of adult physician coverage daily and over 110 hours mid- Come join our team today! level coverage daily. It is a Level III Trauma Center with robust TOP TIER COMPENSATION hospitalist service, interventional The cash compensation package is valued at over $250/hour, including cardiology 24/7, cardiac surgery, evening, night, and holiday differentials, as well as a quarterly incentive neurosurgery, etc. The facility is bonus. We offer a generous sign-on bonus plus moving stipend. The comprehensive benefits package includes Malpractice Insurance Paid; CME Chest Pain and Stroke accredited. Time and Allowance; 403(b) match and 457(b); and health, dental, and other The EMS system is hospital owned desirable benefits. and managed with an award winning paramedic program. Of THE AREA Cape Fear Valley Health is located in the thriving and diverse community of note, the Pediatric ED is separate Fayetteville, NC which consists of more than 319,000 residents. Fayetteville and has 17 dedicated beds with has received the prestigious All-America City Award three times from the an additional 24 hours of physician National Civic League. coverage and 20 hours of mid- Known for its many golf courses (Pinehurst is located only 30 minutes away), our central location provides easy access to beautiful beaches to our east level coverage. We welcomed and to the majestic Blue Ridge Mountains to our west. Our mild climate, our inaugural class of Emergency low cost of living, and patriotic spirit makes our location ideal for rising Medicine Residents in July 2017. healthcare professionals and families. Opportunities exist for both clinical and academic emergency physicians.

Please contact Ashley Dowless, Corporate Director, Physician Recruitment at 910-615-1888 or [email protected] for additional information.

48 EMRA | emra.org • emresident.org ACADEMIC EMERGENCY PHYSICIAN Rutgers New Jersey Medical School, Newark, NJ The Department of Emergency Medicine at Rutgers New Jersey Medical School in Newark is actively recruiting talented, full-time BC/ BE Emergency Physicians at the Assistant or Associate Professor level interested in professional growth opportunities. Join an enthusiastic faculty of academic emergency physicians in an expanding and dynamic department committed to scholarship, education, research, and outstanding clinical care. Clinical services are provided at University Hospital in Newark, NJ, a busy Level I Trauma Center and Comprehensive Stroke Center with 95K annual visits. The hospital cares for the large underserved population of Newark as well as its surrounding suburban communities. Newark, a diverse city and the largest in New Jersey, has undergone substantial rejuvenation. It has world-renowned cuisine, a burgeoning arts scene, is a tech sector hub for the northeast corridor, and is minutes away from New York city by rail or car. Applicants should have a desire for clinical, academic, or administrative excellence. As the department continues to thrive, candidates with subspecialty training, research interests, or simply aspirations for a career in academic emergency medicine are encouraged to apply. For more information or to submit a CV: Rutgers University is an AA/EEO Lewis S. Nelson, MD employer. All applicants will receive Chair, Department of Emergency Medicine consideration for employment without 185 South Orange Avenue, MSB E609 regard to race, color, religion, sex, sexual orientation, gender identity, Newark, NJ 07103 national origin, citizenship, disability [email protected] or protected veteran status.

EMERGENCY MEDICINE OPPORTUNITY NEAR BOSTON, MA

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• working at one of the top hospitals in Boston in a brand new Emergency Department that opened in October 2019 • the benefits of NSMC’s membership in the Partners Healthcare System, founded by Massachusetts General Hospital and Brigham and Women’s Hospital • our annual adult ED volume of 80,000 visits provides an array of pathology with a fast track and PA program in place and excellent multispecialty back up • a culture focused on communication, growth, and work/life balance • excellent compensation and comprehensive fringe benefits • being an active contributor to quality of care, patient safety and process improvement initiatives

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TPECAERONFIBDSNPGFRS QOFJOPJDUPINUQOEAPDI #ACEP19 HBXEFBUFRRBNVQCCIPTS XVQIQMQKSUWHTFJVIXFS Stop by Booth OXEKCWEBERNLBWTLCBMS CXMQIOJBSMCGWZERUUGF #1217 in Denver DBEASGLDAYEPFJIGWKDZ NZRMCSFOTSHYOVKDBOGQ RTGUTLCIGYVBBCXFPFFD LMEAPVURSYSCKLVTWCZF PNNRECQIIRLXYNUKZZBY PSCTAHCFFBXCFKAYFYCW AYYCFINJKQEJSYODXDTK QKBOAPTMDLRQFOGGOJRX BQSNENICIDEMHRSTROKE ADMINISTRATIONEPKTJY TVCEBCDCMIYBQCFVWOOJ DXCHXJXPCMTXWKIGNSIM FYUYQOKCIDVIJHZFZEAM FLSHSTATYKPVLXCKVTDD

MEDICINE NURSE PHYSICIAN ABEM SCRIBE ACEP STROKE ACUITY TOXICOLOGY ADMINISTRATION TRAUMA DENVER EMERGENCY JOBS Emergency HIRING Medicine Physicians

