ResidentOfficial Publication of the Emergency Medicine Residents’ Association October/November 2018 VOL 45 / ISSUE 5 Implicit Bias in Overcrowding

Contrast-Induced Nephropathy SMART Trial Overview The Pediatric ECG ENVISION PHYSICIAN SERVICES OFFERS ... programs that align physicians to become leaders

MANSOOR KHAN, MD, MHA, FAAEM EMERGENCY MEDICINE

Why EM Residents choose Envision Physician Services ■ Professional Development and Career Advancement ■ Employment Flexibility: Full-Time, Part-Time, moonlighting and travel team. Employed and Independent Contractor options ■ Practice Variety: Coast-to-coast opportunities at well-recognized hospitals and health systems ■ Unparalleled practice support ■ Earn While You Learn Program: Provides senior residents with $2,500/month while you complete your residency

For more information, contact: 877.226.6059 [email protected] EDITOR’S FORUM Quality of Life-Saving Care in the ED

Tommy Eales, DO (20.4.4.1) as a core competency of the an excellent complement to the wealth of @tommyeales practice of emergency medicine. Advance knowledge acquired during these rotations. M has come a long way from its directives, coordination with hospice In addition, many residency programs offer humble beginnings as a specialty services, and organ donation are all the ability to work directly with hospice Epracticed in hospital basements with specific topics that emergency physicians and palliative medicine services during scarce resources and minimum hospital are expected to understand and apply elective months. Fellowship in hospice support. As emergency physicians fought while caring for patients. and palliative medicine is increasing in for our place in the house of medicine, the But how can these individuals be popularity among EM graduates, and expectations for the care we deliver in the identified quickly and efficiently in the many residency programs have recruited ED grew exponentially. fast-paced world of EM? emergency physicians with this background In the modern era, emergency The ACEP Palliative Medicine section for the exact purpose of emphasizing this physicians maintain an ever-increasing has created a toolkit2 that can be used to importance skill set on shift. scope of practice that often extends far rapidly screen patients for potential benefit For EM residents interested in beyond the initial resuscitation and from palliative care resources. Designed to pursuing fellowship training in palliative diagnosis of life-threatening pathology. function as a quick check list, the criteria care and hospice medicine, ABEM offers With current trends toward increased include diagnosis of a non-survivable subspecialty certification to graduates of boarding times in EDs across the country, illness and any one of 5 additional ACGME-accredited Hospice and Palliative emergency care has become a complex and elements. These can be summarized to Medicine fellowships. While there are multi-stage event that extends hours past provider-estimated life expectancy of less currently 10 specialties including EM the initial evaluation. than 12 months (or anticipated death prior that offer subspecialty training in this At its most basic definition, palliative to adulthood, for children), multiple ED discipline, the American Board of Internal care is the term given to describe the visits for the same condition in the past Medicine (ABIM) creates the subspecialty medical care provided for patients several months, uncontrolled symptoms certification exam that is currently held with serious illnesses. In a typical (eg pain, dyspnea), functional decline, every 2 years.3 shift, this definition might apply to any and complex care requiring increasing At the interface of the initial number of patients receiving care in our support. While this tool is intended for use resuscitation and ultimate disposition crowded EDs. While the word palliative in patients who already carry the diagnosis of critically ill patients in the ED lies a immediately calls to mind the idea of a of a non-survivable illness, it also serves dynamic period during which emergency patient in extremis, this represents just one as a helpful reminder to identify high-risk physicians are the sole providers of the many instances in which palliative features of other critically ill patients who communicating life-changing diagnoses care interventions have been shown to may benefit from palliative care services. and prognoses to patients and their improve the quality of life for patients.1 During EM training, there is ample loved ones. It is during this time that The Model of the Clinical Practice opportunity to develop skill in palliative this essential skill set of our craft can of Emergency Medicine (EM Model) care. While routine EM practice provides provide the key resources, support, and is produced by the American Board significant experience, there are multiple comfort needed during devastating disease of Emergency Medicine (ABEM) and ways to hone palliative care skills outside of processes. Just as we strive to perfect the serves as a content blueprint for ABEM the ED. During ICU blocks, interaction and art and science of resuscitation, so too examinations. The EM Model clearly collaboration with palliative care specialists should we strive to provide high-quality identifies end-of-life and palliative care is a common occurrence and can provide palliative care. ¬

References available online. October/November 2018 | EM Resident 1 TABLE OF CONTENTS EDITORIAL STAFF Categories EDITOR-IN-CHIEF Tommy Eales, DO Indiana University COVER STORY

DEPUTY EDITOR 7 Implicit Bias Brian Fromm, MD Thomas Jefferson University and ED Overcrowding EDITORIAL TEAM Whitney Johnson, MD It’s clear that overcrowding UCSF-Fresno impacts the quality of care in an ED. But does it also Jeremy Lacocque, DO Midwestern University/CCOM affect the equality of care?

Leah McDonald, MD NYU/Bellevue Medical Center 5 PRESIDENT’S MESSAGE 16 TOXICOLOGY Clark Owyang, MD What Can We Accomplish Tackling Stanford Critical Care Medicine Fellow in Our Next 45 Years? Valproate Overdose Jayram Pai, MD Mount Sinai

Yagnaram Ravichandran, MBBS, MD, FAAP CARDIOLOGY/PEDIATRICS Children’s Hospital of Michigan 18 The Pediatric ECG and Long QT Syndrome Danny VanValkinburgh, MD CRITICAL CARE University of Tennessee 10 College of Medicine Doubling Down on Re-Expansion ECG Editor Pulmonary Edema Jeremy Berberian, MD Treatment Approach Christiana Care Health System and Ventilator Management MSC Editor TOXICOLOGY Morgan Bobb 20 Bleach University of Iowa Carver RISK MANAGEMENT College of Medicine Ingestion 12 Falls in the To Scope or Emergency Not to Scope? Department

EM Resident (ISSN 2377-438X) is the bi- An Investigation NEPHROLOGY monthly magazine of the Emergency Medicine 22 Residents’ Association (EMRA). The opinions Catching Up with herein are those of the authors and not of CRITICAL CARE ALERT Contrast-Induced EMRA or any institutions, organizations, or 14 Balanced Crystalloids Nephropathy federal agencies. EMRA encourages readers versus Saline in Critically Ill to inform themselves fully about all issues presented. EM Resident reserves the right Adults (the SMART trial) SPORTS MEDICINE to edit all material and does not guarantee 23 Emergency publication. PEDIATRICS Management © Copyright 2018 15 When You Hear Hooves, of Heat-Related Emergency Medicine Residents’ Association Consider a Zebra Illness

2 EMRA | emra.org • emresident.org UPCOMING EVENTS Oct. 13–16: ABEM Fall Oral Certification SPORTS MEDICINE ECG CHALLENGE Exam 26 Berlin Concussion 39 Nov. 30: NRMP standard registration deadline Summary and Nov. 30: CORD Abstract submissions due Active Rehabilitation Regional Meeting funding for Concussion Dec. 15: Management applications due Jan. 1: Medical Student Council applications due INTERNATIONAL MEDICINE VISUAL DIAGNOSIS Jan. 10: Committee chair-elect applications due 28 Small Bowel Obstruction What’s Jan. 15: EMRA Spring Awards Secondary to the Diagnosis? nominations due Ascariasis Infection Jan. 30: NRMP rank order list entry opens An Alarming @ noon ET Finding in the Feb. 20: NRMP rank order lists due Remote Territory March 11-14: SOAP of Eastern NRMP Match Day Honduras March 15: March 31–April 3: CORD Academic FINANCIAL Assembly/EMRA Spring Meeting MEDICAL STUDENTS 42 EM’s Own Emergency: @ Hyatt Regency Seattle 30 Unraveling the Mystery Financial Education of Dizziness in the ED

First Thursday of every month 45 PRACTICE ENVIRONMENT A Guide for the Student Clerkship Locums Life TRAUMA So Many 32 The Use of Low Titer Choices Group O Whole Blood in Emergency Medicine EMRA-FIED PROGRAMS EMRA-Cast: Listen at your convenience PREHOSPITAL & DISASTER 46 34 Emerging Prehospital Protocols ADVERTISE WITH US PRINT AND ONLINE MARKETING These Programs Rock! OPPORTUNITIES AVAILABLE Contact Cynthia Kucera | 201-767-4170 [email protected] NEWS & NOTES Download EM Resident Media Kit The More You Know 47 Do You Love Your Program emra.org/advertise Leaders?; National MEDICAL EDUCATION Leadership Opportunities; Be sure to check EMResident.org Annals of Emergency for exclusive online content! 36 Understanding EMS Medicine and more Provider Education Want to improve your CV? and How to Participate Write for EM Resident! as a Resident BOARD REVIEW Submit online at emresident.org. More Than a Powerpoint 49 Questions from PEER

October/November 2018 | EM Resident 3 EmBassador Travel Team Seeking the Best and Brightest EM Physicians

Enjoy the flexibility to live where you want and practice where you are needed.

EMBASSADOR TRAVEL TEAM PHYSICIANS RECEIVE:

Paid travel and Practice variety accommodations

Concierge support Travel convenience package

Regional engagements, Paid medical staff dues, equitable scheduling and licenses, certifications and no mandatory long-term applications employment commitment

Exceptional Fast track to future compensation package leadership opportunities

For More Information: Mansoor Khan, MD National Director, EmBassador Program 917.656.6958 | [email protected]

4 EMRA | emra.org • emresident.org PRESIDENT’S MESSAGE

What Can We Accomplish in Our Next 45 Years? Omar Z. Maniya, MD, MBA Physicians, emergency medicine became that it deserves. And through it all, more The Mount Sinai Hospital the 23rd medical specialty recognized in and more patients arrive at the ED. @omarmaniya the United States.1 In response, we’re finding more and “Anyone, anything, anytime.” In the years since that landmark event more ways to meet their needs, through hat offer — and pledge — of help in 1979, EM has grown to include: EMS advancements, ED-based ICUs, is so embedded in our culture • 10 recognized subspecialties (plus virtual health, freestanding EDs, urgent 2 that nobody in residency today fellowships in dozens more niches) care, and ever-more-sophisticated T 3 can remember a time before it. We • 240 EM residency programs training and education. don’t recall when the emergency room • 53,000 board-certified emergency These challenges and others — 4 was nothing more than ill-maintained physicians government reimbursement, private 5 storage space (typically in the hospital • 137 million ED visits per year (and insurance antics, internal strife — are basement). We weren’t around when growing) not the same as the ones our specialty emergency care was provided by • EMTALA, the law that ensures we overcame merely to gain recognition. perform a medical screening exam on Yet at their core they still center on our unsupervised interns and off-hours anyone who arrives in the ED pivotal point of unity: a desire to be the dermatologists, if it was available at all. Emergency medicine has become the place people turn when they need help Or when they could turn patients away lifesaving safety net its pioneers wanted it the most. Anyone, anything, anytime. who did not have the ability to pay. to be. We keep the doors open 24/7, 365 But we will only get there if we’re But as ACEP celebrates its 50th days a year, for anyone, anything, anytime. united and we all play our part. year and EMRA prepares for its 45th But it’s not easy standing in the gap Learning emergency medicine anniversary, we’re proud to honor between patient needs and public policy. isn’t enough. We all need to find our those roots. We are a product of the Just read the Medicare Payment Advisory leaders and blaze trails for those who ingenuity and sheer determination of Commission (MedPAC) report7 and you’ll will follow, whether it be in academia, the physicians of that era who imagined get an idea of the weight of bureaucracy community medicine, policy, business, a better way – and then made it under which medicine now labors. or a subspecialty or niche of emergency happen. (Watch our Emmy-winning For a variety of reasons, hospital medicine. That’s why, in honor of ACEP’s documentary, “24|7|365” for an eye- closures are on the rise.8 The emergency 50th and EMRA’s 45th, I humbly ask you opening look at how our specialty physician workforce is evolving.9 to continue your service to your patients began.) Physician burnout is being investigated as by serving your profession and consider They fought in the boardrooms and a contributing factor in medical errors.10 applying for an EMRA Committee, emergency rooms and lecture halls, Our widespread use of ultrasound, writing a book with EMRA, giving a talk steadily building up our credibility procedural sedation, and trauma at an EMRA event, or just showing up — through research and policy and resuscitation are coming under fire from so that 50 years from now we can look experience and results. After years of other specialties. Far too often, our back and smile a little bit wider at how unwavering advocacy by the fledgling specialty does not get the respect from far we’ve come in reshaping emergency American College of Emergency patients, policy makers, and colleagues care for Americans. ¬ LEADERSHIP ACADEMY References available online. AEROS October/November 2018 | EM Resident 5 Because your next step could be the biggest.

At Vituity, we’re here to guide you, no matter where you’re headed. Our ownership-based culture supports career development, mentorship, and leadership. Our real-world perspective o� ers clarity for the road ahead. Vituity. Acute Care Practice & Management. Take the next step and download our Women’s Guide for Career Momentum at go.vituity.com/BigSteps

Vituity® is a registered trademark of CEP America, LLC. © CEP America, LLC, All Rights Reserved. ADMINISTRATION & OPERATIONS Implicit Bias and ED Overcrowding IS THERE A CONNECTION? Carly Loner, MD University of Rochester Jason Rotoli, MD Assistant Professor, Department of Emergency Medicine University of Rochester vercrowding in the emergency department can be a significant Obarrier to delivering efficient and high-quality care, but the impact on delivering equitable health care is less commonly discussed. Literature demonstrates a connection between overcrowding and increased length of stay, mortality, and higher cost per admission.1 Overcrowding negatively impacts clinical decision-making by increasing miscommunication, delaying recognition and treatment, and increasing physician cognitive load.2,3 A large contributor to overcrowding is inefficient hospital throughput, especially in hospitals operating at greater than 100% capacity resulting in patients boarding in the ED. An overwhelmed primary health care system also contributes to an increasing number of patients relying on the ED as their sole access to the health care system. EDs are challenged to meet the needs of increasingly complex and diverse patients while managing higher patient volumes within the confines of limited hospital throughput and bed availability. Like many other specialties, emergency medicine has discrepancies in care outcomes in marginalized cognitive stress, which are exacerbated nets for vulnerable populations, providing populations in comparison to the general by the overcrowded conditions of the access to care independent of income, population.4-6 However, emergency ED, may amplify internal bias held by insurance, gender, race, or ethnicity.5 medicine is unique from other specialties providers and have an increased role The effects of overcrowding can influence in the high number of decisions made in clinical decision-making.3,7,8 These biases from the time of ED triage, during each shift based on limited patient biases include subconscious attitudes and ED provider evaluation, and throughout information, while also subject to perpetuating generalizations/stereotypes hospitalization. frequent work-flow interruptions and of marginalized patients (ethnic/racial/ Patient bias may begin in the time constraints. Clinical decisions are linguistic minorities, those with poor prehospital setting or in ED triage and made without a long-term doctor-patient social support, those with substance can be perpetuated by the patient’s relationship and are based on initial abuse or psychiatric disorders, ED location in the ED. It is standard of impression that can be influenced by “frequent flyers,” etc.). This is important care that patients are triaged based on extraneous factors. Physician fatigue and to consider because EDs serve as safety acuity and resource utilization. Thus,

References available online. October/November 2018 | EM Resident 7 ADMINISTRATION & OPERATIONS

under normal circumstances without likely to end up placed in an ostensibly ED boarding, one could easily presume lower acuity area of the ED. Patients who that a patient placed in the hallway face language barriers may be unable Implicit biases is lower acuity, leading to a lower to communicate illness severity or have provider suspicion of acute pathology their primary complaints misunderstood, during ED in comparison to a patient placed in a leading to inappropriate initial regular treatment room. For example, assessment. Patients with history of high evaluation one could easily imagine the discrepant ED utilization may have their medical assessment and work up for a hallway concerns minimized, making them can negatively patient triaged as “somnolent and susceptible to limited clinical assessment intoxicated” in comparison to that of a and the potential to miss acute pathology. impact not patient who enters a critical care area for Thus, patient location in the ED in the same chief complaint. addition to inherent patient factors of only the ED However, with increasing ED vulnerability may lead to suboptimal care. volumes and overcrowding, this may ED overcrowding can contribute evaluation be a dangerous mindset, as many of to implicit bias during ED provider our hallways are now considered to be evaluation, especially if the patient but the entire normal treatment areas and are filled with has characteristics that are prone to patients with varying levels of acuity. The stereotyping. One such factor is the hospitalization. triage provider is also making patient care stigma associated with mental illness. decisions with even less information and Patients with mental health disorders time than the patient’s main ED provider, experience societal stigma, suboptimal and these decisions can be influenced by social interaction and limited vocational prehospital personnel, patient behavior, opportunities.9 Many of them limit health appearance, and ability to express severity care interactions due to their own self- of illness. Multiple factors make patients stigma and fear of experiencing further susceptible to inaccurate triage and more negative interaction.10 Due to these

8 EMRA | emra.org • emresident.org stigmas, mental health illness is often ED overcrowding may also increase to suboptimal downstream health linked to homelessness and substance provider reliance on heuristics and care decisions. Unfortunately, ED abuse. These patients have many risk promote implicit stereotypes.15 In overcrowding can promote these biases factors for acute pathology and may be a study investigating ED provider and may contribute to increased health subjected to inaccurate assessment due ethnicity bias pre- and post-shift, it care disparities in vulnerable patient to increased provider bias during the ED was found that ED overcrowding and populations. evaluation. Implicit biases may include higher patient volumes caused a greater The ED is the safety net for many 5 attributing distress to mental illness pro-white implicit bias. In contrast, vulnerable populations. Recognition of instead of an acute medical process. when cognitive burdens are reduced possible implicit biases and cognitive Patients with mental health problems providers are more likely to individualize stressors that may promote these biases often require increased face to face patients and employ strategies that will assist providers in more accurately provider time due to complicated social reduce unconscious bias.16,17 As a result, assessing at-risk patients and reduce situations and, unfortunately, may receive reduced ED overcrowding can promote health care disparities. Strategies to a cursory evaluation due to the inability more equitable health care decisions for address ED overcrowding, hospital or aversion to dedicating large amounts of patients. throughput, and provider fatigue can also time in a busy emergency department.9 All Implicit biases during ED evaluation these factors can set these patients up for can negatively impact not only the ED reduce the extraneous stressors that can suboptimal health care, especially within evaluation but the entire hospitalization. increase reliance on heuristics and patient the time-pressured environment of the ED. Under conditions of heavy workload stereotyping. Greater education in mental One of the most studied factors and time constraint, unconscious bias health disorders may also promote an contributing to provider bias within may play an even greater role in the improved interaction between providers health care is patient ethnicity. Previous rapid decision-making and disposition and these patients — leading to improved research has shown that provider bias planning by ED providers.17 It has also access to emergency care. By becoming due to ethnicity has altered health been reported that patient generalizations aware of what specific stressors can care decisions in management of affect not only immediate treatment augment these biases and which patient thrombolysis, chest pain, and treatment decisions, but also decisions of further characteristics increase vulnerability, ED of acute pain.6,11,12 This implicit bias specialist involvement and procedural providers can implement decision-making has been shown to be promoted by intervention.11,18,19 If these first patient- that is less influenced by unconscious the heavy cognitive stressors and time provider interactions are compromised bias and help improve the care of the 13,14 pressures of the ED environment. by implicit biases, they will contribute marginalized patient. ¬

ACEP and EMRAs official online career center.

October/November 2018 | EM Resident 9 CRITICAL CARE Doubling Down on Re-Expansion Pulmonary Edema Treatment Approach and Ventilator Management

Mark M. Ramzy, DO, EMT-P when the small pig-tail catheter doesn’t Emergency Drexel University do the job, the answer is to replace it with @MarkRamzyDO a larger bore — right? physicians Case 39-year-old male presented to Diagnosis performing the emergency department with The exact mechanism of REPE is not Athe chief complaint of difficulty clear. The current theory is that lung expansion leads to increased vascular chest tube breathing after being punched in the chest 3 days prior. On arrival, a chest placement must x-ray (CXR) was obtained (Figure 1), revealing a left pneumothorax and understand the associated lateral 6th rib fracture. A small-bore chest tube (pig-tail pathophysiology catheter) was placed. After placement, the patient continued to complain of of REPE and its shortness of breath, developing new hypoxemia. Despite the confirmation of treatment. the pig-tail catheter on CXR (Figure 2), a large-bore chest tube was placed instead without any clinical improvement. The patient demonstrated persistent hypoxia and worsening tachypnea subsequently requiring intubation for hypoxic respiratory failure. Repeat CXR to confirm endotracheal tube placement showed worsening fluid accumulation in FIGURE 1. Initial CXR at 18:32 showing the affected lung (Figure 3). a large pneumothorax in the left upper So, what happened? More important: lobe along with a fracture of the lateral How do we fix it? The treatment of choice aspect of the sixth rib (white circular for a pneumothorax is a chest tube; and, markings).

