Terminal Extubation C-Spine Injuries in Children COVID Or Coral? Exciting Opportunities at Our Growing Organization

ResidentOfficial Publication of the Emergency Medicine Residents’ Association August/September 2020 VOL 47 / ISSUE 4

Terminal Extubation C-Spine Injuries in Children COVID or Coral? Exciting opportunities at our growing organization

• Adult and Pediatric Emergency Medicine Faculty positions • Medical Director • Vice Chair, Clinical Operations • Vice Chair, Research • Medical Student Clerkship Director

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

FOR MORE INFORMATION PLEASE CONTACT: Heather Pefﬂ ey, PHR FASPR at: hpefﬂ [email protected]

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. EDITOR'S FORUM

On the Importance of Anti-Racism Black lives matter.

Priyanka Lauber, DO that Black patients, especially Black men, justice to act together in their communities. Editor-in-Chief, EM Resident trusted medical advice more when it came The impetus for that commitment was, and Lehigh Valley Health Network from Black doctors than White doctors. The still is, the rampant and deliberate violence @PriyankaLauber paper argued that centuries of oppression inflicted on us by the state.” he past few months we have seen a and brutality has made Black patients The statement is much longer, and resurgence of Black advocacy and trust White authority figures less than the I would empower all EMRA readers to empowerment like we haven’t seen doctors who looked more like themselves.5 take a few minutes to visit their website Tin years. There were Black Lives Matter Thus, increasing representation becomes (blacklivesmatter.com) to learn more. I protests in all 50 states and numerous even more important. would also encourage you to join EMRA’s countries around the world. The world wept together. The world marched Even though by now we have all heard Diversity and Inclusion committee. This together. about Black Lives Matter movement, it committee has hosted international and However, we still have so much more was important to me to highlight part of national leaders at their events, which has work to do. In so many avenues Black and the group’s mission statement for all of always left me so fulfilled and refreshed. minority communities are disadvantaged. #EMRAFamily to read: The resurgence of anti-racism mentality Black women are up to 4 times more “Four years ago, what is now known in this country is the growth the country likely to experience a pregnancy-related as the Black Lives Matter Global Network has been long overdue. We have been death when compared to White women, began to organize. It started out as a forced, repeatedly, to come to terms with even with things like income and chapter-based, member-led organization the racism in this country. Racism is not education were factored in.1 And a study whose mission was to build local power dead. It is very much alive and thriving. that examined trends 2013 to 2017 noted and to intervene when violence was And it’s important for us to understand that White patients in the United States inflicted on Black communities by the it will never be dead. We all need to received higher quality health care when state and vigilantes. continuously work to be the change we compared to 40% of Black patients.2 “In the years since, we’ve committed want to see. I have already witnessed Recent statistics noted that only 6% of to struggling together and to imagining positive changes in the community, with my physicians and surgeons are Black, even and creating a world free of anti- hospital creating a task force that works to though Black people make up 14% of the Blackness, where every Black person has intentionally increase diversity in residency United States population.3 This becomes the social, economic, and political power programs and in program leadership. even more problematic when we consider to thrive. Multiple studies have demonstrated that that minority populations tend to have “Black Lives Matter began as a call diversity in an organization’s leadership higher rates of obesity, chronic illness. to action in response to state-sanctioned is important and has shown that diverse Black men have the lowest life expectancy violence and anti-Black racism. Our companies produce 19% more revenue.6 of any racial group.4 intention from the very beginning was I implore everyone reading this to not Research from the National Bureau to connect Black people from all over only be educated and informed, but to be of Economic Research demonstrated the world who have a shared desire for anti-racist. ¬

References available online August/September 2020 | EM Resident 1 PRESIDENT’S MESSAGE Life of an ED Resident in the Era of COVID-19 Hannah R. Hughes, MD, MBA President, EMRA At the end of 8 hours, I've seen 32 patients Chief Resident, University of Cincinnati Emergency Medicine and called time of death on 8 people. @hrh_approved t’s night 6 of 6, with 51 clinical hours None of them had COVID, but COVID already logged in the books. Walking into shift, I’m thinking about all the affected every one of us. I“extra” things I have to do outside my clinical responsibilities — that Grand battle their mental health diseases on the EMS’ gurney, but the patient Rounds lecture I’m giving in 3 weeks; while coping with new realities of doesn’t respond. Back to the SRU I go. finishing up the next month’s resident unemployment, food scarcity, and The patient had ingested over 200 pills shift schedule; the dozens of medical even homelessness of his anti-hypertensive medications and student emails with questions about the Of the 6 patients who roll in, 2 go benzodiazepines within 30 minutes. We upcoming residency application cycle up immediately to the operating rooms, move swiftly to intubate him and drop needing responses. another 2 go to the CT scanners in the a gastric lavage tube, something I’ve The back doors of the ED open with ED for imaging, and 1 moves swiftly to never done before in training but figure a sign that says, “DO NOT ENTER” in the pod, as he is not in critical condition. it out on the fly. As I literally pump his big capital letters. Underneath, “Only For the final patient, I call time of death stomach, I think how rarely indicated it clinicians treating ED patients permitted after we’ve given multiple blood products, is to perform the procedure, how archaic past this point.” It serves as a reminder intubated, and performed a thoracotomy. it seems to do so. By the time we’re done, that most people, patients and hospital It’s less than an hour into my shift. he’s on 3 pressors, high-dose insulin and staff alike, are doing everything they can The social worker finds me, glucose, and methylene blue. Off to the to stay away from the place where I’ve handing over a purple Post-It note with medical ICU he goes. spent the most time during the past week. information for the patient’s mother. He At the end of 8 hours, I’ve seen 32 It was eerily quiet, with no one was 16. I braced myself as I dialed her patients and called time of death on 8 in the lobby and no one in the Shock number to deliver the worst news she will people, 4 in the ED and 4 in the field. Resuscitation Unit, what we lovingly call ever hear — all via telephone — because I walk out, defeated by so much loss, the SRU (“shrew”). But I put on my armor COVID-related restrictions prohibit and go home to my husband (a resident anyway – N95, surgical mask, face shield visitors from entering the hospital. Her himself) to decompress and get ready to – ready for the battle that will inevitably sobs are unforgettable. do it all over again in 2 days. come. As I prepare to take sign out from No sooner than hanging up the None of the patients I saw that day my colleague, the telemetry phone rings. phone, I’m called by EMS again for had COVID, but COVID affected every I answer, “University Hospital, this is MD not one but two different patients who one of us — from the sweaty mask I took 2104. Go ahead with report.” I can sense sustained cardiac arrests in the field and off at the end of my shift to the mental the angst in the paramedic’s voice as he had no return of spontaneous circulation. health implications, socioeconomic tells me about incoming patients. I call The death toll for the shift is already up to factors, and health-seeking behaviors it out over the hospital system, “Trauma 3 and I can’t help but wonder — were they wrought in my patients. STAT, multiple GSW victims, ETA 5 having chest pain and afraid to come to I never imagined training during the minutes.” The SRU went from no one to the ED? Were their deaths preventable? middle of a pandemic. But I did sign up 6 patients instantaneously. I throw away the thought, not because to be available 24-7-365 for any patient What is it like to be an emergency it isn’t important to understand the who walks through the door — regardless medicine resident in the era of COVID, unintended implications of stay at home of age, gender, orientation, race, religion, particularly in a city that is not a hot spot? orders, but because there are now 9 citizenship status, or ability to pay. ● Crime is up, with more penetrating new stable patients waiting to see me in I did not sign up to be on the front trauma than usual the pod with complaints ranging from lines of COVID. But I am humbled to ● Accidental opioid overdoses are abdominal pain, to frequent falls, to put on my armor and return each day, up, leading to more buprenorphine dizziness. because there is no greater honor in life administration than I’ve ever given As I’m catching up on documentation, than to step up during a time of need. before I look up from my computer and see the I am an emergency medicine ● Suicide attempts are up, as patients charge nurse trying to wake a patient resident.¬

2 EMRA | emra.org • emresident.org TABLE OF CONTENTS 4 Terminal Extubation A Model for EM Resident EDITORIAL STAFF in the ED 30 and Ski Patrol Cross- EDITOR-IN-CHIEF PALLIATIVE CARE Educational Training Day Priyanka Lauber, DO Lehigh Valley Health Network COVID or CORAL? WILDERNESS, MEDICAL EDUCATION EDITORS 8 A Case Report Erich Burton, DO TOXICOLOGY Preparing for a Global Greenville Health System 32 Marc Cassone, DO Plus One: Care of the Health Experience Geisinger Medical Center 9 Pregnant Trauma Patient INTERNATIONAL MEDICINE Nicholas Cozzi, MD, MBA Spectrum Health/Michigan State University TRAUMA, OB/GYN 36 Are You Satisfied Sean Hickey, MD Preeclampsia with Your Patient Icahn SOM at Mount Sinai 12 Complicated by a Satisfaction Scores? Whitney Johnson, MD ADMIN & OPS UCSF-Fresno Cerebrovascular Accident Amie Kolimas, DO OB/GYN, NEUROLOGY Substance Use University of Illinois Hospital – Chicago 38 Disorder Education Emily Luvison, MD Cervical Spine Injuries ChristianaCare 15 in the Pediatric Population for EM Residents Devan Pandya, MD PEDIATRICS, ORTHOPEDICS LEADERSHIP UC Riverside Sarah Ring, MD Cocktails with Chairs: Dank Vapes: A Tale of 40 Icahn SOM at Mount Sinai 18 a Pediatric E-cigarette Pearls for EM Jason Silberman, MD Vaping Associated Physicians-In Training University of Tennessee LEADERSHIP Samuel Southgate, MD, MA Lung Injury Regions Hospital PULMONARY, TOXICOLOGY Medical Education MSC Editor 41 Fellowship Director David Wilson COVID-19 Management: Thomas Jefferson University 20 Classical Treatments Interview Series MEDICAL EDUCATION ECG Faculty Editor for a New Disease Jeremy Berberian, MD INFECTIOUS DISEASE, When Medicine Robs You ChristianaCare TOXICOLOGY 43 HEART OF EM Anesthesia A Rare Case of Adolescent Daniel Bral, DO, MPH, MSc Lord NRMP Match URMC Anesthesia Residency 22 Joint Pain in the ED 44 HEART OF EM PEM Faculty Editor ORTHOPEDICS, SPORTS Yagnaram Ravichandran, MBBS, MD, FAAP MEDICINE EMRA @ ACEP20 Dayton Children's Hospital/Wright State 46 CONFERENCE Dysuria and Progressive Toxicology Faculty Editor 23 David J. Vearrier, MD, MPH, FACMT, Abdominal Pain in a News & Notes FAACT, FAAEM Male Pediatric Patient 48 ABEM NEWS, AND MORE University of Mississippi PEDIATRICS, UROLOGY ECG Challenge EM Resident (ISSN 2377-438X) is the bi-monthly 49 magazine of the Emergency Medicine Residents’ Learning to Take the Heat CARDIOLOGY Association (EMRA). The opinions herein are 25 WELLNESS those of the authors and not of EMRA or any Visual Diagnosis institutions, organizations, or federal agencies. Emergency Medicine 51 INTERPRET AND DIAGNOSE EMRA encourages readers to inform themselves 28 fully about all issues presented. EM Resident Dispatch: The reserves the right to edit all material and does True First Responder Board Review not guarantee publication. 53 Questions PREHOSPITAL & DISASTER © Copyright 2020 MEDICINE PEER ASSISTANCE Emergency Medicine Residents’ Association

August/September 2020 | EM Resident 3 PALLIATIVE CARE

Terminal Extubation in the ED oward the end of your shift, EMS presents with a 94-year-old female found obtunded in her home by neighbors after an unknown period of time. She Palliative required intubation in the field by the paramedic for depressed level of Tconsciousness; neither family nor a POLST form were available on scene. Her vitals are stable on arrival and she has a history of hypertension, prior ischemic stroke, and Care in EM atrial fibrillation on coumadin. Her CT shows a large intraparenchymal hemorrhage Marc Cassone, DO with intraventricular extension and midline shift. Her bleed is deemed to have poor Geisinger Medical Center chance of recovery by the EM, Neurology, and Neurosurgery Teams. A discussion Garrett Stoltzfus, MD with her children who have arrived at bedside reveals that she did not want to receive Geisinger Medical Center aggressive treatment or be on a ventilator for any period of time. The decision is made Eric Melnychuk, DO to transition to comfort measures. Your ICU is at full capacity and you are boarding EM-Critical Care Attending critical care patients in your ED; therefore, you make the decision to terminally Geisinger Medical Center extubate the patient in the ED and transition her to the palliative care service. @GeisingerEM

Palliative Care in the ED with the need to terminally extubate a Palliative care is a growing topic patient in the ED during their careers; of interest in EM. Greater than 50% of this has become especially relevant in this geriatric and 80% of metastatic cancer time of the COVID-19 pandemic. Comfort patients visit the ED within the final measures and terminal extubation may be months of life.1 Beyond discussions of one of the most important procedures you advance directives, goals of care, POLST perform during your shift. forms, and hospice services, providing Teamwork and Communication palliation and end-of-life care has become Goals of care discussions and an important aspect of emergency breaking bad news are fundamental skills medicine. Providers likely will be faced for an EM clinician. Once the decision

4 EMRA | emra.org • emresident.org to transition to comfort care has been in place at the provider and family’s achieved with infusions, long-acting decided, effective communication with discretion; condom-catheters may be formulations, or repeated dosing. family members is key to understanding considered in male patients as a less Infusions are particularly useful for their wishes and setting expectations. intrusive option. Wound care in patients the ease of titration. For example, a Several studies have shown that open and with traumatic injuries should be limited morphine infusion of 2 mg/hr and 2 mg clear dialogue with families regarding to limit odor and drainage and preserve IV q15min for breakthrough pain or RR their relative’s wishes and symptom patient dignity. > 18 with increase in rate by 1 mg/hr if 3 management contributed to higher If the patient is on vasopressors, or more PRNs are used within one hour family satisfaction during end of life care IV fluids or receiving any other non- is one commonly used approach.4 Doses in ICUs.2,3 Ensure you have thoroughly palliative interventions these should be may need to be titrated up to 10 mg/ explained the steps that will take place stopped prior to terminal extubation. hr or more, particularly in patients with and signs of the dying process that family Patients with automated implantable chronic opioid use or severe respiratory may notice. Reinforce that your team cardioverter-defibrillators (AICD) failure.5 will be attentive to keeping the patient should have the defibrillator function Providers may be concerned about comfortable. If possible, consider moving deactivated with a ring magnet and left- using opioids in comfort-care patients the patient to a private room in a quieter ventricular assist devices (LVAD) can be due to the theoretical effect of depressing section of the department with more disconnected from their battery source respiratory drive and thus hastening room for family members and loved ones. or driveline controller unit. Depending death. This is known in palliative care A sign on the door indicating the need on your state guidelines and patient’s as the “double-effect”. Providers have for privacy can be considered. Ensure the presentation, endotracheal tubes (ETT) a legal and ethical mandate to provide nursing team and respiratory therapists and IV access must remain in place appropriate comfort as a primary goal, are aware of the plan and prioritize prior to evaluation by the local coroner’s even if this may hasten patient death as patient and family comfort. Consider office. Withdrawal of life-sustaining a secondary effect.4 However, there is speaking with organ donation services, treatment may be delayed in order to evidence that when opioids are titrated social workers, and spiritual care if achieve appropriate and anticipatory for subjective respiratory comfort, they requested by family as well your hospital’s symptom management. Delaying do not significantly alter PaCO2, PaO2, palliative care team. withdrawal of care for family arrival or or overall survival.6 In fact, appropriately Preparing Your Patient spiritual rites should be considered by elevated morphine dosing has been Prior to terminal extubation, consider the provider but not unduly prolong associated with no change or a longer 5, 7 several steps to prepare the patient. This suffering of the patient. time to death. However, opioids are will be the last time family members Medications certainly not benign medications and will be able to see their loved one alive. Prior to terminal extubation, providers should be ready to manage Therefore, compassion and respect for providers should actively treat any side effects including histamine response the patient, family and loved ones are symptoms the patient is experiencing and nausea. paramount. Attempt to organize the room as well as anticipate symptoms that Patients nearing end of life may also and provide the patient with enough may occur after extubation. Opioids, be experiencing anxiety, and/or delirium. blankets and pillows. Adjust clothing or benzodiazepines, and anticholinergic Mainstays of treatment will include hospital garb for the patient. medications are the cornerstones of benzodiazepines and antipsychotics Anecdotal evidence indicates pharmacotherapy of the dying patient. (Table 1).4 These medications will need to aspiration and emesis can sometimes Appropriate, early and frequent re-dosing be titrated to effect with significant ranges occur during the process of terminal are key to ensuring the patient remains in effective doses due to many factors extubation: consider decompression comfortable during the dying process. including age, gender, renal/hepatic of the patient’s stomach contents with Opioids play a large role in palliative function, and prior exposure to these a nasogastric tube if already in place. care for the management of both pain medications. A patient’s comorbidities The care team should remove blood and dyspnea. Morphine is a mainstay of and prognosis may influence your pressure cuffs, telemetry leads and any palliative care, but providers may also medication choice, i.e., use of lorazepam other monitoring devices in the room; choose to use hydromorphone or fentanyl for patients with hepatic impairment or this ensures a peaceful environment for (Table 1). Bolus dosing of morphine in midazolam when faster onset is a priority. the patient and limits additional stress opioid-naïve patients typically starts Some patients may experience to family. If remote-only monitoring is at 0.1 mg/kg IV for analgesia or 0.05 nausea or vomiting and are particularly possible, providers may consider leaving mg/kg IV for air hunger.4 This should at risk following extubation and with only finger pulse-oximetry to monitor be repeated every 15-30 minutes to the use of opioids. Ondansetron is a waveform/pulse on telemetry to note time achieve desired effect and may require commonly prescribed antiemetic and of death. If a prolonged course is expected significantly higher doses for patient may be particularly effective in patients and it does not provide discomfort to the chronically taking opioids.5 Maintaining receiving chemotherapy. Dexamethasone patient, urinary catheters may remain adequate serum levels can then be may also alleviate nausea related to