KetteringKettering Health Health Network Network is seekingis seeking BC/BE a BC/BE Emergency MedicineEmergency physicians Medicine to joinphysician a highly to join regarded, a highly regional regarded, privateregional group private in Dayton, group locatedOH. in Dayton, OH. •Strong,•Strong democratic group of group70+ physicians of 80+ physicians and advanced and advanced practice providers practice providers •Group•Provide covers care 11 atof six Kettering of Kettering Health Health Network’s Network's Emergency Emergency Departments, including 4 hospitals and 2 Departments,freestanding including Emergency 7 hospitals Centers and 4 freestanding Emergency Centers •Trauma Level II and III options •Trauma Level II and III •Competitive•Competitive salary, salary, generous generous benefits benefits package package •$80,000•Sign-on Sign-on bonus Bonus up to $40,000 matched by group and •$20,000hospital Early Bonus for residents who sign before they start their• Epicfinal EMR year utilized of residency across the network •Epic•Warmth EMR used and throughout charm of the the Midwest network •Warmth, charm, and work-life balance of the Midwest Site visits are being scheduled now! Contact Cindy Corson Physician Recruitment Manager [email protected] (937) 558-3475 (office) (503) 201-8588 (cell)

ketteringdocs.org

EMERGENCY MEDICINE

Academic and Community Openings for BE/BC Emergency Physicians Vibrant and varied career possibilities in academic and community settings in the Baltimore metropolitan area as well as near Washington, Philadelphia and Maryland’s coastline. Live and work in an urban, suburban or rural community, in an atmosphere that encourages work/life balance.

Current EM Practice Opportunities Downtown Baltimore – Volumes from 21 to 66K North of Baltimore – Volumes from 32 to 65K Eastern Shore – Volumes from 15 to 37K DC Suburbs – Volumes from 34 to 60K Our supportive team approach in the delivery of high quality patient care features: • Dedicated fast track and intake units staffed by Family Practice physicians and PAs • ED scribes and medical information systems • Stoke centers & STEMI programs • Ultrasound programs with bedside US machines • Contact us at Advanced airway equipment including GlideScope® [email protected] Generous Compensation and Benefit Package or Contact667-214-2208 us at [email protected] • Additional incentive compensation UMEMor 667-214-2208 is an EOE/AAE • Medical, dental, vision and life insurance • Employer-paid CME, PTO and 401K safe harbor retirement plan UMEM is an EOE/AAE • Employer-paid malpractice insurance with full tail coverage

October/November 2019 | EM Resident 51 Seeking Emergency Medicine Physicia n for Huntsville Hospital

BC/BE EMERGENCY PHYSICIANS NEEDED to join current staff of 40+ physicians Level I Trauma Center with 75 beds and fast track Medical Observation Unit with 16 beds Pediatric ED with 16 beds Community hospital ED with 25 beds EXCELLENT COMPENSATION PACKAGE! Competitive salary with RVU-based incentives, CME, paid vacation, health/life/malpractice, 401k

Huntsville Hospital is looking for additional coverage for our progressive Emergency Department. We see approximately 150,000 patient visits per year across our 4 different units (Level I Trauma Center, Medical Observation Unit, Pediatric ED at Children’s hospital, community hospital in Madison - plus an OB ED staffed by our OBGYN Hospitalist team. Our physicians work an average of 14-15 shifts per month (9 hours per shift), allowing for an excellent work/life balance. Teaching opportunities with 3rd/4th year medical students from UAB and Family Medicine and Internal Medicine residents at UAB-Huntsville rotate through our ED.

Huntsville Hospital is a Level I Trauma Center and the Regional Referral Center for North Alabama and Southern Tennessee. Huntsville Hospital is Alabama’s only Top 50 Heart Hospital by Truven Health Analytics and one of America’s 50 Best Cardiac Surgery Programs by HealthGrades.

Huntsville is situated in the fastest growing major metropolitan area of Alabama, and with the highest per-capita income in the Southeast, Huntsville is the best place to live, learn, and work. We are a community on the move, rich with values and creative talents. These unique characteristics will certainly provide a place for you and your family to flourish. With a population of 385K, we are a high-tech, family-oriented, multicultural community with excellent schools, dining, and entertainment - all nestled in the foothills of the beautiful Appalachian Mountains.

For further information, please contact Suzanne LeCroix at (256) 265-9639 or [email protected]

huntsvillehospital.org YUR HEALTH IS PRECIOUS. Are You Ready?

Free Services l Confidentiality l Personal Attention

Industry Knowledge l Coaching

TeedCo. has opportunities available from the coast of Maine to the beautiful Hawaiian islands and the states in between. We are all about your best fit! At TeedCo., it’s all about you! SOUTHERN CALIFORNIA ORANGE COUNTY Positions available for full and part time Visit us at the EMRA Job Fair & ACEP in Denver at BC/BE EM and Peds EM physicians. Booth #1408 so we can discuss how we can help you find Partnership track is available for full time physicians. We are a stable, democratic your perfect fit! group established in 1976 serving two best in class hospitals. St. Joseph Hospital Orange is a STEMI You can also visit our website: www.teedco.com. and Stroke Center with 80,000 visits per year. CHOC Children’s Hospital is a In confidence contact: Mark Ariano, Director Level II trauma center, tertiary referral center and teaching hospital (several (203) 295.8310 l [email protected] residency and fellowship rotations) with 80,000 visits per year. Please send CV and references to Excellent call panel coverage, excellent [email protected] compensation, malpractice and tail coverage, and scribe coverage. Sign on bonus for full time hires.