10 EMRA | emra.org • emresident.org permeability. Rapid inflow of blood diuresis. The mechanism of REPE ventilators each connected to a to atelectatic lung segments results is different from that of cardiogenic lung. The second ventilator utilizes 3, 7,10 in an increase in both pulmonary edema. Unlike cardiogenic edema, a PEEP of 5 cm H2O for the REPE capillary and hydrostatic pressures.1,2 the rapid onset of fluid in REPE results lung in order to assist its poor The increased flow and permeability from increased hydrostatic pressure compliance and resolve the lung’s in the setting of alveolar injury, because of alveolar and capillary overall state of hyperperfusion. contribute to the transudation of inflammation.3 Therefore, treatment Improvement in the patient’s vital inflammatory mediators into the lung.3 goals should focus on returning the signs and arterial blood gas analysis Inflammatory molecules such as nitric vascular permeability, altered by this were appreciated within 3 hours oxide and free radicals alter capillary inflammation, to its original balanced of asynchronous ventilation. This permeability leading to pulmonary state. Anti-inflammatory medications patient continued to improve over edema and the clinical symptoms of have proven to be beneficial once the the next 6 days ultimately leading to hypoxia and tachypnea as seen in the diagnosis is suspected, Trachiotis et extubation and eventually hospital 4-6 aforementioned patient. al. optimized on the cytoprotective discharge. The amount of time the lung actions of misoprostol and ibuprofen While the recognition and remains collapsed is a major with resolution of REPE within 24-72 treatment of a pneumothorax in the contributing factor of REPE. The hours.10 ED is vital and can be gratifying, it is timeline varies, with several cases For severe cases, where intubation equally important to beware of the reporting REPE’s onset from hours and mechanical ventilation is necessary, complications of our interventions. after lung collapse to between 3 and there are several options described: 7 days.2-4, 6- 8 REPE is often diagnosed It is vital that emergency physicians 1. Position the patient in the lateral on CXR; however, clinical symptoms performing chest tube placement decubitus position with the affected of tachypnea and dyspnea generally understand the pathophysiology of side up to reduce intrapulmonary develop within less than an hour REPE and its treatment. Awareness of shunting secondary to edema.1,3,10 of chest tube thoracostomy.9 In the its occurrence in high-risk patients may aforementioned case, chest trauma 2. Apply more positive end-expiratory allow for more immediate recognition in the preceding 3 days as well as pressure (PEEP) and decrease tidal of its presence and earlier intervention, the persistence of symptoms after volumes to prevent further alveolar potentially preventing deterioration and appropriate chest tube placement offer injury and transudation. respiratory failure. Proper knowledge strong supporting evidence for REPE. 3. Use of asynchronous differential of ventilator management and the How is REPE treated? The lung ventilation. Described by Cho potential use of novel techniques such mainstay therapy for mild cases is well- et al in a case report, this treatment as asynchronous differential lung described in the literature and consists method involves the use of a double ventilation may improve treatment for of supplemental oxygen and cautious lumen endobronchial tube and two this high-severity condition. ¬

FIGURE 2. Second CXR at 20:01 confirming placement of a FIGURE 3. Third CXR at 22:05 displaying an appropriately small caliber thoracostomy tube and new consolidation in placed endotracheal tube, a large bore thoracostomy the left lower lung. tube replacing the small caliber thoracostomy tube, and worsened opacification of the left thorax.

References available online. October/November 2018 | EM Resident 11 RISK MANAGEMENT

AN INVESTIGATION Falls in the Emergency Department

Ashley Guthrie, DO to determine how many of these falls There are many fall risk assessment EMRA Board, 2016-2017 actually occur in the ED. A few studies tools available; however, most were St. Joseph’s Regional Medical Center have quoted fall rates anywhere from developed specifically for inpatient Steven Hochman, MD, FACEP 2 3 Medical Director of Research 0.15 to 0.288 per 1000 patients, up settings. Of all the studies, there are Department of Emergency Medicine to as high as 0.734 per 1000, prior to only two fall risk assessment tools that St. Joseph’s Regional Medical Center interventions. have been designed for the emergency rowded, busy emergency Clearly, falling is bad for patients. department: the Memorial ED Fall Risk 4 departments seem susceptible to It places them at risk for a multitude of Assessment Tool (MEDFRAT) and the 6 an increased risk of slip-and-fall injuries, from abrasions or contusions KINDER1 Fall Risk Assessment tool. C The MEDFRAT tool was developed accidents that keep administrators awak to fractures, head injuries, and even at night. But does the evidence bear out severe disability and death. According to after a two-ED hospital system with a this assumption? the Joint Commission, 30-50% of falls combined annual volume of 140,000 The literature reveals plenty of result in injuries, leading to an average visits evaluated an inpatient tool called 4 research on inpatient falls, outpatient of 6.3 days in increased length of stay the Conley Fall Risk Assessment tool . falls, falls in geriatrics, and methods of and about $14,000 in additional medical The researchers discovered that the preventing falls in geriatrics. However, costs per admission.5 inpatient tool identified a dismal 44% there is little data on falls that actually Analyzing falls in the ED can be a of patients who fell. This was consistent occur in the emergency department. 2-step process. First, how do we identify with the other inpatient assessment tool The vast majority of existing literature who is at risk? Second, what do we do that has been evaluated for ED use, the regarding falls in the ED has been once we have identified them? Hendrich II Fall Risk Model evaluated 3 developed and published in nursing Identifying patients at risk for falls by Terrell et al which identified 37% of journals, but corresponding articles have is harder than it sounds. Some patients patients at risk for falls in the ED. not filtered into the physician space. are at risk in the short term, such as a MEDFRAT As of 2013, between 700,000 to 1 patient who is intoxicated or influenced The MEDFRAT tool was utilized million patients fall in U.S. hospitals by mind-altering substances. Some to assess: confusion/disorientation, each year.1 Because most of the patients, such as a demented elderly intoxication or sedation, impaired gait, literature aggregates all falls occurring patient with gait disturbances, will use of assistive mobility devices, altered in the hospital as a whole, it is hard always be considered a fall risk. elimination, and history of fall in the

12 EMRA | emra.org • emresident.org patient is at risk for fall. If any one factor The second component of our was present, the patient was considered assessment shifts from identification of a high risk for falls. Investigators risk to management of it. At St. Joseph’s retrospectively applied the tool to charts University Medical Center, a bundle of for an almost three-year period, during items was created to easily identify fall which time they had 150 reported falls. Of risk patients to any employee working the 150 falls, only 35% had been identified with the patient. All items in the bundle as a fall risk by their previous inpatient are bright yellow. The bundle includes tool. Applying KINDER1 retrospectively socks, blanket, a star to hang on the wall they identified an additional 49% of falls. and a fall risk wristband. It also includes In total, they were able to retrospectively a sign-out sheet that goes with the patient identify 84% of the 150 patient falls. After to other departments. The sign-out sheet implementation, the KINDER1 screening alerts transport and employees in other tool prospectively identified 73% of departments that the patient is a fall risk. patients who subsequently fell. The original plan for my study was to The problem with fall risk compare number of falls before and after assessment tools for the emergency implementation of this bundle. However, department is the need to take into this was where the study fell apart. account that emergency departments There is different software for reporting are high volume with rapid through-put. incidents than our ED Electronic Medical Thus, tools should be short and easy Records (EMR) software so when we to use. Physical Therapy and Physical checked the falls reports, the incident Medicine and Rehabilitation have spent reports did not always match up with decades developing many different tests the EMR. Those that were a match to determine fall risk, but they practice had suboptimal reports, often just in very different environments from the documenting a fall without specifying emergency department, so their tools what happened or whether there were have been difficult to apply to patients in injuries. In the ED record, there was not past 3 months. The investigators used an ED setting. always documentation of the fall. One MEDFRAT for a one-year period with Also of note, several fall risk tools give could assume that if the fall resulted a total sample population of 91,190 points for impaired gait but not necessarily patients, 18 years and older, for 110 in injuries or required that the patient enough points to automatically make them received extra care, it would have been falls (0.73 per 1000 patient visits). a fall risk in the emergency department. MEDFRAT still only properly identified documented, but such assumptions do For example, another tool, which happens not make for good research. Thus this 43% of patients at risk for falls. The to be the one my department uses, is the demographics of the patients who fell project met its end. Johns Hopkins Fall Risk Assessment From the available literature were similar to previous study statistics Tool (JHFRAT)8. JHFRAT gives 2 points with an average of 46 years of age, 62% evaluated, many hospitals are also taking for unsteady gait and 2 points for needs extra precautions and are implementing male and 40% intoxicated. Statistics supervision for mobility, transfer, or show 77% of patients who fell had no fall risk prevention protocols similar to ambulation. It takes 6 points to make our yellow fall risk bundle. However, injuries, while 15% required wound patients a moderate fall risk and 14 from the available literature it is repair, splinting, or radiographs. No points to make them high risk. Logically, unclear if these bundles actually make patient required casting, traction, an impaired or unsteady gait should a difference. So once again, further surgery, or consults. There were no automatically place a patient at high risk studies are needed. We need to know deaths as a result of the falls. for a fall. once we identify these patients that our KINDER1 It remains clear that existing tools interventions are actually minimizing the The second fall risk assessment tool are not optimal for identifying falls in the risk of falls. developed for ED use and the better study emergency department. While they seem was the KINDER1 study6. KINDER1 was to be improving with the development Acknowledgements: I would like to developed at a Level 1 Trauma center of emergency department focused thank Richard E. Schultz, RN, CEN, with 96,000 patient visits per year. Risk tools, it remains that even the best MICN, who originally conceived this factors assessed were age great than 70 study identified only 73% of falls when project, Marianna Karounos, DO, MS, years, presentation to the ED for fall, implemented prospectively. This leads for the hours attempting to make this altered mental status for any reason me to believe we need more studies on work, and Chris Carpenter, who steered including substance use, impaired how we can best identify fall risks in the us in the right direction and kindly mobility, and nursing judgement that emergency department. pointed out its flaws. ¬

References available online. October/November 2018 | EM Resident 13 EMRA Critical Care Alert

CRITICAL CARE ALERT Balanced Crystalloids versus Saline in Critically Ill Adults (the SMART trial)

Semler MW, Self WH, Wanderer JP, et al, for the SMART Investigators and the Pragmatic Critical Care Research Group. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839.

Susannah Empson, MD ● Secondary Harbor-UCLA Medical Center — Clinical outcomes Background In-hospital death before ICU discharge or at 30 days or at V crystalloid solutions are commonly administered to critically 60 days; ICU free days; ventilator-free days; vasopressor- ill patients. Normal saline (0.9% sodium chloride) is the most free days; days alive and free of renal-replacement Icommonly administered IV fluid. However, many observational therapy during the 28 days after enrollment studies and experimental modes have suggested that normal — Renal outcomes saline administration might be associated with hyperchloremic New real-replacement therapy; persistent renal metabolic acidosis, AKI, and death. This study investigated dysfunction; acute kidney injury stage 2 or higher; whether the administration of balance crystalloids, compared with highest creatinine level during hospital stay; change from saline, reduced a 30-day composite outcome of death, new renal baseline to the highest creatinine level; final creatinine replacement therapy, or persistent renal dysfunction. level before hospital discharge Study Design Results ● Pragmatic, non-blinded, cluster-randomized, multiple-crossover ● Primary Outcome study — Major adverse kidney event in 30 days ● 15,802 patients randomized in 5 ICUs at single academic center (MAKE-30) ● Inclusion Criteria 14.3% in balanced crystalloid group vs. 15.4% saline — Adults 18 years of age and older group (P=0.04) — Admission to 1 of 5 participating ICUs during trial period The difference is more pronounced among patients ● Exclusion Criteria receiving larger volumes of crystalloids and among — Age < 18 years patients with sepsis — Relative contraindications to balanced crystalloids: ● Secondary Outcomes hyperkalemia and brain injury — administration by physician — In-hospital mortality at 30 days: 10.3% in balanced- discretion crystalloid group vs. 11.1% in saline group (P=0.06) ● Randomization — Incidence of new renal-replacement therapy: — All patients admitted to 1 of 5 ICUs at one academic center 2.5% in balanced-crystalloid group vs. 2.9% in saline were assigned to received saline (0.9% sodium chloride) or group (P=0.08) balanced crystalloids (lactated Ringers solution or Plasma- — Incidence of persistent renal dysfunction: 6.4% in Lyte A) balanced crystalloid group compared to 6.6% in normal — ICUs were randomly assigned to use saline during and saline group (P=0.60) balanced crystalloids, alternatingly from month to month Conclusion — The trial was coordinated with the emergency department The study concludes that among critically ill adults, the use and the operating rooms of balanced crystalloids resulted in a lower rate of composite Population Characteristics outcome of death from any cause, new renal-replacement ● 15,802 patients from 5 ICUs – 7,942 received balanced therapy, or persistent renal dysfunction with a NNT of 94. Given crystalloids; 7,860 received normal saline – with no significant that the study was conducted at a single academic center, the differences in baseline characteristics between the two groups generalizability of the findings might be limited. Furthermore, ● Median Age: 58 years the treating physicians were unblinded, which may lead to ● Gender: 57.6% male conscious and unconscious biases. It is important to note that the Outcomes Measures patients in the study received relatively small volumes of fluid ● Primary (median 1000 mL for balanced crystalloids group, 1020 mL for — Major adverse kidney event in 30 days (MAKE-30) the saline group). As stated in the study, the difference in primary A composite of death from any cause, new renal-replacement outcome was more prominent in the analysis of subgroup who therapy, or persistent renal dysfunction (elevation in sCr received larger volume of fluid. The use of balanced crystalloids to ≥ 200% of baseline). These were censored at 30 days or might be safer compared to saline in resuscitating critically ill hospital discharge, whichever occurred first. patients who require massive amount of fluid resuscitation. ¬

14 EMRA | emra.org • emresident.org PEDIATRICS When You Hear Hooves, Consider a Zebra Yagnaram Ravichandran, MBBS, MD, FAAP skin changes. The rest of the exam is Fellow, Pediatric Emergency Medicine unremarkable. CBC shows a normal white Children’s Hospital of Michigan count of 5500/mm3 with no abnormal Rajan Arora, MD (blasts/band) cells in the peripheral smear Associate Director, Quality Children’s Hospital of Michigan with elevated LDH and uric acid. The posterior pole is not visualized on Case ophthalmologic evaluation under sedation. 3-year-old African-American boy Emergent MRI shows an intracranial IMAGE 1 with autism spectrum disorder expansive, erosive mass within the sphenoid and global developmental delay A body extending into right orbital apex and presents to the ED with right “eye swelling” its musculature. Signal characteristics of for 1 week. Review of systems is negative. the mass (low T1 and T2 with significant Vitals are age appropriate. Parents diffusion restriction) and extension into the attribute fussiness to pain on manipulation orbital musculature are highly suggestive of his right eye. Exam, though limited, of the tumor’s lymphoid nature. (Images is significant for swelling of the right 1, 2). PET scan demonstrates sphenoid periorbital region, in the absence of body mass, renal, hepatic lesions, and erythema or discharge. It is not possible to appendicular skeletal lesions with focal assess pain with extraocular movements. fluorodeoxyglucose uptake. Endoscopic The rest of his exam is unremarkable. nasal biopsy confirms Burkitt’s lymphoma. Basic labs including CBC and CRP Given the large tumor burden with multi- are unremarkable. Ophthalmology is organ system involvement, the patient is consulted. Despite a limited exam, the classified as stage III, high-risk lymphoma suspicion for orbital cellulitis is low. and started on chemotherapy. Antibiotic treatment for presumed IMAGE 2 preseptal cellulitis is recommended. Discussion No imaging is recommended, and he is Ocular swelling in children is a discharged home on oral antibiotics. common complaint. Based on etiology disease process originating elsewhere in the Patient returns the following week for and pathogenesis, it can be categorized as body (see Table 1). progressive worsening swelling. Vitals primary or secondary. Primary swellings Burkitt’s lymphoma is a highly are unremarkable. Exam is significant for arise from the globe and its orbital aggressive small B-cell non-Hodgkin right eye proptosis, chemosis, periorbital appendages, including the orbit. Secondary lymphoma. Orbital involvement is rare; edema, and restricted eye opening without swellings are ocular manifestations of a it usually involves extraocular muscles and adjacent paranasal sinuses with a TABLE 1. Causes of Ocular Swelling predilection for medial and inferior rectus. Category Examples Clinical Clues Key Teaching Points Unilateral Eye Swelling Infection Cellulitis, abscess, infectious granuloma Acute onset, painful, local signs of inflammation, fever ● Know how to recognize orbital Malignancy Rhabdomyosarcoma, Glioma, Ewing’s Insidious onset, painless/painful, systemic features vs. periorbital swelling. Clues sarcoma, metastatic lesions (lymphoma, of malignancy, hematological clues (elevated white like proptosis, asymmetrical or leukemic chloroma) count, low hemoglobin and platelet count, abnormal restricted eye movements, pupillary blood smear) Miscellaneous Trauma, Insect Bites Inciting incident, punctum (insect bite), mechanism abnormalities, decreased visual acuity of injury and/or inability to visualize the fundus Bilateral Eye Swelling indicate orbital pathology and warrant Allergic Angioedema Recurrent episodes, swelling of tongue, uvula, facial urgent evaluation. swelling, abdominal pain , precipitating factors like cold or specific allergens, features of systemic ● Consider imaging all orbital swelling involvement with anaphylaxis suspicious for malignancy, with Systemic Nephrotic syndrome, fluid retention, Painless, symptomatology and history of suggestive systemic illness or inadequate ABx thyrotoxicosis illnesses response. Miscellaneous Trauma (Racoon eyes), Cavernous sinus Pertinent historical and clinical findings thrombosis, optic nerve glioma, intracranial ● Procedural sedation is key to a SOL, metastatic tumors (neuroblastoma) comprehensive exam. ¬

October/November 2018 | EM Resident 15 TOXICOLOGY Tackling Valproate Overdose John Mark Sawyer, MSIV Medical University of South Carolina Nicholas J. Connors, MD Assistant Professor, Division of Toxicology, Department of Emergency Medicine Medical University of South Carolina 53-year-old man with a history of bipolar affective disorder presents to the ED after a suicidal ingestion of approximately 30 tablets of valproic acid Aand 14 tablets of haloperidol. He is hemodynamically stable and somnolent, but easily arousable and able to answer questions appropriately. He has no signs or symptoms of anticholinergic toxicity or extrapyramidal symptoms. Background Most physicians are well acquainted with the teratogenic potential of valproic acid (VPA) and have an intuitive understanding of its hepatotoxic potential. For the emergency physician, many cases of acute VPA overdose result in only mild impairment. However, recognition of severe toxicity is essential and an understanding of VPA pharmacokinetics can help guide treatment.1 Pharmacology and Pharmacokinetics VPA is a widely prescribed anticonvulsant and mood stabilizer that is also used for migraine prophylaxis and treatment of neuropathic pain.2, 3 The described mechanism of action accounting for its anticonvulsant activity is prolonged inactivation of neuronal voltage-activated sodium channels similar to the action of carbamazepine and phenytoin.2 Additionally, inhibition of GABA metabolism has been shown to increase

FIGURE 1. Simplified Diagram of Valproate Metabolism in Hepatocytes VPA

Mitochondrial VPA–CoA Pathway

VPA–Carnitine VPA–Carnitine

Peroxisomal Pathway VPA–CoA L–Carnitine

Beta-Oxidation Urea Cycle

16 EMRA | emra.org • emresident.org References available online. this inhibitory neurotransmitter in vitro alternate oxidation pathway. A byproduct though the relationship of this effect to in is an inhibitor of the urea cycle ultimately vivo anticonvulsant activity is unclear. Oral raising serum ammonia concentrations. absorption of VPA is rapid and complete, Administration of L-carnitine enhances peak levels are reached 1-4 hours after movement of VPA into the mitochondria ingestion, and the elimination half-life is where it will eventually be metabolized.8 approximately 15 hours. At therapeutic Clinical studies currently consist only concentrations (50-100 mcg/dL), it is highly of retrospective case reports and case protein bound (90%) with an apparent series, but good clinical outcomes without volume of distribution of approximately adverse events are described.9, 10 Figure 1 2 0.2 L/kg. Hepatic metabolism via UDP- breifly outlines metabolic pathways, and glucuronosyltransferases and beta- dosing recommendations are outlined in oxidation predominates. Figure 2. Toxicity Hemodialysis CNS depression is common, ranging Typical VPA pharmacokinetics from somnolence and lethargy to would preclude hemodialysis due to severe coma.3, 4 Respiratory depression, the high degree of protein binding. hypotension, metabolic acidosis, and However, at extremely high serum electrolyte abnormalities (such as concentrations the protein bound hypocalcemia, hypernatremia, and fraction decreases and provides a hypophosphatemia) are possible.3 Unique rationale for hemodialysis.4 For patients features of acute overdose include with manifestations of cerebral edema hepatitis, pancreatitis, thrombocytopenia, or shock, or serum VPA concentration and leukopenia.5 Delayed symptoms and >1300 mg/dL, intermittent hemodialysis peak concentrations should be anticipated is recommended.11 Other considerations in cases of enteric coated formulations.6, 7 and treatment parameters are outlined Management and Treatment in Figure 2. For the patient with a known or suspected ingestion, serum ammonia and Emerging Approaches VPA concentrations should be obtained A recently published case in addition to liver function tests. A series (n=5) proposes L-arginine four-hour post-ingestion acetaminophen supplementation as an additional concentration should be obtained in all therapeutic approach in VPA overdose patients with intentional ingestions. Due patients to stimulate N-acetylglutamate to the delayed absorption of enteric- synthetase, which is inhibited by coated formulations, VPA and ammonia VPA.12 Although the case series shows a concentrations should be followed until temporal relationship between declining they begin to downtrend.3 ammonia concentrations and L-arginine Supportive Measures supplementation, 2 of the 5 patients were also treated with hemodialysis, and In addition to following serum drug concentrations, it is reasonable to consider further study of larger cohorts need to be multi-dose activated charcoal to reduce undertaken. absorption in ingestions of enteric coated Case Resolution formulations. It is also recommended to The patient had an initially elevated review and discontinue medications which VPA concentration that peaked 8 hours affect VPA metabolism.3 post-ingestion at 437 mg/dL. Prior L-carnitine Supplementation to starting L-carnitine, this patient Within hepatocytes, VPA is metabolized also had a peak ammonia level of 133 as a fatty acid and is shuttled into micromol/L. Liver transaminases and mitochondria conjugated to carnitine. In INR in the ED were within normal overdose, the quantity of VPA overwhelms limits. The patient was admitted to the mitochondrial beta-oxidation. VPA MICU and L-carnitine was continued and other fatty acids accumulate in the for 48 hours. Subsequently deemed hepatocytes causing steatosis. Additionally, medically stable, the patient was FIGURE 2. Summary of Management VPA in the cytoplasm is metabolized by an transferred to inpatient psychiatry. ¬ Approaches