August/September 2020 | EM Resident 5 PALLIATIVE CARE

chemotherapy use.8 Metoclopramide by several guidelines due to concerns secretions and blood landing on their should be considered if gastroparesis for emergence reactions.11-14 Paralytic gown. Providers should consider wearing or stomach compression are thought agents during terminal extubation are not PPE depending on the circumstance to be contributory.8 Finally, dopamine recommended as they may blunt the care as this can be an aerosol-generating antagonists can be effective for refractory team’s ability to assess the patient for procedure. Once off ventilator support, nausea.8 signs of distress and may unnecessarily guidelines vary on removal of the Secretions commonly contribute to hasten the dying process.11-14 Propofol may ETT.11,13,18 Many providers will remove the anxiety of family members and loved be considered as a sedative/anxiolytic the ETT for patient comfort and family ones due to the characteristic death and has anti-emetic properties.13 request. However, in some cases such as rattle.9 Anticholinergics can be provided Terminal Extubation massive hemoptysis, major facial trauma, to decrease secretion production with Once the patient has been adequately significant secretions or swollen tongue glycopyrrolate and scopolamine showing medicated and other life-sustaining the patient may be more comfortable with 10 equivalent efficacy. These medications measures stopped, the patient can be the ETT kept in place with a T-piece and only limit new secretion production considered for terminal extubation. There humidified air. If stridor is anticipated so they may take time to effectively are two general techniques for removing or noted post-extubation, providers may show a change in symptoms. Frequent, a patient from ventilator support — give nebulized epinephrine or steroids gentle suctioning is key. Atropine terminal extubation and terminal wean such as methylprednisolone to help with 11,21 ophthalmic drops work quickly and — each with various indications and symptom management (Table 1). In may be administered PO if IV access is outcomes.4,11,13,17-20 Terminal extubation general, guidelines do not recommend not possible or the patient’s skin is not (without a slow taper in respiratory transitioning to non-invasive ventilation 10 14 amenable to patches. (Table 1) support) may be considered in after extubation. When choosing medications patients without significant respiratory Setting Expectations to address symptomatic care and compromise (ie, those intubated for Family members may inquire how preparation for terminal extubation, depressed GCS) and still have a gag reflex. long the dying process will take and what EM providers should consider onset Terminal wean is preferred when there symptoms may occur. Answering these of action, half-life, and dosing. Unlike is concern for respiratory compromise questions can be difficult but important patients that have been admitted for (ie, ARDS, pulmonary edema, COPD). for anticipating symptom management, hours or days, patients arriving in the To perform a terminal wean, patients family expectations, and disposition. On ED have not yet received prior treatment should be placed on IMV or PS mode and average, ICU patients survive between or reached therapeutic levels. An initial then should have a step-wise decrease in 35 minutes to 7.5 hours after terminal bolus followed by infusion or long acting 11 the FiO2 to 40% and PEEP to 5 cm H2O. extubation. Providers must be able to medications is generally necessary. At each step-down, the patient should recognize key symptoms that require Building flexibility into your orders via be reassessed for signs of air hunger or interventions in the dying patient. The titration and/or PRNs will allow your agitation and receive appropriate bolus most common symptoms requiring team to meet patient needs in a setting dosing and up-titration of infusions to intervention include fatigue (28.7%), where patients will need to be frequently match symptoms. The RSBI (Rapid- pain (22.1%), and respiratory distress re-evaluated. Having additional PRN Shallowing Breathing Index: respiratory (22.1%).22 Several studies have shown that doses available at bedside during the rate divided by tidal volume) can be it is difficult for providers to accurately extubation process can help in avoiding used to determine level of distress.4 The predict time of survival in individual delays in treatment. Intravenous terminal wean is usually performed over patients after extubation.11,22,23 The death medications are preferred due to the 10-60 min depending on the patient.4,12 rattle (sound of secretions pooling in faster rate of onset and the ease of Once the ventilator settings have been the hypopharynx and bronchial tree), titration. If IV access is unavailable weaned and the patient’s symptoms respiration with mandibular movement, providers may consider buccal, nasal, addressed, the provider can consider Cheyne-Stokes respirations, and cyanosis subcutaneous, oral, or intramuscular extubating the patient. If imminent loss of of extremities are common symptoms routes for certain medications. (Table airway or significant respiratory distress in the dying patient, however none is 1) The care team should monitor the is anticipated during weaning or removal specifically predictive of imminent death patient closely for signs of distress of the ETT, several guidelines suggest a (can be noted hours to days before death) including fist-clenching, tears, grimacing, proactive rather reactive approach using or used to accurately predict duration tachycardia, diaphoresis, tachypnea, aggressive palliative sedation.4,12 of survival.24 Other factors such as GCS

accessory muscle use, and nasal flaring. When performing the extubation, score, SpO2, and the amount and duration Standardized assessments scales such have suction ready, turn off the ventilator of sedation/analgesia required have also as Sedation-Agitation Score (SAS) or alarms, and have a respiratory therapist not been found to be predictive of time the Ramsay Agitation Sedation Scale at bedside if possible. Consider draping of death.11 It is important for providers (RASS) may provide additional input. the patient’s chest with absorbing to communicate these uncertainties to Ketamine is not routinely recommended pads during the extubation to prevent families when setting expectations.

6 EMRA | emra.org • emresident.org TABLE 1. Review of Medications to be Used in Symptomatic Care for Palliative Patients

Medication Initial Bolus Infusion with Titration/PRN Time to Onset Pain Morphine 0.1 mg/kg IV 2 mg/hr IV and 2 mg q15m for 5-10 min breakthrough pain Hydromorphone 1 mg IV 0.5-3 mg/hr 5 min Fentanyl 1-2 mcg/kg IV Repeat 0.35-0.5 mcg/kg q30- Immediate 60min PRN Dyspnea Morphine 0.05 mg/kg IV 0.05 mg/kg/hr IV with 1-2 mg 5-10 min IV PRN Anxiety/Agitation Haloperidol 2-10 mg IV Repeat 0.5 to 6 hrs PRN 3-20 min Midazolam 0.5-5 mg IV Repeat 0.5-2 mg/hr 3-5 min Lorazepam 0.25-2 mg IV Repeat q3-6hr PRN 2-3 min Nausea/Vomiting Ondansetron 0.15 mg/kg or 4-8 mg IV Repeat q8hr PRN 30 min Dexamethasone 4-20 mg/day IV Dosed daily or split BID 2-6 hours Haloperidol 0.5-2 mg IV Repeat q6-8hr PRN 3-20 min Metoclopramide 5-10 mg IV Repeat q4-6hr PRN 1-3 min Secretions Glycopyrrolate 4 mcg/kg IM/SC/SL/IV Repeat q6-8hr PRN IV < 1 min IM 15-30 min Scopolamine 1 patch Repeat daily 4-8 hours Atropine 0.4-1 mg IV/SL/SC Repeat q4-6hr PRN IV, opth solution 1% Opth Solution: 1-2 drops PO – 30 min Respiratory Stridor Methylprednisolone 100 mg IV or IM Repeat q8-12h PRN 1 hour Nebulized 0.5mL via nebulizer Immediate Epinephrine Assume immediate-release formulations of medications and availability of IV access. Doses provided are for medication-naïve patients and higher doses may be needed for chronic users of opioids/benzodiazepines. IV – intravenous, IM – intramuscular, SC – subcutaneous, SL – sublingual, PO – by mouth.4,12,15,16

Improving the Process aggressive management of symptoms, TAKE-HOME POINTS Providing end-of-life care in the ED and understanding the concepts of l When transitioning a patient to is an essential skill for EM providers. terminal extubation will help ensure a comfort care and performing terminal The ABEM Model of Clinical Practice compassionate and dignified process for extubation in the ED, maintain open includes palliative care as an essential your patients and their families. and clear communication with your 25 patient, their families, nursing and part of residency training. Programs Case Resolution should consider including didactics and ancillary staff. After discussing the plan with both l It is important to set the scene. simulations on end-of-life discussions the patient’s family and nurse, you Establish a private space, turn off and terminal extubation. Residents can move the patient to a private room monitors, and avoid unnecessary continue to improve these skills and designated for end-of-life care. The nurse procedures to reflect the respect and the processes in their departments by compassion this situation deserves. administers a bolus dose and infusion providing dedicated training to fellow l Be aware of and closely monitor of morphine. Once your patient appears residents, nursing, and ancillary ED staff, symptoms associated with the dying comfortable, the respiratory therapist discussing guidelines with department process. Appropriate medications terminally extubates the patient. You and leadership and debriefing sessions after such as opiates, benzodiazepines, and individual cases. Several guidelines exist the nurse frequently re-assess the patient anticholinergics should be given early 12,13,26,27 for additional PRN doses of medications and as frequently as needed. that providers may reference. l and gentle suctioning as needed. After Be familiar with the process of terminal Palliative care, and particularly the extubation. Understanding the monitoring for 40 minutes and checking process of terminal extubation, does not preparatory steps and post-extubation make for an easy shift. Transitioning with family, your patient continues to care are essential to ensuring a from managing a critically ill patient have a faint pulse and SpO2 around 84%. comfort-oriented, compassionate and to the application of comfort care is You discuss with the palliative care team, dignified process for your patient. taxing for patients, families, and health who admits her to their service. Your Training and establishing departmental care teams. Clear communication, patient passes away peacefully 6 hours guidelines can help ease what can be a difficult process. establishing an appropriate environment, later with her family at bedside. ¬

References available online August/September 2020 | EM Resident 7 TOXICOLOGY COVID or CORAL? A Case Report Louisa Mazza-Hilway, MD Upon re-evaluation, the patient failure, in some reports, clinical toxidrome PGY-1 Emergency Medicine mentions he recently cleaned his home can present with GI symptoms and St. Joseph’s Regional Medical Center aquarium for the first time in 7 years. He distorted sense of taste,1 very like the ay 2020: You’re working in a didn't use any chemicals, but his aquarium 2019 novel coronavirus. Palytoxin may busy inner-city ED amid the contains some living coral, over which he even cause generalized fatigue and muscle Mcoronavirus pandemic. You get ran hot water. Could this be related to the weakness due to rhabdomyolysis or cardiac an ALS call: 44-year-old male, no known clinical presentation? dysrhythmias,10 and overall can lead to PMX, en route wtih shortness of breath, death.1,11 saturating 80% on room air. Your next Discussion In addition to inhalation exposure, there steps have become rote. The escalation Palytoxin is a nonprotein are reports of GI and dermatological toxicity algorithm flashes in your head: nasal environmental toxin found in the Zoanthid through ingesting the toxin in contaminated cannula, non-rebreather mask, non- coral species, which includes Palythoa seafood or handling coral, respectively.4-5 invasive positive pressure ventilation, and, and Zoanthus subspecies. This compound There is no specific antitoxin. if all else fails, endotracheal intubation. was first isolated in the 1970s and is Treatment is often supportive, sometimes The patient arrives in moderate thought to be one of the most toxic marine 1 including inhaled steroids. Patients usually respiratory distress, tachypneic, RR > substances ever classified. The ornate recover within several days of exposure. 40. There is obvious increased work of corals that contain this toxin are soft; they breathing, though he is still able to speak are occasionally used in home aquariums Case Conclusion in full sentences. He has had some tactile and are sometimes available for commercial The whole family was admitted to the fevers and GI symptoms, both of which you purchase. In vivo, palytoxin acts on blood hospital. The patient and wife were afebrile; know by now are typical of COVID-19. His vessels to cause vasoconstriction. On the however, their daughter had a temperature wife and daughter have similar symptoms cellular level palytoxin inhibits the sodium- of 101°F. Labs showed elevated ESR, CRP, and are in the ED, further solidifying a potassium ATPase.2 lactic acid, and procalcitonin, as well as viral picture in your head. Treatment Though exceedingly rare, inhalation acute kidney injury. Chest CT showed with oxygen via nonrebreather improves can cause respiratory distress and even confluent ground-glass opacities with his symptoms. You establish IV access, respiratory failure. The irritant properties areas of consolidation involving the lung get labs, and continue to monitor. Chest of palytoxin are thought to contribute apices, plus interlobular septal thickening radiography looks familiar: bilateral to the inflammatory reactions seen with (Figure 2). Leukocytosis (WBC as high as ground glass opacities (Figure 1). ABG inhalational contact.3 Often released upon 27 x 103/uL for the patient, 35 for the wife, reveals a P/F (PaO2/FiO2) ratio of 116. cleaning this specific type of coral, steam and 37 for his daughter) trended down over Labs show moderately high leukocytosis containing palytoxin is pungent and foul- time. Each family member was hospitalized – not something routinely associated with smelling. Symptom onset is usually minutes several days, with symptoms and CXR COVID-19, but this evolving virus requires to hours following exposure.4-7 Lab studies infiltrates peaking on day 2–3. High flow diagnostic flexibility. often show leukocytosis, and patients can nasal cannula was used for symptomatic Then you notice something else odd: his present febrile.8 Without sufficient history, treatment, and the patient's acute kidney inflammatory markers (namely D-dimer this presentation could easily be mistaken injury resolved with hydration. The family and ferritin) are not as elevated as you for pneumonia, especially in conjunction was discharged with strict instructions expect. Then the COVID-19 test comes back with an abnormal chest x-ray.9-10 not to handle or attempt to clean the coral negative. What are you missing? Aside from respiratory distress and again. ¬

FIGURE 1 (left). Bilateral Ground Glass Opacities FIGURE 2 (above). Interlobular Septal Thickening

8 EMRA | emra.org • emresident.org References available online TRAUMA, OB/GYN Plus One Care of the Pregnant Trauma Patient

R. Gentry Wilkerson, MD, FACEP, FAAEM improved quality of chest compressions aspiration, an orogastric tube placement Assistant Professor, Assistant Residency Program and ease of performing resuscitation should follow intubation.8 Director, Director of Clinical Research procedures (eg, intubation). These same 2. Breathing Department of Emergency Medicine recommendations should be followed Evaluation of respirations in the University of Maryland School of Medicine when possible when cardiac arrest pregnant patient mirrors what is done Youssef Annous, MD Postdoctoral Research Fellow is secondary to trauma. Additional in the non-pregnant patient. As noted in

Department of Emergency Medicine resuscitative measures include obtaining Table 1, PaCO2 is reduced in pregnancy. A