August/September 2019 | EM Resident 53 NOW HIRING EMERGENCY PHYSICIANS IN DAYTONA BEACH AREA LIVE BY THE OCEAN UPMC has a long history of emergency medicine excellence, with a deep and diverse EM faculty also a part of the University of Pittsburgh. We are internationally recognized for superiority CONTROL in research, teaching and clinical care. With a large integrated insurance division and over 25 hospitals in Pennsylvania and growing, UPMC is one of the nation’s leading health care systems. We do what others dream - cutting edge emergency YOUR care inside a thriving top-tier academic health system. We can match opportunities with growth in pure clinical or mixed careers with teaching, research, and administration/ leadership in all settings - urban, suburban and rural, with both community and teaching hospitals. Our outstanding compensation and bene ts package includes malpractice SCHEDULE... without the need for tail coverage, and employer-funded Join EMPros in Sunny Central Florida! retirement plan, generous CME allowance and more.

• Private EM group staffing 5 hospitals and Daytona International Speedway To discuss joining our large and successful physician group, • Employee Option with Full Benefits or email [email protected] or call 412-432-7400. Independent Contractor • Flexible Scheduling • Comradery with Fellow Physicians

FOR MORE INFORMATION, VISIT EMPROSONLINE.COM OR FACEBOOK.COM/EMERGENCYMEDICINEPROFESSIONALS

ACEP Booth #1716

For more info: JOIN TEXAS’ LEADING EDGE TEAM Suzy Meek, MD [email protected] POWERED BY AMERICAN PHYSICIAN PARTNERS

54 EMRA | emra.org • emresident.org Emergency Medicine & Toxicology Faculty

Faculty Positions-Emergency Medicine Rutgers Robert Wood Johnson Medical School The George Washington University Medical Faculty Associates, an independent The Department of Emergency Medicine at Rutgers Robert Wood non-profit academic clinical practice group affiliated with The George Johnson Medical School, one of the nation’s leading comprehensive Washington University, is seeking full-time academic Emergency Medicine medical schools, is currently recruiting Emergency Physicians and physicians. The Department of Emergency Medicine (http://smhs.gwu.edu/ Medical Toxicologists to join our growing academic faculty. emed) provides staffing for the emergency units of George Washington Robert Wood Johnson Medical School and its principal teaching University Hospital, United Medical Center, the Walter Reed National Military affiliate, Robert Wood Johnson University Hospital, comprise New Medical Center, and the Washington DC Veterans Administration Medical Jersey’s premier academic medical center. A 580-bed, Level 1 Trauma Center. The Department’s educational programs include a four-year residency Center and New Jersey’s only Level 2 Pediatric Trauma Center, program and ten fellowship programs. Robert Wood Johnson University Hospital has an annual ED census Responsibilities include providing clinical and consultative service; teaching of greater than 90,000 visits. fellows, residents, and medical students; and maintaining an active research The department has a well-established, three-year residency program program. These non-tenure track appointments will be made at a rank (Instructor/ and an Emergency Ultrasound fellowship. The department is seeking physicians who can contribute to our clinical, education and Assistant/Associate/Full Professor) and salary commensurate with experience. research missions. Basic Qualifications: Applicants must be ABEM or AOBEM certified, or have Qualified candidates must be ABEM/ABOEM certified/eligible. Salary completed an ACGME or AOA certified Emergency Medicine residency, and be and benefits are competitive and commensurate with experience. eligible for licensure in the District of Columbia, at the time of appointment. Sub specialty training is desired but not necessary. Application Procedure: Complete the online faculty application at http://www. For consideration, please send a letter of intent and a curriculum vitae to: gwu.jobs/postings/68602 and upload a CV and cover letter. Review of applications Robert Eisenstein, MD, Chair, Department of Emergency Medicine will be ongoing beginning August 30, 2019 and will continue until positions are Rutgers Robert Wood Johnson Medical School filled. Only complete applications will be considered. Employment offers are 1 Robert Wood Johnson Place, MEB 104, New Brunswick, NJ 08901 contingent on the satisfactory outcome of a standard background screening. Email: [email protected] Questions about these positions may be directed to Department Chair, Robert Phone: 732-235·8717 · Fax: 732 235-7379 Shesser M.D., at [email protected]. The George Washington University and the George Washington University Medical Faculty Associates are Equal Employment Opportunity/Affirmative Action employers that do not unlawfully discriminate in any of its programs or activities on the basis of race, color, religion, Rutgers, The State University of New Jersey, sex, national origin, age, disability, veteran status, sexual orientation, gender identity or is an Affirmative Action/ Equal Opportunity expression, or on any other basis prohibited by applicable law. Employer, M/F/D/V.