October/November 2018 | EM Resident 17 CARDIOLOGY/PEDIATRICS The Pediatric ECG and Long QT Syndrome Cullen Clark, MD LSU Emergency Medicine/ Pediatrics Residency Program he pediatric ECG has numerous subtle and not-so-subtle Tdifferences when compared to the average adult ECG. Detecting these differences can focus your differential, impact your treatment, and most importantly provide you with solid footing in making a relevant consultation to pediatric cardiology. This review will focus on the key differences in rate, axis, and intervals. Rate The foremost difference is rate. Unlike adults, children not only tolerate a much higher heart rate but depend on an increase in heart rate alone to grows during the first years of life, a Other characteristics that would raise increase cardiac output. The resting decrease in the amplitude of the R concern would be right precordial Q heart rate does not coincide with adult waves and corresponding increase in the waves, wide Q waves, abnormally deep range until at least age 5 years. amplitude of S waves is seen in the right Q waves.1,3 1,2,3 Children can also have wider precordial leads. Intervals variation in heart rate associated with Precordial T waves Children have shortened PR intervals the respiratory cycle and changes in A pediatric norm that can initially and QRS complexes compared with P-P interval. This phenomenon is termed seem alarming to an adult practitioner adults. This is often overlooked as most sinus arrhythmia. Up to 50% of infants is the “juvenile T-wave pattern.” The of us have committed normal adult can have sudden prolongation of the precordial leads have T-wave inversions wavelength ranges to memory. It is P-P interval with no symptomatic or that normally persists until age 10-12 important to remember that what may 4 long-term effects. years. Occasionally, this pattern can be a normal PR interval in an adult can Axis last later into adolescence and young be a manifestation of 1st degree block At birth, all neonates have a rightward adulthood. Presence of a positive T in a young child. Additionally, a normal axis because of relative right ventricular wave in V1-V3 past the first week of adult QRS could be a bundle branch hypertrophy. Most pronounced at 1-2 life is pathologic and warrants further block in a young child. The PR interval 2 months of age, the axis slowly migrates investigation. The T waves in V5 and V6 initially shortens in the first year of life from right to left as the left ventricular should always be positive after the first 3 before gradually widening to the adult 1 myocardium hypertrophies to account days of life. range through childhood.2 Both P wave for the postnatal increase in systemic Q waves and QRS slowly widen to adult ranges vascular resistance and a concomitant Young children can have a significant as the child ages. Age-based charts are decrease in pulmonary vasculature Q wave in the inferior and lateral leads available and should be referenced when pressures. The normal adult ratio of from birth until age 3-5 years, when determining appropriate PR interval and right-to-left ventricle mass — and thus they recede. They can be as deep as 8 QRS complex duration. a normal axis — is expected to be seen mm in lead III during childhood. These Of note, healthy teenagers can have by age 6 months. A persistent rightward Q waves are expected, so much so that significant abnormalities on ECG that axis can be indicative of congenital heart their absence in the lateral leads can be are normal variants. Bradycardia at disease. Similarly, as the left ventricle an indication of congenital heart disease. rest is often seen in young, healthy and

18 EMRA | emra.org • emresident.org mostly athletic teenagers. Additionally, is the QTc or the corrected QT interval, abnormalities are the leading causes these adolescents can have a prolonged which reflects the QT interval corrected of persistently prolonged QT interval.7 PR interval at rest — some to the extent for heart rate. Normal range for the There are numerous inherited mutations they have ongoing 1st degree block QTc is generally accepted as <0.44 that fall under the classification of while sleeping. Around 10% can develop sec or 440msec. QTc from 0.44-0.46 long QT syndrome; luckily, they tend transient, asymptomatic Mobitz Type sec is considered borderline and only to present similarly and treatment is I 2nd degree AV block at rest. This significant if symptomatic. Anything often uniform. Other causes include percentage was shown to be higher when greater than 0.46 sec is prolonged QT. electrolyte abnormalities (hypocalcemia, a group of teenagers in intensive physical Most ECG machines provide a QTc hypomagnesemia, hypokalemia), 5,6 training were analyzed. on the computer interpretation. The hypothermia, increased ICP, and Long QT machines use the default Bazett formula, medications. While these other causes typically have additional findings Identification of differences in which is useful when the heart rate is on exam and ECG, familial long QT the pediatric and adult ECG aid within the normal adult range but is syndromes and medications often in distinguishing potentially life- inaccurate when the rate is <60 or >100. manifest as prolonged QT alone. threatening abnormalities from a normal There are several other formulas that Symptomatic prolonged QT ECG, with one of the most notable and are more accurate for calculating QTc syndrome may require emergent vastly overlooked conditions being for heart rates outside of normal adult cardiology assessment and intervention prolonged QT interval. range (eg, Fredericia, Framingham, depending on degree of prolonged QT. Prolonged QT is perceived as a In severe cases, rate control clinical specter that is transiently either by medication or considered on an academic pacing can be initiated in basis when we approach a the emergency department. patient with syncope or Knowing the differences order one of the many Prolonged QT with mild or medications that can between the pediatric and no symptoms requires a elongate the interval. more extensive outpatient While seemingly rare, it adult ECG will help you workup by a cardiologist, is an important clinical but identification in the consideration given the distinguish potentially life- ED can be life-saving. correct circumstances and These patients should be should not be overlooked threatening abnormalities counseled to avoid certain in the emergency from a normal ECG. medications and strenuous department.8 What makes activity until they can be assessment for prolonged evaluated by a cardiologist; QT especially important in this includes exemption for children is symptoms may sports (especially swimming or diving) and PE in school. The extended not manifest until they progress to life- Hodges). The ECG computer tends to workup includes serial ECGs, stress threatening dysrhythmia, torsades de overestimate the QTc, especially if the pointes, or sudden cardiac death.7 heart rate is outside the normal range. testing, and potential genetic testing for The identification of prolonged QT When you receive an ECG that lists the familial long QT. syndrome requires an index of suspicion QTc as borderline or prolonged, the first Conclusion enough to warrant a workup with ECG. step should be to look at the heart rate Being familiar with measuring the Often symptomatic patients will present and calculate the QTc manually using a QT interval and identifying a prolonged with syncope or presyncope manifesting formula that accounts for heart rate <60 QT is important for the ED provider as dizziness or lightheadedness. A small or >100 if applicable. The computer- because outcomes are good if long QT is percentage of patients will present with generated QT and RR measurement has detected early. These patients can lead seizure activity. In many cases, exercise, been found to be consistently accurate normal lives with appropriate treatment, emotional stress, swimming/diving, and in most ECG computers and thus can be which may include pharmacologic rate 9 startle responses elicit these symptoms. used to manually calculate the QTc. control, AICD placement, or operative Prolonged QT is identified via ECG. Prolonged QT interval can be sympathetic ganglionectomy. A good way to screen for a prolonged QT caused by numerous factors. The most is to draw a line in the middle of an R-R concerning in an otherwise healthy Acknowledgments interval. If the T wave occurs after the child is congenital Long QT syndrome. Special thanks to Dr. Bianca Castellanos dividing line or that line bisects part of Family history is one of the most and Dr. Kelly Gajewski from the the T wave, investigate the QT interval important aspects of the patient’s LSUHSC Department of Pediatric further. The most reliable measurement history because inherited conduction Cardiology for their contributions. ¬

References available online. October/November 2018 | EM Resident 19 TOXICOLOGY BLEACH INGESTION To Scope or Not to Scope? but became more commonplace in the US important to assess for structural Darren Cuthbert, MD, MPH 2 Rutgers Robert Wood Johnson in the 1980s. Due to its easy accessibility, damage after bleach ingestion. This [email protected] it is commonly involved in potentially is a task that is always completed by Guillermo Ortega, MD toxic ingestions. consultants, typically otolaryngology or Rutgers Robert Wood Johnson Bleach comes in various gastroenterology; though toxicologists Eric Levy, DO concentrations, which carry a difference and poison centers can also provide Rutgers Robert Wood Johnson in potential sequelae. Typical household recommendations. Ann-Jeannette Geib, MD, FACEP bleach comes in concentrations ranging Director of Toxicology Mechanism Rutgers Robert Wood Johnson from 3 to 5 percent and usually does not cause injury beyond local irritation, with Bleach is toxic by direct contact 32-year-old Spanish-speaking minimal gastroenterological effects.1 of the hypochlorite moiety of sodium male presents to your ED via Large ingestions, or ingestion of higher- hypochlorite causing damage via EMS after coworkers caught him 1,4 A concentration bleach (up to 35 percent), liquefactive necrosis. Saponification of drinking bleach. The incident occurred carries a small potential risk for caustic tissue proteins and fats causes cellular approximately 45 minutes prior to his injury.1,3,4 One human study of bleach damage. Extent of tissue destruction arrival in the ED, shortly after he had ingestion done on 393 patients revealed is dependent upon concentration, pH, been reprimanded by his supervisor at zero cases of perforation, strictures, or and degree of exposure.1,4 Due to route the factory where he works. He states he long-term sequelae, with the majority of of exposure, ingestion of bleach has the was angry at work but refuses to provide serious adverse outcomes limited to case potential to cause corrosive or caustic further details or answer additional reports and animal studies.1 injury to oropharynx, esophagus, or questions regarding the incident. EMS Though the risk is low, bleach stomach. Symptoms usually present reports that it was an ”‘industrial bleach” ingestion has been shown in rare cases of unknown concentration, and that his as odynophagia, drooling, stridor, to cause severe coworkers stated that half the contents complications, were missing from the 1-gallon bottle, including although they did not know whether it strictures, was full prior to ingestion. perforation, The patient admits to a psychiatric hypernatremia, history of bipolar disorder and hyperchloremic depression. He denies significant acidosis, and even nonpsychiatric past medical/surgical death. A canine history, has no allergies, and took model study unknown medications in the past for showed a single his psychiatric disease but has been case of perforation noncompliant for years. His vital signs following long term are within normal limits. He is awake, contact.1 alert, and oriented. Physical exam is For typical unremarkable, revealing clear breath household bleach sounds, no signs of caustic injury to ingestions, most oropharynx, and an abdomen that is poison centers soft, nontender, and nondistended. recommend only Background conservative home Sodium hypochlorite, commonly management or known as bleach, is an oxidizing agent supportive care.1,5 that can be found in most homes and We look to provide workplaces across America, regularly recommendations used as a disinfectant and whitening for emergency agent.1,2 The use of bleach for these providers as purposes dates back to the early 1800s to when it’s

20 EMRA | emra.org • emresident.org dysphagia, sore throat, vomiting, which must be managed accordingly. Emergency Management abdominal pain, or chest pain.1,4 If If the patient is suffering from a Recommendations aspirated, severe respiratory distress hyperchloremic metabolic acidosis, IV While using clinical judgment, and shock can occur due to pulmonary bicarbonate or buffer solutions can be contact gastroenterology or 1,4 4 parenchymal damage. started. otolaryngology early following initial Management To Scope or Not to Scope? stabilization of the patient, as there is No specific antidote for bleach toxicity Upper endoscopy is a vital tool of a high level of variability among when or exposure currently exists. In the initial prognostic value to determine the extent flexible endoscopy should be used triage, patients should be undressed and of injury in a patient suffering from a to look for caustic injury. Literature decontaminated due to potential risk of corrosive ingestion.1-9 Direct visualization from toxicology, otolaryngology, secondary exposures. Irrigate any areas of the esophagus via flexible endoscope and gastroenterology ranges from potentially exposed with normal saline, is the most commonly used method for recommending endoscopy from 4 to 72 D5W, or lactated Ringer’s solution. diagnosis due to the minimal risk of hours, with most sources in agreement Airway and breathing should also be perforation. Endoscopic evaluation is that patients should be evaluated for 1-9 immediately evaluated and managed not limited to the esophagus, as there endoscopy within 24 hours. Due to the appropriately.1,4 is no correlation between injury to the multi-speciality disaccord, reach out to Activated charcoal, or anything that esophagus and whether the stomach or consultants immediately if corrosive or can induce emesis is contraindicated, duodenum are also affected.4 Endoscopy caustic injury is suspected. due to risk of aspiration and secondary is contraindicated in unstable patients or pulmonary injury. Non-critical patients if there is signs of perforation or airway KEY POINTS who have a normal mental status, a compromise.4 ● Toxic ingestion patients are patent airway, and the ability to swallow As emergency providers, we should often unreliable historians, can be provided 4 to 8 ounces of milk or always assume the worst. If the patient so approach clinical water for dilution of the substance.4 is symptomatic, details are not available symptomatology with a grain of If a bleach ingestion patient presents regarding the concentration of ingested salt. bleach, or the history is unreliable, then acutely ill, the patient should immediately ● Key portions of history-taking get consultants on board early. Approach be placed on a cardiac monitor and are: venous access should be obtained. Careful symptomatology loosely, as these patients — Concentration of product attention should be paid to the ABCs, are often unable to provide a reliable history. A study done in — Volume of ingestant the European Journal — Duration of exposure of Gastroenterology — Potential co-ingestants and Hepatology in 2014 ● Symptoms vary widely, but reported that clinical usually presents as: signs and symptoms — Odynophagia are a poor indicator of — Drooling severe injury in potential — Stridor caustic ingestions — Dysphagia (sensitivity: 75%), while — Sore throat also recommending — Vomiting early flexible endoscopy in almost all potential — Abdominal or chest pain cases.9 Though bleach ● Management: itself is usually not — ABCs harmful, it is important — Expose and decontaminate to keep in mind that — Can give milk/water if the there have been cases patient is stable and airway reported of severe patent complications, where it — If critical manage accordingly would be vital evaluate and keep in mind potential the extent of injury via need for bicarbonate infusion endoscopy.1,5,7,9 The ● Get consultants on board early: timeline of when to — Contact local poison center, initiate this process is highly variable among consult hospital toxicology providers. team, ENT, or GI ¬

References available online. October/November 2018 | EM Resident 21 NEPHROLOGY Catching Up with Contrast- Induced Nephropathy Rebecca Lee contrast media (HOCM). The mechanism confounding variables that influence the University of Maryland by which CIN is thought to occur is due to selection of patients who receive IV contrast @BeckyLeeEM 3 potential causes: and those who do not. This has been ad- [email protected] 1. Medullary ischemia dressed with the use of propensity scoring, Gentry Wilkerson, MD which takes into account the likelihood that University of Maryland 2. The creation of reactive oxygen species 4 @GentryWMD 3. Direct tubular cell toxicity a patient would be assigned to either group The degree to which CM is directly based on known confounders that can cause Introduction 6 responsible for the development of AKI is AKI other than CM. ontrast-induced nephropathy (CIN) a matter of considerable debate. Published There have been multiple single-center, is the development of acute kidney studies measuring the incidence of CIN are retrospective comparisons of contrast- injury (AKI) as a direct result of C composed entirely of observational trials, exposed versus contrast-unexposed the administration of iodinated contrast and recent studies suggest that the risk of patients that have failed to demonstrate media (CM). This is a causative diagnosis CIN is overestimated. A randomized control a statistically significant increase in the with a direct cause-and-effect relationship. trial (RCT) would provide the best level of risk of developing AKI after exposure to Post-contrast AKI is a correlative 8,9 evidence to determine whether there is a CM. A subgroup analysis in a study by diagnosis in that it is the development causal relationship between contrast and Davenport et al. did find an association of AKI after administration of CM. This AKI, but designing such an RCT would of CM with AKI in patients having an correlation does not equate to causation. not be possible given the ethical issues elevated baseline creatinine of ≥1.6 mg/ The American College of Radiology (ACR) 10 associated with such a trial. Consequently, dL; however, a recently published study Manual on Contrast Media states that there have not been any RCTs to date by Hinson et al. did not find this same these terms are neither synonymous nor association.11 The meta-analysis by Aycock evaluating the risk of developing CIN. interchangeable.1 et al. included more than 100,000 patients Past studies have not used a standard The Evidence from 28 observational studies. They found diagnostic criterion for CIN and PC-AKI. The first report of CIN was published the risk of AKI from contrast-enhanced Most use both an absolute and relative in 1954 describing the case of a 69-year- CT compared to non-contrast CT was not increase in serum creatinine levels to old male, posthumously diagnosed with increased (odds ratio [OR] 0.94; 95% make the diagnosis. According to the multiple myeloma, who underwent confidence interval [CI] 0.83 to 1.07). No Acute Kidney Injury Network (AKIN), intravenous pyelography and subsequently risk was also seen in the 6 studies that used AKI is present when there is an increase developed anuria.5 Older studies of CIN matching techniques (OR 0.98; 95% CI in serum creatinine of more than 0.3mg/ were performed when most contrast 0.92 to 1.05).7 dL, an increase of more than 50% from the imaging studies utilized HOCM. Some Conclusion conclusions regarding the association of patient’s baseline creatinine level, or the Despite being widely feared by the CM with the development of AKI were presence of oliguria (< 0.5 mL/hr urine medical community for decades, the risk extrapolated from patients who underwent output) for more than 6 hours within 48 of CIN has been seriously challenged by 2 hours. cardiac angiography procedures, which recent studies. Ultimately, RCT-based Intravascular CM are concentrated greatly overestimates its risk compared evidence is necessary to reveal an accurate solutions containing monomeric or to that of intravenous administration incidence of CIN as well as to elucidate dimeric tri-iodobenzene with differing side commonly encountered in emergency whether causality is present. Previous 6 chains. Iodine, with a high atomic number department settings. observational studies, though limited (Z=53), imparts an increased density Calculating the risk of CIN is difficult by the effect of potential confounding, to the solution, which allows for visual to determine due also to a lack of standard- strongly suggest that the risk of CIN, at the 3 contrast versus anatomic structures. ization used in prior studies regarding the very least, has been highly overestimated. CM can be classified as ionic or nonionic definition of CIN. A recent meta-analysis The impact this common-belief has on as well as high-, low-, and iso-osmolar. found 28 studies, all observational, with physician diagnostic behavior has not First generation CM were high osmolar many using an absolute rise in serum been quantified. Given the importance agents (> 1200 mosm/kg) compared to creatinine of 0.3 to 0.5 mg/dL or a relative that CM has in the diagnosis of multiple plasma osmolarity of 280-290 mosm/kg. increase of 25% from baseline within three life-threatening diseases, it is essential that Low osmolar contrast media (LOCM) and days of contrast administration.7 A common policies and guidelines provide a realistic iso-osmolar contrast media (IOCM) have limitation among these observational studies and evidence-based calculation of the risk largely replaced the use of high osmolar is that without randomization, there may be of AKI due to use of these agents. ¬

22 EMRA | emra.org • emresident.org References available online. SPORTS MEDICINE Emergency Management of Heat-Related Illness The best treatment for heat-related illnesses is public education and prevention.

Wes Troyer, DO sustained temperatures > 32.2° C or 90° Exertional heat injuries tend to Physical Medicine and Fahrenheit. occur in young, physically fit individuals Rehabilitation Residency Program Non-environmental risk factors performing under conditions of high heat, University of Kentucky include heavy clothing or equipment, including sports, recreational physical John Kiel, DO, MPH Assistant Professor of Emergency Medicine children younger than 4 years of age, activity, firefighting, and military training. Assistant Professor of Sports Medicine adults older than age 65, obesity, and Treatment University of Florida– underlying medical conditions such as The best treatment for heat-related Jacksonville College of Medicine diabetes, heart, and pulmonary disease. illnesses is public education and Young individuals participating in eat-related illness is classically prevention. Air-conditioning is the No. strenuous activity during warm weather taught to represent a spectrum 1 protective factor against developing increases their risk of heat-related illness. Hof hyperthermic disease ranging heat-related illness and death.2 During Environmental risk factors include warm from heat cramps, heat syncope, heat a heat wave, public facilities with air temperatures and humidity, especially exhaustion, and – in extreme cases – conditioning should be made available. in populations not acclimated to them, heat stroke. Symptoms present when the In mass participation events, several and can be exacerbated by lack of access body is exposed to heat with inability to measures can be taken by organizers to transportation, medical care, and properly cool core body temperature. and medical staff to reduce the risk of cooling centers. Normal core temperature ranges between developing heat-related illness. Care 36-38° Celsius. Below 35° C, radiation Types of Heat Illness should be taken to avoid scheduling represents 60% of heat dissipation with Heat-related illness may be classified during hot and humid months, and events an additional 30% from evaporation; as exertional or non-exertional should be held during the cooler hours above 35° C, this native process becomes (classic). Exertional type is related to the of the day. If possible, athletes should overwhelmed and insufficient to maintain endogenous heat production of physical prepare with heat acclimatization; a adequately cooled core body temperature. activity and generally occurs in young, process of increasing activity duration and Subsequently, thermoregulatory failure healthy individuals. Non-exertional type intensity during the preceding 10-14 days. occurs and the body is unable to release tends to be environmentally related and Athletes should have fluid intake, diet, heat quickly, leading to elevated core occurs insidiously in children and the and whole-body sodium levels monitored, temperatures. elderly. wear lightweight, light-colored and loose- Incidence and Risk Factors Classic heat-related illness occurs fitting clothing, and have shaded areas Between 1999 and 2010, 8081 during periods of high environmental available for rest and recovery. Finally, heat-related deaths were reported in heat stress, and physical exertion is not coaches, athletes, administrators, and the United States, with 94% of deaths required. In non-exertional heat illness, medical providers should be educated on occurring between May in September.1 the increase in core temperature is prevention, recognition, and treatment of Because reporting of heat-related generally slow, occurring over hours to heat-related illness. illness is not mandatory, the incidence days. Subsequently, these individuals are Heat edema is a self-limited process is likely underestimated. A heat wave likely to develop volume or electrolyte defined as dependent pretibial edema is defined as >3 consecutive days of disturbances. of the lower extremities and/or hands