University of Maryland School of Medicine intravenous (IV) access, leg elevation, and normal or elevated PaCO2 may represent 2 Yasmin Hasbini, MD supplemental O2 administration. pending respiratory failure. Due to the Research Scholar elevation of the diaphragm that occurs The Office of Women’s Health ED Assessment and Management during pregnancy, management of a Wayne State University Primary Survey pneumothorax proceeds with placement anagement of a pregnant trauma The ED management of the pregnant of a tube thoracostomy 1 to 2 intercostal patient can be challenging as the trauma patient should ideally consist of spaces superior to the usual 4th or 5th physician must be aware of the a multidisciplinary approach. If possible, M the trauma and obstetrical teams should intercostal space anterior to the mid- anatomical and physiological changes axillary line.8 of pregnancy in addition to the clinical be activated early. Additionally, the 3. Circulation implications these changes have in a neonatal intensive care unit should All trauma patients should have 2 trauma setting. It is important to keep be consulted as early as possible in large-bore IV cannulas placed to aid in mind that the mother’s wellness is a preparation for a potential infant with volume resuscitation. Shock may priority during resuscitation of pregnant resuscitation. be due to hemorrhage, direct cardiac trauma patients as fetal outcome is 1. Airway injury, or obstructive mechanisms such as largely dependent on aggressive and early Pregnant patients have altered tamponade or tension pneumothorax. The resuscitation of the mother. This concise respiratory physiology resulting in a uterus should be displaced manually or by review article highlights key concepts in decreased functional reserve capacity placing the patient in left lateral decubitus the management of a pregnant trauma (FRC), increased oxygen demand, and thus lower tolerance to prolonged position. When transfusion is necessary, patient. Table 1 provides an overview of apnea times. Therefore, a pregnant the risk of alloimmunization in the Rh (-) the anatomic and physiologic changes of trauma patient should be preoxygenated mother is reduced by administering un- pregnancy. adequately when the airway needs to crossmatched type O, Rh (-) blood until Pre-hospital Care be secured. Airway management is type specific blood is available.9 The pre-hospital care of pregnant further complicated due to increased 4. Disability trauma patients focuses on rapid edema, hyperemia, and friability of Disability assessment is a rapid assessment, adequate stabilization, and the mucosa of the upper airway in neurologic assessment that includes transport to the nearest appropriate pregnant women and may result in an a Glasgow Coma Scoring, pupillary medical facility. It is recommended to increase in the Mallampati score.3 In examination, as well as an evaluation for place pregnant women in the left lateral the pregnant population, the rate of lateralizing neurological deficits. decubitus position in order to alleviate failed tracheal intubation is 0.4%, ten 5. Exposure and environmental compression on the inferior vena cava times higher than for the non-pregnant control (IVC) and improve hemodynamics.1 population (0.04%).4 The application of As in the general population, the The 2015 American Heart Association cricoid pressure has been recommended patient should be fully exposed and guidelines on cardiac arrest in pregnancy despite the lack of evidence supporting thoroughly assessed. Hypothermia recommend placing pregnant women its benefit.5,6 Because of the decreased should be prevented in order to avoid the in supine position with manual esophageal sphincter tone during “trauma triad of death” — a vicious cycle displacement of the uterus superiorly pregnancy, there is an elevated risk involving hypothermia, coagulopathy, and laterally towards the left due to of aspiration.7 To reduce this risk of and acidosis.10

August/September 2020 | EM Resident 9 TRAUMA, OB/GYN

Secondary Survey Physical Exam hemorrhage or placental abruption. History Uterine tenderness, vaginal Addition of lung windows to the FAST exam In addition to obtaining a thorough bleeding, and pooling of fluid in the is known as the extended FAST (eFAST) obstetrical history, providers can use the vagina are indicators of possible exam. Lung ultrasound is more sensitive and has similar specificity as supine mnemonic AMPLE (allergies, medications, complications with the uterus. Bimanual anteroposterior chest radiographs.14 past illnesses/pregnancies, last meal, exam should be avoided when rupture events/environment related to trauma) to of membranes is suspected. If the Laboratory Testing aid in history taking.11 gestational age is > 23 weeks, speculum Lab testing largely follows what Fetal Assessment exam should be deferred until placenta would be done in most patients with Ultrasound can be utilized to assess fetal previa is ruled out. While examining the traumatic injuries. The Rh status should heart rate, fetal movement, amniotic fluid vagina, the physician should also assess be determined as Rh (-) patients are at risk of alloimmunization. Fibrinogen levels quantity, position of the placenta, as well as for the presence of lacerations or bony fetal femur length for calculating gestational are often elevated in pregnancy15,16 and fragments. age. A femur length > 4 cm is suggestive of low fibrinogen levels are associated with viability.12 A pregnant patient with a viable Imaging Studies severe hemorrhage or the development of fetus (more than 22 to 24 weeks) should Focused assessment with sonography disseminated intravascular coagulation undergo continuous fetal cardiotocographic for trauma (FAST) is less accurate in (DIC). The Kleihauer-Betke (KB) test is monitoring for a minimum of 4 hours. pregnant patients, although serial FAST used to detect the approximate the volume The presence of prolonged, painful, and/ exams may improve the accuracy.13 Due of fetal-maternal hemorrhage (FMH) but or regular contractions necessitates further to low sensitivity, ultrasound should its lower limit of sensitivity does not allow monitoring or obstetric intervention. not be used to rule out retroperitoneal this test to rule out the presence of FMH.

TABLE 1. Anatomical and Physiological Changes of Pregnancy and Their Clinical Implications Anatomical changes during pregnancy 21 Relative protection of uterus by pelvic bones during first 12 weeks of pregnancy Uterine enlargement causes compression of IVC and/or aorta à Supine Hypotension Syndrome (aortocaval hypotensive syndrome) Cephalad displacement of intra-abdominal organs and diaphragm: à Relative protection of intra-abdominal organs by thoracic wall in cases of blunt abdominal trauma à Tube thoracostomy at a more superior rib interspace than in a non-pregnant patient Physiological changes during pregnancy40-50 System Effects/clinical implications Cardiovascular ↑ Heart rate (HR) 15-20 bpm Elevated heart rate and decreased blood pressure at baseline ↑ Stroke Volume (SV) Physiologic anemia of pregnancy ↑ Cardiac output (CO) by up to 40% Delayed clinical symptoms of hemorrhagic shock ↑ Plasma volume 40-50% ↑ RBC mass 20-30% ↓ Mean Arterial Pressure (MAP) Pulmonary ↑ Diaphragm excursion during inspiration Primary respiratory alkalosis ↑ IC Lower tolerance to apnea times ↑ TV 30-50 % ↓ FRC 20-30% Renal ↑ Intravascular volume Decreased serum levels of creatinine, blood urea nitrogen, and uric acid ↑ GFR 40-50% Hydronephrosis and hydroureter are common findings Hematologic ↑ Factors I, VII, VIII, X Increased risk of venous thromboembolism ↑ Von Willebrand Factor ↓ Protein S ↓ Resistance to activated protein C Gastrointestinal ↑ Gastrin Increased gastric acid production ↓ Gastric emptying Increased risk of aspiration ↓ Lower esophageal sphincter tone

10 EMRA | emra.org • emresident.org The formula used is: vs Placebo 1.9%), with most benefit seen compression of the IVC by the uterus and % of fetal cells determined by KB in patients who received TXA between thus improves maternal hemodynamics test/100 x 5,000 ml = volume of FMH 1 and 3 hours of delivery.26 Multiple and fetal perfusion. Ideally, but rarely in (in mls).17 studies have studied the utility of TXA in practice, the procedure should commence Flow cytometry is a superior the trauma setting; however, none have within 4 minutes of the arrest with alternative test for estimating the volume looked specifically at the use of TXA in delivery of the fetus one minute later.35,36 of FMH but it is rarely available in most pregnant trauma patients. The CRASH-2 There are reports in the literature showing hospitals.18,19 Evaluation for prelabor trial showed that TXA administration fetal survival even if delivered 30 minutes rupture of membranes (PROM) is done significantly decreased all-cause mortality after arrest.37 Procedural success can be by testing vaginal fluid for the presence due to trauma by 1.5% (14.5% in TXA optimized by contacting an obstetrician of ferning, higher pH (vaginal pH is group vs 16.0% in placebo group).27,28 and a neonatologist, as well as ensuring 5 vs amniotic fluid pH is 7), or for the Similarly, results from the retrospective that an incubator, pediatric crash cart, and presence of specific amniotic proteins MATTERS study showed that TXA surgical tools are available.38 such as IGFBP-1 and AFP.20 administration in a trauma setting was The first step in the procedure is to associated with reduction in unadjusted Medications perform a vertical incision through the mortality (TXA 17.4% vs No TXA 23.9%).29 skin of the abdominal wall, starting from Rho(D) immune globulin (anti-D The dose of TXA frequently used is 1 g the pubic symphysis and extending to IgG, Rhogam) infused over 10 minutes, followed by an the xiphoid process. The subcutaneous It is recommended that anti-D IgG is infusion of 1 g over eight hours. tissue is bluntly dissected to expose the administered within 72 hours to all Rh peritoneum, which is then cut. The uterus (-) pregnant trauma patients at risk of Complications Specific should be delivered anteriorly in order FMH.21 The standard dose of 300 mcg to Trauma in Pregnancy to improve visualization. Generally, the administered intramuscularly is effective Placental abruption is the second uterine incision should be performed on at preventing alloimmunization to 30 mL highest cause of perinatal mortality from 6 the inferior aspect of the uterus owing to of fetal blood. The need for additional trauma. The diagnosis is often made the usual superior location of the placenta. doses of anti-D IgG is determined by the clinically with cardiotocographic fetal 30,31 However, if the location of the placenta is results of KB testing or less frequently monitoring. Because 40% of abruption already known, then the incision should flow cytometry.22 hemorrhages are retroperitoneal, computed tomography (CT) imaging be performed opposite to that location. Corticosteroids is more sensitive for diagnosis than If the placenta is located anteriorly, then For imminent delivery of a viable fetus ultrasonography.32 Uterine rupture it should be cut through in order prevent between 24- and 34-weeks gestational is another dangerous complication of delay in delivery. After delivering the fetus, age, corticosteroids (e.g. betamethasone trauma, with a fetal mortality rate of the cord is clamped and cut immediately, or dexamethasone) given over a period almost 100%.25 If present, examination and the fetus is transferred to an assistant of 24 hours before birth or even in single may reveal an irregularly shaped uterus, for resuscitation. The placenta should doses has been shown to reduce overall palpable fetal parts, or abdominal be delivered manually, followed by 23 neonatal morbidity and mortality. tenderness. Prompt laparotomy with fetal packing of the uterus. If there is return of Tocolytics delivery and either hysterectomy or uterine spontaneous circulation, uterine massage The role of tocolytics in pregnant repair is the treatment of choice. Amniotic and oxytocin administration may be trauma patients is widely controversial. fluid embolism (AFE) presents with necessary to prevent atony. Oxytocin Their use might be valuable when sudden hypoxemia and cardiovascular should be infused slowly in order to delaying delivery is vital for administering collapse and can progress to DIC and prevent hypotension.39 important medications such as multi-organ failure. The mechanism of Conclusion 24 magnesium sulfate or corticosteroids. AFE is hypothesized to be amniotic fluid Management of traumatic injuries Tocolytics that have beta adrenergic entering the maternal circulation and in pregnant patients requires careful activity (e.g. terbutaline) should be leading to either vascular obstruction evaluation with an understanding of the avoided in the trauma setting as they may or anaphylaxis. Treatment is supportive alterations in anatomy and physiology 25 cause tachycardia and/or hypotension. with resuscitation and potential delivery that occur during pregnancy. Standard 33 Tranexamic Acid of the fetus. The risk of preterm labor, evaluation of pregnant patients proceeds In the setting of pregnancy, preterm premature rupture of membranes in the usual fashion as for non-pregnant tranexamic acid (TXA) has been used to (PPROM), or PROM is significantly higher patient with primary attention to the prevent complications from postpartum after traumatic injury and may not present A-B-Cs of trauma care. Interpretation of 34 hemorrhage. Results of the World immediately after the injury. vital signs and lab tests may be different Maternal Antifibrinolytic (WOMAN) Perimortem Cesarean Section for the pregnant patient. To optimize trial demonstrated that the use of TXA in Perimortem cesarean delivery is the potential for good outcomes for the postpartum hemorrhage resulted in lower considered a life-saving procedure for both mother and the fetus, resuscitation of the reported outcomes of death (TXA 1.5% the mother and the fetus as it alleviates the mother takes priority. ¬

References available online August/September 2020 | EM Resident 11 OB/GYN, NEUROLOGY Preeclampsia Complicated by a Cerebrovascular Accident Posterior Reversible Encephalopathy Syndrome, or Reversible Cerebral Vasoconstrictive Syndrome?

Nicholas A. Gonzalez, Jr., MD (2pt) is given. The abdomen is gravid to FIGURE 2. CTA Head University of Connecticut School of Medicine the subxiphoid process. One plus pitting Michael Light, MD edema in bilateral lower extremities is University of Connecticut School of Medicine noted without calf tenderness. Kevin A. O’Toole, MD The patient is given hydralazine Faculty Physician in Emergency Medicine 10mg intravenously (IV) times three Medical Toxicologist Hartford Hospital and magnesium sulfate IV for the University of Connecticut School of Medicine presumptive diagnosis of preeclampsia 38-year-old G1P0 right-hand with severe features and blood pressure dominant female at 34 weeks and improves to 164/94 with no change in A3 days gestation with a history neurological status. The patient was taken to the OR for of hyperlipidemia presents to the ED at 7:15 pm as a “Stroke Alert” for expressive an emergent cesarian section secondary aphasia since 2 pm while eating dinner to a non-reassuring fetal heart rate. with family. Family describes it as Post-operatively, the patient was taken “word salad.” In addition, the patient to the CT suite for the CT of the head CTA Head Impression complained of a left-sided headache without IV contrast in addition to a CT 1. Moderate to severe diffuse narrowing shortly after the aphasia and dysarthria Angiogram (CTA) of the head and neck of the M2 segment of the left middle started. No history of hypertension, with intravenous contrast. cerebral artery with diminished cardiac disease, diabetes, or pregnancy FIGURE 1. CT Head contrast opacification of the distal complications. The patient is being cortical branches relative to the managed by Maternal-Fetal Medicine contralateral side. Overall, the (MFM) given her advanced maternal significant vascular abnormalities on age. The patient only takes prenatal this study are most suspicious for an vitamins. No alcohol, tobacco, drug use underlying process such as reversible during pregnancy. cerebral vasoconstriction syndrome. On the patient’s arrival to the 2. Moderate irregular narrowing of the emergency department, Neurology and vertebrobasilar circulation which is Obstetrics are at bedside evaluating the most pronounced in the left posterior patient given she presents as a “Stroke cerebral artery. Alert” in the third trimester. The patient Discussion is found to be hypertensive to 220/115 Preeclampsia is a life-threatening with a heart rate of 80 on arrival to obstetric condition on a spectrum of the ED. On physical exam, the patient hypertensive disorders in pregnancy. is well appearing. She has profound Preeclampsia with severe features expressive aphasia and dysarthria presents with signs of end-organ with an inability to follow commands. damage — which includes cerebral insult. No other neurological deficits noted CT Head Impression Posterior Reversible Encephalopathy (5/5 strength, no limb ataxia). NIH 1. Focus of hypoattenuation in the left Syndrome (PRES) and Reversible stroke scale (NIHSS) of 4 for level of temporo-occipital lobe which is better Cerebral Vasoconstrictive Syndrome consciousness (2pt) and best language visualized on the CTA head/neck. (RCVS) are considered to be two rare

12 EMRA | emra.org • emresident.org AIRWAY complications of preeclampsia. This level between 4.8 to 8.4 for 24hrs hyperperfusion, breakdown of the blood discussion highlights preeclampsia and postpartum — and delivery if emergent. brain barrier and the extravasation of fluid these two rare complications as well as Reversible Posterior and blood products into parenchyma. the clinical and radiological difficulty in Leukoencephalopathy Syndrome Cerebral ischemia can in turn occur due diagnosing these two conditions. After A clinical radiographic syndrome to focal vasoconstriction/vasospasm and reviewing these conditions, you — the of heterogenous etiologies that are hypoperfusion and resultant cytotoxic reader — will have the opportunity to grouped together because of similar edema OR hydrostatic vasogenic edema and decide if the patient suffered from a findings on neuroimaging studies – microcirculatory compression. This edema cerebrovascular accident, PRES, or RCVS. Posterior Reversible Encephalopathy can increase cerebral perfusion pressure. Preeclampsia Syndrome (PRES), Reversible Posterior Preeclampsia and cytotoxic therapies Preeclampsia is a hypertensive Cerebral Edema Syndrome, Posterior may lead to capillary leakage and disorder of pregnancy diagnosed after Leukoencephalopathy Syndrome, blood brain barrier disruption, axonal 20 weeks of gestation and up to 4 weeks Hyperperfusion Encephalopathy, or swelling, and trigger vasogenic edema. In postpartum. It is theorized to be caused by Brain Capillary Leak Syndrome. Despite preeclampsia, secretion of trophoblastic maternal and fetal vascular dysfunction. the name, the syndrome is not always cytotoxic factors from poorly perfused fetal Diagnosis is by an elevated blood pressure reversible and it is not confined to either unit may provide an initial stimulus and greater than 140 systolic and/or greater the white matter or posterior regions of result in elevated markers of endothelial than 90 diastolic OR proteinuria greater the brain — though it is unclear why there damage. Some even suggest that RPLS than 0.3g in 24 hours. is primary involvement of posterior brain could be considered an indicator of Risk factors include advanced regions. eclampsia — even when the other features maternal age, chronic kidney disease, twin The syndrome is most commonly of eclampsia (hypertension, proteinuria) gestation, antiphospholipid antibodies, seen in hypertensive encephalopathy, are not present. first pregnancy, past medical history or eclampsia, and with the use of cytotoxic Diagnosis is by neuroimaging family history of preeclampsia, BMI >26.1, and immunosuppressant drugs (cisplatin, with symmetrical (subcortical) white or a nulliparous state. cyclosporine). It is also noted to be most matter edema in the posterior cerebral Clinical features of preeclampsia common in women and all age groups hemispheres — particularly the parieto- include headache, visual changes, are susceptible. Other conditions noted occipital regions — and it is usually not epigastric/RUQ pain, elevated blood to be associated with RPLS include AKI, confined to a single vascular territory. pressure, peripheral edema, pulmonary CKD, Sepsis, MultiOrgan Dysfunction, RPLS can be picked up on CT, but it is best edema, altered mental status, and lab autoimmune diseases, and organ depicted by MRI. CTA and MRA studies abnormalities (acute kidney injury (AKI), transplantation. have documented irregular vascular AST/ALT elevation, Uric acid elevation, RPLS is characterized by an insidious narrowing in medium to large-sized and proteinuria). onset of constant, nonlocalized headache vessels in some groups. Resolution of Preeclampsia is managed with unrelieved by analgesia, confusion or neuroimaging findings is expected within blood pressure maintenance with decreased level of consciousness, visual days to weeks — suggesting edema rather antihypertensives such as labetalol, changes, and seizures associated with the than infarction. hydralazine, nifedipine, or methyldopa. To posterior cerebral white matter edema Blood pressure should be lowered prevent the progression of preeclampsia seen on neuroimaging. within two to six hours with easily to eclampsia (above findings + seizures), The pathogenesis is unclear, but it titratable parenteral agents like seizure prophylaxis is achieved through is thought that sudden blood pressure nicardipine or labetalol — with the magnesium sulfate with an initial 4 gram elevation causes cerebral autoregulation maximum initial fall not exceeding twenty- loading dose IV followed by a 2 gram per to exceed the upper limit and the five percent of presenting value. Most hour IV infusion to maintain magnesium arterioles dilate resulting in cerebral seizures should be treated with phenytoin — except in the setting of eclampsia where TABLE 1. Pertinent Laboratory Findings treatment with magnesium and delivery of Lab Result Comment the baby and placenta are sufficient. WBC 14.3 Prognosis in most case series and Hemoglobin/Hematocrit 16.1/46.1 HIGH Platelets 171 reports suggest that RPLS is fully reversible Creatinine 1.0 HIGH (<0.8 in pregnancy) within a period of days to weeks and Magnesium 2.1 radiologic improvement lags behind clinical Bilirubin Direct/Total <0.2/0.2 recovery. Rarely do patients survive with AST/ALT 60/49 permanent neurologic disability. Alkaline Phosphatase 147 Reversible Cerebral Uric Acid 7.8 HIGH Vasoconstriction Syndrome LDH 388 HIGH Also known as Call-Fleming Random Protein:Creatinine Ratio 5.87 HIGH Syndrome, Postpartum cerebral