ART#: 223412_RURWJMS_EMR.indd PUBLICATION: EM Resident EXCELLENCED: mh AT WORK.

Emergency Medicine Opportunities Central, South-Central and Northeast PA

At Geisinger, we’re committed to doing things differently when it To learn more about our exceptional compensation and benefits comes to delivering excellent care. That spirit of innovation drives packages, which provide professional development and support for a everything we do – from our state-of-the-art emergency medicine healthy work/life balance, visit geisingerjobs.org/emergency-medicine. services program to expanding our graduate medical education Interested candidates, please reach out to Miranda Grace at programs to progressive care models focused on preventive 717-899-0131 or at [email protected] care. These are just some of the ways we go above and beyond for the communities we serve.

The future of health is in you. geisinger.org/careers

AA/EOE: disability/vet.

October/November 2019 | EM Resident 55 EMERGENCY MEDICINE OPPORTUNITIES IN SOUTHEASTERN PA

Phoenixville Hospital, a 139-bed tertiary care facility located in Phoenixville, Pennsylvania, is growing its Emergency Medicine team and is looking for Emergency Medicine Physicians; day/evening and nocturnal positions available. Phoenixville Hospital: n 24,000 patient visits annually n 24 ED beds n Triple coverage at peak times n 24/7 OB/GYN, Pediatrics, Interventional Cardiology, and Anesthesia coverage n Vibrant, diverse community provides a picturesque setting with a downtown that is the center of commerce and community living

Chestnut Hill Hospital is a 148-bed facility located near Philadelphia with inpatient and outpatient, diagnostic and treatment services including minimally- invasive laparoscopic and robotic-assisted surgery, cardiology, gynecology, oncology, orthopedics, primary care practices, two Women’s Centers, and an off-site physical therapy center. The hospital has openings for Emergency Medicine Physicians; day/evening and nocturnal positions available. Chestnut Hill Hospital: n 40,000 patient visits annually n 22-bed main ED plus eight fast-track beds n Supportive and engaged nursing staff and close relationships with consultants n Easy admission process with health system employed Hospitalist Services n Close-knit and welcoming group of physicians with supportive hospital leadership n Suburban community feel within the city limits of Philadelphia

What We Offer: n Competitive compensation n Comprehensive benefits including health, dental, vision, life, and disability insurance n Retirement savings plan with employer automatic contribution and match n Claims-made malpractice insurance with tail coverage n Generous paid time-off allowance n CME time and stipend n Relocation assistance n Supportive health system to advance goals

For more information, please contact: Carrie Moore, MBA, FASPR, Physician Recruiter, Emergency Medicine 484-628-8153 • [email protected] Careers.TowerHealth.org

EOE EMERGENCY MEDICINE OPPORTUNITIES IN SOUTHEASTERN PA

Phoenixville Hospital, a 139-bed tertiary care facility located in Phoenixville, Pennsylvania, is growing its Emergency Medicine team and is looking for Emergency Medicine Physicians; day/evening and nocturnal positions available. Phoenixville Hospital: n 24,000 patient visits annually n 24 ED beds n Triple coverage at peak times n 24/7 OB/GYN, Pediatrics, Interventional Cardiology, and Anesthesia coverage n Vibrant, diverse community provides a picturesque setting with a downtown that is the center of commerce and community living

Chestnut Hill Hospital is a 148-bed facility located near Philadelphia with inpatient and outpatient, diagnostic and treatment services including minimally- invasive laparoscopic and robotic-assisted surgery, cardiology, gynecology, oncology, orthopedics, primary care practices, two Women’s Centers, and an off-site physical therapy center. The hospital has openings for Emergency Medicine Physicians; day/evening and nocturnal positions available. Chestnut Hill Hospital: n 40,000 patient visits annually n 22-bed main ED plus eight fast-track beds n Supportive and engaged nursing staff and close relationships with consultants n Easy admission process with health system employed Hospitalist Services n Close-knit and welcoming group of physicians with supportive hospital leadership n Suburban community feel within the city limits of Philadelphia

What We Offer: Meet the Leadership team of over n Competitive compensation n Comprehensive benefits including health, dental, vision, life, and disability 60 Independent, physician managed insurance groups at #ACEP19 in Denver! n Retirement savings plan with employer automatic contribution and match n Claims-made malpractice insurance with tail coverage n Generous paid time-off allowance n CME time and stipend n Relocation assistance n Supportive health system to advance goals Explore all your job options

Metro, suburban, For more information, please contact: 877.379.1088 and rural locations Carrie Moore, MBA, FASPR, Physician Recruiter, Emergency Medicine 484-628-8153 • [email protected] www.emrecruits.com across the nation. Careers.TowerHealth.org

EOE Exciting opportunities at our growing organization

• Core Emergency Medicine and PEM Faculty positions • EM Medical Director • EMS Medical Director / EMS Fellowship Director • Vice Chair, Clinical Operations & Strategy Development • Vice Chair, Research