October/November 2018 | EM Resident 23 SPORTS MEDICINE

during the first few days of exposure to Heat syncope is due to a combination True Medical Emergency increased temperature. Although it usually of volume depletion, peripheral Heat stroke, whether classical or resolves within days of onset, patients vasodilation, and decreased vasomotor exertional, is the most serious presentation may be symptomatic for up to 6 weeks. No tone resulting in postural hypotension. of heat-related illness. Mortality rates specific treatment is necessary; elevation Evaluation includes workup of other causes range from 30-80% and is universally fatal and compression stockings may accelerate of syncope including cardiac, metabolic, if left untreated. The diagnosis is generally recovery and aid in symptomatic relief. and neurologic etiologies, and treatment is clinical and defined by encephalopathy Diuretics are not indicated and may directed at rehydration, rest, and removing and hyperthermia > 40° C, although precipitate more severe heat-related illness. the patient from the area of heat exposure. temperature less than 40° C should not be Prickly heat, also known as Hospitalization is often unnecessary. exclusive criteria for treatment. miliaria rubra or heat rash, is a pruritic, Heat exhaustion is the result of The presence of mental status maculopapular, erythematous rash due to both hypovolemia and hyponatremia. changes in a hot and/or humid inflammation, dilation, and rupture of the Hypovolemia occurs in individuals in environment should be considered heat sweat glands, producing small vesicles that warm environments with inadequate water stroke until proven otherwise. Anhidrosis presents over clothed areas of the body. replacement; hyponatremia occurs when is not diagnostically reliable. Ataxia Patients generally complain of itching, individuals replace fluid losses with water or is an early symptom due to sensitivity which responds well to antihistamines. other hypotonic fluids. Symptoms include of the cerebellum; patients may also Wearing light, loose-fitting clothing will headache, nausea and vomiting, malaise, have irritability, confusion, behavior reduce likelihood of developing heat dizziness, muscle cramps, and other clinical changes, combativeness, hallucinations, rash. Talc and baby powder do not help; indicators of hypovolemia. Notably, patients decorticate and decerebrate posturing, chlorhexidine lotion may provide relief. do not have altered mentation. Patients hemiplegia, and coma. Seizures Heat cramps are painful, involuntary are tachycardic and may have positional are common. Neurologic injury is a muscle contractions, typically of the calves, hypotension, temperature is elevated function of duration of exposure and occurring in sweating individuals with but typically below 40° C. Laboratory maximum temperature. The patient inadequate volume replacement or who are evaluation reflects hemoconcentration; may be tachycardic, tachypneic, and/or hydrating with hypotonic fluids. Cramps patients may have hypotonic or isotonic hypotensive. may occur during exercise or commonly hypovolemia. Treatment is directed at Heat Stroke Management during a rest period following physical fluid replacement, electrolyte correction, Initial treatment of exertional heat activity. Although self-limited, patients removal from warm environment and rest. stroke is directed at removing the patient may present to the emergency department These patients may require active cooling, from the offending environment and due to persistent myalgias. Cramping is especially if not responding to the first immediate cooling with cold-water usually isolated to a specific muscle group 30-60 minutes of therapy. immersion, as it has been shown to be the and rarely leads to the development of Traditionally heat-related illness fastest cooling modality.7 If cold water rhabdomyolysis. Electrolyte disturbances has been presented as a spectrum of immersion is not available, cold water include hyponatremia and hypochloremia. hyperthermic disease; however, there is a dousing and wet ice towel rotation may be Primary treatment is with oral isotonic lack of consensus in the literature that heat used, but these have not been found to be fluid replacement and rest in a cool cramps, heat syncope, and heat exhaustion as efficient. environment. Oral hydration with 0.1% progress to or increase the risk of heat The length of time that core body saline solution or with commercially stroke. While many of these previously temperature is elevated has been linked available electrolyte drinks are adequate described phenomena can occur in the with increased morbidity and mortality, for most patients. Patients with severe presence of increased temperatures, they with practitioners aiming to lower body symptoms may require IV rehydration. can also occur in its absence. Alternative temperature below 39° C within 30 Prevention is directed at maintaining pathophysiologic mechanisms independent minutes to decrease these risks.5 Because sufficient hydration with either water and of heat have been proposed; such as external thermometry is unreliable, salt tablets or commercial electrolyte drink. neuromuscular control theory for exercise accurate temperature measurement Heat tetany is caused by induced muscle cramps8 or heat syncope with a core temperature is essential; hyperventilation and subsequent explained as exercise associated collapse regardless, cold-water immersion should respiratory alkalosis, presenting as in the presence of heat by the Edholm- be initiated as soon as the diagnosis is paresthesias of the extremities, perioral Barcroft reflex as described by Noakes.9 suspected.4 Rapid cooling should be area, and carpopedal spasm. It is often While investigation into the pathophys- discontinued once temperature reaches confused with heat cramps; however, iology of these disease states continues, the 39° C to avoid rebound hypothermia. it is a separate clinical entity typically risk of referring to them as a spectrum of Heat stroke is a medical emergency and not accompanied by muscle cramps. hyperthermic illness may overstate their patient should be transported to hospital Treatment is directed at moving the clinical significance as it relates to the most for further evaluation. patient to a cooler area and reducing their important diagnosis caused by increased In the ED, treatment is directed respiratory rate. temperature: heat stroke. at addressing the ABCs of airway,

24 EMRA | emra.org • emresident.org breathing, and circulation, along with those who suffered exertional heat stroke duration, intensity, and heat exposure volume resuscitation and continued should be held from exercise for at least if patients remain asymptomatic. active cooling of the patient. Cold water 7 days with follow up laboratory testing A progressive heat tolerance test is immersion of body up to torso or diffuse prior to return to any physical exertion.3 frequently employed prior to granting application of ice and cold packs provide When cleared, a progression from clearance for return to full activity if a the most rapid decrease in temperature exercise in cool environments indoors patient experiences difficulty with the and the lowest morbidity and mortality. can be initiated with gradual increase in ACSM guidelines. ¬ The disadvantage of these methods is it is more difficult to provide other resuscitative measures. The United States military has developed an Arm Immersion Cooling System (AICS), which involves submerging one of the patient’s arms in ice water and may be as effective as full body immersion.6 Spraying cool water on patients with a fan directed at them is easy to initiate in the emergency department but provides slower cooling than immersion techniques. There is inadequate data to recommend invasive cold water lavage or ECMO. Antipyretics and dantrolene are not indicated for temperature reduction. Intravenous fluid resuscitation should be isotonic fluids with a target urine output of 2-3 mL/kg/hr. It is important for the provider to consider other causes of altered mentation and to assess for end organ damage. Diagnostic studies include complete blood count, metabolic panel, blood gas, creatine phosphokinase, myoglobin, coagulation panel, urinalysis. An electrocardiogram and chest radiograph should be obtained. Lumbar puncture and head CT should be considered. In the first 24-72 hours following heat stroke, organ system damage becomes evident, including ARDS, metabolic acidosis, respiratory alkalosis, electrolyte imbalance, hypoglycemia, increased CPK, rhabdomyolysis, leukocytosis, coagulation disorder, and hepatic dysfunction. Late complications include acute renal failure, pulmonary edema, stroke and hepatic failure. All patients presenting with heat stroke require admission to the hospital. Return to Play Individuals who experience exertional heat stroke should consult their physician prior to return to physical activity, as heat stroke itself can be a risk factor for repeat incidence. The 2007 American College of Sports Medicine guidelines suggest that

References available online. October/November 2018 | EM Resident 25 SPORTS MEDICINE

Summary and Active Rehabilitation for Concussion Management

Dustin Harris, MD result from structural or functional An important Chair-Elect, EMRA Sports Medicine Committee damage to the brain1 oncussion has a wide variety of This article touches on some of question definitions in health care today. the new recommendations produced still being CThe term has sometimes been by the most recent Concussion in used interchangeably with traumatic Sport International Conference, along researched is brain injury. The Concussion in Sport with research suggesting an active Group (CSIG), who recently held rehabilitation program. how much rest the 5th International Conference on When an athlete suffers an injury to prescribe Concussion in Berlin, defines sport- during a sport, one should include related concussion as “a traumatic concussion in the differential diagnosis if after a brain injury induced by biomechanical the athlete displays any of the following: forces” (McCrory et al.). They then go on headache, variable emotions, memory concussion to break down the features of a sport- loss, loss of consciousness or trouble prior to related concussion to include: with balance.1 The most widely accepted • Force applied to the body that then test to evaluate for concussion is the starting applies force to the head, whether Sport Concussion Assessment Tool that be a direct or indirect head 5th Edition (SCAT5). It is important activity. injury1 to be thorough with your evaluation • Neurologic impairment that could because early return to play resulting

26 EMRA | emra.org • emresident.org in a subsequent injury could increase on neurocognitive testing as opposed to younger, female athletes as well as those the athlete’s risk for post-concussion those who chose to perform no activity with previously diagnosed depression syndrome. Along with the SCAT5, or even those who participated in a high or migraines.1,2 It is very important athletes should have their vision, gait, level of activity after their injury.3 to perform a thorough physical and balance, and reaction time tested for Physiologically, concussion causes neurologic exam after the injury and at abnormalities post-injury.1 alteration in the autonomic nervous subsequent clinic visits. If concussion is suspected after the system, leading to impairment of Cervical and vestibular injuries initial assessment, the patient must be cerebral blood flow.3 Increasing blood can lead to dizziness, headaches, and completely removed from play. The past flow through subthreshold exercise vision changes.2 Cervical, vestibular and consensus was to prescribe a period could lead to improvements in recovery. psychological rehabilitation are some of physical and cognitive rest after a Studies have shown greater levels of examples of why the approach to the concussion injury until the patient neuronal repair and cortical connectivity management of concussions needs to 3 was asymptomatic. Now providers are through aerobic exercise. include multiple facets. starting to prescribe “subthreshold Another theoretical detriment caused Lastly, another new recommendation exercise” (Leddy et al.) after the acute by concussions is the body’s response to from CSIG was to involve neuro­ 1,4 phase of injury, 24-48 hours. This CO2. Athletes with prolonged symptoms psychologists in the assessment and includes activity that is below the leading to post-concussion syndrome, in management of patients who have threshold of causing concussion-related one study, showed an abnormal rise in suffered a concussion.1 symptoms. Studies have shown that this CO2 during exercise, which subsequently may lead to improved outcomes and led to increase blood flow to the brain Conclusion faster recovery. — exacerbating concussion symptoms.3 Research continues to advance An important question still being Subthreshold exercise was able to restore our knowledge of concussion and lead researched is how much rest to prescribe their sensitivity to CO2. to improved ways of managing this after a concussion prior to starting If a patient is still experiencing condition. With the advent of active activity. When athletes were not concussion-related symptoms weeks rehabilitation, along with the other instructed how much rest to take, those to months after the initial injury, they concepts outlined above, we can better who participated in a medium amount may be suffering from post-concussion manage our concussion patients on the of physical activity performed superiorly syndrome (PCS). PCS rates are higher in field and in the clinic. ¬

When seconds count, education makes a difference. Strengthen your practice and boost your confidence for the Boards and beyond.

ü ERcast: Free for all EMRA members. Down-to-earth clinical topics in easily digestible episodes from the legendary Rob Orman. Keep up on what’s current in EM, plus practice-changing information from Essentials of Emergency Medicine.

ü EM Board Review Resident Package: $189 for PGY2 and up; 20% off for alumni. High-yield, laugh-out-loud video lectures and an adaptive Qbank that attacks your weakest topic areas.

ü EEM On-Demand: $189 for medical students, residents and fellows; 20% off for alumni. Practice-changing education that you’ll use on your next shift. Over one hundred 5-10 minute lectures from the best EM educators across the country.

ü Foundations: Pediatric Acute Care & Emergency Medicine: 20% off for all EMRA members. A quick clinical refresher, with a focus on quick. Be prepared for critical, acutely ill and injured pediatric patients.

hippoed.com

References available online. October/November 2018 | EM Resident 27 INTERNATIONAL MEDICINE

Small Bowel Obstruction Secondary to Ascariasis Infection

FIGURE 3. The transfer up-river is prepped for a 15-year-old female with an acute bowel obstruction secondary to an ascariasis infection. An Alarming Finding in the Remote Territory of Eastern Honduras The etiologies of small bowel obstructions may vary between underdeveloped and developed nations, but the presenting signs and symptoms of an acute bowel obstruction are similar. A bowel obstruction is a gastrointestinal condition in which digested material is prevented from passing through the bowel normally. Patients may present with abdominal bloating, constipation, inability to pass stool, nausea, vomiting, or diffuse abdominal pain, typically with guarding.

Jett MacPherson, MSII access to surgical capabilities and generalized guarding. She appeared weak Marshall University other modern health care technologies and uncomfortable. Further investigation Saundra Jackson, MD, RDMS, FACEP are limited, the risks for acute intra- with a portable ultrasound revealed a Ultrasound Director, abdominal pathologies are shifted small bowel obstruction of unknown Emergency Resources Group towards environmental exposures, such etiology (Figure 1). Wesley Wallace, MD, FACEP as parasitic infections. The patient had not had any previous Associate Professor, Department of EM abdominal surgeries and the cause of UNC Chapel Hill Case Report A 15-year-old indigenous female her evident bowel obstruction remained Introduction presented to a medical missionary clinic unknown. With a quick urge to vomit, mall bowel obstruction (SBO) in the remote territory of La Moskitia the patient quickly ran outside and began is a common gastrointestinal in eastern Honduras with a 3-month expelling roundworms that were greater Scondition often warranting acute history of poor appetite, nausea, than a foot in length within her emesis surgical intervention in developed worsening epigastric pain, and new onset (Figure 2). It was logically assumed that nations. It is estimated that over 300,000 of vomiting. The patient had been seen the cause of this patient’s SBO was a laparotomies per year are performed in recently at a health clinic in her local parasitic infection. the United States alone for adhesion- village, where she was diagnosed with In such a remote area, this patient related obstructions.1 Common risk gastritis. After achieving no relief with was at best 2 hours by boat and 4 hours factors for SBO in developed countries antacids, her mother brought her to the by car to the nearest hospital with include prior abdominal/pelvic surgeries, transient medical clinic established by a surgical capabilities, located in La Ceiba, abdominal wall or groin hernias, team of health care professionals from the Honduras. Her transfer was prepped and intestinal inflammation, prior radiation, United States. she was quickly sent on a long journey or history of foreign body ingestion. On initial examination, the patient to reach the medical care she required In underdeveloped countries, where had diffuse abdominal tenderness with (Figure 3).

28 EMRA | emra.org • emresident.org Discussion Case Conclusion of helminthic infections, our team Ascariasis is a common parasitic Although our patient was young, she treats all patients empirically with infection in underdeveloped nations. lived in an undeveloped location where albendazole during our visit. It is caused by the roundworm Ascaris hand hygiene and sanitization are poor, However, in the case of this lumbricoides, which lives in the and exposure to human feces is common. 15-year-old girl with a small bowel intestines of its infected hosts and There has also been a well-established obstruction, her infection was too transmits eggs through the feces of its relationship between malnutrition and advanced for this treatment. She was hosts.2 intestinal helminth infection, which is transferred to the closest hospital The most common routes of entry for common in such a remote area.2 with modern health care capabilities roundworms include oral ingestion from The medical capabilities available in La Ceiba, Honduras, where drinking water in which the parasite’s within her surrounding location were she was admitted and monitored eggs are present, or subcutaneously minimal, and our medical missionary closely. Her ascariasis-associated through bare feet that come in contact teams’ yearly travel to this territory intestinal obstruction was managed with infected feces. Ascariasis is common is the only access that many of these conservatively with appropriate in locations where there is poor hand individuals have to modern health anthelmintic therapy and did not hygiene, poor sanitization, and use of care. Given the widespread prevalence require enterotomy or resection. ¬ human feces as soil. The eggs of the parasite first hatch in the intestines of its infected host and the larvae move into the bloodstream, where it establishes residency in the lungs.3 After a process of maturing, the roundworms leave the lungs and travel into the trachea, where they are expectorated or swallowed into the esophagus. The worms that are ingested travel back into the intestines, where they continue to grow, mate, and produce additional eggs. The cycle continues as eggs are either excreted through the feces or hatch in the intestines and travel to the lungs via the bloodstream. An uninterrupted progression of the parasitic infection can lead to small bowel obstruction as the roundworms reproduce in the intestines to a level that impedes the normal flow of digestive FIGURE 1. Portable ultrasound was used to diagnose a small bowel obstruction. material through the GI tract. As the digestive tract becomes obstructed, the patient will begin to experience generalized abdominal pain, nausea, vomiting, and poor appetite. If left untreated, the condition can lead to death as the patient becomes dehydrated or the bowels are perforated by a worsening obstruction. Treatment Ascariasis infections can typically be treated by common anthelmintic drugs, such as albendazole, ivermectin, and mebendazole.4 In advanced cases causing SBO, surgical intervention requiring enterotomy or resection may FIGURE 2. A roundworm retrieved from the emesis of a female with a SBO be necessary if the complete obstruction secondary to ascariasis infection appears next to a Honduran lempira, roughly the does not improve within 24–48 hours.5 same size as a dollar bill.

References available online. October/November 2018 | EM Resident 29 MEDICAL STUDENTS

Unraveling the Mystery of Dizziness in the ED

Kevin Wilcox, OMS-\IV lead to proper management and reduced WellSpan York Hospital Emergency Department negative outcomes. A Guide Krystle Shafer, MD While there are many potential WellSpan York Hospital Emergency Department causes for dizziness, let’s look at how to izziness is the third most differentiate between 4 common causes: for the common complaint reported in syncope vs. vertigo vs. disequilibrium vs. Dthe ED, responsible for 5% of non-specific dizziness. presentations to the ED and outpatient As a medical student, it can be Student clinics with a 30% lifetime prevalence. difficult to determine which questions Asking the right questions and teasing out to ask to determine emergent, “can’t Clerkship the details of this vague complaint can miss” (Table 1) vs. benign processes and TABLE 1. Red Flags of Dizziness Presenting Symptoms Potential Cause Deadly Ds: Diplopia, Dysphagia, Ischemic Stroke Dysarthria, Dysmetria) Hemorrhagic Stroke Posterior Fossa Mass New onset headache Ischemic Stroke Hemorrhagic Stroke Subarachnoid Hemorrhage New onset neck pain or recent trauma Vertebral Artery Dissection

Fever and headache Meningitis Encephalitis

30 EMRA | emra.org • emresident.org TABLE 2. Syncopal Episodes their sense of dizziness, which can then Suspected be attributed to significant past medical Cause History of Syncope Underlying Etiology history of conditions such as peripheral Vasovagal Prodrome of nausea, dizziness, Stimulus-Induced (Blood, Injury, Fear) neuropathy, musculoskeletal disorders, and increased sweating Autonomics (Coughing, Micturition, cerebellar disorders, and neurologic followed by syncopal episode Defecation) disorders. Carotid Sinus Hypersensitivity Non-Specific Dizziness Orthostatic Sudden change in posture after Volume Depletion This diagnosis should remain prolonged period, ie, “I stood Autonomic Dysfunction lower on your differential and only be up, suddenly felt dizzy, then utilized as a diagnosis of exclusion. must have passed out.” Most patients are healthy and young Cardiac Sudden onset of syncopal Tachydysrhythmias without underlying comorbidities of episode without prodrome Young: Hypertrophic Cardiomyopathy the cardiovascular, pulmonary, or Elderly: Aortic Stenosis neurologic systems that could account for their symptoms. In a prospective how you will work-up and potentially Disequilibrium study of 100 patients with chronic treat this patient, but the key to success Disequilibrium is characterized dizziness in ambulatory care conducted all starts with a detailed history and by a sense of imbalance with physical by Kroenke, et al, roughly 50 percent physical exam. activity. The patient with suspected of the study population had a history of Syncope/Near Syncope disequilibrium might describe a major depression/generalized anxiety/ Syncope is defined as a transient loss sensation they are “going to fall if I don’t panic disorder, suggesting underlying of consciousness with accompanying have something to hold on to,” or “ I psychiatric disorders as a potential loss of postural tone, followed by feel like I’m floating,” or even that “the cause of dizziness. complete resolution and return to world feels tilted.” These descriptors Conclusion baseline. The syncopal patient will often have been documented in the ED Dizziness is a common complaint describe a feeling of lost consciousness encounter for disequilibrium and can and a challenge to the medical student or blacking out. Determining syncope be your initial cue directing your H&P during clerkships. Utilizing this as a possible diagnosis for your patient exam. approach can help you obtain a detailed requires appropriate questioning when In most cases, these patients will history and physical exam, leading to a eliciting a detailed history, capturing present with past complaints of gait more appropriate differential diagnosis key data such as is noted in Table 2. and/or visual disturbances leading to and treatment plan. ¬ Vertigo The patient with signs and TABLE 3. Vertigo symptoms of vertigo will classically Peripheral Vertigo Central Vertigo present with the complaint of “the room is spinning,” due to mismatches Onset and Severity Sudden and More Intense Gradual and Less Intense in the perception of movement. The Duration Intermittent Constant challenge in this diagnosis is identifying Worse with Movement Yes No any potential “red flags” in the history and physical exam and differentiating Nausea/Vomiting Yes No between peripheral and central causes. Nystagmus Mixed Horizontal-Rotational Vertical, Horizontal, Medical students should be capable Rotational of discerning between the two with in-depth questions regarding onset, Hearing Loss/Tinnitus May Occur No severity, and associated symptoms, CNS Symptoms Usually Absent Usually Present as well as a detailed physical exam as described in Table 3. TABLE 4. HINTS Exam HINTS Peripheral Vertigo Central Vertigo Additional physical examination testing in the form of the HINTS (Head Head Impulse Negative (No catch up Positive (Catch up saccade) Impulse, Nystagmus, Test-of-Skew) saccade) exam can distinguish between central Nystagmus Unidirectional Direction Changing and peripheral causes as described in Table 4. Test of Skew Negative Positive (Vertical saccade)