August/September 2020 | EM Resident 13 OB/GYN, NEUROLOGY

angiopathy, and CNS pseudovasculitis; Routine blood tests, inflammatory patient’s creatinine and hemoglobin and Reversible Cerebral Vasoconstrictive markers, and cerebrospinal fluid analysis hematocrit improved over the days while Syndrome (RCVS) is a rare condition are typically normal in RCVS. CTA and maintaining excellent urinary output. that occurs as the result of a sudden, MRA can identify seventy percent of cases Patient improved rapidly to where transient, diffuse dysregulatory by revealing diffuse reversible cerebral she felt she was back at baseline and was constriction of intracranial vessels vasoconstriction that appear as “string discharged home without home services producing the main feature of recurrent of beads” on angiography with complete on aspirin 81 mg, labetalol 100 mg twice sudden, severe, and disabling headaches resolution within 1-3 months. Initial MRI daily, and Procardia XL 90 mg daily. that are characterized as “thunderclap”. is normal during the first week in 30- Patient was scheduled for neurology Other symptoms associated with 70% of cases; 10% of patients have MRI follow-up. RCVS include vomiting, photophobia, abnormalities consistent with PRES. Conclusion phonophobia, visual changes, Currently, there is no approved Given the history and hospitalization hemiplegia, ataxia, dysarthria, aphasia, treatment. Verapamil, nimodipine, and course that this young primigravida and seizures. other calcium channel blockers may female endured, it is quite possible these Some risk factors proposed to cause help reduce the intensity and frequency 3 processes are not independent and these multifocal arterial vasoconstriction of the headaches. Triptans and ergot exclusive, but in fact a continuum of and dilations include preeclampsia and derivatives are contraindication as they related processes. Our patient possibly eclampsia, childbirth, hypercalcemia, have vasoconstrictive actions. experienced preeclampsia while at home vasogenic tumors, prescription and over Prognosis is usually full recovery in that progressed to reversible cerebral the counter medications, and illicit drugs most patients to permanent brain damage vasoconstriction syndrome and PRES. that cause vasoconstriction. in others. All symptoms normally resolve The imaging performed as part of the RCVS is most commonly found within 3 months and may only last a few broader work-up seem to reveal findings among women between the ages of 20 days. of both RCVS and PRES. We know these and 50 and is underdiagnosed because Case Conclusion 2 conditions are likely associated with it mimics common conditions like A viable, 1660 g female infant was one another and are also associated with migraines. PRES has a very similar delivered with reassuring APGAR scores preeclampsia. Re-imaging and follow-up presentation and is found in 10-38% of and transferred to the neonatal intensive are necessary in order to establish the RCVS patients. care unit, where she did very well. The final diagnosis. ¬ Because someone always takes it one step too far. You’re there for them, we’re here for you.

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14 EMRA | emra.org • emresident.org PEDIATRICS, ORTHOPEDICS CERVICAL SPINE INJURIES in the Pediatric Population Nicholas Kos University of Illinois College of Medicine Class of 2021 Myrna Aboudiab University of Illinois College of Medicine Class of 2021 Zaza Atanelov, MD, MPH North Florida Regional Medical Center @Zatanelov Amber Hathcock, MD Assistant Professor of Clinical Emergency Medicine University of Illinois College of Medicine Case Presentation ase 1. A 6-year-old girl is brought in via EMS to your level C1 Trauma as a bicycle vs. car. It is approximated the car was traveling approximately 25 mph. During your initial examination: the patient is crying, equal and bilateral breath sounds, tachypneic and tachycardic with a GCS of 15. She is in a cervical collar and after exposing her you appreciate left shoulder, back, and left leg abrasions. Upon log- roll, it is difficult to appreciate if the patient is having any cervical/thoracic or lumbar spine tenderness as she is intermittently crying, but no step offs are appreciated. What would be your next step? Would you image her C-spine? If so, what type of imaging would you get? Can you apply the same clinical tools for cervical spine injury imaging in adults to pediatric patients? Case 2. A 2-year-old boy is brought in by mom after her car was rear-ended by another car going 30 mph while she Background acceleration-deceleration forces, or a 3 was parked and breastfeeding him in the Cervical spine injuries (CSIs) are clotheslining force. Depending on the back seat. Mom states the patient has not fortunately very rare in the pediatric patient’s age group, certain mechanisms wanted to move his neck and has been population. Of all pediatric patients of injuries are noted to be more common breathing “funny.” Prior to the exam, the admitted for blunt injuries, only 1.3% than in others. MVC and falls are most common in children less than 2 years child was placed in a C-collar due to high are diagnosed with a CSI.1 However, old; MVC, falls, and pedestrians struck by suspicion of C-spine injury (CSI). During when examining pediatric spinal injuries the exam, the patient does not speak to motor vehicle in children 2 to 7 years old; overall, CSIs account for the majority, you, has irregular breathing, tachycardic, and sports injuries and MVC in children occurring in 60-80%.2 avoiding moving his neck, and has 8 to 15 years old.4 In a cohort of 540 minimal movement of his extremities. The Mechanisms of Injury children with CSIs, 1% had injuries due patient was immediately intubated. What The most common mechanisms to assault, of which half were attributed is your next step? Do you go straight to CT of injury include motor vehicle to child abuse.4 Although non-accidental or MRI as you are worried about a CSI? collisions (MVC), falls, diving accidents, trauma appears to be a rare cause of

August/September 2020 | EM Resident 15 PEDIATRICS, ORTHOPEDICS

CSIs, clinicians must be vigilant in their exam involving palpation of the neck were asymptomatic at presentation assessment of a patient, looking for other and cervical spine, focused neurologic although their mechanism of injury was locations of questionable injuries and examination, and history-taking can high-risk.7 Patients with a concerning reporting any suspicions that a CSI was occur. This process may be challenging history or any of these presentations on non-accidental. with younger patients or those who are the exam require continued cervical spine Common Sites of Injury unable to fully provide a history and immobilization and further evaluation. cooperate with the examination. For The probable location of a CSI can Clinical Tools these patients, it’s prudent to understand vary among age groups. Injuries to the Unfortunately, clinical decision tools the mechanism of injury to determine axial region (C1-C3) were seen in 74% of such as the Canadian C-Spine Rule and whether a CSI may be present and utilize CSIs in children less than 2 years old and the Nexus criteria have not been well this information for further management. 78% of CSIs in children 2 to 7 years old.4 validated in the pediatric population. The In children 8 to 15 years old, however, Examination Canadian C-Spine study has not been subaxial injuries were more prevalent, In patients with suspected CSIs, validated for pediatric patients since it accounting for 53% of CSIs.4 In the the examination should focus on did not include patients under the age same cohort of 540 children mentioned vital signs, neck examination, and of 16.9 In contrast, the NEXUS (Table 1) previously, only 1% had dislocations neurologic evaluation. Upper CSIs study contained 3,065 patients under the at more than one cervical level and 3% may result in patients with arrested age of 18 years. However, only 30 of these had fractures of more than one cervical respiration, hypotension, or altered patients were found to have CSIs. Almost vertebra.4 mental status, and injuries to C3-C5 all of the injured patients were older may result in apnea or hypoventilation patients, with just four patients being Anatomy and Physiology of 6 due to loss of diaphragmatic control. under the age of 9 and no patients under Pediatric Patients with Suspected Upon neck examination, CSIs present the age of 2.10 One study demonstrated CSI more commonly as midline cervical that the NEXUS criteria has a 100% Children’s anatomic development tenderness, though a triad of neck sensitivity and a 19.9% specificity for increases their susceptibility to CSI. symptoms including cervical pain, muscle diagnosing cranial spine injuries in Compared to adults, children have larger spasm, and decreased range of motion pediatric patients aged 9-17 years old.11 heads relative to their bodies, their spinal should prompt suspicion for a CSI.7 If Despite this study, the NEXUS criteria column is more elastic, and their cervical there is midline tenderness to palpation, should only be used as an aid to the 5 spine muscles are weaker. Further, there ROM testing should be deferred, and overall clinical gestalt as it has yet to be is greater ligamentous laxity in their the patient should be re-immobilized validated as a tool in pediatric trauma. 5 spine. In addition, the atlas (C1) and in a C-collar. In combination with the Another study conducted in the axis (C2) have ossification centers that do initial assignment of the Glasgow Coma Pediatric Emergency Care Applied not complete fusion until up to 7 years of Scale score, the neurologic examination Research Network (PECARN) compared 5 age. This may explain why children are must evaluate the patient’s tone, pediatric patients from the ages of 0 to 2.5x more likely to sustain atlantoaxial strength, sensation, and reflexes, since 15 years with CSIs to control patients. 5 injuries than adults. This not only places approximately 53% of children with The study determined that there were 8 children at increased risk for CSI, but cervical cord injuries have neurologic findings, as illustrated in Table 2, that 8 also can make interpreting imaging more deficits. However, pediatric patients could be used to recommend imaging difficult for clinicians. Ossification centers who are asymptomatic or are able to and detect CSIs. The findings listed in can appear widely different between walk should not have a CSI ruled out if the study had a 98% sensitivity and 26% patients, leaving room for the possibility the mechanism of injury suggests the specificity.6 Unfortunately, these risk of misdiagnosing fusion lines as vertebral possibility of one. Among children with factors have yet to be fully validated. 5 fractures. Despite all these inherent risk diagnosed CSIs, a study found that 18% Therefore, we are currently limited factors, the incidence of CSIs is still low to only using the NEXUS criteria and in children. However, there should be TABLE 1. NEXUS Criteria for Imaging PECARN findings as clinical assessment increased suspicion of CSI in multisystem of Patients with CSI guides along with our clinical gestalt in trauma and patients with a head injury. Imaging deciding C-spine imaging. Work-Up NEXUS Criteria Recommended Imaging One should first immobilize the Midline cervical Yes Once the patient warrants further neck based on suspicion of CSI and spine tenderness evaluation to rule out a CSI, an imaging then follow the guidelines established Focal neurologic Yes modality must be chosen. With increasing by the Advanced Trauma Life Support deficit awareness of the impact of radiation, beginning with the primary assessment Not alert or Yes medical costs, and practicality, the and management (ie, ABCDEs). Once the intoxicated decision for one form of imaging over patient has been stabilized during the the other depends on the patient’s Distracting injury Yes primary evaluation, then the secondary circumstances. For most pediatric

16 EMRA | emra.org • emresident.org TABLE 2. PECARN Findings for Imaging of Patients with CSI thoracic fractures and dislocations.19 For Imaging those with no neurologic deficits and NEXUS Criteria Recommended minor spinal fracture patterns on imaging, outpatient management may be possible Neck pain Yes with analgesics and follow-up care being Decreased neck ROM Yes the main components of the plan.20 Torticollis Yes Case Resolutions Altered mental status (intoxication or trauma) Yes Case 1 Focal neurologic deficit Yes Utilizing clinical gestalt, NEXUS, and the unvalidated PECARN criteria Substantial co-existing injury Yes you decide she is at high risk for Conditions predisposing to cervical injury (Down Syndrome, Yes sustaining CSI (MVC vs Bicycle) and Ehlers-Danlos, cervical arthritis) get a cervical spine x-ray series, which High-risk mechanism (diving, MVC, clotheslining injury) Yes were inadequate, so you get a CT which was normal. You perform a thorough patients with a normal mental status pediatric population, in terms of radiation neurologic exam which is negative for and benign mechanism of injury, plain exposure. CT delivers a 50% higher mean signs of neurologic deficits with no pain cervical spine radiographs are reasonable radiation dose relative to conventional or impinged range of motion, so you to exclude significant CSIs with 2-3 views radiography.17 clear the spine and take off the C-collar (anteroposterior, lateral ± open-mouth Magnetic resonance imaging (MRI) and discharge the patient home with odontoid views) being standard. The use has slowly become the imaging modality instructions to follow up with her PCP of a cross-table lateral view radiograph of choice, sometimes even before and return precautions if she begins to provides a 79% sensitivity; the addition plain radiography and CT. However, have any neurologic symptoms. of the AP and odontoid views increases the current practice guidelines still Case 2 7 sensitivity to 94%. However, the biggest recommend plain radiographs and CT Due to clinical findings and pitfall in using plain radiographs is imaging prior to the use of MRI. MRI can history you promptly order a CT, call obtaining a series that adequately be exceptionally useful for patients that neurosurgery, and admit to the trauma evaluates the cervical spine. Complete have neurologic dysfunction but normal service ensuring that everyone on your evaluation of the cervical spine requires plain radiograph and CT imaging, also team knows there must be strict C-spine that all seven vertebrae, including the C7/ known as SCIWORA (Spinal Cord Injury precautions and continued C-collar 18 T1 junction, be visualized. Furthermore, without Radiographic Abnormality). use. ¬ interpreting cervical spine radiographs This is mainly due to the fact that MRI is can be quite challenging, especially significantly more sensitive in visualizing since normal anatomic variants of soft tissues, intervertebral disk herniation, TAKE-HOME POINTS children, such as ligamentous laxity and ligamentous injuries, and spinal cord l C-spine injuries are rare in incomplete ossification of the posterior damage. Unfortunately, limited access, children elements, must be distinguished from cost, time to obtain the study, and the l Children less than 8 years old: 12 possible need for sedation in younger pathological findings. C2-C3 injuries; children greater children prevent the use of MRI from Therefore, CT should be utilized than 8 years old: C5-C6 injuries being readily utilized. Despite these if inadequate plain radiographs were l Use physical exam to initially obtained, there were suspicious findings challenges, the benefits outweigh the risks clear a patient but do not on plain radiograph, the patient has when it comes to diagnosing CSIs. hesitate to obtain imaging a GCS less than 9, and with patients Disposition l If imaging is needed start with with a mechanism of injury and/ With regard to the treatment options plain films or physical exam findings that are for these patients, it depends on the l suspicious for CSI.13,14 The sensitivity and fracture stability and concomitant injuries CT in cases of high suspicion specificity of CT for detecting cervical of the patients. For all children with of CSI in the context of spine osseous injury is about 98%.15,16 neurologic abnormalities or possible CSIs, negative or inadequate plain In making the decision to utilize CT it is best to consult neurosurgery/spine films or high-risk mechanism imaging, the recommended study of service. If unavailable, immediate transfer l Can consider limited CT to choice is multidetector CT with sagittal to a center with these services should be C3 in younger children and coronal reconstructions. You can arranged. The treatment for children with (3-8 years old) also consider a limited CT up to C3 in unstable cervical fractures utilizes closed l MRI if pain or neurological patients less than 8 years old. However, reduction under fluoroscopic guidance deficits persist despite normal when deciding to utilize CT one must and halo-vest immobilization, which can CT to assess for SCIWORA. be aware of the risks, specifically to the be applied for cervical and even upper