Penn State Health, Hershey PA, is expanding our health system. We offer multiple What the Area Offers: new positions for exceptional physicians eager to join our dynamic team of EM and We welcome you to a community PEM faculty treating patients at the only Level I Adult and Level I Pediatrics Trauma that emulates the values Milton Center in Central Pennsylvania. Hershey instilled in a town that holds his name. Located in a safe family- What We’re Offering: friendly setting, Hershey, PA, our local • Salaries commensurate with qualifi cations neighborhoods boast a reasonable cost • Sign-on Bonus of living whether you prefer a more • Relocation Assistance suburban setting or thriving city rich • Retirement options, Penn State University Tuition Discount, and so much more! in theater, arts, and culture. Known as What We’re Seeking: the home of the Hershey chocolate • Core Emergency Medicine trained physicians with additional training in any of bar, Hershey’s community is rich in the following: Toxicology, Ultrasound, Geriatric Medicine, Pediatric Emergency history and offers an abundant range Medicine, Research of outdoor activities, arts, and diverse • Completion of an accredited Emergency Medicine Residency Program and experiences. We’re conveniently located Fellowship for PEM positions within a short distance to major cities • BE/BC by ABEM or ABOEM such as Philadelphia, Pittsburgh, NYC, • Observation experience is a plus Baltimore, and Washington DC.

FOR MORE INFORMATION PLEASE CONTACT: Heather Peffl ey, PHR FASPR at: hpeffl [email protected] 58 EMRA | emra.org • emresident.org

Penn State Health is committed to affi rmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled. Be a part of the largest private emergency medicine group in Connecticut! Join Our Emergency Medicine Team

Exciting opportunities at MEET OUR LEADERSHIP TEAM IN DENVER - #ACEP19 For over 30 years, MEDS has partnered with regional, our growing organization rural, and critical access hospitals by providing physician staffing and management solutions. • Core Emergency Medicine and PEM Faculty positions We are currently seeking Emergency Medicine Today, we provide the management and staffing services Trained Physicians to join our group of experienced, • EM Medical Director to multiple facilities treating emergency medicine, stable, and tenured physicians that share the same hospital inpatient, telemedicine, and urgent care • EMS Medical Director / EMS Fellowship Director focus and commitment. patients throughout the Midwest. • Vice Chair, Clinical Operations & Strategy Development • Vice Chair, Research Send your CV to [email protected] Our commitment to efficient high quality health care, supported by our accessibility, responsiveness, and management expertise, helps us deliver personalized Penn State Health, Hershey PA, is expanding our health system. We offer multiple What the Area Offers: Compassion - Quality - Leadership - Responsiveness excellence that larger competitors can’t match. new positions for exceptional physicians eager to join our dynamic team of EM and We welcome you to a community PEM faculty treating patients at the only Level I Adult and Level I Pediatrics Trauma that emulates the values Milton STOP BY ACEP BOOTH #1043 Center in Central Pennsylvania. Hershey instilled in a town that holds Democratic, Physician Partnership Providing & EMRA TABLE #415 IN DENVER his name. Located in a safe family- Excellence in Emergency Medicine in Connecticut since 2008 What We’re Offering: friendly setting, Hershey, PA, our local Please send CV's to: [email protected] • Salaries commensurate with qualifi cations neighborhoods boast a reasonable cost • Sign-on Bonus of living whether you prefer a more • Relocation Assistance suburban setting or thriving city rich • Retirement options, Penn State University Tuition Discount, and so much more! in theater, arts, and culture. Known as What We’re Seeking: the home of the Hershey chocolate Texas, Florida, Missouri, and Oklahoma • Core Emergency Medicine trained physicians with additional training in any of bar, Hershey’s community is rich in history and offers an abundant range the following: Toxicology, Ultrasound, Geriatric Medicine, Pediatric Emergency Join a physician owned, private group that recruits of outdoor activities, arts, and diverse Medicine, Research residency trained, board certified emergency physicians • Completion of an accredited Emergency Medicine Residency Program and experiences. We’re conveniently located wanting to take ownership in the direction and success of Fellowship for PEM positions within a short distance to major cities their career in emergency medicine. • BE/BC by ABEM or ABOEM such as Philadelphia, Pittsburgh, NYC, We are constantly engaged in assisting our physicians to Multiple Locations • Observation experience is a plus Baltimore, and Washington DC. manage toward better patient throughput time, reducing in Arizona & New Mexico diversions, and seeking to build ED patient volume. As a INDEPENDENT , PHYSICIAN GROUP result of those efforts, our team members consistently rank in the 90th Percentile of income nationally. We are currently in a phase of expansion and growth! We are looking for Emergency Physicians who would rather Texoma Medical Center - Denison, Texas work in a collegial environment with like minded physicians Northwest Texas Healthcare System - Amarillo, Texas instead of a corporate management group (CMG) model. Northwest Emergency at Town Square - Amarillo, Texas Send your CV to [email protected] Comanche County Memorial Hospital - Lawton, Oklahoma Visit ACEP Booth #1217 & EMRA Table #734 in Denver Golden Valley Memorial Hospital, Clinton, Missouri Manatee Memorial Hospital - Bradenton, Florida Lakewood Ranch Medical Center - Lakewood Ranch, Florida Wellington Regional Medical Center - Wellington, Florida