October/November 2018 | EM Resident 31 TRAUMA The Use of Low Titer Group O Whole Blood in Emergency Medicine Christa A.L. Arefieva, MS, MSIV Department of Defense (DoD).8 This Texas A&M College of Medicine attempt to reconstitute whole blood using Bryan Chen, MSIV the 1:1:1 ratios in military trauma was Texas A&M College of Medicine aimed at the prevention and correction Theodore T. Redman, MD, MPH of trauma induced coagulopathy with Uniformed Services University minimal use of crystalloids.2 Prehospital Research in Military and Expeditionary Environments (PRIME2) The conflicts in Iraq and Afghanistan Andrew D. Fisher, MPAS, PA-C, LP revived an interest in fresh whole blood Texas A&M College of Medicine (FWB) for DCR during hemorrhagic PRIME2 shock. The use of FWB in combat @FisherAD1 demonstrated superior outcomes 9-11 Introduction over component therapy. In 2014, rauma is the leading cause of death the Committee on Tactical Combat for ages 46 and under in the U.S. Casualty Care recommended FWB as the — yet up to 20% of trauma deaths preferred resuscitative product for DCR 12 T 1 in hemorrhagic shock. In an effort to are potentially survivable. Aside from surgical intervention, these deaths are seamlessly provide FWB at the point-of- th best mitigated through early hemorrhage injury (POI), the U.S. Army’s 75 Ranger control with tourniquets, hemostatic Regiment developed a LTOWB program 13 dressings, and an aggressive approach to in 2015. In 2016, due to the collection difficulties that can occur with FWB at the damage control resuscitation (DCR). titers >512 with one severe transfusion POI, the Armed Services Blood Program For many years, the standard for reaction of an IgM anti—A titer of 8000.4 (ASBP) began collecting and shipping DCR consisted of crystalloid solutions In response, the Army Blood Program cold-stored LTOWB from Joint Base and red blood cells (RBCs). This standard defined low titer group O whole blood Lewis-McCord to units in Afghanistan.14 in trauma resuscitation has evolved to (LTOWB) to help mitigate and eliminate The use of cold-stored LTOWB is now include the use of balanced fluids and further severe reactions. LTOWB is being used in civilian sector emergency massive transfusion protocols (MTP) defined as with IgM anti—A and anti—B services, to include prehospital use.6,15- utilizing RBCs, fresh frozen plasma (FFP) <250.4 This program was carried over 17 The AABB now recommends the and platelets (PLTs) in a 1:1:1 ratio (>10 to Korea, where over 400,000 units of emergency release and use of LTOWB in units of RBCs in 24 hours).2 The use of LTOWB were shipped from the U.S. and the setting of life-threatening hemorrhagic 1:1:1 ratio protocols attempts to mimic transfused to casualties.4 shock because of its advantages.18 the benefits of whole blood (WB) with As blood fractionalization was individual components. developed, civilian blood banks What is Low-Titer Group O WB has been used on a mass scale shifted away from WB and towards Whole Blood? for resuscitation of trauma patients since component-based therapy due to risk of LTOWB is unseparated blood, World War I.3 The US Army documented transfusion transmitted diseases (TTD), collected from a donor with “low” IgM the safety of group O WB as a universal requirements for specific component and/or IgG anti—A and anti—B and can product as early as 1917.4 While plasma therapy, and logistical issues.6 With this either be stored or given fresh (within and albumin were first favored by the development, the use of crystalloids 8-24 hours). There is no universally US forces in World War II, eventually solutions for trauma resuscitation accepted definition of LTOWB and the WB was sent to the European and Pacific became more prevalent, especially in the AABB states that low titer may be defined theaters.5 Military units also established prehospital setting. The consequence of by institutions. The DoD and University walking blood banks at far forward mixing components and crystalloids in of Texas San Antonio Health Sciences settings through larger surgical hospitals. trauma resuscitation was an unbalanced Center University Hospital define These efforts resulted in almost all approach, leading to iatrogenic LTOWB as IgM anti—A and anti—B transfusions being group O WB.6 Near coagulopathy, acidosis, and hypothermia, <256. Cypress Creek EMS uses IgM the end of World War II, the Army Blood more commonly known as the “Lethal anti—A and anti—B <150. Finally, the Program noted mild transfusion reactions Triad.”7 In 2004, the concept of DCR University of Pittsburgh Medical Center in WB with IgM anti—A and anti—B was developed and implemented by the used IgM anti—A and anti—B < 50.15-17

32 EMRA | emra.org • emresident.org Internationally, in addition to IgM, IgG and platelets. RBCs are washed to remove skepticism about the safety of LTOWB is often used to define low titer status. proteins that did not remain with the has resulted in new research. The most The presence or absence of the Rhesus plasma after centrifugation. Plasma significant remaining issue is shelf- (Rh) (D) antigen is much less relevant is frozen but can be also be processed life extension. CPDA-1 can extend during hemorrhagic shock resuscitation, to make cryoprecipitate. This process WB out to 35 days but does nothing therefore, LTOWB is not defined by its Rh can be costly, which is passed onto for extending PLT function viability. factor status. Rh negative patients do not the patient.24,25 All blood is pre-tested Development of new anticoagulants develop sensitivity to Rh positive blood for TTDs. LTOWB requires minimal and additives that will preserve WB until weeks after exposure.16 Therefore, interventions, but does require TTD, titer functionality would greatly enhance in the acute trauma setting, Rh positive testing, and leukocyte reduction before this shortcoming. blood can be administered to Rh negative use or storage. LTOWB has the potential The debate over safe titer levels patients without significant risk of to reduce logistical concerns regarding is ongoing. At this time, among transfusion reaction. Still, Rh negative is cost. There has been concern about the civilian hospitals utilizing LTOWB, optimal for females of child-bearing age short shelf life of LTOWB and increase there is a range of critical antibody out of concern for sensitization that can waste of the WB product, but these titer thresholds varying from cause hemolytic anemia of the newborn. concerns can be mitigated as LTOWB is <50 to <256.15-17,28 Concerns with Advantages able to be separated into RBCs after a setting an antibody titer threshold predetermined date to maximize use and Simplicity and less error that is too high may result in the eliminate waste. increased possibility of transfusion Evidence suggests that early (<34 min reactions. Whereas, a threshold from time of injury) administration of Avoiding excess fluid set too low may exclude many safe any blood product to severely injured Additives and anticoagulants are donors. International consensus of patients has early survival benefit.19 It required for any blood collection. a scientifically-demonstrated safe is important that clinicians understand However, when components are used threshold is needed. that this statistic defines the time from for MTP, they contain three times the In smaller communities or the initial trauma, not the time that the additives and anticoagulants in terms 20 military, there is concern over a patient arrives to the hospital. Using of volume compared to whole blood. change in donor titer status over time. blood products in the prehospital setting This excess anticoagulant and additives Current literature shows there is no can therefore significantly reduce the lag may cause a dilutional coagulopathy change in titer status with vaccinations time to WB infusion, which in turn can in patients receiving components. In and minimal variability titer levels.29,30 decrease mortality from trauma. When situations where surgery might not be Unpublished data from the US military using LTOWB, one bag is delivered versus readily available, this additional fluid can shows titer changes do often occur, but a separate bag for each component for raise a patient’s blood pressure to a level there is a trend towards low titer. The equivalent resuscitation efforts.20 When where it may cause previous formed clots question remains, should blood banks compared to ABO group-specific WB to break, resulting in re-bleeding. Citrate, require titer testing on a regular basis? in emergent situations, LTOWB may an anticoagulant added to blood collection expedite treatment due to reduction bags, is metabolized by the liver and can Conclusion 26 in time necessary for ABO typing and lead to acidosis and hypocalemia. While RBCs and FFP have longer reduce the under-resuscitation that may Disadvantages shelf lives and are useful in specific happen when specific ABO groups are Shelf life conditions, LTOWB use in trauma not available.21 Also, LTOWB use over Probably the greatest disadvantage of and hemorrhagic shock has proven group-specific WB reduces the likelihood LTOWB is the shelf life. LTOWB is usually advantages over component therapy. of human error as well as the probability anticoagulated with citrate phosphate It is less likely to cause a severe of severe blood cell and plasma-related dextrose (CPD) and has a shelf life of 21 transfusion reaction, contains less transfusion reactions. The ease of days. When citrate phosphate dextrose anticoagulants and additives, causes administering one product, especially adenine (CPDA-1) is used in lieu of CPD, less dilutional coagulopathy, is faster in the prehospital setting, therefore the shelf life is extended to 35 days. and easier to deliver, and is more cost decreasing confusion in decision-making However, platelet function drops after 14 effective to produce. Efforts should and tracking may facilitate resuscitation days and significantly after 21 days.27 This be made to implement LTOWB in efforts in the field and emergency room, is shorter than the shelf lives of PRBCs prehospital medicine and for DCR in which could in turn translate to improved and FFP which are 42 days and a year, the emergency room. clinical outcomes.22,23 respectively.2 Acknowledgments Savings Future research The authors would like to thank When preparing and storing There is significant data from the past Brandon M. Carius, MPAS, PA-C, for components, whole blood is centrifuged 70 years on the use of WB and LTOWB reviewing the manuscript and his to separate the red blood cells, plasma for trauma resuscitation. Currently, the valuable comments. ¬

References available online. October/November 2018 | EM Resident 33 PREHOSPITAL & DISASTER MEDICINE The More You Know Emerging Prehospital Protocols Noah Bernhardson, MD, MS, NRP ambulance gurneys provide University of Mississippi Medical Center a similar level of motion @nbernie restriction without the risks Cameron B. Justice, AEMT, OMSIII of respiratory compromise, Pacific Northwest University skin breakdown, and pain College of Osteopathic Medicine caused by backboards. Jared L. Ross, DO, FF/EMT-T In addition, the use of EMS and Tactical Medicine Fellow Washington University of St Louis cervical collars is now being @JaredEMS questioned. Many EMS agencies are ver the course of the past 5 implementing “selective decades, EMS has undergone spinal motion restriction” drastic changes. The use of O using evidence-based pneumatic, military anti-shock trousers (MAST Pants) has all but disappeared, guidelines based on and gone are the days of atropine in NEXUS and Canadian asystole and “bite block” insertion in C-Spine rules to determine seizing patients. The field has expanded which patients need to include multiple levels of training, spinal precautions ranging from medical first responders based on mechanism of with 80 hours of training to paramedics injury, age, and exam who often hold associates or even findings. Updated clinical bachelor’s degrees in prehospital decision pathways and care. Evolving EMS protocols impact protocols allow for the care that patients receive before more individualized they present to the ED. Therefore, it implementation of spinal is crucial for emergency physicians to motion restriction in the understand these changes to continue prehospital environment to provide a higher level of integrated and are better patient care. This article will dive into several outcomes. of these evolving protocols, including Non-Invasive Positive cervical collar and backboard utilization, Pressure Ventilation airway management, ketamine, and the (NIPPV) in EMS expanding role of EMS. Several studies have Cervical Collars/Backboards shown that early institution The utilization of the rigid cervical of CPAP in the prehospital collar and backboard date back to the environment has decreased EMT-Ambulance national standard the need for intubation curriculum developed in 1984. Providers by up to 60%, thereby 2 a retrospective study of Kansas City Fire were trained to immobilize the spine if reducing associated complications. there was even the slightest possibility of CPAP and BiPAP have been available on Department patients, early use of NIPPV spinal cord injury. This training became Advanced Life Support units for some showed a more than 50% decrease in the standard of care, and was further time, but CPAP is now being included on mortality rate with no increase in scene 4 reinforced by courses such as Advanced Basic Life Support and First Responder or transport times. With a simpler and Trauma Life Support and Prehospital units.3 Early use of CPAP has been more cost-effective product design, Trauma Life Support.1 shown to significantly reduce mortality prehospital NIPPV is becoming nearly It is now widely accepted that rigid rates not only in rural areas with longer universal and is changing the way that backboards still allow for significant transport times, but also in urban care is delivered in the prehospital movement of the spine and that systems with shorter transport times. In setting.5

34 EMRA | emra.org • emresident.org Prehospital Airways endotracheal intubation. in 1981. The dual-lumen Combitube was The gold standard for definitive While there is little debate the first to have wide adoption into EMS airway management remains regarding the importance of airway beginning in 1986. While these were often endotracheal intubation. However, management, continued debate exists viewed by many providers as “back-up” with effective alternatives and higher over prehospital endotracheal intubation. devices, studies performed over several prehospital intubation failure rates,6 Many publications support the notion decades have shown that successful many systems have moved away from that prehospital intubation correlates placement rates are significantly higher with higher incidence of for these devices than for endotracheal mortality. One prospective intubation.9 With improvements in both study by Cobas et al. device design and technology, there is showed a 31% incidence strong literature support for supraglottic of failed prehospital devices10 including the King Tube and intubation, but found no iGel, with studies demonstrating equal difference in mortality ventilation to that provided via ET tube. between patients who were Ketamine properly intubated and Ketamine is being implemented those who were not.7 Still in the prehospital setting for multiple other studies would suggest indications intubation, behavioral that intubation in the field emergencies, pain management, and is a vital component to procedural sedation.11 Ketamine provides patient survival. Miraflor both dissociative anesthesia and analgesic et al. demonstrated early effects and has a long history of use, intubation of initially stable, established safety record, and low cost. moderately injured trauma Ketamine is being used in low doses as patients reduces mortality an alternative to opioid pain medications. by up to 85%.8 Intubation Moderate doses are used for intubation is a highly perishable skill, or supraglottic airway induction with and with the advent of or without paralytic agents. High dose prehospital CPAP/BiPAP, intramuscular ketamine is being used fewer patients are being for excited delirium and violent patients. intubated and providers Ketamine has a positive side effect of have less opportunity increasing bronchodilation and MAP and to maintain their skills. is also being used for patients with severe Additionally, intubation asthma. Recent studies suggest it may in the prehospital setting also be helpful in septic shock.12,13 is usually performed in non-ideal conditions (low Expanding Role of EMS light, poor ergonomics) and In many EMS systems, new without the use of paralytic and specialized roles of prehospital agents. providers are being explored. There Alternatives to has been an effort to increase the endotracheal intubation education of paramedics beyond the originated in anesthesia, NREMT standard to include specialty with the Laryngeal Mask certification in air and ground critical Airway (LMA) developed care transport and community paramedicine. Many states have critical care paramedic certification with further education on ventilator management, The changes currently underway IABPs, sedation medications, and vasopressors. Community paramedics in prehospital medicine mirror focus on public health and proactively visit patients to manage chronic medical the growth and development conditions and prevent future 911 calls. The changes currently underway in of emergency medicine itself. prehospital medicine mirror the growth and development of emergency medicine itself. ¬

References available online. October/November 2018 | EM Resident 35 MEDICAL EDUCATION MORE THAN A POWERPOINT Understanding EMS Provider Education and How to Participate as a Resident

Geoff B. Comp, DO, FAWM Advanced EMT (AEMT), and paramedic Doctors Hospital/OhioHealth as well as a national credentialing body, @gbcomp the National Registry of Emergency Rachel Munn, DO Medical Technicians (NREMT). Doctors Hospital/OhioHealth EMT, AEMT, and paramedic Vishnu Mudrakola, MD training courses are typically sequential Doctors Hospital/OhioHealth with increasing hour requirements Eric Cortez, MD, FACEP Associate Medical Director, ranging from 100 to up to 1300 hours Columbus Division of Fire of classroom, clinical, and simulation Clinical Assistant Professor, Emergency (SIM). Additionally, providers must pass Medicine, Doctors Hospital/OhioHealth the NREMT exam for their respective ealth care providers are attracted level of certification. Recertification is to their specialties for a variety typically completed every 2 years and Hof reasons. Like EM residents, requirements can be met with courses, emergency medical services (EMS) conferences, research, online resources. providers don’t particularly enjoy As there is significant state and local learning via hours of PowerPoint lecture. variation in the educational methods EM residents did not choose the busy used and the requirements themselves, and chaotic practice environments of identifying exactly what teaching the emergency department (ED) or the modalities are most commonly used back of an ambulance because we enjoy would be quite difficult. For example, warming chairs. To understand how Seattle Fire requires considerably to create educational and fun events in more classroom, SIM, and actually residency it is important to understand cadaver lab and operating room (OR) the training process of EMS providers. time for intubations than the national 1 Background of EMS Education guidelines . This extra education, as well as their greater-than-average number of EMS education requirements were intubations per year may contribute to first laid out in 1993 with a document their higher success rates.1 called “the Blueprint” and further delineated in 2005 with the “EMS Things to Consider Education Agenda.” This consensus 1. EMS providers treat a lot of people! document itemizes the five tenets of EMS That is 25-30 million patients per education, their respective associated year, to be exact.2 goals, and a game-plan for achieving 2. Not all EMS providers have the same them. These tenets include: Core Content, skill set. The scope of practice varies Scope of Practice, Education Standards, greatly between first responders, Education Program Accreditation, EMTs, and paramedics. and EMS Certification. We now have a 3. There are national guidelines. national scope of practice model which The EMS Education Agenda lays defines the different types of providers: the foundations governing EMS Emergency Medical Technician (EMT,) education.

36 EMRA | emra.org • emresident.org 4. State lines actually matter. The to put more than bragging rights on the and relationships with the EMS providers MORE THAN A POWERPOINT state-to-state variation regarding table next time. we take signout from each shift. Resident educational requirements and scope This event not only helped us as instruction of our EMS and prehospital of practice is huge! EM residents gain insight into how colleagues can be a valuable experience 5. Everyone loves airways. Everyone EMS education is structured, but for both parties and helps to strengthen also loves a good, old fashioned additionally improved our camaraderie the acute care team. ¬ competition. There are undeniable similarities both in the education and practice of EMS providers and EM residents. Airway management is one such critical clinical skill shared by both sets of providers. Intubations performed in the field or the ED are often challenging for a variety of reasons: austere environments, trauma, critically ill patients, or the recent ingestion of cheeseburger to name a few. Historically, EM resident involvement in EMS education has been limited to going on ride-alongs and possibly giving lectures. Only 89% of residencies in a recent survey had a designated EMS rotation and only 64% noted a requirement for education of EMS providers by residents.3 Contrary to this, 92% had a requirement for direct medical control.3 After learning all this (and more), Doctors Hospital decided to shake it up with an event meant to be both fun and educational for everyone involved: an airway competition. This contest consisted of sequential stations meant to simulate different difficult airway scenarios. The 23 competing EMS providers from several local agencies performed the challenges in a head-to-head race for time. Seeking to repair potentially bruised relationships caused by the individual competition, we then paired providers for a team-based challenge in which they, literally, had to be each other’s eyes and hands to intubate a “victim” trapped in a building collapse. The stellar EM residents involved either served as race officiators or performed a debrief with discussion of difficult airway techniques, equipment, indications, and trouble-shooting with the EMS providers after their competition. Overall, participating EMS providers said they enjoyed the competition and found the debriefing sessions to be valuable. We aim to continue pioneering future educational ventures and promise

References available online. October/November 2018 | EM Resident 37 SPONSORS

Flipping out over our 2018 sponsors! Thank you for a great year!

PLATINUM SPONSORS

GOLD SPONSORS

FRIEND SPONSORS

38 EMRA | emra.org • emresident.orgSEE YOU IN DENVER AT ACEP19! ECG/VISUAL DIAGNOSIS ECG Challenge Gregory Taylor, DO Scott Sikorski, DO Beaumont Hospital Ascension St. John Robert W. Mathews, DO, FACOEP Jeremy Berberian, MD Assistant Clinical Professor, Associate Director of Resident Education, Dept. of Dept. of Emergency Medicine Emergency Medicine Beaumont Hospital Christiana Care Health System

CASE. A 44-year-old male presents to the ED with intermittent chest pain for 2 weeks, worse with exertion, and resolves with rest. He is currently symptom free. What is your See the ANSWER on page 40 interpretation of her EKG?

Matin Shah, MD Medical Education Chief Resident, Emergency Medicine Alpert Medical School of Brown University Visual Diagnosis

A 3-month-old female born at 37 weeks via vacuum-assisted vaginal delivery presented as a referral to the emergency department from an outpatient imaging center after obtaining a computed tomography (CT) scan of the brain to evaluate a misshapen head. On examination, she was active and had a full anterior fontanelle with a cranial deformity most prominent at the occiput, bilateral horizontal nystagmus, and globally increased muscle tone. CT brain demonstrated marked hydrocephalus with a preserved fourth ventricle, extensive cerebral What’s the Diagnosis? atrophy, and scattered calcifications along the gray-white matter junction. See the ANSWER on page 41

October/November 2018 | EM Resident 39 ECG ECG Challenge ANSWER Pseudo-Wellen’s Syndrome The EKG shows a normal sinus rhythm, biphasic T-waves in V2 and V3, STD and TWI in the lateral leads, increased S-wave amplitude in aVR and V1-V3, and poor R-wave progression. The EKG was initially interpreted as concerning for Type A Wellen’s Syndrome, but after further discussion it was determined that the EKG abnormalities are more likely caused by LVH (also called Pseudo-Wellen’s). In particular, Wellen’s syndrome is associated with a preserved R-wave progression, whereas LVH is a common cause of poor R-wave progression. Wellen’s syndrome, also called “coronary T-wave syndrome” or “the widow maker sign,” consists of characteristic EKG findings that suggest critical LAD stenosis. If untreated, approximately 75% of patients will develop an anterior myocardial infarction, usually within a few days. The classic EKG findings are biphasic T waves in V2-V3 (Type A, 25% of cases) or deeply inverted T waves in V2-V3 (Type B, 75% of cases). This EKG pattern is associated with a pain-free state and the T-wave abnormalities are result of reperfusion. Other EKG findings include a preserved R-wave progression and the absence of any significant STE or precordial Q-waves. Pseudo-Wellen’s syndrome has a similar pattern of abnormal precordial T-waves that are the result of LVH repolarization abnormalities. There are multiple voltage criteria for LVH, but echocardiography is the superior diagnostic modality. While the EKG above does not meet any of the common voltage criteria, the repolarization abnormalities, often called “strain pattern,” are typical for LVH. The presence of LVH can make EKG interpretation more challenging as the strain pattern can mimic ischemic findings and confound an EKG’s ability to detect ACS, particularly an anteroseptal MI.