References available online August/September 2020 | EM Resident 17 PULMONARY, TOXICOLOGY DANK VAPES A Tale of a Pediatric E-cigarette Vaping Associated Lung Injury

Kellan Etter (Figure 1), and a chest CT showed EMRA Pediatric EM Committee Vice Chair extensive ground glass alveolar opacities Des Moines University (Figure 2). The patient was started on Class of 2021 @kellanetter22 supplemental oxygen and admitted. Brian Kelley Des Moines University Scott Sutton, MD Clinical Fellow, Department of Emergency Medicine, Pediatric Emergency Medicine University of California, San Francisco 17-year-old male with a history of FIGURE 3. chronic abdominal pain presented Ato the emergency department with 2 weeks of worsening abdominal pain and diarrhea. His CT scan showed FIGURE 2. Extensive Interstitial and possible early appendicitis and incidental More Notably Alveolar Ground Glass findings of bibasilar ground glass Opacities in a Patchy Distribution in opacities in the lungs. Stool studies were Both Lungs on Chest CT positive for Clostridium difficile (C.diff) and enteropathogenic Escherichia coli Vaping: An Epidemic in Teens (EPEC), and laboratory work-up revealed In the time before COVID-19, elevated inflammatory markers and electronic cigarette use, or “vaping,” FIGURE 4. leukocytosis. He had no respiratory occupied the airwaves as an emerging complaints and had normal saturations public health concern, particularly within In the more recent years, there has on room air. He was diagnosed with pediatric and adolescent populations. been an up-trend of vaping product colitis and discharged home on oral Considered to be an alternative to purchases within the adolescent metronidazole. Two days later, the patient traditional cigarettes and marijuana population, as vaping use rose up to returned to the ED with worsening smoking, vaping is a smoking method nearly 8% (approximately 1.3 million abdominal pain and fever. He had oxygen that involves heating a liquid so that teenagers) between 2017-2019. Not saturations of 91% on room air and a it aerosolizes and can be subsequently only do weaker FDA regulations on respiratory rate of 28. A chest x-ray inhaled. The liquid itself contains e-cigarette and vaping devices contribute showed diffuse interstitial lung markings various different toxins, including highly to these findings,5 social media, too, is concentrated amounts of nicotine, another influential factor.6-10 One study cannabis-derived extract, propylene glycol, found that > 78% of middle and high- vegetable glycerin, acrolein, formaldehyde, school aged students were exposed to at ethanol, and menthol which provides least one vaping advertisement.11 Other flavoring.2-4 Vaping can be performed studies revealed that flavor is one of the through a variety of devices, all of which most appealing qualities of vapine, and are made differently depending on the therefore producers have created an users needs. For example, there are newer assortment of eye-catching vaping devices generation types of products such as the that offer fruit and candy flavors.12-13 “Mod” (Figure 3), or JUUL (Figure 4), Addiction with vaping occurs much both of which are longer lasting, are faster than combustible cigarettes; reusable, and have the potential to deliver while addiction occurs with the daily FIGURE 1. Diffuse Interstitial Lung higher amounts of nicotine than earlier consumption of four to five traditional Markings in Both Lungs on Chest x-ray generation devices. cigarettes, this is equivalent to only a

18 EMRA | emra.org • emresident.org quarter of the amount within a JUUL patient encounters, EM physicians with Back to Our Patient 14 pod. Contributing to the dependency on heightened suspicion can expand their While recent reports show that 77% of these products is the higher concentration differential and start treatment before patients with EVALI have gastrointestinal of nicotine found in vaping devices respiratory decompensation occurs. symptoms, as was experienced by our compared to traditional nicotine products. Identifying presentations and creating patient, it is rare for these to be present A recent study by University of California, guidelines for the evaluation and care without concomitant respiratory San Francisco found that blood nicotine of pediatric and adolescent patients is symptoms.17 concentrations in the JUUL group was 5.2 necessary to reduce the morbidity and Our patient’s GI symptoms and 15 times higher than traditional cigarettes. mortality that has been associated with respiratory distress worsened early on in Therefore, it is critical to recognize the vaping. As of December 2019, there have his course, leading to a temporary stay in risk factors, histories, and presentations been over 2,000 hospitalized EVALI cases the pediatric intensive care unit (PICU) of patients to treat E-cigarette or Vaping and 48 deaths reported, highlighting the where he needed additional respiratory Associated Lung Injury (EVALI) to avoid significance of its rise to prominence as support in the form of bilevel positive long term health complications. EVALI was only first described in 2019.15 airway pressure (BIPAP). His antibiotics E-Cigarette or Vaping With the recent rise in the number of were broadened for empiric treatment of Use-Associated Lung Injury cases, much has been done to develop other potential intra-abdominal pathology. (EVALI): A Diagnosis of Exclusion these guidelines; however, these do After obtaining a more extensive history, Despite EVALI becoming more not fully encompass the wide variety the patient admitted to a 2-year history of 18 prevalent in our society, our understanding of ED presentations with EVALI. In vaping. His product of choice was JUUL behind its underlying pathophysiology order to screen these patients, it may e-cigarettes, and he smoked approximately remains unclear. There are no specific be advisable to complete chest imaging one nicotine pod daily. He admitted to symptoms, imaging modalities, or markers (either x-ray or CT) in patients with non- smoking marijuana as well, but denied that directly lead to its diagnosis.16 specific presentations and significant smoking synthetic marijuana or using Although it is more common for EVALI vaping use. The exact pathogenesis and marijuana containing pods in e-cigarettes. to present with respiratory symptoms, progression of this new disease are still After these revelations, the patient was there have been case series showing that being researched and may allow for more subsequently started on high dose intra it can, too, manifest as gastrointestinal specific screening protocols as more venous methylprednisolone. Over the next and constitutional complaints. In one case information is uncovered. 48 hours, the patient improved clinically, study, patients identified with EVALI were Current treatment guidelines center and he was weaned off BIPAP to room air often white males with a median age of 21 on attempting to treat the overlying within 72 hours. He was discharged home who presented with shortness of breath pneumonia with antibiotics based on prednisolone and fluticasone propionate (85%) and cough (85%). Subjective fever on community-acquired pneumonia therapy and was counselled extensively (84%) and chills (60%) were also common guidelines, bacterial isolates, and clinical on the effects of vaping and lung related in these patients, as well as nausea (66%), suspicion. Additionally, starting systemic injuries, as well as the need for continued vomiting (61%), diarrhea (44%), and steroids has shown promise in inpatient pulmonology follow up. abdominal pain (34%). Patients were also treatment, but has yet to be adequately Conclusion 19 generally found to be tachycardic and, on studied in the outpatient setting. In While vaping has disappeared from lab studies, had increased inflammatory general, it is advisable to discharge the forefront of our collective minds in markers and a leukocytosis. It should be patients with EVALI to complete light of recent global pandemics, its place noted that 100% of patients in this study outpatient workup and management if: in and effect on pediatric populations is were found to have bilateral infiltrates on 1. O2 saturation >95% not going anywhere anytime soon. Vaping- chest CT, which, along with the patients’ 2. There is no respiratory distress induced lung injury is a new diagnosis that histories, aided the ED staff in deriving the 3. There are no comorbidities that has increased drastically in prevalence as diagnosis.17 compromise pulmonary reserve the popularity of electronic cigarettes, or Given EVALI’s non-specific 4. The patient has reliable access to care “vaping,” has grown at an incredible rate. presentations, it is critical to maintain with a 24-48 hr follow-up Many users are not aware of the harms this a high index of suspicion to ensure 5. The patient has strict return practice can do to the body, and furthering these cases are diagnosed early. This precautions knowledge about the consequences may be involves the emergency healthcare In addition, organizing plans to quit able to prevent disease. provider screening adolescents with and giving resources to help patients EM physicians should have a non-specific symptoms for EVALI. By overcome their dependence is extremely high index of suspicion for electronic assessing vaping history and risk factors important to prevent additional cigarette use in adolescents presenting including social and environmental progression of the disease. As this is a new with gastrointestinal symptoms with no factors, smoking history, drug use and developing disease, reporting cases to pertinent history, and it is imperative that history, and family stressors, such as local health departments for further study we continue to examine the syndrome as having divorced parents,11 during initial is also encouraged by the CDC. its prevalence rises. ¬

References available online August/September 2020 | EM Resident 19 INFECTIOUS DISEASE, TOXICOLOGY

Classical Treatments for a New Disease COVID-19 Management

Jayson Fernando, MD, MS narrow therapeutic index and increased In addition to their antibacterial Hackensack University Medical Center incidence of toxidromes globally from properties, macrolides (erythromycin, Jonathan Meadows, DO, MS, MPH, CPH COVID-19 treatments. clarithromycin, and azithromycin) also EMRA Toxicology Committee Current Proposed Treatments have immunomodulatory effects. They Michael Marlin, MD Given the global pandemic of the have been shown to have viral reduction Assistant Professor, efficacy in treatment of rhinovirus, Department of Emergency Medicine novel SARS-CoV-2, clinical trials are Medical Director, Medical Toxicology Services underway to elucidate an effective influenza, zika and ebola; azithromycin University of Mississippi Medical Center treatment. Several treatment options reduced influenza virus replication in 5 ou are working a shift when a for COVID-19 are being used in the ED vitro. A recent study illustrated that 34-year-old Caucasian woman and across hospitals, such as the low- treating COVID-19 patients with HCQ, presents to your ED with altered cost antimalarial drug CQ, its derivative along with azithromycin, for six days Y showed significant viral reduction mental status (AMS), hypotension HCQ, macrolides, antivirals, monoclonal and tachycardia. An emergent EKG antibodies (MABs), and convalescent via polymerase chain reaction (PCR) shows a sinus tachyarrhythmia at plasma (used first in the 1890s for nasopharyngeal swab; in comparison 6 119 beats/min with a prolonged QTc diphtheria). Countries across the globe with HCQ alone. The mechanism is interval 600 ms. Labs are significant for have begun clinical trials involving these currently not well understood however hypokalemia 2.1 mEq/L, and CT scan agents, including both CQ and HCQ.3 studies suggest it to be promising in of the brain shows no acute findings. CQ and HCQ are used as treatment treatment of COVID-19. Research is You find out the patient self-medicated and prophylaxis of malaria, but there being released daily with new data to be prophylactically with approximately are chloroquine resistant strains analyzed. 15 pills of hydroxychloroquine (HCQ) of malaria and HCQ is a less toxic Antiviral agents are being (7.5 g) in an attempt to prevent derivative.4 HCQ is also therapeutic considered. These include RNA- symptoms of COVID-19. Suddenly, the for several autoimmune diseases, dependent RNA polymerase inhibitor nurse calls you to the bedside, where the including systemic lupus erythematous, Remdesivir (RDV), neuraminidase patient’s cardiac monitor indicates a rheumatoid arthritis, Sjogren’s inhibitor Oseltamivir (OTV), and rate of 220 with polymorphic ventricular syndrome, and dermatomyositis. protease inhibitor Lopinavir (LPV). tachycardia; you’re contemplating The molecular mechanism of action RDV has recently been approved by torsades de pointes (Image 1). suggested by in vitro studies of CQ the FDA for treatment of COVID-19 as Case reports illustrate this and HCQ against COVID-19 occur at Emergency Use Authorization.7 RDV hypothetical. A female patient presented multiple steps in the viral pathway. resembles adenosine triphosphate to the ED with AMS and VTach after These drugs alter cellular entry and (ATP) and is used as a substrate for ingesting approximately 30 g of HCQ exit, alter intracellular pH, and induce viral RNA polymerase resulting in purchased online in an attempt to prevent endoplasmic reticulum stress, which termination of viral RNA production.8-9 COVID-19.1 A couple in their sixth decade retards the formation of essential OTV is also currently being investigated of life from Arizona presented to the ED viral proteins4. Both medications have as a treatment option as it is known to in critical condition after ingesting fish narrow therapeutic windows. There reduce viral shedding in respiratory tank cleaner that contained chloroquine are many factors that can alter drug secretions.10 LPV has shown to be a (CQ) phosphate in an attempt to prevent bioavailability such as the patient’s strong inhibitor of the protease enzyme COVID-19 symptoms.2 It is important for genome, metabolism, drug-drug present in SARS-CoV-1 which is a key emergency physicians to recognize the interactions, kidney function, and dose. enzyme for the viral life cycle.10

20 EMRA | emra.org • emresident.org Clinical Manifestations QTc Prolongation is published by the primary survey (airway, breathing, 14 CQ is rapidly absorbed from the American College of Cardiology. and circulation). Supportive care is GI tract and symptoms can present RDV has mild adverse effects critical to enhance survival. Current within 1-3 hours of ingestion. Common including nausea and vomiting. Patients recommendations for CQ/HCQ overdose, side effects at therapeutic CQ doses treated with RDV should have liver based on assessment of patient, include (500mg-2500mg per day) for malaria enzymes monitored as there have been the following main points. Diazepam prophylaxis and treatment are nausea, cases that suggest RDV-induced liver 2 mg/kg IV (or 0.5 mg/kg midazolam) vomiting, headache, and vision changes. injury. The most common adverse should be given over 30 minutes for Of particular concern is the development reactions (incidence at least 5%) for seizure and sedation. Diazepam has of hemolysis in G6PD-deficient patients the IL-6 inhibitor tocilizumab are been shown in porcine animal models to in particular11. Rarely at therapeutic upper respiratory tract infections, improve vitals and shorten QT duration 19 concentrations, hypoglycemia, nasopharyngitis, headache, hypertension, indicating cardioprotective effects. sensorineural deafness, and retinal increased ALT, and injection site Higher doses of diazepam has been 16 damage may be seen (bull’s eye retina; reactions. Convalescent plasma shown to reduce mortality in other animal models and one prospective, image 2). Symptoms at supratherapeutic transfusions have adverse risk factors multi-center, double-blind, placebo- levels can be lethal and can include such as transfusion related acute lung controlled study showed that low dose apnea, hypotension, and cardiovascular injury, transfusion associated circulatory 17 diazepam (0.5 mg/kg loading dose collapse. EKG abnormalities include QRS overload, and allergic/anaphylaxis. then 1 mg/kg infusion over 24 hrs) prolongation, atrioventricular block, ST-T Work Up did not affect serial ECGs in overdose depression, presence of U waves, and QT A thorough history and physical CQ patients.20-21 Early intubation and prolongation.11 Significant hypokalemia exam is especially essential in patients mechanical ventilation should be can be secondary to CQ-induced presenting with altered mental status to planned. Other medical intervention intracellular shifts and exacerbate verify history through bystanders, such include the following: epinephrine any direct chloroquine-induced QT as family, friends, EMS personnel, law 0.25 µg/kg/min IV targets vasodilation prolongation.12 enforcement, pharmacies, and available and myocardial depression; potassium HCQ overdose is relatively rare pill bottles. Diagnostics should begin repletion (if below 2 mEq/L) along and most of the current understanding with a basic metabolic panel evaluating with magnesium and calcium repletion; of toxicity and management of HCQ for emergent electrolyte abnormalities and activated charcoal 1 g/kg PO, for overdose comes from its related and an EKG. Specific drug concentrations gastrointestinal decontamination if compound, CQ.4 Observed side effects may help with diagnosis and directing ingestion occurred within one to two with routine HCQ dosing (400 mg) for treatment depending on the drug of hours of presentation.22-27 Consider malaria prophylaxis are similar to CQ.11 concern. All intentional overdoses sodium bicarbonate in the setting of The current literature demonstrates a should include an acetaminophen QRS prolongation.23 Always consult wide range of outcomes with varying concentration.18 Use the available with your local poison control center for doses of HCQ ingested, with death history, physical, and laboratory findings specific recommendations. The efficacy occurring with as little as 5 g and to narrow the differential as much as of currently recommended treatment survival after 20 g.12 Studies suggest possible. modalities may differ in patients affected that HCQ mortality is primarily due Clinical Management Pearls by COVID-19. Further research is needed to rapid cardiovascular collapse with Initial treatment for any potential to elucidate optimal treatment in this refractory hypotension and ventricular overdose should be focused on the patient population. ¬ arrhythmias.13 Several case reports also provide echocardiogram (using pulse TAKE-HOME POINTS doppler of the mitral inflow analyzing the • Multiple medications, MABs, and transfusion products are being used to treat E-wave to A-wave ratio) and magnetic COVID-19. resonance evidence of this restrictive • Recognize the toxidromes above. cardiomyopathy (image 3).14 • Assess and treat the patient. Acute oral overdoses of macrolides • Be aware of your available treatments at your institution, ranging from are usually not life-threatening and benzodiazepines to ECMO. comprise mainly of gastrointestinal • Main treatment is supportive care. • symptoms. Rarely, macrolides cause As of this publication, prepublished studies on HCQ are showing questionable 28 QT prolongation and torsades de mortality benefits, peer review is pending. • Clinical trials are underway, including with the World Health Organization, called pointes. The risk of macrolide-induced the Solidarity Trials.29 arrhythmias is increased when combined • Research is ongoing. Critique the literature using basic research skills, using with other drugs, cardiac disease, cardiac resources such as the ACEP EMBRS Webinars or the SAEM Research Learning channelopathies that prolong the QT Series.30-31 interval.15 A score for Drug Induced