Interested? Send your CV to [email protected] Meet our Leadership team in Denver FOR MORE INFORMATION PLEASE CONTACT: EMrecruits Booth #1217 Heather Peffl ey, PHR FASPR at: hpeffl [email protected] October/November 2019 | EM Resident 59

Penn State Health is committed to affi rmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled. When you become an owner in one of the largest, fastest -growing physician- owned groups in the nation, you get the support you need with the culture and benefi ts you want. • Highly competitive fi nancial/ WORK WHERE YOU WANT TO LIVE. benefi ts package • Physician equity ownership for all LOCATIONS NATIONWIDE! full-time physicians • Industry-leading 401(k) company contribution • Yearly CME/BEA (Business Expense Account) • Student loan refi nancing as low as 2.99% • Groundbreaking Paid Parental Leave • Pioneering Paid Military Leave • Short- and long-term disability (own occupation) • Comprehensive medical, dental, vision and Rx coverage • The best medical malpractice including tail coverage • Outstanding Professional development programs • Location fl exibility and career stability of a national group

To learn more about our opportunities contact: FOR SELECT Sign On Bonus! LOCATIONS Darrin P. Grella | VP of Recruiting [email protected] or 844-863-6797 Ownership Matters FEATURED OPPORTUNITIES Visit usacs.com/locations to view a complete list of locations.

AdventHealth System Catholic Medical Center Sentara RMH Medical Center Tampa, FL | 7-42,000 pts./yr. Manchester, NH | 33,000 pts/yr. Harrisonburg, VA | 68,000 pts./yr.

Allegheny Valley Hospital Doctors Hospital Sharon Regional Medical Center Columbus, OH | 72,000 pts/yr. Natrona Heights, PA | 32,000 pts./yr. Sharon, PA | 33,000 pts./yr. Fairfi eld Medical Center Allegheny Health Lancaster, OH | 37,000 pts/yr. Springfi eld Regional Medical Center Neighborhood Hospitals Springfi eld, OH | 62,000 pts./yr. Pittsburgh, PA | 12-20,000 pts./yr. Lake Health System Cleveland, OH | 10-34,000 pts./yr. Stamford Health Atrium Health System Stamford, CT | 56,000 pts./yr. Charlotte, NC | 15-77,000 pts./yr. Mercy Health System Cincinnati, OH | 9-53,000 pts./yr. Summa Health System CarolinaEast Medical Center Akron, OH | 7-81,000 pts./yr. MedStar St. Mary’s Hospital New Bern, NC | 68,000 pts./yr. Leonardtown, MD | 49,000 pts./yr. Valley Children’s Hospital (PEM) Madera, CA | 113,000 pts./yr. Carteret Health Care Meritus Medical Center Morehead City, NC | 49,000 pts/yr. Hagerstown, MD | 68,000 pts./yr. University Medical Center Saint Francis Hospital Las Vegas, NV | 79,000 pts./yr. Denotes an academic leadership position Tulsa, OK | 107,000 pts./yr. Visit Booth #461 at ACEP19 for more information. Working together to better serve patients

Congratulations to Mount Sinai’s own Michelle Lin, MD, MPH, MS, FACEP, named among EMRA’s 45 Under 45 top influencers in emergency Want to work medicine! for Mount Sinai? Start your search here. Integrated system of emergency services that provides comprehensive, Veronica Fernandez state-of-the-art, emergency clinical care, Director Physician Recruitment Department of Emergency Medicine Mount Sinai Health System education and research. [email protected] Emergency Medicine

EMERGENCY MEDICINE RESIDENTS - PLAN YOUR TRANSTION NOW! Find us at EMERGENCY MEDICINE RESIDENTS’ ASSOCIATION #ACEP2019 DISABILITY INSURANCE PROGRAM An individual, long-term disability insurance program designed for EMRA students, residents and alumni.

Important highlights of the program: • Up to $7,500 monthly tax-free benefit with no financial disclosure • Specialty Specific definition of disability – 6 options in most states • Personalized comparison of plans, taking advantage of regional, GME or association discounts as available to you • Easy online application process

Obtain your disability protection today! Visit the EMRA webpage: www.iwcglobal.net/our partners/EMRA Connect with us @IWCAdvisor Yale University School of Medicine Department of Emergency Medicine Fellowship Programs