LEARNING POINTS General Features LVH • Marker of increased risk of adverse • Abnormal T-wave pattern present in pain- General Features outcome in the chest pain patient free state with recent history of angina • EKG is only suggestive of LVH • Diagnosis of LVH in the presence of − EKG changes are sometimes called • Echocardiography is superior diagnostic intraventricular conduction abnormalities “Wellen’s waves” if patient is having modality (e.g., fascicular blocks, bundle branch pain • Often demonstrates ST and T-wave blocks) should be made with caution as • Normal or minimally elevated cardiac abnormalities, termed “LVH with strain they may impact the accuracy of the EKG biomarkers pattern” criteria for LVH

• LVH or high voltage can make diagnosis • Numerous diagnostic EKG criteria with limited DDx for T-wave Inversions more difficulty sensitivity • Bundle Branch Blocks EKG Features • No criteria are recommended for use exclu- • CNS Injury • Deeply inverted or biphasic T-waves in sive of other validated criteria • Digitalis Effect precordial leads, typically V2-V3 EKG Features • Intra-abdominal Disorders • Isoelectric or minimally elevated ST- • Commonly used criteria include: • Juvenile T-wave Pattern segment (< 1 mm) − Sokolow-Lyon- S in V1 + R in V5 or V6 > 35 • Left Ventricular Hypertrophy • No precordial Q-waves mm • Metabolic Abnormalities • Preserved precordial R-wave progression − Cornell- R in aVL + S in V3 > 28 mm in • Pericarditis Clinical Significance males or 20 mm in females • Pre-excitation Syndromes • Suggestive of proximal LAD lesion • STE in V1-V3 • Pulmonary Embolism • Not currently an indication for emergent • STD and TWI in I, aVL and V4-V6 • Toxicologic Abnormalities cardiac catheterization but requires • Increased S-wave depth in III, aVR, and V1-V3 • Ventricular Paced Rhythms • Increased R-wave peak time > 50 ms in V5 or admission Causes of poor R-wave progression V6 − Coronary angiography is most (< 3 mm R-wave by lead V3) • appropriate testing modality (avoid Increased R-wave amplitude in I, aVL and V4- • Dilated cardiomyopathy exercise stress testing) V6 • LAFB • − T-wave abnormalities resolve with PCI Left axis deviation typical, but can occur with • LBBB or CABG any axis • LVH • • Type A (less common): Can see increased QRS and QT duration • Misplaced precordial leads − Biphasic T-waves Clinical Significance • Normal variant − Seen immediately upon reperfusion • Confounds EKG’s ability to detect ACS, • Pre-excitation syndromes • Type B (more common): particularly anteroseptal MI, and mimics ACS • Prior anterior myocardial infarction − Deeply inverted T-waves findings • RVH

40 EMRA | emra.org • emresident.org VISUAL DIAGNOSIS Assessment Congenital Toxoplasmosis References available online Congenital toxoplasmosis is an infection acquired in utero by transmission of the protozoan parasite Toxoplasma gondii. Transmission occurs across the placenta from mothers exposed to cat feces; those who consume raw or undercooked meats, fruits, or vegetables; or those who are immunosuppressed.1 The prevalence in the United States based on neonatal serologic screening is approximately 1 in 10,000 live births.2 The parasite causes necrosis within all parts of the central nervous system, including the cerebrum, cerebellum, brainstem, and spinal cord. Regions of necrosis often undergo calcification from an immature immune system and the resulting impaired phagocytic ability of macrophages.3 The classic triad of signs are chorioretinitis, intracranial calcifications, and hydrocephalus causing profound visual and neurodevelopmental abnormalities.1 The patient was admitted for ventriculoperitoneal shunt placement. She was started on a regimen of drugs that inhibit the synthesis of tetrahydrofolate (pyrimethamine and sulfadiazine), as well as folinic acid, which prevents bone marrow suppression from pyrimethamine.1

October/November 2018 | EM Resident 41 FINANCIAL EM’s Own Emergency Financial Education Peter Patitsas, MD, MBA older generation who lived in a different for an American medical student is Geisinger economic world when the cost of currently worse than it was 40 years never trusted the “good old days.” We education was far less and the American ago. The average medical student in idealize the past and assume the future economy was growing as much as 5% each 1978 graduated with about $13,500 in Iwill always progressively get worse year. However, the cost of education has debt, or $46,500 in 2011 dollars, while been growing at an unprecedented rate, the average medical student in 2011 and worse until the apocalypse hits, but maybe this attitude or perspective is nearly 8% per year. This is beginning graduated with $161,300 in debt. Even more a reflection of human nature than to literally change the culture of the after accounting for inflation of the U.S. an accurate comparison of today vs. United States and the futures of millions dollar, that is a nearly 350% increase in yesterday. Speaking of yesteryear, can you of Americans in a very negative way as medical school debt. This means that guess which “modern-day” figure spoke people forego buying homes, starting from 1978 to 2011, medical student debt the following quote? business, getting married, having has grown at an average rate of 7.8% per “The children now love luxury; children, and spending time with family year, twice the rate of inflation (which the they have bad manners, contempt and friends – all to keep up with student Bureau of Labor Statistics shows has been for authority; they show disrespect loan payments. lower than 2.5% per year for the past for elders and love chatter in place of The average college graduate owes decade).6-7 At its best, the U.S. economy exercise. Children are now tyrants, not $37,172 in student loans. That might just grows about 5% per year; although it’s the servants of their households. They no sound like the price of a fancy, brand-new been a while since we hit those numbers, longer rise when elders enter the room. car you probably don’t need, but the debt GDP for 2018 is at 4.2% and has trended 8 They contradict their parents, chatter is substantial in comparison to average near 3% for the past 2 years. before company, gobble up dainties at household income. According to 2015 Personally, I now have nearly the table, cross their legs, and tyrannize data from the U.S. Census, the median $300,000 in student loan debt after their teachers.” household income in the United States is going through 4 years of college and 4 This was actually a quote from $56,516. But remember, household income years of medical school. Bear in mind, I Socrates, who lived in 400 BC. So when represents all people living in a single had paid off my overpriced liberal arts 5 were the “good old days,” anyway? Is household contributing to taxable income. undergraduate education before starting yesterday always better than today? I So conceivably, a nice new married couple medical school. Here is a little math: Let’s am not sure. However, when it comes to with a child or two may only be making imagine that I pay 6% per year in interest student loans, I can objectively say today around $56,516 a year. Having student on my student loans. I have been told I has never been worse. loans from both mom and dad may have a “good” rate. represent more than they make annually. $300,000 (principal, the total loan Student Debt: Grim Picture But as physicians, why should we care? money received) x 0.06 (interest rate) = According to an analysis completed Are we average? Are we mortal? There $18,000 (annual interest owed in Year 1) by the Federal Reserve Bank of St Louis has got to be a reason that everyone’s Therefore, each year, just to keep at the beginning of 2018, 44 million mom and dad wanted them to become a my loans from compounding (gaining Americans owe a collective $1.5 trillion doctor. We are surely immune from the interest on prior interest), I need to 1 in student loan debt. That is more financial trouble — right? Wrong. The come up with $18,000 to stay even. In money than the entire national debt of numbers show otherwise, especially when 2015, 13.5% of the U.S. population, or 2 Greece and Spain combined! Americans considering the financial woes of student 43.1 million people, lived in poverty.3 hold more student loan debt than credit loans for medical students. Depending on family size, if your card debt, making it the second largest According to an analysis of medical household comprises fewer than 4 people 3 expense behind owning a home. We all student debt published in 2012 by and your household made less than know credit card debt is bad, but student the AAMC, the student loan burden $18,871, you are in poverty. This means loan debt has got it beat by about $620 4 billion. TABLE 1. Compounding Debt There was a time when the ethos Year Starting Debt Interest Rate Interest Gained Ending Debt in America was that you could never Year 1 $300,000 0.06 $18,000 $318,000 go wrong with spending more money $318,000 0.06 $19,080 $337,080 on your education. Keep in mind that Year 2 was probably advice given to you by an Year 3 $337,080 0.06 $20,245 $357,305

42 EMRA | emra.org • emresident.org TABLE 2. Your “Real Salary” Budget ever before. For example, one AAMC study Annual Salary $340,000 predicts that by 2025, the U.S. will have a Tax Rate 36% (Federal, FICA, State, Local)10 shortage of more than 35,600 primary care 12 Annual After-Tax Income $217,242 physicians. This will only get worse under Monthly After-Tax Income $18,103 the current economic conditions and trends. Monthly Student Loan Payment So, what’s the point? ($357,304.80) for 5-year repayment at 6% $6907.70 The truth is those in other professions Monthly after tax income and after student are working very hard, too. People are often loan payment income $11,195.30 working multiple jobs, picking up side work, and not taking vacations. And outside the Cost of Living Comparison TABLE 3. house of medicine, job predictably is not Monthly Cost Boston, MA Harrisburg, PA always stable. Food $877 $766 Child Care $2,225 $1,542 Possible Solutions Transportation $1,103 $1,169 Student loans are truly burdensome Health Care $837 $1,512 and have never been worse; therefore, we Other Necessities $1,056 $728 must call for policy changes to improve (utilities, etc.) our financial reality. Although physicians Housing $4,541 * Housing (monthly $3,121 * Housing (monthly cannot unionize, why can’t we use basic (3 bedroom, two mortgage payment for $700k mortgage payment for $400k principles of economics to lower our bathroom home) home with 0% down) with home with 0% down) with interest rates? Why can’t we collectively Property and School Tax and PMI Property and School Tax and consolidate our loans, with one private in an average school district PMI in an average school district company, at a low interest rate? Imagine Total $10,639 $8,838 thousands of physicians approaching one EPI calculator11 bank with hundreds of millions of dollars millions of families across America find Okay, so another round of calculation. of loans requesting a 2% annual interest it difficult to even generate the amount of Once we start making attending salaries rate. They make money, we save money. money I owe on interest payments alone. and we have to start making payments Everyone wins. The government recognizes this and so on our student loans, how does the With a bit more delayed gratification, assists these families, rightfully so, with budget look then? The average annual your loans can be paid off within 5 years. many programs and benefits. What does salary of an EM doc in the mid-Atlantic You may be in your mid- to late 30s when the government do for the young student? was quoted to be $340,000 annually.9 that happens, but the math suddenly gets ¬ Well, there are flexible debt repayment Six figures, baby! Sounds great, but let’s better after the loans are gone. programs that allow us to forego making break it down (see Table 2). any payments on our student loans while So $11,000 per month take-home in residency, which is at least 3 years for salary is the long story short. Is that EMRA RESOURCES any physician. What a nice thing, right? enough? Consider the EPI calculator, EMRA members! No payments, no worries. But the interest a free online tool that estimates costs Don’t forget you have access is compounding. Let’s calculate what I of living for many metropolitan areas to special benefits through Doctors would owe at the end of a 3-year residency across the United States.11 Compare the Without Quarters, Laurel Road, if I were to take advantage of the flexible annual cost of living for a family of 4 in and Integrated Wealthcare. debt repayment program. Harrisburg, Pennsylvania vs. annual cost Check out your benefits page at Table 1 should make anyone’s jaw of living for an urban center like Boston emra.org! clench! So, for me to put my head in the (see Table 3). sand for 3 years and have the flexibility of There isn’t much money left over. foregoing payments increases my debt an Where are the savings for retirement, extra $57,000. Thank you, Uncle Sam! your deductible on health insurance, your Why not make some payments kid’s college fund, or a vacation? If you during residency? According to a survey weren’t paying nearly $7,000 a month for completed by more than 1,500 residents, years on student loans, there would be a the average resident in the U.S. earned lot more room for that. about $57,200 in 2017. The average The next generation is beginning to resident simply doesn’t have money to feel the negative financial pressure of spare to put toward loans. This was not this system, and it may begin to scare a problem for the average physician a away good future physicians. Of course, generation or two ago who owed far less with the aging of the Baby Boomers, in loans than we do now. there is a need for more physicians than

References available online. EMF Resident VIP Club Your residency program directly benefits from EMF-funded research. Make your mark on emergency medicine today.

A $120 tax-deductible gift (you can make quarterly installments of only $30) will place you in the prestigious Resident VIP Club. Resident VIP Club members* receive: ü Two Invitations to EMF VIP event ü Special Resident Donor ribbon distributed at the annual ACEP Scientific Assembly ü One All-Access Pass to the EMF Donor Lounge during the annual ACEP Scientific Assembly *Emergency medicine resident or medical student who contributes $120 annually. GIVE TODAY and Pay it Forward! emfoundation.org • 469-499-0296

Save the Date Exclusive Webinar MARCH 31 - Student Loan Best Practices APRIL 3 2019 for EMRA Members We welcome EMRA back to the Academic Unsure how to repay your student loans? Assembly for the second year! EMRA has teamed with Laurel Road to provide guidance on student loan refinancing. Bringing the best that CORD & EMRA have to offer, including the Quiz Show, Rep Council, EMRA Party, EMRA members get an additional 0.25% rate discount when refinancing. Chief Resident Track & so much more. Enjoy the "Emerald City" of Sea�le, Washington with October 16th | 8pm EST an a�ernoon to explore and closing party at one the Sign up at best spots in Sea�le. You don't want to miss ge�ng laurelroad.com/EMRA-Webinar Be�er Together! Registra�on opens mid-November Laurel Road Bank is a Connecticut-chartered bank, Member FDIC, and Equal Housing/Opportunity Lender. 1001 Post Road, Darien, CT 06820 For #CORDAA19 Registra�on and Travel Informa�on APAD1018A-13 www.cordem.org/aa

44 EMRA | emra.org • emresident.org PRACTICE ENVIRONMENT

Locums Life So Many Choices Editor’s note: After early ABEM certification in the late 1970s, Paul Weinberg of ER Doc Tips was drawn to the intense but fulfilling practice at a high-volume, high-acuity urban trauma center in Orange County, California, from 1976-2006. For Dr. Weinberg, retirement is just a phase. Now he travels the country, continuing his career in EDs, large and small, quiet and busy.

Paul Weinberg, MD Its acceptance allowed me to continue locum position if it required overnights. Freelance Locum Tenens Provider along the medical path with a sense of This did reduce some opportunity, but it he practice of emergency medicine contentment. I needed to find a way to allowed for longevity. is awesome: it is broad, intense, achieve longevity and satisfaction within Schedule: The children’s school Tknowledge-based, and packed the practice of emergency medicine. I vacation schedule ruled. I wanted time off with emotion – and all of that eventually chose to go the locums path. with them! I was able to control my work can be exhausting. After so many years Smooth Sailing with Locum Tenens availability to allow for that pleasure. Income: Almost always you will of effort to achieve an EM position, Entering the locums practice is a be paid an hourly rate, open to some the thought of leaving the field can be bit like the first day on a new rotation. negotiation. You can choose a production discouraging and filled with social and You know the nuts and bolts of the model of more charges per patient or economic dread. practice, but the details are to be learned. patients per hour. i.e. earn through Rough Road of Burnout Procedural components are important intensity of service or duration on duty. to getting the job done, and you do not The early symptoms of burnout, once Committee Service: Gone! You are yet know the system. That procedural identified, should create some questions not on any Committee. about what is next on the path. One knowledge, once learned, allows you Location: Limited by the effort suggestion that can work is to enter the to work in an efficient manner and not required to get licensed in different states. locum tenens circuit. Locums allow for feel frustrated with the delay between Allows a chance to see different regions choices in your practice life; choices that knowledge of what you want to do and and explore their offerings. are so needed to avoid the emotional its completion. Do not underestimate Impediments of locums include damage often created by the daily and the power of the electronic medical burdensome applications and paperwork nightly old-school practice in a single site. record to make you feel like for each hospital. Remember from high After a brief trial of not practicing chewing the eraser off a pencil. school geometry, “Things equal to the medicine, I returned to a locums-only So, it worked for me. Here are a few same thing are equal to one another”? practice. My time away from medicine areas of workplace-specific improvements Well, the hospital credentialing was used to develop non-medical income to consider: community does not believe in that sources, read novels, and re-bond with Shift length: You can find positions corollary, so electronically save all my middle-school aged children. that have shift lengths from 8 hours to your required documentation (health The overarching concept was one 24/7. records, practice history, malpractice, of sustainability. I had many years of Shift time: Yes, you can work immunizations, licensing, CME, productive life ahead, and one of my the shift time you want to work. The identification, certifications, etc.) so it can self-discoveries during my time away democratic group-share requirement or be easily found and emailed to those who from medicine was that, despite my required buy-in times can be avoided ask for it. And remember, as you work in varied and many business interests, at by being a locums provider. For me, it more sites and for a longer time you have my core I am a doctor. This insight was was the overnight shift (too old, enzyme a more complicated history to share with slow in recognition but deep in emotion. systems worn out). I would decline the those who require the information. ¬

October/November 2018 | EM Resident 45 EMRA-FIED PROGRAMS These Programs Rock! When a program pays dues for all of its EM residents, that is 100% EMRAfied! Designating your residency as “100% EMRAfied” is our way of recognizing a program as one that supports its residents, advocates for its patients, and contributes to the specialty of emergency medicine day in and day out. We are proud to be your colleagues! Programs paid as of September 11, 2018.

Advocate Christ Medical Center HealthPartners Institute/Regions Hospital Ohio Valley Medical Center University of Florida – Jacksonville Akron General Medical Center Hennepin County Medical Center Oregon Health and Science University University of Illinois Hospital – Chicago Albany Medical Center Henry Ford Hospital Orlando Regional Medical Center University of Iowa Hospital & Clinics Albert Einstein Medical Center Henry Ford Macomb Hospital OUCOM Grandview Hospital (CORE) University of Kansas School of Medicine Allegheny General Hospital Hofstra North Shore – LIJ at Long Island Palmetto Health Richland University of Kentucky Alpert Medical School of Brown University Jewish Medical Center Penn State Health Milton S Hershey University of Louisville – Kentucky Arnot Ogden Medical Center Hofstra Northwell SOM at North Shore/ Presence Resurrection Medical Center University of Maryland Aventura Hospital & Medical Center LIJ Queens Univ/Kingston Hosp – FRCP University of Massachusetts Baylor College of Medicine Hospital of University of Pennsylvania Reading Health System University of Michigan Baystate Medical Center Indiana University School of Medicine Ronald Reagan UCLA Medical Center/ University of Mississippi Medical Center Beaumont Hospital Trenton INTEGRIS Health Olive View UCLA Medical Center University of Missouri – Columbia School Boston Medical Center Jackson Memorial Hospital Rowan University School of Osteopathic of Medicine Brookdale University Medical Center Johns Hopkins University Medicine/Jefferson Health University of Nebraska Medical Center Brooklyn Hospital Center Kaiser Permanente San Diego Medical Rush University Medical Center University of Nevada – Las Vegas Cape Fear Valley Medical Center Center Rutgers New Jersey Medical School University of New Mexico Carilion Clinic – Virginia Tech Carilion Kaweah Delta Health Care District Rutgers Robert Wood Johnson University of North Carolina Carolinas Medical Center Kendall Regional Medical Center Medical School University of Oklahoma College of Case Western Reserve University/Metro LAC+USC Medical Center Southern Illinois University Medicine/Tulsa Health Medical Center Lakeland Health Spectrum Health/Michigan State University of Pittsburgh Medical Center Case Western Reserve University/ Lehigh Valley Health Network University University of Puerto Rico University Hospital Cleveland Loma Linda University School of St. John Hospital and Medical Center University of Rochester Medical Center Medicine St. John’s Riverside Hospital University of South Florida Central Michigan University College Louisiana State University – Baton Rouge St. Louis University School of Medicine University of Tennessee – Nashville of Medicine Louisiana State University – New Orleans St. Luke’s University Health Network University of Tennessee College of Charleston Area Medical Center Louisiana State University – Shreveport St. Mary Mercy Hospital Medicine at Memphis Christiana Care Health Services Maimonides Medical Center Stanford University Medical Center/ University of Tennessee COM at CHRISTUS Health/Texas A&M Maine Medical Center Kaiser Permanente Medical Center Chattanooga Conemaugh Memorial Medical Center Maricopa Medical Center SUNY – Stony Brook University of Texas at Austin Dell Coney Island Hospital McGovern Medical School at UTHealth SUNY Downstate/Kings County Hospital Medical School Cooper Hospital McLaren Macomb Medical Center SUNY University at Buffalo University of Texas Health Science Crozer Chester Medical Center McLaren Oakland Hospital SUNY Upstate – Syracuse Center at San Antonio Dartmouth-Hitchcock Medical Center Medical College of Georgia at Augusta Tawam Hospital University of Texas Southwestern Denver Health Medical Center University Texas A&M/Scott & White Medical Center Medical Center – Dallas Detroit Medical Center/Wayne State Medical College of Wisconsin – Temple University of Toledo Medical Center University Medical University of South Carolina Texas Tech Health Science Center University of Utah Hospitals & Clinics Doctors Hospital–Ohio Health Memorial Health System Program Thomas Jefferson University University of Virginia Health System Duke University Medical Center Mercy St. Vincent Medical Center UNECOM – Kent Hospital University of Wisconsin East Carolina University/Vidant Medical Merit Health Wesley Unity Health – White County Medical UPMC Hamot Medical Center Center Michigan State University/Sparrow Center Vanderbilt University Eastern Virginia Medical School Hospital – Lansing University of Alabama Virginia Commonwealth University – Emory University School of Medicine Midwestern University – CCOM University of Arizona Medical College of Virginia Florida Atlantic University Morristown Memorial Hospital University of Arizona COM at South Wake Forest University Florida Hospital Medical Center Orlando Mount Sinai School of Medicine – Campus Washington University St Louis/ Freeman Health System New York University of Arkansas Barnes-Jewish Hospital Genesys Regional Medical Center Mount Sinai St. Luke’s Roosevelt University of CA – Irvine Wayne State University/Detroit Medical George Washington University Hospital Center University of California – Davis Center Sinai-Grace Hospital Georgetown University Hospital/ Mount Sinai: Beth Israel University of California – San Diego Wellspan York Hospital Washington Hospital Center MSUCOM/ProMedica Monroe University of California San Francisco – West Virginia University Good Samaritan Hospital Medical Center Regional Hospital Fresno Western Michigan University Homer Grand Strand Medical Center Nassau University Medical Center University of California San Francisco – Stryker MD School of Medicine Greenville Health System New York Methodist Hospital San Francisco General Hospital William Beaumont Hospital Hackensack University Medical Center New York Presbyterian Queens University of Chicago Wright State University Harvard Affiliated Emergency Medicine Newark Beth Israel Medical Center University of Cincinnati College of Yale New Haven Medical Center Residency at Beth Israel Deaconess Norman Regional Health System Medicine Zucker School of Medicine at Hofstra/ Harvard Affiliated Emergency Medicine NYU/Bellevue Medical Center University of Connecticut Northwell at Staten Island University Residency at Brigham and Women’s Ohio State University Medical Center University of Florida – Gainesville Hospital Program