References available online August/September 2020 | EM Resident 21 ORTHOPEDICS, SPORTS MEDICINE A RARE CASE Adolescent Joint Pain in the ED Tanner Miles, MD PGY-3, Emergency Medicine John Kiel, DO, MPH Assistant Professor Alexandra Mannix, MD Assistant Professor Assistant Residency Program Director Department of Emergency Medicine University of Florida College of Medicine — Jacksonville n 18-year-old male presented to the Emergency Department A(ED) with a chief complaint of left knee pain. The patient states the pain woke him from sleep and has been ongoing for several hours. He reports a past medical history of chronic left FIGURE 1. knee pain and psoriasis. His chronic knee pain has been waxing and waning able to be ranged passively from 0-110˚. for 6 months with moderate relief with No joint laxity was noted with anterior ibuprofen, acetaminophen, and topical drawer, posterior drawer, varus, or lidocaine. He has no prior surgeries, valgus stress. His gait exam was antalgic allergies, tobacco/alcohol/drug use, or and he avoided putting his full weight on recent sexual activity. He reports that his left knee. he participated in high school football Given the patient’s age, history, but did not sustain specific injuries to the and exam, the differential was broad. knee. On review of systems, he reports It included psoriatic arthritis, juvenile no trauma, recent injury, fevers, chills, idiopathic arthritis, gout, pseudogout, penile discharge, rash, or history of gout. septic arthritis, osteomyelitis, fracture, Initial vital signs were BP 140/72, meniscal injury, ligamentous injury, HR 72, RR 16, T 36.7, and SpO2 99% patellofemoral pain syndrome, and remained stable. Throughout the osteochondral defect, and Osgood- interview, he held his knee in a flexed Schlatter disease, among others. A CBC, FIGURE 2. position at approximately 30˚. On BMP, ESR, CRP, urinalysis, and x-ray were ordered. An arthrocentesis was exam, he was noted to have a moderate Discussion to large left knee effusion. The left knee performed. The blood and urine studies Osteochondral defect (OCD), was warm compared to the right. He were unremarkable. Synovial fluid historically referred to as Osteochondritis had generalized tenderness to palpation analysis (Table 1) was not consistent with Dissecans, was described by Dr. Franz to the knee. The active range of motion an infectious, or inflammatory etiology. König more than 125 years ago. It was limited due to pain. The knee was The x-rays (Figures 1 and 2) is an acquired subchondral lesion demonstrated a 9 mm free-floating characterized by osseous resorption, TABLE 1. Synovial Fluid Analysis osseous density without evidence of collapse, and sequestrum formation.4 Reference fracture and an irregularity of the Fluid Analysis Value Range OCD is a rare cause of joint pain with lateral articular aspect of the medial RBC count 15,000 ≤ 0/µL an incidence of 20 per 100,000 people.5 femoral condyle, which was concerning WBC count 1052 0-10/µL Patients aged 10-20 account for the Yellow N/A for osteochondral defect. The patient Fluid color majority of cases, although it may also Crystals None seen N/A reported significant pain relief after the be seen in adults. Incidence is 2-4 times Fluid neutrophils 26 0-5% aspiration of joint fluid. An ACE wrap was higher in males than in females. The most Fluid lymphocytes 71 28-96% applied to the knee, he was provided with common joint involved is the knee, with Fluid 3 N/A crutches, and made non-weight bearing the lateral aspect of the medial femoral macrophages until able to follow up in the orthopedic Fluid eosinophils 0 N/A clinic. continued on page 24

22 EMRA | emra.org • emresident.org PEDIATRICS, UROLOGY Dysuria and Progressive Abdominal Pain in a Male Pediatric Patient Carolina Vega, MD Chelsey Yurkovich, DO Jennifer Noble, MD, FAAP Pediatric Emergency Medicine Children’s Hospital of Michigan rachal abnormalities are a rare etiology of pediatric abdominal Upain, most commonly occurring secondary to infected urachal cysts or abscesses.1 We present the case of a 10-year-old male who presented with significant suprapubic abdominal pain who was found to have an infected urachal cyst. Case A 10-year-old previously healthy male presented to the pediatric emergency department (ED) with severe abdominal pain. The pain started four days prior and progressively worsened, discharge, testicular erythema, swelling, Given the concern for a new with pain greatest in the suprapubic or tenderness. abdominal mass, an abdominal and region. He developed significant The differential diagnosis considered pelvic computed tomography (CT) with dysuria, urinary frequency, and urgency included urinary tract infection, contrast was obtained. CT demonstrated over the last two days. Recent history intrabdominal mass, renal stone, post- a multi-lobular collection with peripheral was significant for a diagnosis of streptococcal glomerulonephritis, and enhancement anterior to the bladder that streptococcal pharyngitis two weeks appendicitis. Lab results revealed an measured 2.8 % 2.3 % 2.6 centimeters, prior, for which symptoms resolved elevated C-reactive protein 40.9 mg/L concerning for an infected urachal cyst. and antibiotics were not initiated. The (normal <5), mildly elevated white The patient was admitted to inpatient patient did not have a report of fever, blood cell count 11.4 k/mm3 (range pediatrics with urology consulting, and nausea, vomiting, diarrhea, urethral 4.1-10.1) with 78% neutrophils, and received intravenous ceftriaxone to treat discharge, or weight loss. The family mildly elevated platelets 469 k/mm3 the infection, and ketorolac for pain denied a history of trauma. (range 130-450). Rapid strep testing control. After 3 days, the patient was On arrival in the ED, he had a was positive. Comprehensive metabolic tolerating an oral diet with significantly temperature of 37.2° Celsius, blood improved abdominal discomfort and pressure 107/71, heart rate 104, panel, hemoglobin, lipase, and urinalysis was discharged with fourteen days of respiratory rate 20, and oxygen were unremarkable. Fecal occult blood cefixime to continue antibiotic coverage. saturation 99%. His exam was significant testing was negative, as were swabs for Urology obtained a follow-up voiding for moderate suprapubic tenderness. respiratory syncytial virus and influenza. cystourethrogram 6 days after discharge Obturator sign was negative, however Abdominal ultrasound was significant that was unremarkable, and planned for the patient experienced significant for a 3 cm non-compressible complex outpatient surgery following resolution of abdominal pain with a short vertical structure anterior to the bladder with the acute infection. jump. Bowel sounds were normal, echogenic and vascular structural and there was no distension, palpable components, and a small volume of free Discussion hepatosplenomegaly, costovertebral fluid in the lower abdomen. Chest x-ray Urachal remnants are residual angle tenderness, or rebound and renal ultrasound were done, with embryonic structures situated between tenderness. Genitourinary exam was no visualized masses or acute structural and sometimes connecting the bladder within normal limits, with no evidence of abnormalities. and the umbilicus. They occur due to

August/September 2020 | EM Resident 23 PEDIATRICS, UROLOGY

failed obliteration of the allantois, the is not received, patients can also present persistent urachus, and infection.8 structure that drains fetal urine from the with significant peritoneal signs and a Therefore, conservative management is bladder. This can result in a persistent clinical acute abdomen.7 recommended as the first line approach, patent urachus, urachal cyst, urachal Diagnosis of infected urachal cysts is with surgical intervention considered for sinus, or vesicourachal diverticulum.2-4 by clinical presentation in conjunction recurrent symptoms.3 In infants, urachi typically spontaneously with abdominal imaging. Imaging is most Conclusion involute by 6 months, however this commonly initially by ultrasound, and Urachal cysts are embryonic 1-3 is less common in older patients. confirmatory scans can include CT or remnants that can become symptomatic Incidence is relatively rare after infancy, magnetic resonance imaging when there secondary to infection, causing with asymptomatic and symptomatic is a high suspicion of urachal cyst and for suprapubic or umbilical abdominal 2,4,6 urachi detected by ultrasound in 1.6% of surgical management. pain. Conservative management pediatric patients and 0.063% of adult While surgical removal was previously should be highly considered in younger 2 patients. In patients presenting to the recommended for all cases due to concern patients and first-time presentations of ED with abdominal pain, the incidence for future malignancy and recurrent urachal remnants due to high rates of of symptomatic urachi is even lower, infection, in first time presentations spontaneous resolution. ¬ occurring in approximately 0.03% of there is now greater consideration of presentations secondary to infected conservative treatment with antibiotics TAKE-HOME POINTS urachal cysts and abscesses.1 and pain management. This is due to the ü Infected urachal cysts typically present Urachal cysts are typically high rate of spontaneous resolution, with with umbilical or suprapubic abdominal pain and can have associated fevers asymptomatic until infected, at which up to 80 percent of urachal remnants and dysuria. Not all cases have visible time they can present with fevers, resolving in infants less than 6 months umbilical abnormalities. 1,4-6 abdominal pain, and dysuria. Cases old, and up to 50 percent resolving in ü Diagnosis is by clinical exam and can present with umbilical erythema, childhood overall.3 Urachal malignancies diagnostic imaging, with ultrasound swelling, or drainage, though not all cause less than 0.4 percent of bladder being the most common first line imaging modality. cases result in visible abnormalities at cancers, and their occurrence has not 1,4-6 ü Given high rates of urachal remnant the umbilicus. On exam, tenderness been linked to resolved pediatric urachal resolution, conservative management 3 is often greatest at the umbilical or remnants. Additionally, postoperative should be considered for first time suprapubic area,5-7 and a mass may be complication rates can reach 14.7%, with presentations of infected urachal cysts, palpable at the site of maximal pain. Due surgical complications including bladder and the patients should follow with to infection progression when treatment leak or rupture, bladder diverticulum, urology in the outpatient clinic. Adolescent Joint Pain in the ED continued from page 22 condyle being the most common location. lesion. The physical exam should be for healing and the patient follows a Lesions can also be found in the ankle thorough as it can help rule out other gradual return to activity. Operative and elbow.4 potential etiologies.1 strategies include arthroscopy, chondral There are many hypotheses regarding ED workup should begin with X-rays. resurfacing, and osteochondral grafting.3,4 the etiology of OCD. They include Imaging of both knees should be Most athletes return to sports with varied inflammation, vascular deficiency, obtained as 25% of cases have degrees of success. spontaneous osteonecrosis, genetics, and bilateral involvement.3 Serum and Conclusion repetitive microtrauma. Currently, the synovial fluid evaluation should be Although OCD is a rare entity, most accepted of these is the microtrauma considered depending on the differential hypothesis. Many studies and case reports diagnosis. If imaging reveals concern for emergency physicians should consider have suggested that repetitive trauma, OCD, the knee should be immobilized, it in their differential for both traumatic frequently in the setting of athletic weight bearing and activity should be and atraumatic joint pain. The diagnosis activity, may be the cause.2 restricted, and the patient should be is made radiographically and is Patients may present in one of three instructed to follow-up with orthopedics. often missed by emergency medicine ways with pain during sports, pain with In the outpatient setting, MRI is used physicians and radiologists. These mechanical movement, or incidental to help stage the lesion and determine patients should be made non-weight findings in an asymptomatic individual. operative vs non-operative management. bearing, restricted from all activity, and The most common symptom is pain with Non-operative management strategies urgently referred to orthopedic surgery. weight-bearing which is present in up to include immobilization, restricted A missed diagnosis can progress to 80% of cases. A sudden increase in pain, weight-bearing, and activity restriction. chronic pain, mechanical symptoms, and or a joint effusion suggests an unstable Serial x-rays are obtained to assess early onset osteoarthritis.4 ¬

24 EMRA | emra.org • emresident.org References available online WELLNESS Learning to Take the Heat Michael J. Lauria, MD, NRP, FP-C Scott Weingart, MD University of New Mexico Hospital Professor of Emergency Medicine Flight Physician Chief, Division of Emergency Lifeguard Air Emergency Services Critical Care www.resusperformance.com Stony Brook Hospital

Anand Swaminathan, MD, MPH Christopher Hicks, MD, MEd Assistant Professor of Emergency Medicine Assistant Professor of Emergency Medicine St. Joseph's Regional Medical Center St. Michael's Hospital, University of Toronto

The Problem with Stress he job of an emergency physician is stressful.1 Multiple factors, such as unpredictable patient volume and acuity, fatigue, and Tlack of previous relationship with the patient, all play a part in the magnitude of this stress. In fact, managing critically ill or injured patients manifests characteristics of “crisis situations”: circumstances rife with uncertainty, clear and present danger to life, the need to take immediate action, and at least partial inability to control certain features of the situation.2 These situations, where patients’ lives are on the line, necessitate optimal performance. However, stress compromises our ability to perform at our very best by degrading important faculties. For example, one very well- documented effect is attentional narrowing. In the world of engineering psychology, this is referred to as “increased selectivity.”3 People have a tendency to lose global situational awareness and focus on particular tasks. Evidence demonstrates this can be a result of numerous stressors including noise, visual distractions, or time pressure.4,5 Under these circumstances, study participants have shown decreases in detection of objects in the peripheral vision.6 Furthermore, the problem is more than just a decrease in visual field or breadth of what an individual’s mind can attend to, it is also a failure to focus on the most appropriate information. As it turns out, we seem to focus on what we perceive to be the most important information7 (an adaptive cognitive triage mechanism of sorts), but this could be dangerous if the stimulus that grabs our attention is not the most critical to actually solving the clinical puzzle presented.8 Not surprisingly, the fewer pieces of information we have to process, the lower the cognitive load, and the lesser the tunnelling effect.9 This attentional narrowing is further complicated by increased perseveration: continuing or repeating a given action or plan that they have recently used or regularly apply. As stress increases and cognitive faculties deteriorate, people are more likely to continue trying the same unsuccessful solution despite clear evidence of its failure.10,11 Cognitive psychologists have suggested this aligns with current understanding of human behaviour: people tend to default to what is known or familiar in times of stress. Thus, in a problem-solving situation, the range of options is not only narrow, but we fail to explore other solutions even if the narrow range of options are failing.12,13 The result is a potentially dangerous enhanced effect of confirmation bias.14 Stress also decreases information processing and working memory.15,16,17 It affects both internal dialogue18 (keeping information at hand) and also causes increased distraction of attention.19 The compromise to working memory is more pronounced the more complex the task. Researchers have demonstrated marked effects on complex

August/September 2020 | EM Resident 25 WELLNESS

problem solving20 and decision problems Operations have adopted these concepts processes and technical skills during that involve special visualization for and incorporate them into training and resuscitation. In this phase of training it successful resolution.21 So, our ability to selection.36 should be made clear that deterioration perform clinically important cognitive tasks The general goals of incorporating in their faculties is normal; it is nearly (such as thinking about the underlying this paradigm into technical skills universal, it is a natural result of the pathological process) is inhibited, to an training and simulation are37,38: trainees’ psychological response, and it is extent, and takes more time. 1. To gain knowledge and familiarity no way a sign of weakness or inadequacy. These effects have specific implications with the stressful environment and This explanation sets realistic cognitive for emergency physicians. The dynamic each individual’s unique emotional and behavioral expectations of how nature of practice in the emergency response as well as its effects on trainees will respond to a medical department and levels of stress make it cognition emergency. Having realistic expectations, uniquely prone to these aforementioned 2. To develop and practice task-specific as it turns out, is crucial. Just by having cognitive sequelae, resulting in mistakes skills (including various psychological more reasonable expectations, people and medical error.22 While many skills), as well as decision making perform better under stress.38 authors discuss the complexities of faculties, to be performed under Another important part of this phase general diagnostic errors or medication stress is making it clear that providers aren’t errors,23,24,25 a few have identified 3. To build confidence in one’s helpless in the face of these hard-wired errors involved in common emergency capabilities stress responses. The belief that people procedures.26,27 For example, providers have the capacity to exert control over Structure and Content can lose situational awareness during their behavior is also critical. This endotracheal intubation. Cemalovic et of Stress Inoculation Training understanding of self-efficacy and al found that emergency physicians’ for Emergency Medicine maintenance of an internal locus of perception of time to intubation was Driskell and Johnson suggested control has been linked to improved significantly skewed. Providers believed some slight modifications to the initial performance in different domains.39,40 It they were actually much faster than they SIT training structure proposed by also allows you to predict potential areas were in reality. Possibly more concerning Meichenbaum. These adjustments of weakness and motivate individuals to was the fact that providers consistently made training adaptable to both a obtain the necessary skills to improve underestimated how often their patients broader domain of technical skills and their response under stress.41,42 desaturated during intubation attempts.28 preparation for performance in a stressful environment (as opposed to a therapeutic Skills Acquisition The Training Paradigm modality after a stressful incident). The The second phase of this training of Stress Inoculation general structure of this training was paradigm is, perhaps, the most important Stress Inoculation Training (SIT) is a divided into three phases35: phase. Many would argue that it is multifaceted type of cognitive-behavioral more important than the application 1. Information provision — This therapy that was originally designed to of stressful stimuli. Furthermore, it phase provides information on the help individuals cope with stress. It was should be emphasized that inadequate human stress response, conditions initially developed by psychologist Donald development of this phase, skipping participants should expect to Meichenbaum in the 1980s and has it entirely, or moving too quickly encounter, and other preparatory been employed to mitigate the sequelae to apply stressful stimuli can be information of stress in a variety of situations. The counterproductive.45,46 2. Skills acquisition — This is phase essence of SIT is that by exposing people Skills acquisition develops the host is designed to develop and refine to increasing levels of perceived stress, of technical and non-technical skills behavioral, technical, and cognitive they practice employing different coping needed to perform in the resuscitation skills skills and eventually develop increased environment under low or “no-stress” 3. Application and practice — This tolerance or immunity to a particular conditions. The goal is to learn and phase includes practicing skills under stimulus.29 develop constructive coping mechanisms conditions that approximate the This cognitive behavior therapy and to develop effective performance operational environment and that paradigm was adapted over time habits. The fundamental technical skills gradually attain the level of stress and applied to preparing individuals of emergency medical care must be expected to perform in high-stress, high-risk established in conjunction with various occupations. Organizations like NASA Information Provision cognitive and behavioral techniques. and the military, although not formally In the first phase, preparatory Trainees and experienced clinicians referring to it as SIT, have applied information is provided to trainees. can both be taught to develop various these concepts to improve performance They are taught about the physiological psychological tools to help manage stress. and reduce stress in their respective response to stress normally and how While teaching the knowledge and domains.30-35 In particular, various these natural physiological mechanisms technical skills needed to perform well organizations within the Special can interfere with the specific cognitive during medical emergencies has been