For specific information including deadlines and requirements, visit http://medicine.yale.edu/emergencymed The Implementation Science fellowship is consists of structured time in the ED performing mannequin simulation with computer program a 2-3 year program that will train investigators in bedside examinations, examination QA and review, training, acquisition of debriefing and teaching skills, the principles and practice of dissemination and research into new applications, and education in the use of novel wearable technologies, and procedural implementation science. Supported by a K12 grant academic/community arenas. We have a particular simulation. The fellow will participate in all educational from NIH’s National Heart, Lung, and Blood Institute, focus on emergency echo and utilize state of the programs for medical students, nurses, residents fellows will receive training at the new Yale Center art equipment, as well as wireless image review. and faculty at the Yale Center for Medical Simulation. for Implementation Science (YCIS), the Yale Center Information about our Section can be found at The program includes options to train in research for Clinical Investigation, and the National Clinician http://eus.yale.edu . For further information, contact methodology through the Research Division of the Scholars Program. Eligible candidates may receive Rachel Liu MD, [email protected], or apply online Department of Emergency Medicine and participate a Masters in Health Sciences degree. Mentors come at www.eusfellowships.com. in medical education coursework through Yale School from the Yale Schools of Medicine, Nursing, and The Administration fellowship is a 2-year program of Medicine. The fellowship will include attendance of Public Health, as well as many community-based that will prepare graduates to assume administrative the one-week Comprehensive Instructor Workshop organizations in New Haven. For further information, leadership positions in private or academic emergency at the Institute for Medical Simulation in Boston. contact Steven L. Bernstein, MD, steven.bernstein medicine as well as hospitals and health systems. For further information, contact Leigh Evans, MD, @yale.edu. The fellow will acquire experience in all facets of [email protected]. The Research fellowship is a 2-3 year emergency department clinical operations, with The Educational Leadership fellowship is a 1 program focused on training clinician scholars as close mentorship from department and hospital or 2-year program that provides the training and independent researchers in Emergency Medicine. administrative leaders. Fellows will complete the education to develop academic emergency physicians Scholars will earn a Master of Health Sciences recently #1 ranked Executive MBA program at the Yale to have the skills, knowledge and experience to be degree from Yale combining clinical experience with School of Management. In addition, the candidate will strong educators and leaders in Emergency Medicine extensive training in research methods, statistics, assume graduated leadership roles on one or more education with the focus on developing leaders in EM and research design. With the guidance of research projects supporting departmental activities usually residencies or in Undergraduate Medical Education. content experts and professional coach mentors, culminating as Assistant Medical Director in the The fellow will be an Assistant Residency Program the scholar will develop a research program, second year of the fellowship. For further information, Director and an integral member of the education complete a publishable project and submit a grant contact Arjun Venkatesh, MD, MBA, MHS, arjun. faculty. They will be supported to attend leadership application prior to completion of the program. The [email protected]. training as well as using other internal resources, program is credentialed by the Society for Academic The Global Health and International Emergency CORD and ACEP to further their education. For further Emergency Medicine. For further information, Medicine fellowship is a 2-year program offered by information, contact David Della-Giustina, MD, contact Steven L. Bernstein, MD, steven. Yale in partnership with the London School of Hygiene FACEP, FAWM, [email protected]. [email protected]. & Tropical Medicine (LSHTM). Fellows will develop a The Wilderness Medicine fellowship is a 1-year The Yale Drug use, Addiction, and HIV strong foundation in global public health, tropical program that provides the core content of medical Research Scholars (DAHRS) Mentored Career medicine, humanitarian assistance and research. knowledge and skills in being able to plan for and Development Program (NIDA K12) provides a 3 year They will receive an MSc from LSHTM, a diploma in to provide care in an environment that is limited post-doctoral interdisciplinary, research training Tropical Medicine (DTM&H) and complete the Health by resources and geographically separated from experience preparing investigators for careers Emergencies in Large Populations (HELP) course definitive medical care in all types of weather and focusing on drug use, addiction, and HIV prevention offered by the ICRC in Geneva. In addition, fellows evacuation situations. The fellow will be supported to and treatment in general medical settings. Scholars spend 6 months in the field working with on-going obtain the Diploma in Mountain Medicine and other earn the Master in Health Sciences degree that Yale global health projects or on an independent Wilderness Medical education. The fellow will become combines vigorous research methodology, statistics project they develop. For further information, contact a leader and national educator in the growing specialty and design didactics in small group sessions the fellowship director, Hani Mowafi, MD, MPH, of wilderness medicine. For further information, and seminars covering topics related to drug [email protected]. contact David Della-Giustina, MD, FACEP, FAWM, use, addiction and HIV, leadership, grant writing The fellowship in EMS is a 1-year program that [email protected]. and responsible conduct of research. Candidates provides training in all aspects of EMS, including The Clinical Informatics fellowship is a 2-year complete mentored research project(s), multiple academics, administration, medical oversight, program that provides ACGME-approved training manuscripts, and apply for independent funding. research, teaching, and clinical components. The in all aspects of clinical informatics. The program For further information, visit www.medicine.yale. ACGME-accredited program focuses on operational is administered through the Yale Department of edu/dahrs or contact Gail D’Onofrio, MD, MS, EMS, with the fellow actively participating in the Emergency Medicine. In the first year, the fellow [email protected]. system’s physician response team, and all fellows will rotate between the Yale-New Haven Health The fellowship in Emergency Ultrasound is offered training to the Firefighter I or II level. A 1-year and Veterans Affairs. Major blocks will be devoted to a 1 or 2 year program that will prepare graduates MPH program is available for fellows choosing electronic health records, clinical decision support, to lead an academic/community emergency additional research training. The fellowship graduate databases and data analysis, and quality and safety. ultrasound program. The 2-year option includes a will be prepared for a career in academic EMS and/or Experiential learning will be combined with didactic Master of Health Sciences or Master of Public Health medical direction of a local or regional EMS system, classes and conferences. The second year is dedicated with a focus on emergency ultrasound research. and for the ABEM subspecialty examination. For to advanced learning and project leadership. The This fellowship satisfies recommendations of all further information, contact David Cone, MD, fellow will attend the American Medical Informatics major societies for the interpretation of emergency [email protected]. Association annual meeting. The program prepares ultrasound, and will include exposure to aspects of The Medical Simulation fellowship is a 1-year fellows for Clinical Informatics Board examination. For program development, quality assurance, properties program that provides training in all aspects of further information, contact Ted Melnick, MD, MHS, of coding and billing, and research. The program healthcare simulation, including high fidelity [email protected].