46 EMRA | emra.org • emresident.org NEWS & NOTES Do You Love Your Program Leaders? ABEM Online ITE EMRA honors outstanding EM program leaders each year — including $1,000 for The 2019 In-training Program Coordinator of the Year, plus honors for Program Director of the Year, Associate Examination (ITE) begins on PD of the Year, and Chief Resident(s) of the Year. the last Tuesday of February Help put your program in the national spotlight by nominating someone for these and can be administered awards, plus all our other travel scholarships, merit honors, project grants, educational on a single day or over the courses and more! course of 5 days. The online testing targets the expected knowledge and The following awards are now open for nominations: experience of a PGY3 EM resident; • Critical Care Medicine Conference Scholarship results should not be used to compare • Academic Excellence Award programs or residents within programs. • Dr. Alexandra Greene Medical Student(s) of the Year Award All 225 multiple choice questions are • Jean Hollister Contribution to Prehospital Care Award drawn from EM Model, with these topics • Resident of the Year weighted as shown. • Fellow of the Year Medical Knowledge, Patient Care, • Program Coordinator of the Year and Procedural Skills • Associate Residency Director of the Year • 1.0 Signs, Symptoms and • Residency Director of the Year Presentations: 9% • Rosh Review “One Step Further” Award • 2.0 Abdominal & Gastrointestinal • Be the Change Project Grant Disorders: 8% • ACEP Scientific Review Subcommittee Appointment • 3.0 Cardiovascular Disorders: 10% • EMRA Congressional Health Policy Fellowship in Washington, D.C. • 4.0 Cutaneous Disorders: 1% • EDDA Travel Scholarship • 5.0 Endocrine, Metabolic & Nutritional • EMBRS Scholarship Disorders: 2% • ACEP Teaching Fellowship • 6.0 Environmental Disorders: 3% • SAEM Travel Scholarship • 7.0 Head, Ear, Eye, Nose & Throat Apply by Jan. 15 through our online application at emra.org/be-involved/awards. ¬ Disorders: 5% • 8.0 Hematologic Disorders: 2% National Leadership Opportunities • 9.0 Immune System Disorders: 2% • Each year, EMRA appoints chairs-elect and vice chairs for each of our 16 committees. 10.0 Systemic Infectious Disorders: 5% These positions offer a chance to grow your passion for a subspecialty while building • 11.0 Musculoskeletal Disorders your name as an EM leader. (Non-traumatic): 3% The positions include travel reimbursement for in-person meetings during CORD • 12.0 Nervous System Disorders: 5% Academic Assembly in the spring and ACEP Scientific Assembly in the fall. In addition, • 13.0 Obstetrics and Gynecology: 4% committee leaders are invited to participate in the EMRA Leadership Academy, with • 14.0 Psychobehavioral Disorders: 4% yearlong networking and project development opportunities. • 15.0 Renal and Urogenital Disorders: 3% Apply online at emra.org/committee-application. Deadline is Jan. 10. ¬ • 16.0 Thoracic-Respiratory Disorders: 8% Annals of Emergency Medicine • 17.0 Toxicologic Disorders: 5% • 18.0 Traumatic Disorders: 10% Names New Resident Fellow • Appendix I: Procedures & Skills: 8% • Each year, Annals of Emergency Medicine selects a Resident Appendix II: Other Components: 3% • Fellow (formerly the Resident Editor) to serve on the Editorial Board. Total: 100% Mariam Fofana, MD, PhD, of BWH/MGH Harvard-Affiliated Emergency Acuity Frames: Target (± 5%) Medicine Residency has been selected to serve as the new Editorial • Critical: 30% Board Resident Fellow for the coming year. Dr. Fofana received her • Emergent: 40% MD and a PhD in epidemiology from Johns Hopkins. • Lower Acuity: 21% If you have an idea, an issue, or an experience about which you • None: 9% would like to write, submit an abstract (limit 250 words, double-spaced) through Physician Tasks Annals’ online submission system, Editorial Manager, at www.editorialmanager. For this dimension, the Board has com/annemergmed (use the “Residents’ Perspective” article type). If your abstract assigned the following specific is approved, you will be asked to write the full-length article for the “Residents’ percentage weights to the Modifying Perspective” section. If you have any other questions for Dr. Fofana, contact her at Factor of age: [email protected]. ¬ • Pediatrics: 8% minimum • Geriatrics: 6% minimum ¬

October/November 2018 | EM Resident 47 Physician’s Evaluation and Educational Review in Emergency Medicine Physician’s Evaluation and Educational Review in Emergency Medicine Bring the power of PEER assessments to your residency training program

PEER for Residency Programs!

Sign up your program, buy memberships for your residents and faculty at a discounted annual fee, then assign and monitor tests to each augment your program curriculum. $95 OR LESS seat

Three Program Director Seats Learn more at acep.org/PEER FREE!

First. Best.Transformed.

Tens of Thousands of Emergency Medicine Physicians Have Turned First to PEER for Content Review and Self-Assessment

Find out why at acep.org/PEER

EMR_1019_1313_0918

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

PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. For complete answers and explanations, visit the Board Review Questions page at emresident.org, under “Test Your Knowledge.” Order PEER acep.org/peer.

1. A 31-year-old woman presents with severe pelvic pain 1 week after delivering a healthy baby. She passed a large, foul-smelling clot just before arrival. She reports chills. Vital signs include BP 115/74, P 84, T 38°C (100.4°F). Which of the following is a risk factor for the development of this condition? A. Advanced maternal age B. Cesarean delivery C. External fetal monitoring D. Precipitous delivery 2. Which of the following conditions can falsely lower a B-type natriuretic peptide level? A. Advanced age B. Obesity C. Pulmonary disease D. Renal disease 3. A 56-year-old woman presents after an episode of near syncope. Vital signs are BP 93/40, P 104, R 20, T 36.1°C (97°F); Spo2 is 95% on room air. Blood glucose is 94. She recently received a diagnosis of idiopathic pulmonary hypertension; an ECG is unchanged from her most recent one. She denies fever, chest pain, and recent illness. Her dyspnea is slightly increased from baseline. Auscultation of the chest yields a loud split S1 but no murmurs. There is no jugular venous distention, hepatomegaly, or lower extremity swelling. Lungs are clear. Chest x-ray shows moderate cardiomegaly. After placing the patient on supplemental oxygen, what is the next treatment goal? A. Decrease left ventricular afterload B. Decrease pulmonary artery pressures C. Maintain adequate right ventricular filling pressure D. Maintain pulmonary vascular resistance 4. In the setting of chronic digoxin poisoning, which of the following findings is the best indication for administering digoxin-specific antibody fragments? A. Bidirectional ventricular tachycardia B. Serum digoxin concentration 2.4 ng/mL C. Serum potassium 5.6 mEq/L D. Vomiting 5. A 26-year-old man presents with pain, swelling, and ecchymosis of the right eye. He says he was attacked the night before and struck in the face with an unknown object. On examination, his orbital rim is tender to palpation. Which of the following additional signs would be most concerning for an orbital blowout fracture? A. Ecchymosis B. Enophthalmos

C. Exophthalmos 1. B; 2. B; 3. C; 4. A; 5. B 5. A; 4. C; 3. B; 2. B; 1. D. Photophobia ¬ ANSWERS

October/November 2018 | EM Resident 49 Opportunities in Pennsylvania's Busiest ED! Advancing Health. Transforming Lives.

Tower Health is seeking Emergency Medicine physicians across its six acute-care hospitals to help serve a population of more than 2.5 million with comprehensive services and technology!

Spotlight: Reading Hospital in West Reading, PA • #1 Busiest Emergency Department in Pennsylvania • #8 Busiest Emergency Department in the US in 2017 • Over 50 physicians treating 135,000+ patients annually • Adult Fast Track • Opening Fall 2018: 16-bed self-contained Pediatric Emergency Unit • 120 Beds; 100+ specialty and multi-purpose treatment rooms

CURRENTLY HIRING: Emergency Medicine Physicians Pediatric Emergency Medicine Physicians For more information, contact: Carrie Moore, MBA The Reading Hospital Emergency Medicine Residency 484-628-8153 [email protected] With 120 ED beds, Reading Hospital’s EM residents practice in an outstanding clinical environment with a large variation of patient Visit our websites: conditions and populations. The curriculum has been designed to towerhealth.org expose residents to a multitude of experiences throughout their training to ensure they're equipped to practice Emergency Medicine careers.towerhealth.org in any setting. Energetic and forward-thinking residents are sought to join our team! Equal Opportunity Employer

50 EMRA | emra.org • emresident.org CLASSIFIED ADVERTISING ALABAMA Mobile — ACADEMIC EMERGENCY MEDICINE POSITIONS ON THE GEORGEOUS GULF COAST — The University of South Alabama, is seeking faculty for growing EM academic programs at both hospital ED’s (level 1 University Medical Center and the Children’s Hospital). Must be UPMC has a long history of emergency medicine excellence, EM or Peds EM trained and board eligible/certified. Fellowship in PEM, with a deep and diverse EM faculty also a part of the University EMS, education/admin or research is a plus. Opportunities to lead, of Pittsburgh. We are internationally recognized for superiority initiate or contribute to new programs and services. Also recruiting for in research, teaching and clinical care. With a large integrated Chief, Division of Peds EM and Research Director. Applicants are invited insurance division and over 25 hospitals in Pennsylvania to submit CV and letter of interest to: Edward A. Panacek, MD, MPH, and growing, UPMC is one of the nation’s leading health care Chair of Emergency Medicine, USA-COM, Mobile, AL (eapanacek@health. systems. We do what others dream - cutting edge emergency southalabama.edu). Further information at https://www.southalabama.edu/ care inside a thriving top-tier academic health system. departments/academicaffairs/healthsciences.html. We can match opportunities with growth in pure clinical or ALASKA mixed careers with teaching, research, and administration/ leadership in all settings - urban, suburban and rural, with Fairbanks — New full-time position for a BC/BE Emergency Medicine both community and teaching hospitals. Our outstanding physician to join a stable, democratic group of 10 physicians. This is a compensation and bene ts package includes malpractice hospital practice based at Fairbanks Memorial Hospital. Annual visits without the need for tail coverage, and employer-funded exceed 36,000. Fairbanks Memorial Hospital is a JCAHO accredited 159- retirement plan, generous CME allowance and more. bed hospital that is the primary referral center for the 100,000 citizens of Alaska’s interior. Fairbanks is a truly unique university community To discuss joining our large and successful physician group, with unmatched accessibility to both wilderness recreation and urban email [email protected] or call 412-432-7400. culture. We aim to strike a balance between life and medicine, offering excellent compensation and benefits with a 2-year partnership track. 10 hour shifts with excellent mid-level coverage. For additional information please contact: Michael Burton MD, President (907) 460-0902 mrb5w@ hotmail.com or Art Strauss MD, Medical Director (907) 388-2470 art@ ghepak.com. CALIFORNIA Ventura — New hospital under construction and scheduled to open in the spring of 2018 with a state-of-the-art Emergency Department. 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 physician. Main facility is a STEMI Center, Stroke Center with on-call coverage of all specialties. This is a teaching facility with Global Emergency Medicine residents in Family Practice, Surgery, Orthopedics and Internal Medicine. Admitting hospital teams for Medicine and Pediatrics. 24-hour OB Humanitarian Training Fellowship coverage in house and a well-established NICU. Annual volume is 48K ü 5 months mandatory field-work and patients with nearly 70 hours of coverage daily and 12 hours of PA/NP coverage. All shifts and providers have scribe services 24/7. Affiliated mentorship under expert leaders within hospital is a smaller rural facility 20 minutes from Ventura in Ojai. internationally renown International Medical Malpractice and tail coverage is provided. New hires will work days, Corps. nights, weekends and weekdays. Come work with a well-established ü Develop the expertise YOU want to focus on high caliber group with expected volume growth potential at our new with over 30 IMC field sites to choose from. facility. Enjoy the life style of a beach community yet outside the hustle of the LA area. Please send a resume to Alex Kowblansky, MD, FACEP, at ü 1 and 2 year tracks available. [email protected]. ü MPH degree from Case Western Reserve FLORIDA University offered for 2-year fellowship EMERGENCY MEDICINE PHYSICIANS BC/BE track. Full-time, Part-time or Per diem Needed in Coastal Central Florida ü Join as Junior Faculty at a thriving residency Steward Health Care a physician-led organization is seeking Emergency with a Level-1 Trauma Center Medicine physicians to join our rapidly expanding system in Eastern Florida. Steward Health Care is a fully integrated community care organization and community hospital network operating 39 hospitals in the US, across 10 states and the country of Malta. Our Emergency Medicine departments offer excellent support staff, EMR, midlevel coverage, flexible scheduling, and more. Full-time, part-time, and per diem opportunities available. Our practices are located in beautiful Questions about applying? beachfront communities on the East Coast of Central Florida and border Please email [email protected] seventy-two miles of white sand beaches which lie in wait of sunbathers, Visit our website at www.cwruiemfellowship.com surfers, families, and fishermen year-round. The area is home to numerous top notch private, charter and public A-rated schools. One

October/November 2018 | EM Resident 51 Brody School of Medicine EMERGENCY MEDICINE FACULTY

◊ Clinician-Educator ◊ Clinical-Researcher ◊ Critical Care Medicine ◊

◊ Pediatric Emergency Medicine ◊ Ultrasound ◊

The Department of Emergency Medicine at East Carolina University Brody School of Medicine seeks BC/BP emergency physicians and pediatric emergency physicians for tenure or clinical track positions at the rank of assistant professor or above, depend- ing on qualifications. We are expanding our faculty to increase our cadre of clini- cian-educators and further develop programs in pediatric EM, ultrasound, clinical re- search, and critical care. Our current faculty members possess diverse interests and expertise leading to extensive state and national-level involvement. The emergency medicine residency is well-established and includes 12 EM and 2 EM/IM residents per year. We treat more than 130,000 patients per year in a state-of-the-art ED at Vidant Medical Center. VMC is a 960+ bed level 1 trauma center and regional referral center. Our tertiary care catchment area includes more than 1.5 million people in eastern A BETTER CHOICE North Carolina, many of whom arrive via our integrated mobile critical care and air medical service. Our new children’s ED opened in July 2012, and a new children’s hospital open in June 2013. Greenville, NC is a fast-growing university community located near beautiful North Carolina beaches. Cultural and recreational opportunities a better career are abundant. Compensation is competitive and commensurate with qualifications; excellent fringe benefits are provided. Successful applicants will be board certified or prepared in Emergency Medicine or Pediatrics Emergency Medicine. They will possess outstanding clinical and teaching skills and qualify for appropriate privileges from ECU Physicians and VMC. Join our Emergency Medicine program in Confidential inquiry may be made to: beautiful northern Wisconsin STAT! Theodore Delbridge, MD, MPH Chair, Department of Emergency Medicine Contact, Stephanie Luedke [email protected] [email protected] ECU is an EEO/AA employer and accommodates individuals with disabilities. Applicants must comply with the Immigration Reform and Control Act. Proper documentation of identity and employability required at the time 414.389.2668 of employment. Current references must be provided upon request.

aurora.org/doctor www.ecu.edu/ecuem/ 252-744-1418

52 EMRA | emra.org • emresident.org CLASSIFIED ADVERTISING of the many other advantages of living in this beautiful area is its close INDIANA proximity to the area attractions and theme parks like Universal Studios, Richmond — Long standing Emergency Medicine group of 12 — Epcot, Sea World, Islands of Adventure, Walt Disney World, Aquatica and recruiting 3 BE/BC residency trained EM physician. Partnership Kennedy Space Center! Fine dining, golf, camping, fishing, water sports, day one! Excellent compensation package including $50K signing outlet/ mall & specialty shopping, MLB spring training, NBA team within bonus, $100K student loan repayment and $10k relocation. 401(k) distance and night life also a bonus! with match and profit sharing! Community hospital with annual Other Steward Florida Emergency Medicine highlights include: volume of 48,000 emergency room visits. New 217-bed hospital • Join a large group of Emergency Medicine physicians featuring 33-bed ER designated as Level 3 trauma. Epic EMR, • Newly constructed state-of-the-art Emergency Departments • Provides 24 x 7 x 365 quality emergency care no admitting orders, and strong specialty support. Richmond • One-hour drive to Orlando is a college community of 40,000 with draw area of 150,000. If you are interested in learning more about this opportunity, or would like Three major metro cities within one hour — Indianapolis, Dayton to apply, please contact: Dave Rezendes, Senior Physician Recruitment and Cincinnati. Family oriented community with relaxed lifestyle Specialist, Steward Health Care at 781-551-5640 or email: david. and excellent schools. Outdoor Recreational activities abound. [email protected]. Great place to live and practice medicine. Contact Amy Powell, All inquiries will remain confidential. Steward Health Care is an equal Recruiter, Reid Health, [email protected] opportunity/affirmative action employer. or 765-983-3104. Jacksonville — St. Luke’s Emergency Care Group, LLC in Jacksonville, South Bend — Memorial Hospital. Very stable, Democratic, Florida. Independent Physician-run group at St. Vincent’s Medical Center- single hospital, 24-member group seeks additional Emergency Southside in beautiful Northeast FL. Great area/community with river Physicians. 60K visits, Level II Trauma Center, double, triple and ocean access, good schools, sports, and entertainment. Emergency and quad physician coverage. Equal pay, schedule and Medicine residency trained BC/BE physicians with PAs providing MLP vote from day one. Over 375K total package with qualified coverage. FT/PT available. Low physician turnover. Flexible scheduling retirement plan; group health and disability insurance; medical, with overlapping shifts. Holiday pay, shift differential, competitive base dental and CME reimbursement, etc. Very favorable Indiana salary, and quarterly RVU bonus pool. Sign-on bonus and moving stipend malpractice environment. University town, low cost of living, available. Cerner EMR. Supportive medical staff with hospitalists and good schools, 90 minutes to Chicago, 40 minutes to Lake intensive care coverage, L&D/Neonatal ICU. 39,500 ED visits/year. Michigan. Teaching opportunities at four year medical school and Please contact us directly and send CV to: Katherine Considine, MD, with FP residency program. Contact Joseph D’Haenens MD at Medical Director at [email protected]; (904) 296-3885. [email protected].

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 410-328-8025Contact us at [email protected] • Additional incentive compensation UMEM is an EOE/AAE or 410-328-8025 • 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 2018 | EM Resident 53 #OWNERSHIP MATTERS When you become an owner in one of the largest, fastest -growing physcian- owned and led groups in the nation, you get the support you need, and the culture and benefits you want. WORK WHERE YOU WANT TO LIVE. • Highly competitive financial/benefits LOCATIONS NATIONWIDE! package • Physician equity ownership for all full-time physicians • Industry-leading and company funded 401(k) (an additional 10%) • Yearly CME/BEA (Business Expense Account) • Student loan refinancing 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 • Professional development programs • Location flexibility and career stability of a national group Sign On Bonus for Select Locations!

To learn more about our FEATURED opportunies contact: Darrin P. Grella | VP of Recruiting OPPORTUNITIES [email protected] or 844-863-6797 Visit usacs.com to view a complete list of locations.

Catholic Medical Center Saint Francis Hospital Lake Health System Manchester, NH | 32,000 pts./yr. Tulsa, OK | 104,000 pts./yr. Eastern Cleveland, OH | 12-35,000 pts./yr.

Lawrence & Memorial Hospital Frederick Memorial Hospital Summa Health System New London, CT | 47,000 pts./yr. Frederick, MD | 61,000 pts./yr. Akron, OH | 10-84,000 pts./yr.

Marshall Medical Center Providence Health Center Mercy Health Placerville, CA | 33,000 pts./yr. Waco, TX | 69,000 pts./yr. Cincinnatti, OH region | 14-60,000 pts./yr.

Doctors Hospital Valley Baptist Medical Center Florida Hospital System Columbus, OH | 79,000 pts./yr. Harlingen, TX | 49,000 pts./yr. Florida Heartlands | 13-45,000 pts./yr.

Valley Children’s Hospital Peterson Regional Medical Center Dignity Health Micro-Hospitals (4) Madera, CA | 124,000 pts./yr. Kerrville, TX | 29,000 pts./yr. Las Vegas, NV | 17,000 pts./yr.

Albany Memorial Hospital CHI St. Joseph Health Regional Hospital Carolinas HealthCare System Albany, NY | 42,000 pts./yr. Bryan, TX | 50,000 pts./yr. Charlotte, NC | 17-69,000 pts./yr.