26 EMRA | emra.org • emresident.org well-developed by clinician educations of interventions required). Extrinsic it helps teams identify critical patient over the years, psychological skills stressors represent other elements not deterioration earlier than traditional instruction is somewhat novel. These directly linked to the simulated patient’s training53,54 and even improved cardiac skills have been developed in other clinical condition (e.g. noise in the arrest outcomes in one center.55 Finally, domains by performance psychologists room, poor lighting, malfunctioning it has the added benefit of identifying and have yielded significant benefits.43 equipment). Socio-evaluative stressors latent safety threats and opportunities for Some of these skills include breathing are both a natural extension of the process improvement.56,57 techniques, positive self-talk, mental simulation (i.e. peers and instructors The first two phases of SIT might be practice, and attention control watching and evaluating trainee conducted in a more traditional learning techniques.44 These psychological skills performance in real time) or artificially environment such as the classroom or can be taught and incorporated in a generated as part of the simulation (eg, simulation lab. However, once trainees domain specific fashion. For example, an intimidating consultant telling the move to the third phase of application trainees can be taught to perform trainee to “hurry up”). and practice, conducting training in situ structured visualization and mental What remains unclear, and difficult may be advantageous. This is because practice of emergency endotracheal to generalize, is when, how, and to what many distractions and stressful stimuli intubation as they are preparing their degree to increase these individual are specific to environment in which equipment for the procedure. stressful stimuli. In the absence of clear resuscitation occurs.35,37 Therefore, there Other authors have established evidence, it stands to reasons that these may be significant benefit to allowing several other important aspects of must be carefully titrated by skilled trainees to work through stressors and skills acquisition.35 Some of these clinician educators to the skill level and challenges that might be encountered in a include training decision-making skills education needs of individual trainees. real clinical environment.58.59,60 (e.g. institution specific airway algorithms Small increases in stimuli may push Conclusion novices to be overwhelmed while more or checklists), over-learning technical Clinician educators have worked senior trainees can be pushed with a high skills (e.g. central venous access, diligently and made significant advances degree of many stressful stimuli. laryngoscopy, or chest tube insertion), over the years in developing effective communication, and team training. Incorporating SIT into methods for providing residents with Although beyond the scope of this article, Existing Training Models the knowledge and technical skills each of these topics is important in its One of the most promising training needed to manage medical emergencies. own right and worth mentioning. techniques where SIT may be ideal for While knowledge and technical skills Application and Practice incorporation is in-situ simulation. This are certainly required to treat critically This phase is designed to take the type of simulation occurs in the actual ill patients, they may not be sufficient. psychological and technical skills learned clinical environment where people The unique stressors experienced in and rehearse them under increasingly work with the actual staff on duty at the emergency department may cause 49 stressful conditions. This allows trainees the time. Moving the simulation out untoward effects on cognition and skills to experience, in real-time simulation, the of the lab and into the real clinical performance. SIT offers a promising various performance challenges they will space has showed promise by better solution that can incorporate existing 50 face in a specific (OR, ED, or prehospital) retention of clinical concepts and medical education modalities into 51,52 setting. It also reduces uncertainty and enhanced team performance. It an accepted cognitive and behavioral anxiety as well as increases confidence has even demonstrated evidence that training framework. ¬ when individuals realize that they can overcome stressors. Finally, stimuli As stress experienced during stress training are less distracting when experienced in real increases and life. Requisite to these desired effects is cognitive faculties a graduated approach to stress exposure. deteriorate, people It is by incrementally increasing the stress that the desirable outcomes, are more likely to familiarity, resilience, and confidence, are continue trying the developed.35,37,41 The application of stressful same unsuccessful stimuli can be generally divided into solution despite three categories: intrinsic, extrinsic, clear evidence of and socio-evaluative stressors.47,48 Intrinsic stressors represent elements its failure. specific to the clinical scenario (eg, simulated disease severity or difficulty

References available online August/September 2020 | EM Resident 27 PREHOSPITAL & DISASTER MEDICINE Emergency Medicine Dispatch The True First Responder Bryan Everitt, MD, NRP answering points may deploy different of a computer-based script that helps the PGY3 Resident avenues for emergency response. call-taker guide the caller through a series University of Texas San Antonio of yes/no questions. Depending on the Department of Emergency Medicine The Call @dr_ev85 Generally, in the United States, once a answers, the call-taker is prompted to ask Katherine K. Raczek, MD prehospital emergency becomes apparent, different follow-up questions. Assistant Professor/Clinical most patients gain access to the emergency The process begins by asking the University of Texas San Antonio medical system by dialing or having a patient’s age and chief complaint followed Department of Emergency Medicine by “Are they conscious?” and then “Are they Associate EMS Medical Director, bystander call 911. These calls are routed breathing?”2 If the answer is “no” to both of San Antonio Fire Department to a designated Public Safety Answering these questions, the call-taker determines ach year, an estimated 240 million Point (PSAP). The first priority of the that the patient is likely in cardiac arrest calls are made to 911 by patients call-taker is to determine the nature of and will require the highest level response or bystanders for the full range the emergency; in other words, are police, E 1 (“ECHO”) as well as pre-arrival instructions of emergencies. For the majority of fire, or EMS assistance needed? The first callers, it is their first interaction with immediate challenge can be determining for the caller to perform bystander the emergency medical services (EMS) the location of the emergency. This can cardiopulmonary resuscitation (CPR). This system. At the other end of the call is be difficult as callers may not know their results in the simple concept of “no-no-go,” often a specially trained call-taker who location, cell phones may ping a tower resulting in earlier CPR, which has been is referred to as an Emergency Medical that is outside the jurisdiction of the local proven to be one of the main mitigating Dispatcher (EMD).2 Without ever seeing PSAP, or automatic location technology factors that can positively influence the the patient or the scene, these individuals (E911) may be inaccurate.5 However, outcome of an out-of-hospital cardiac 6 are tasked with identifying the complaint, call-takers are trained in dealing with this arrest. Otherwise, if the answers are “yes,” triaging the patient’s severity, and challenge and can promptly help callers the call-taker continues to ask questions providing pre-arrival instructions to identify their location and then direct the per the algorithm, ultimately sending the callers.2,3 Historically, these providers appropriate first responders to the closest appropriate response, giving pre-arrival were overlooked as key links in the EMS location.2 instructions to the caller on basic medical and emergency health care system, Once the nature and location of care, making the scene easy for responders leading to low standards, poor funding, the emergency has been confirmed, to find, and mitigating on-scene safety and inadequate training.2 However, the the call-taker’s responsibility turns to concerns. expertise of EMDs, together with their identifying the chief complaint, age, level There are several other obstacles that calm demeanor and guiding nature, has of consciousness and breathing status call-takers must overcome when gathering led to improvements in patient outcomes. of the patient.2 Challenges quickly arise information about an emergency. In addition to the caller not knowing the History as callers may not fully understand or exact location of the patient, panic or Emergency medical dispatching, may not be able to describe effectively refusal by the caller to provide pre-arrival similar to other aspects of EMS, is a a patient’s condition. For example, a care are common challenges.2,3 EMDs are relatively new concept. In the 1970s it patient with altered mental status may be trained to overcome these obstacles using was recognized that calls for emergency having a stroke, toxic exposure, metabolic techniques such as repeatedly asking the medical help were on the rise and emergency, or hypoxia. Therefore, many same question and reassuring callers that systems needed to be developed to deploy agencies choose to employ a standardized help is on the way even as they speak.3 resources appropriately. In 1978 Salt Lake interrogation of the caller designed to This particular type of dispatch is known Fire/EMS identified the dispatcher as elicit key information that allows the chief as horizontal dispatch, which refers to the the “weak link” in the chain of survival.4 complaint to be categorized as one of 33 call-taker continuing to gather information It wasn’t until the 1980s that the first standard chief complaints.2 An example from the caller while a second EMD structured EMD protocols and training of this approach is known as the Medical simultaneously dispatches response units.2 started to be adopted. Service providers Priority Dispatch System (MPDS). wanted to send the right resource, to the MPDS is a set of protocolized decision Pre-arrival Instructions right person, for the right complaint, and tools designed to allow the identification of From the time the call is dispatched to provide direction prior to that resource’s the complaint, determine the appropriate the time the first unit arrives on scene, the arrival. Even today, the availability of resource response, and provide pre-arrival EMD plays an important role in providing EMD is not standardized and different instructions.3 The system involves use pre-arrival instructions (PAI). These are a

28 EMRA | emra.org • emresident.org set of medically approved, standardized, Some call centers will identify the patient the placement of helicopter EMS resources and protocolized instructions given to a experiencing chest pain and have the on standby when chest pain is the chief layperson by EMDs.2 A study by Billittier patient self-administer aspirin if the caller complaint. Protocols will occasionally need et al found that callers expect instructions has access to the drug.18 updating as new evidence-based practices to be given while waiting for responders Stroke is difficult to identify over the change the prehospital care plan. Quality to help mitigate the situation.7 PAI phone as callers often use vague terms to review of protocol compliance has been incorporate components of Dispatch Life describe symptoms.14 For example, a caller shown to improve the accuracy of resource Support (DLS) and have been shown to may dial 911 for “fall” but not recognize allocation and DLS implementation, which effectively prevent further mortality and focal weakness. Despite these challenges, is an important part of medical direction.2 morbidity during the response phase EMDs are able to correctly identify strokes Future Developments 2 14,15 of EMS. Examples include opening with surprising accuracy. The EMD will Improvements in cell phone the airway, cooling burns, removing interrogate callers for time of symptom technology continue to be game-changing dangerous objects from around the onset, rule out common stroke mimics (eg, in the initial care and triage of patients. victim, and administering certain hypoglycemia), gather important previous Ideas being developed include the use medications. One of the first instances medical history (eg, prior strokes), and of crowdsourcing responses from non- of PAI took place in Phoenix, Arizona, discover pertinent medications (eg, traditional responders. Programs such as in 1975. In that case, a paramedic in the antiplatelet agents or anticoagulants), PulsePoint push cardiac arrest locations to dispatch center gave instructions to the thereby helping responders make registered laypersons notifying them of a mother of an apneic child while EMS was improved triage and transport decisions. nearby cardiac arrest, thereby allowing for en route.4 That child survived. Trauma patients are clearly also in bystander CPR to be initiated faster.20 DLS focuses on the most time- need of prompt emergency medical care. A large percentage of 911 calls are sensitive medical emergencies such as Bleeding control and expedited transport made from smartphones with built- acute myocardial infarctions, stroke, to surgical services are mainstays in in cameras. Further developments in trauma, and cardiac arrest. Cardiac prehospital treatment of trauma. The EMD technology could allow EMDs and first arrest victims are the most time-sensitive will attempt to identify the mechanism of responders to see the patient prior to EMS of all prehospital patients. Without injury (eg, gunshot wound versus fall), the arrival, resulting in better triage and pre- bystander CPR, their chance of survival severity of the injury (eg, fall from standing arrival instructions to the caller. In one quickly diminishes.8,9,10 Laypersons are versus fall from height), and the timing of feasibility study, dispatchers were able to often ineffective in locating a pulse, the injury (eg, occurring today or occurring view a livestream from the caller’s phone 2 and they may not be able to identify > 9 hours ago). Additionally, the EMD in order to decide on whether to dispatch a agonal breathing. The risks associated plays an important role in recognizing helicopter to the scene.21 with performing CPR on a patient not life-threatening bleeding. Language that Other ideas include incorporating in arrest are significantly less than the differentiates the type of bleeding (venous augmented reality to demonstrate proper risks associated with withholding CPR, versus arterial) is employed by asking if CPR, identify patient medications, and therefore the assumption is that the the blood is “spurting or shooting” from and provide instructions to stop life- patient is in cardiac arrest.2 Dispatch the wound. The EMD may instruct the threatening bleeding. Assisted-CPR or Telephone-CPR (DA-CPR caller to simply apply direct pressure or Dispatcher Health and Wellness even guide tourniquet placement.2 In the or T-CPR) instructs the caller on how to It is important to remember that San Antonio Fire Department, in Texas, perform CPR and has been associated with EMDs are critical members of the 10 the first metropolitan EMS service to carry increased rates of bystander CPR. Some emergency response system. They often whole blood, dispatchers are responsible systems employ specific instructions on have to listen to extremely dynamic, for determining what calls may warrant the how to perform CPR along with counters heart-wrenching, and violent incidents, all dispatch of whole blood, which is carried or metronomes to identify inadequate while maintaining their composure and by a select number of units in the city.19 breathing and ensure CPR is done at an professionalism. They provide emergency appropriate rate.11 EMDs may also be Medical Oversight medical care without being able to directly able to identify the location of automatic Physician oversight of EMD protocols see or interact with patients. Often they external defibrillators (AEDs) and help are an integral part of ensuring the quality are not able to find out the outcome of callers properly place and use AEDs: of out-of-hospital emergency medical the patients they interact with as they another proven life-saving intervention.12,13 care. EMS Medical Directors should be have to immediately move on to the next Calls to 911 for chest pain are common. directly involved in the development, caller.22 These factors can lead to burnout, One study suggests those that call 911 with review, and implementation of EMD depression, and posttraumatic stress chest pain may self-select and be sicker protocols. Some protocols require input disorder. Timely resources should be than those that transport themselves to depending on local medical resources. provided to EMDs, as would be provided the hospital.16 Aspirin has been shown For example, a community with limited to other first responders, including to be the drug of choice for reducing percutaneous coronary intervention might counseling, incident debriefing, and praise mortality in acute myocardial infarction.17 adjust their dispatch protocols to include for jobs well done. ¬