All require the applicant to be BP/BC emergency physicians and offer an appointment as an Instructor to the faculty of the Department of Emergency Medicine at Yale University School of Medicine. Applications are available at the Yale Emergency Medicine web page http://medicine.yale.edu/emergencymed/ and are due by November 15, 2019 with the exception of the Clinical Informatics Fellowship, the Wilderness Fellowship, and the Educational Leadership Fellowship, which are due by October 1, 2019. Yale University and Yale-New Haven Hospital are affirmative action, equal opportunity employers and women, persons with disabilities, protected veterans, and members of minority groups are encouraged to apply.

62 EMRA | emra.org • emresident.org CAREERS Nationwide

INNOVATORS

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careers.soundphysicians.com PRACTICE San Antonio, Texas EMERGENCY MEDICINE IN 7 Metro Locations HAWAII

SCHEDULE AN INTERVIEW TODAY

Schedule an Our new physicians work the same number of shifts as our Interview Today shareholders, have access to revenue, expenses, and productivity - and eligible for partnership after 2,000 hours.

Interested in Interviewing? Send your CV to [email protected] As Hawaii's oldest and largest ED physician group, we are dedicated to Work in the #1 ranked hospital system in San Antonio nurturing the next generation of quality emergency physicians and meeting the Live in a Metropolitan City with a Low Cost of Living ever-changing healthcare challenges. Enjoy Great Neighbors and Award Winning Schools Send your CV to [email protected] Visit ACEP Booth #1217 & EMRA Table #735 in Denver Visit ACEP Booth #1217 & EMRA Table #517 in Denver

Virginia - Loudoun & Fairfax Counties CINCINNATI, OHIO Join our team of excellent physicians

Qualified Emergency Specialists, Inc. is an Independent, Physician owned and managed Group serving the Greater Cincinnati Area since 1984. Commonwealth Emergency Physicians is a physician owned and managed Emergency Medicine group in Northern Virginia offering We are aligned with TriHealth, a unique and attractive career opportunity. the regional leader in integrated healthcare delivery. Our staff of We are seeking EM Physicians who have a broad experience with 45 Physicians and 33 Advanced high acuity and share our philosophy to provide progressive, Practice Clinicians provides care compassionate, emergency medicine care. for 5 Emergency Departments - Stable, Private, Democratic Group - Employed and 2 Clinical Decision Units. - Medical Benefits, Retirement Plan, Paid Malpractice

From Alexandria west to Loudoun County communities have We offer a lucrative production adopted elements of both urban and suburban lifestyles, allowing based compensation structure, Send your CV to young families living in the commonwealth their choice of full partnership with no buy-in, [email protected] affordable and fast growing or established and stocked with full benefits, equitable amenities. scheduling and the opportunity Visit ACEP Booth #1217

& EMRA Table #425 Send CV to [email protected] to have a voice in your new practice. in Denver Denver - ACEP Booth #1217 & EMRA Table #817 or #616 CHEERS TO 40 YEARS!

Forty years ago, TeamHealth’s foundation was built on quality, efficiency and patient care. Today, we continue to live out this purpose by perfecting the practice of medicine every day, in everything we do. As TeamHealth celebrates its 40th anniversary in 2019, we want to celebrate with you!

Visit booth #1445 to get a free drink ticket to use in the ACEP Brew Park during the event. It’s our way of saying cheers to 40 years!

Join our team email [email protected], visit teamhealth.com/join or call 877.709.4638

TH-12107 40th Anniversary - EMRA Res size: 7.5x10 PRSRT STD U.S. POSTAGE PAID Emergency Medicine Residents’ Association BOLINGBROOK, IL 4950 W. Royal Lane PERMIT NO. 467 Irving, TX 75063 972.550.0920 emra.org

Our culture rocks. Here’s how we roll.

At US Acute Care Solutions we share the kind of camaraderie you can only experience when you love what you do and who you work with. We share the adrenaline rush cases, and the stories from residency. The saves and the heart breaks. Friendships and family. We even share our sushi rolls. At USACS we’re all in.

Discover USACS where every full-time physician is given ownership. Culture matters. Find out why at USACS.com.

Own your future now. Visit USACS.com or call Darrin Grella at 800-828-0898. [email protected]