Allegheny Health Network Emergency Meritus Medical Center CarlolinaEast Medical Center Medicine Management Hagerstown, MD | 71,000 pts./yr. New Bern, NC | 67,000 pts./yr. Western PA | 12-55,000 pts./yr. Emergency CLASSIFIED ADVERTISING HIRING Medicine Physicians MASSACHUSETTS EMERGENCY MEDICINE — GREATER BOSTON Kettering Health Network is seeking a BC/BE Steward Health Care is seeking Emergency Medicine physicians to Emergency Medicine physician to join a highly regarded, join our rapidly expanding system. Full and part-time opportunities are available throughout Eastern Massachusetts. Full-time, part-time regional private group located in Dayton, OH. or per diem opportunities are available for qualified candidates. Must •Strong group of 70+ physicians and advanced Be Board Certified/ Board Eligible in Emergency Medicine. practice providers Steward Health Care System Emergency Medicine highlights: •Provide care at six of Kettering Health Network's • Locations in and around Boston Emergency Departments, including 4 hospitals and 2 • More than 90 Emergency Medicine physicians freestanding Emergency Centers • Provides quality care to 400,000 patients annually •Trauma Level II and III options • Recently opened 4 newly constructed Emergency Departments • 3 of our EDs have resident rotations, including 2 with Emergency •Competitive salary, generous benefits package Medicine •Sign-on bonus up to $40,000 matched by group and Benefits of joining the Steward physician-governed dedicated EM hospital group: • Competitive compensation package •Epic EMR utilized across the network • Attractive year-end incentive bonus •Warmth and charm of the Midwest • Comprehensive benefits package • 401K and deferred compensation Site visits are being scheduled now! • and more! Contact Cindy Corson Steward Health Care, the largest private hospital operator in the Physician Recruitment Manager United States, is a physician-led health care services organization [email protected] committed to providing the highest quality of care in the communities (937) 558-3475 (office) where patients live. Steward operates 39 community hospitals in (503) 201-8588 (cell) the United States and the country of Malta, that regularly receive top awards for quality and safety. For additional information, please ketteringdocs.org contact: Catrina Morgan, Physician Recruitment Specialist, E: Catrina. [email protected] P: 781-551-5629. OHIO EMERGENCY MEDICINE PHYSICIANS BC/BE Full-time, Part-time or Per diem Needed in Northeast OH Trumbull Regional Medical Center, a Steward Family teaching Hospital, is currently seeking a BC/BE Emergency Medicine Physician with excellent clinical acumen, strong interpersonal skills, and a commitment to providing outstanding patient centered care. We are also looking for a leadership candidate to assist the current ED Chair. The ED is a Level 3 trauma center averaging approximately 32,000 patients annually treating a full range of acuity. Our department is staffed by 15 dedicated EM physicians and seasoned advanced practitioners, along with a newly established IM/FM residency. Benefits of joining our physician-governed EM group include: • Competitive Salary • Comprehensive benefits package • Attractive year-end incentive bonus • Attractive CME/professional reimbursement • 401K and deferred compensation • Transparent financial monthly statements • Tuition reimbursement • Full-time, Part-Time and Per Diem Physicians Needed Conveniently located 1 hour between Pittsburgh and Cleveland, Trumbull Regional Medical Center, a 346 bed facility in Northeastern Ohio, serves the health care needs of residents of Trumbull County and nearby communities, and has been providing quality care for over a century. The hospital has residents in IM and Family Medicine and is the first in Ohio to achieve Chest Pain v5 accreditation, which is the highest level accreditation from the Society of Cardiovascular Patient Care. Steward Health Care, the largest private hospital operator in the U.S., is a physician-led health care services organization committed to providing the highest quality of care in

October/November 2018 | EM Resident 55 Emergency medicine physician opportunities at Geisinger

Geisinger, a national leader in healthcare innovation and technology, is seeking BC/BE Emergency Medicine trained physicians for opportunities throughout central, south central and northeast Pennsylvania. Join Geisinger’s growing team of Emergency Medicine staff physicians in practicing state-of-the-art medicine in one, or a variety of settings.

With Geisinger, you can take advantage of: Locations throughout PA include: • Competitive compensation package • Geisinger Bloomsburg Hospital (GBH) • Exceptional work life balance, defined clinical hours Bloomsburg • Support from a full range of dedicated specialists and subspecialists • Geisinger Wyoming Valley Medical Center (GWV) Wilkes-Barre • Scribes, pharmacists and Advance Practice support • Geisinger South Wilkes-Barre (GSWB) • Ongoing enhancements to our fully-integrated Electronic Wilkes-Barre Health Record (EHR) – Epic • Geisinger Holy Spirit (GHS) • $150,000 medical school loan repayment Camp Hill • $100,000 forgivable loan • Geisinger Shamokin Area Community Hospital (GSACH) • $2,000 monthly stipend available to current residents upon Coal Township signature of an offer letter

Geisinger is nationally recognized for our innovative practices and quality care. A mature electronic health record connects a comprehensive network of 13 hospital campuses, two research centers and nearly 1,600 Geisinger primary and specialty care physicians. For more information, visit geisinger.org/careers or contact Miranda Grace, Talent Management, at 717-899-0131 or [email protected]

AA/EOE: disability/vet geisinger.org/carers

PRIVATE INDEPENDENT WE BUILD GROUP Top Texas Jobs EM LEADERS TAKE THE LEAD, CONTACT US TODAY: SUZY MEEK, MD [email protected] LEMAMD.COM

56 EMRA | emra.org • emresident.org CLASSIFIED ADVERTISING the communities where patients live. Steward operates 38 community hospitals nationwide that employ approximately 37,000 people and regularly receive top awards for quality and safety. The Steward network includes more than 26 urgent care centers, 42 preferred skilled nursing facilities, substantial behavioral health services, over 7,300 beds under management, and more than 1.1 million covered lives through the company’s managed care and health insurance services. Steward’s unique health care service delivery model leverages technology, innovation, and care coordination to keep patients healthier. With a culture that prioritizes agility, resourcefulness, and continuous improvement, Steward is recognized as one of the nation’s leading accountable care organizations. The Steward Health Care Network includes thousands of physicians who care for approximately or 2 million patients annually. Steward Medical Group, the company’s employed physician group, provides more than 1 million patient encounters per year. The Steward Hospital Group operates hospitals in Arizona, Arkansas, Colorado, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, Texas, Utah and the country of Malta. If you are interested in learning more about this opportunity, or would like to apply, please contact Dave Rezendes, Senior Physician Recruitment Specialist, Steward Health Care at 781-551-5640 or email [email protected]. All inquiries will remain confidential. Steward Health Care is an equal E-609 opportunity/affirmative action employer. OREGON Salem — Outstanding BC/BE EM physician partnership opportunity at Salem Health Emergency Department (SEPS). Well-established, independent, democratic group with 37 physicians and 6 APPs who staff 110K annual visit, Level II trauma center, with excellent specialty backup. Competitive pay and benefits including scribes, flexible scheduling, malpractice, 401k, and more. We structure our practice to minimize turnover through maximizing work-life balance. We love living in Salem, ST. BARNABAS HOSPITAL the heart of Oregon wine country, as it is convenient to the bounty DEPARTMENT OF EMERGENCY MEDICINE of Oregon’s recreational opportunities, and is a safe and affordable community. See what we’re about at sepspc.com, then send your CV, FELLOWSHIP IN SOCIAL EMERGENCY MEDICINE cover letter, and a recent photo to [email protected] or call us A one-year fellowship designed to train and educate the fellow at 503-814-1278. in the field of Social Emergency Medicine. The fellowship will emphasize research and innovation around focused and systemic TEXAS interventions promoting health equity along with operational, policy and legislative interventions.

CORE FACULTY POSITIONS We seek EM faculty dedicated to advancing the specialty and Leading Edge Medical Associates is a one-of-a-kind, private, practice of emergency medicine, and contributing to our missions independent group of all board-certified EM physicians in northeast of clinical, educational and research excellence. Texas, offering a full range of clinical opportunities in EM. Our physicians enjoy shifts in a tertiary care trauma center as well as in St. Barnabas Hospital is a 461-bed safety-net hospital in nearby, lower volume clinical settings, all with high compensation the Bronx. St. Barnabas Hospital is the principal teaching and excellent full benefits. We are known for innovation in the affiliate of CUNY’s School of Medicine, and is also affiliated industry and for developing strong EM leaders through LEMA’s with Albert Einstein and NYCOM. Our ED provides critical Leadership Development Institute. Almost half our physicians are emergency care to over 90,000 patients/year and we are former chief residents. LEMA is unique in its ability to offer physicians home to a well-established four year EM residency program. the best of both worlds, hospital-based and freestanding, academic and community medicine. LEMA is a group of exemplary physicians For more information, please contact: who work together as a team, value each member’s input, and have Daniel G. Murphy, MD, MBA, ED Chair a level of integrity, honesty, and trust that makes this innovative group truly one-of-a-kind. Interested in joining Texas’s premier private [email protected], 718.960.6103 group? Contact: SUZY MEEK, MD, [email protected].

October/November 2018 | EM Resident 57 {}Job Opportunities Division Chief, Pediatric Emergency Medicine EMS Fellowship Director Medical Director/Asst Medical Director PEM/EM Core Faculty Vice Chair Research Emergency Medicine

What We’re Offering: What the Area Offers: • We’ll foster your passion for patient care and cultivate a collaborative We welcome you to a community that environment rich with diversity emulates the values Milton Hershey • Salaries commensurate with qualifi cations instilled in a town that holds his name. • Sign-on bonus Located in a safe family-friendly setting, • Relocation assistance Hershey, PA, our local neighborhoods • Retirement options boast a reasonable cost of living • Penn State University Tuition Discount whether you prefer a more suburban • On-campus fi tness center, daycare, credit union, and so much more! setting or thriving city rich in theater, arts, and culture. Known as the home What We’re Seeking: of the Hershey chocolate bar, Hershey’s • Experienced leaders with a passion to inspire a team community is rich in history and • Ability to work collaboratively within diverse academic and clinical environments offers an abundant range of outdoor • Demonstrate a spark for innovation and research opportunities for Department activities, arts, and diverse experiences. • Completion of an accredited Emergency Medicine Residency Program We’re conveniently located within a • BE/BC by ABEM or ABOEM short distance to major cities such • Observation experience is a plus as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC.

FOR ADDITIONAL INFORMATION PLEASE CONTACT:

Susan B. Promes, Professor and Chair, Department of Emergency Medicine c/o Heather Peffl ey, Physician Recruiter, Penn State Health Milton S. Hershey Medical Center 500 University Drive, MC A595, P O Box 855, Hershey PA 17033 Email: hpeffl [email protected] or apply online at: hmc.pennstatehealth.org/careers/physicians 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. {}Job Opportunities Division Chief, Pediatric Emergency Medicine EMS Fellowship Director Medical Director/Asst Medical Director PEM/EM Core Faculty EMERGENCY MEDICINE OPPORTUNITY NEAR BOSTON, MA Emergency Medicine ONE TEAM. Faculty Position Vice Chair Research Emergency Medicine University Health Physicians, the physician ONE FOCUS. Kansas City group practice for Truman Medical Centers, One thing sets North Shore Medical Center apart—our team based model of is recruiting faculty at the Assistant or offers an care which is founded on the principle that physicians, nurses, and other care Associate Professor level in the Department attractive providers working together will provide higher quality and a better patient of Emergency Medicine at the University of lifestyle with low experience. Today, that team focus drives our providers to be leaders of quality Missouri-Kansas City School of Medicine. cost-of-living of care, patient safety and process improvement initiatives throughout NSMC. Candidates must be board-certified/board- and affordable eligible emergency physicians. All qualified While practicing as an Emergency Medicine physician at NSMC you will enjoy: housing, candidates will be considered, but preference renowned • working at one of the top hospitals in Boston with a new Emergency will be given to candidates with EMS, Research suburbs with or Ultrasound expertise. The department Department opening in October 2019 top-ranked • the benefits of NSMC’s membership in the Partners Healthcare System, supports one of the nation’s oldest fully- schools, and founded by Massachusetts General Hospital and Brigham and Women’s accredited three-year residency programs, Hospital with 33 residents. Truman Medical Center is a numerous • our combined annual adult ED volume of 80,000 visits provides an level I trauma center and the ED has an annual outdoor array of pathology with a fast track and PA program in place and excellent volume of 62,000 adult patients in a modern, activities. multispecialty back up What We’re Offering: What the Area Offers: state-of-the-art facility with 48 beds. • a culture focused on communication, growth, and work/life balance • We’ll foster your passion for patient care and cultivate a collaborative We welcome you to a community that • excellent compensation and comprehensive fringe benefits Interested candidates should e-mail • being an active contributor to quality of care, patient safety and process a letter of interest and CV in confidence to: environment rich with diversity emulates the values Milton Hershey improvement initiatives • Salaries commensurate with qualifi cations instilled in a town that holds his name. Matthew Gratton, MD Let’s work together. Professor and Chair, Department of Emergency Medicine • Sign-on bonus Located in a safe family-friendly setting, 2310 Holmes Street, Ste. 800 • Relocation assistance Hershey, PA, our local neighborhoods Interested candidates should send their CV to: Louis Caligiuri, Director of Kansas City, Missouri 64108 Physician Services at [email protected] [email protected] • Retirement options boast a reasonable cost of living EOE – M/F/Vet/Disabled • Penn State University Tuition Discount whether you prefer a more suburban • On-campus fi tness center, daycare, credit union, and so much more! setting or thriving city rich in theater, arts, and culture. Known as the home What We’re Seeking: of the Hershey chocolate bar, Hershey’s • Experienced leaders with a passion to inspire a team community is rich in history and • Ability to work collaboratively within diverse academic and clinical environments offers an abundant range of outdoor 7 Distinct Locations in Norfolk, Virginia Beach, and Suffolk Located in St. Petersburg, Florida • Demonstrate a spark for innovation and research opportunities for Department activities, arts, and diverse experiences. Seeking Fulltime BC/BE Emergency Physicians • Completion of an accredited Emergency Medicine Residency Program We’re conveniently located within a Since 1972, Emergency Physicians of Tidewater has at a Level II Trauma Center with 48,000 volume. delivered emergency care to Southeastern Virginia We are a rapidly expanding, well-established, • BE/BC by ABEM or ABOEM short distance to major cities such EDs. Our seven locations allow our physicians to independent, democratic group. • Observation experience is a plus as Philadelphia, Pittsburgh, NYC, choose a location based on patient acuity, ED flow, Baltimore, and Washington DC. resident coverage, and trauma designation. Bayfront Health broke ground for a new 37,000 sq ft state-of-the-art EPT employees enjoy the coastal living in Virginia Emergency Department. 480-bed hospital with: Beach and Norfolk as well as the perks of • Primary Stroke Center having plenty US history, quaint towns, and • Chest Pain Center with PCI mountains just a short drive away. • Level IV Epilepsy Center • Aero-Medical Flight Program Opportunities: • Regional Flagship hospital with a network of six hospitals along Flexible Schedule the Florida Gulf Coast Leadership & resident teaching (bedside • 48-hour physician coverage teaching, SIM lab, mock oral boards, • 36-hour PA/ARNP coverage lectures) A free-standing ED is also slated to open November 1, 2018. Many options of involvement within the We offer a comprehensive benefit package including health, group (board representation, committee dental, vision, LTC, CME allowance, 401K, profit-sharing, membership, etc.) along with a partnership track.

FOR ADDITIONAL INFORMATION PLEASE CONTACT: Employees have the option to pursue our 2- Requirements: residency trained, ACLS, ATLS and PALS certified. year track to partnership For more information, contact Susan B. Promes, Professor and Chair, Department of Emergency Medicine c/o Heather Peffl ey, Top Ranked Regional Retirement Plan the Emergency Physicians of St. Petersburg, PA at Physician Recruiter, Penn State Health Milton S. Hershey Medical Center 7 Hospital Democratic Group | Partnership Track | Teaching & Leadership Opportunities (727)-553-7300, fax (727)-553-7395 500 University Drive, MC A595, P O Box 855, Hershey PA 17033 or email: [email protected] Please send your CV to [email protected] Email: hpeffl [email protected] Our web site is EpspBayfront.com or apply online at: hmc.pennstatehealth.org/careers/physicians 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. October/November 2018 | EM Resident 59 Exciting Emergency Medicine Opportunities with Steward Health Care!

STEWARD HEALTH CARE, the largest private hospital Our Emergency Medicine operator in the United States, is a physician-led health care services organization committed to providing the highest departments offer excellent quality of care in the communities where patients live. support staff, EMR, midlevel EXPLORE THE EXCITING OPPORTUNITIES coverage, scribes, flexible AT OUR NUMEROUS HOSPITALS: scheduling, and more. FLORIDA Newly constructed state-of-the- Melbourne Regional Medical Center, Melbourne, FL art EDs Rocklege Regional Medical Center, Rockledge, FL Multiple Teaching Hospitals Sebastian River Medical Center, Sebastian, FL Highly competitive compensation MASSACHUSETTS Carney Hospital, Dorchester, MA and benefits packages Good Samaritan Medical Center, Brockton, MA Productivity based incentive Holy Family Hospital, Haverhill & Methuen, MA programs Norwood Hospital, Norwood, MA Morton Hospital, Taunton, MA Sign On Bonus for select aint nnes Hospital, Fall River, MA locations t. iaets Medical Center, Brighton, MA Part of a large national network of OHIO Hospitals and Physicians Hillside Rehabilitation Center, Warren, OH Trumbull Regional Medical Center, Warren, OH For more information please contact: PENNSYLVANIA Catrina Morgan | Physician Recruitment Specialist Easton Hospital, Easton, PA Network Development | Steward Health Care Sharon Regional Medical Center, Sharon, PA O:781-551-5629 | C:781-635-9703 Email: [email protected]

Own your tomorrow Honolulu, Hawaii today Practice with us. The Emergency Group, Inc. (TEG) is a growing, independent, democratic group that has been providing emergency services at The Queen’s Medical Center (QMC) in Honolulu, Hawaii since 1973. QMC is the largest and only Level 1 Trauma Rewarding opportunities available in: Hospital in the state and cares for more than 65,000 ED patients per year. QMC opened an additional medical center alionia ansas ot aolina io in the community of West Oahu in 2014, which currently sees ennessee eas est iginia 60,000 ED patients annually.

Due to the vastly growing community in the West Oahu area, Ask us about our: TEG is actively recruiting for EM Physicians BC/BE, EM • Sign-on Bonus physicians with Pediatric Fellowship who are BE/BC and an • Residency Stipend Ultrasound Director. Physicians will be credentialed at both • Leadership Development facilities and will work the majority of the shifts at the West Oahu facility in Ewa Beach, Hawaii. oune in ealtae is a eoati poie one We offer competitive compensation, benefi ts and an opportunity to share in the ownership and profi ts of the company. Our to onesip ate ust ous o seie physicians enjoy working in QMC’s excellent facilities and experience the wonderful surroundings of living in Hawaii. . For more information, visit us at teghi.com/careers or submit your CV to the Operations Manager at [email protected]. ..

60 EMRA | emra.org • emresident.org BOSTON EMERGENCY MEDICINE OPPORTUNITY The Department of Emergency Medicine at Tufts Medical Center, the principal teaching hospital for Tufts University School of Medicine in Boston, is seeking an ABEM/AOBEM BP/BC Emergency Physician to join our dynamic, independent group of residency trained, board certified emergency physicians. The Department currently offers a variety of clinical and educational programs with emphasis on resident and medical student education. Research opportunities within the Tufts Clinical and Translational Science Institute abound. Personal growth is guaranteed. At Tufts Medical Center you will experience the following: • ACS Level I Pediatric and Adult Trauma Center • JC Accredited Comprehensive Stroke Center • Dedicated Pediatric Emergency Department • Volume of 50,000 diverse patients/year • Outstanding Pediatric, EMS, Ultrasound and Geriatric Programs • Students and Residents who will stimulate you • Colleagues and Nursing Staff who you will enjoy working with side by side • An excellent compensation package

Please contact or forward CV to: Brien A. Barnewolt, M.D., F.A.C.E.P. Phone: 617-636-4721 Email: [email protected]

October/November 2018 | EM Resident 61 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. Exceptional Emergency Medicine Opportunities with EMMC and Affiliates in Maine!

Eastern Maine Medical Center is seeking BC/BE Emergency Medicine physicians for full-time permanent positions at primary locations in Bangor, Blue Hill, Waterville and Ellsworth

• Dynamic physician-led collaborative Emergency Medicine Model • Supportive hospital administration • Join well-established team at a primary site, with options to work at other sites within our system • Flexible schedule/no call • Medical student teaching options • Full Spectrum of Sub-specialty backup and consultation • In-house collaborative Radiology and Night Hawk Services • In-System LifeFlight of Maine Air/Ground Critical Care Transport Program • In-System ACS-Verified Level II Trauma Center <1 hr away — Trauma Service: on call consult — Critical Care lntensivists:on call consult — Pediatric lntensivists: on call consult

EMMC and affiliates are located in highly desirable, family-centered locations throughout Maine! Enjoy year-round access to Maine’s unmatched coastline, mountains and lakes with limitless outdoor recreational opportunities and unspoiled natural beauty! J-1 Visa candidates welcome to apply!

For more information, please contact: Amanda L. Klausing, AASPR, Physician Recruiter Email: [email protected] Phone: (207) 973-5358

October/November 2018 | EM Resident 63 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 21 beds ECEET CMPESAT PACAE 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 (9-10 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.

Qualified candidates include: Emergency Medicine and Family Medicine physicians. 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

64 EMRA | emra.org • emresident.org Live where you want. Practice where you’re needed.

BE THE BEST PHYSICIAN POSSIBLE AS A MEMBER OF TEAMHEALTH’S SPECIAL OPS PHYSICIAN TEAM.

n First-classexperiencewithfirst-classpay n Leadership training and opportunities n Practice across your region but live where n ABEMorAOBEMcertified/prepared you want n EM residency trained n Independent Contractor status n Enjoy the opportunity to travel to different areas n Preferred scheduling n Reimbursementforlicensure,certificationsand n Work 120 hours per month travel

Join our team teamhealth.com/join or call 877.709.4638 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

Where you live is a reflection of who you are. Over 200 locations and growing.

So is where you work. If you want to be part of a large, stable group, take a look at US Acute Care Solutions. We are the largest, physician-owned group in the country, with over 200 locations, each chosen to appeal to the different tastes and lifestyles of our clinicians. Best of all? Every USACS physician becomes an owner in our group, creating unbeatable camaraderie. Our commitment to physician owner- ship is a reflection of who we are and what we care about most: our patients, and living the lives we’ve always dreamed of.

Visit USACS.com and discover why more than 3,000 providers serving over 6 million patients a year are proud to call US Acute Care Solutions home.

Own your future now. Visit usacs.com or call Darrin Grella at 844-863-6797 [email protected]