References available online August/September 2020 | EM Resident 29 WILDERNESS, MEDICAL EDUCATION A Model for EM Resident and Ski Patrol Cross-Educational Training Day Marc Cassone, DO, FAWM We asked residents to create Christopher Cardillo, DO, Ski Patrol 15-minute, high-yield, talks on topics Jennifer Spinozzi, MD that were planned ahead without the use EM Residents of AV equipment. This was a great way Geisinger Medical Center for residents to practice skills in creating he ED acts as a linchpin between engaging, interactive presentations hospital-based care and pre- targeted to their specific audience. Beyond hospital providers. Environmental T EM residents, this training also builds emergencies and pre-hospital care are collaboration with other specialties that part of core teaching for emergency don’t usually interact with pre-hospital medicine residents and while many providers. In our 3 years of running this residency programs provide experience with EMS, formal training with pre- field training, we have looped in trainees hospital groups like ski patrol are limited. from Critical Care, ENT, Pediatric The residents of Geisinger Medical Center Dentistry, Orthopedic Surgery, Trauma have developed a cross-educational Surgery, General Surgery, Respiratory training day to bridge that gap. Therapy, Internal Medicine, Family Medicine, and Pediatrics. Resident Perspective Cross-educational trainings also including patient assessment and Emergency medicine is a key interface provides residents a chance to better extraction. Residents quickly learned between the health care system and how different it can be to perform a understand the unique set of obstacles the community, making outreach and patient assessment, stabilization and faced by ski patrol, including trying to education to various groups an important transport on the icy slopes with limited care for patients in bulky clothing, in part of training and a career in emergency supplies and personnel compared to the cold and often on dangerous terrain. medicine. Cross-educational trainings usual conditions in the ED or trauma During the second part of the day the such as these provide residents a great bay. The ski patrol trainers encouraged ski patrol trainers designed several avenue to hone their teaching skills, gain residents to troubleshoot and sometimes simulation scenarios on the mountain, a better appreciation for what groups like fail in attempts to rescue the patient — ski patrol do and gives us the opportunity TABLE 2. Example Topics to Consider important lessons for both in the field and to form a better working relationship. Teaching in the hospital. Orthopedic Management of Extremity In addition to valuable experiences TABLE 1. Example Schedule Fractures (various) in teaching and gaining perspective, AM: Resident Didactics Pelvic Fractures Shoulder Dislocations our ski patrol cross-educational days 8:30–9:40 am: Introductions and Breakfast Orthopedic Neurovascular Exam are regarded as a great wellness activity 9:40–10 am: Non-traumatic Causes of Facial Fractures and Nosebleeds and way of promoting collaboration Altered Mental Status Dental Injuries 10–10:20 am: Updates in C-Spine across house staff. Often ski patrol were Immobilization Eye Injuries, including UV Keratitis able to provide introduction to skiing/ 10:20:–10:40 am: Dental Fracture Simulation Altitude Illnesses Hypothermia snowboarding lessons, a great way 10:40–11 am: Hospital Treatment for the of encouraging beginner residents to Hypothermic Patient Frostbite 11–11:20 am: Pediatric Concussion Pediatric Concussions participate as well. Non-traumatic Causes of Altered Mental 11:20–11:40 am: Proper OPA, NPA, and BVM Ski Patrol Perspective Use Status 11:40–12 pm: Lunch Updates in C-Spine and Backboard Ski patrollers have a unique first Immobilization PM: Ski Patrol Didactics responder perspective; they are tasked Stop the Bleed / Until Help Arrives Courses with assessing and transporting injured 12:00–12:30: Ski Patrol Demonstration: Pathophysiology and Treatment of Splints, Slings, and Sleds Traumatic Shock skiers and snowboarders in precarious 12:30a–1:30p: Mock Rescue Scenarios Airway Adjunct Review: Proper OPA, NPA, situations. After completing their duty 1:30p–5:00p: Shadow Ski Patrol or Free Ski and BVM use and safely transporting the patient to a

30 EMRA | emra.org • emresident.org higher level of care, they often are not can get “hands-on” informed of the outcomes and treatment training. Examples of their patients or the exact nature include dental of the patient’s injuries or medical fracture simulators, conditions. Most patrollers (both CPR mannequins, volunteer and employed) are members airway adjuncts, of the National Ski Patrol (NSP) — their and even practice national, nonprofit member association. writing SOAP notes. NSP provides patrollers with their Demonstrating chest medical training known as Outdoor tubes, intubation, Emergency Care (OEC) which is similar portable ultrasound to a Wilderness First Responder (WFR). findings, and other Many patrollers are also trained as advanced modalities EMTs, paramedics or have other medical are procedures that background. We found that patrol staff a patroller will likely are eager to learn more and build on never encounter in the field but will lend guides, and state, national, and municipal whatever medical training they have, them perspective on the follow-up care of park rangers. Many of these groups have including the subtleties for certain their patients. Consider bringing hand- informal or formal medical training that injuries or medical conditions as well as outs with XRay/CT findings, images of residents can build-on as well. follow-up treatment and management of classic injury findings (eg. battle sign, GET MORE INVOLVED! their patients. hemotympanum), and before-and- Join the EMRA Wilderness Ski patrollers love adrenaline and after treatment photos to demonstrate Committee to find more ways to learn exciting medical pathology as much as how certain pathologies are diagnosed about and get involved in activities EM residents. However, similar to EM, and treated. (Be sure to stay HIPAA like this. Visit emra.org/be-involved/ they often lack continuity of care, and compliant.) It is very important during committees/wilderness-committee. ¬ their most frequent question to us is, these sessions that residents encourage “What happens to our patients when they patrollers to always act within their TAKE-HOME POINTS arrive at the hospital?” While developing protocols, training, and scope of practice. a curriculum for a cross-educational day, The overall goal should be to educate and • Pre-hospital groups like ski patrol be sure to incorporate this perspective — inform, not re-educate or reform. While provide a great opportunity for EM residents to lead cross-educational and discuss with ski patrol leadership any patrollers may be interested in shoulder training days. specific topics they would like to review. reduction techniques and how to clear a • Discuss with these groups early While patrollers are already experts C-spine, those tasks might not fall within to find a day they will not be busy. at managing and stabilizing extremity their guidelines; be sure their leadership Get an understanding of their prior injuries and fractures in the field, other confirms ski patrol protocol. medical training, the scope of topics such as non-traumatic causes of Ski patrols are only one group of pre- practice, and topics they want to altered mental status, facial injuries, and hospital wilderness providers. Residency learn more about. airway adjuncts are also areas of interest programs that are not located close to • Come with an open mind and ready for review. ski resorts can consider similar events to answer lots of questions. Dress for the weather and be ready to get your When planning a similar cross- with search and rescue groups, swift hands dirty! educational day, consider ways patrollers water rescue teams, lifeguards, outdoor

August/September 2020 | EM Resident 31 INTERNATIONAL MEDICINE

Preparing for a Global Health Experience Shenna Bannish care through a completely different This marked difference in resources University of New England resource and cultural paradigm and creates the perception that it takes College of Osteopathic Medicine can lead to introspection and critical very little to have a positive impact in Class of 2021 assessment of clinical practice back places that lack so much. And while Mina Ghobrial, MD home. International medical experiences global health interventions can have Emory University School of Medicine EMRA Critical Care Committee Chair-Elect can also help the student learn about a tremendous impact compared to Andrés Patiño, MD pathologies not commonly seen in the relatively low investment when done the Assistant Professor, Emergency Medicine U.S. such as some tropical diseases and right way,5 unfortunately, often global Emory University School of Medicine advanced stages of diseases not treated health interventions can have negative ACEP Ambassador to Ecuador because of lack of resources. unintended consequences for both the n the past several years, medical Beyond the cultural and clinical trainee and the host community.6 student and resident participation learning, many medical trainees Common reasons for negative in international rotations has seek global health experiences as experiences for the trainee include I 1 dramatically increased. Many benefits to an opportunity to help very needy lack of preparation and contingency participating in international rotations populations. After all, there are planning (ie, preparing for when things have been described.23 Students who tremendous needs in low and middle do not go as planned). And common have traveled to other countries reported income countries that, depending on reasons for projects that are ineffective increased cultural and interpersonal the specific setting, range from medical or have a negative impact include lack of competence and improvement in expertise in a given area (eg, emergency, knowledge of and buy-in from the local medical knowledge.4 Global health medicine) to common medications, population and a lack of emphasis on allows the trainee to experience health electricity, or even running water. sustainability.

32 EMRA | emra.org • emresident.org How Do We Avoid These an organization providing medical Often, trainees will run into multiple Negative Consequences? care on a temporary basis. Trip global health experiences they could We asked three global health experts: duration is usually in the order of pursue. How should they choose? Dr. Abigail Hankin-Wei, director of days or weeks. Dr. Yaffee developed Personal interest in a specific country or the first emergency medicine residency her passion for international work culture, connection to an existing project in Mozambique; Dr. Hiren Patel, after volunteering in Tanzania. She via a faculty member, and previous Global Health Fellowship director at cautioned that mission trips are not language skills or experiences are all the Massachusetts General Hospital the “epitome of global health,” but common reasons to choose one specific in Boston; and Dr. Anna Yaffee, the experience did teach her about experience. These are other factors that International Section Chair in the the importance of cultural exchange trainees should consider: Department of Emergency Medicine at in medicine and affirmed her interest ● Timing: Will the experience be Emory University. They offer tips on how in this field. For students who have available during the trainee’s elective to choose and prepare for a global health never had international experience time? experience to increase the chances of before, mission trips may be a ● Safety: Will the experience take place having a positive impact and lower the formative starting point. in a country and province safe enough risk of unintended consequences for the ● Clinical Rotations: During for travel? Will the student be staying trainee and the host community. international medical rotations, in a safe place? Are there severe trainees participate in medical health risks to the trainee (eg, ebola)? Types of Global Health care under the supervision of ● Sponsoring organization and Experiences local or international physicians. local contact: Is the organization Before delving into preparing for a Rotation duration is an important reputable and dependable? Will there global health experience, it is important consideration. Dr. Patel recommends be a local contact that can be easily to consider a few types of experiences one dedicating at least four weeks given reachable in case of emergency and can pursue: the steep learning curve for the to help guide the trainee with any ● Remote Participation: Dr. Hankin- trainee in a new environment before logistical issues. Wei recommended that trainees she can be effective in her role. ● Impact and sustainability: Does look for opportunities to work on ● Research or Development the program seem to listen to and international health projects remotely Projects: Research and capacity uphold the host community’s values? before traveling abroad. The expansion building or development projects Is the program sustainable? What of the internet in the developing world allow the trainee to look at the health are the risks of negative unintended has made it possible for trainees care system in the host country from consequences to the host community to support international projects a broader perspective. Participation from the program? from home. Trainees can help with in these activities usually requires ● Cost and Funding: What will be the activities such as literature reviews, longer term commitment, at least in cost of travel and room and board? data analysis, administrative tasks, the order of months given the need Are there scholarships available? and proposal and report writing for to become familiar with the host Dr. Yaffee encouraged students to research or capacity building projects. community to achieve the project’s work within the framework of an already U.S.-based trainees can also help with results. well-defined system. She recommended teaching activities and journal clubs trainees pursue a larger, more established via video conferencing. One advantage Choosing a Global Health program for their international of this global health experience is that Experience experiences, particularly for trainees who it may fit more easily with training Finding one’s first global health are only traveling for a short period of schedules, as trainees can stay involved experience can feel like a daunting task. time. She added, “no student or resident over time without interrupting their The best place to start is usually global should be going to a site that has not been studies. Remote activities could health faculty in the student or resident’s vetted by either an institutional faculty be stand-alone experiences, or a program. If there are no global health member or another institution that is way to prepare for a planned trip. faculty in one’s program, one can look trusted.” For example, Dr. Hankin-Wei has online for faculty and organizations had U.S. residents collaborate with working in a country and project of Preparation Before Traveling residents in Mozambique on journal one’s interest. “Cold-emailing” may Preparation is crucial for the safety articles and newsletters before visiting be an uncomfortable but sometimes of the participant and the success of Mozambique, which likely contributed necessary part of this process. Dr. Patel the experience, as well as minimize to their overall experience while in recommends global health committees any negative impacts on the host country. and conferences through different community. Figure 1 lists some of the ● Medical Missions: During medical potential organizations (eg, EMRA, recommended steps when preparing for missions, the medical trainee travels ACEP, SAEM) to make global health an international experience. First and for a short period of time to help connections. foremost, the trainee needs at least two

August/September 2020 | EM Resident 33 INTERNATIONAL MEDICINE

good mentors: one in the U.S. and one in considerations include a visit to the travel of understanding of the trainees’ level the host site. A global health experience, clinic for vaccinations and prophylactic of training by the host medical facility. after all, is a learning experience, and medications (e.g. malaria) and reading However, all our interviewees stressed one needs guidance. There is a lot to the country profile in the Department of that trainees should practice with the learn about the host country, healthcare State website for any upcoming political same level of supervision and in a scope in low resource settings, culture, or civil event with potential for turmoil of practice as close as possible to what and language. The pace of work can (e.g. upcoming elections). would be expected of them in the U.S. vary significantly in other countries, Learning as much as possible about the Obviously, working outside of one’s scope which can be a source of frustration local community will not only help with and level of training can cause harm. Take for trainees. Frequently students safety but can help the trainee connect Dr. Yaffee’s advice: “Don’t be a cowboy.” and residents come back from their with local collaborators, understand local Other ethical challenges stem from experiences frustrated because they were patients, and uphold the values of the resource scarcity. All three global health not able to finish their projects. Having community. Dr. Hankin-Wei believes experts indicated that observing patients clear expectations from one’s mentors that, in addition to knowing the state of suffer from potentially preventable that are based on the host community’s Emergency Medicine in the country, one causes is a significant stressor for rotating reality—while remaining flexible—can should be familiar with its history to better trainees. Consider a hypothetical: a U.S.- help the trainee make the most out of understand patients and the systems that based emergency medicine resident is the experience. Dr. Yaffee recommends are currently in place. One should ask caring for a patient X with new kidney contacting the local staff via apps such about the social determinants of health of failure in country Y. The resident has as WhatsApp or Skype to start building the host population and ask what the main cared for similar patients in the U.S. relationships that will be helpful once causes of illness and the main barriers where they have been started on dialysis, the rotation begins. in the healthcare system are. Before feel much better, and go home. However, Not only will the participant find embarking in a global health experience, in country Y, there is only one dialysis the experience more fruitful with good ask if community members were involved clinic, hours away by car and the costs mentor support and clear guidelines and in the planning and execution of the of each treatment is hundreds of times objectives, but mentorship is paramount project/program and what the end goal is. the patient’s family’s daily income. Thus, for the participant’s safety, as trainees In other words, does the community feel patient X is not able to receive dialysis, may be completely out of their element ownership of the program and will they be struggles to breath from volume overload, in a different country. Before traveling able to continue it once foreign aid stops? and dies on day five of hospitalization. It it is important to talk extensively with Ask about local manners. Drs. Hankin can be very upsetting to witness patients the local and U.S.-based mentors about Wei and Yaffee recommend learning suffer or die from conditions one perceives the conditions in the host site and how how to say basic words and phrases in the as very treatable back home, even if it is to stay safe. It is important to have the local language, such as “hello” and “thank completely beyond one’s resources in a phone numbers of people in country who you,” to demonstrate respect and interest given setting. Another common situation can be of help 24/7 in case of emergency. in the local community. is having to choose who gets treatment Furthermore, Dr. Patel brought up it is In addition to the advice above, we when resources are available but limited. important that the trainee recognizes asked our interviewees what resources Schwartz et al. describe a situation in he or she will likely be one of the most trainees should read before departure. rural northeast Africa where a hospital affluent people in the community and Figure 2 contains their recommendations had only one oxygen machine that easily identified as foreign because of and other helpful links. Furthermore, our could not be split between patients. The her look, language, accent, clothing, or experts encouraged trainees to read about clinician had to make the decision about even mannerisms. Extra care should be some of the ethical dilemmas frequently who received life-saving oxygen and who taken to not flaunt expensive clothing experienced during global health did not.8 Resource scarcity can result in or technology. Not only will this create a experiences, as discussed below. myriad situations like these where the barrier when establishing relationships Ethical Considerations trainee can experience moral injury (or with the local community, but it can A common ethical issue trainees run injury to their conscience), feeling guilt make the trainee a target of unwanted into while working abroad is being asked and like they could have done more, even attention, harassment, or crime. Thus, to work outside their scope of practice.7 though they could not. This is another it is important that the trainee discuss Not uncommonly trainees may be asked important reason it is critical to have good with local contacts proper attire and how to perform tasks and procedures beyond supervision, mentorship, and a support to move around the local community their level of training or without the system during a global health experience. most safely (to and from work, grocery level of supervision they would usually Each of our experts acknowledged the store, pharmacy, etc.). Health insurance require. This can happen for many importance of debriefing, whether that is and evacuation insurance should reasons, including lax local regulation, with a supervisor at the site, or in a group also be discussed with your mentors a less hostile malpractice environment, upon returning home. Dr. Patel mentioned and training program. Other safety shortages of healthcare personnel, or lack that journaling is also frequently a helpful

34 EMRA | emra.org • emresident.org adjunct. Being able to process these In contrast to the example above, of respect. “You can’t be judgmental of experiences is essential to caring for one’s sometimes local community members people’s vulnerabilities.” mental health. distrust foreign programs and do not A global health experience can be Trainees witnessing scarcity take advantage of the services provided. intense and transformative. To get the sometimes want to pay for treatments or For example, during the Ebola epidemic, most out of it make sure you take pauses some element of a patient’s care. However, many people in the affected communities and reflect all the way through and Dr. Yaffee and Dr. Patel feel this is not actively avoided healthcare services especially at the end. Debrief with your sustainable. Who will pay when the trainee provided by NGOs because of distrust.9 mentors and other people who have had leaves? Other people may hear about Dr. Patel highlighted the necessity similar experiences. How do care and the trainee giving financial assistance of understanding what is important to resources compare across countries? and come asking for help. Where does the community one wishes to serve. All What do you wish you would have the trainee draw the line? If trainees are three interviewees indicated that it is known before going? What would you motivated to make a financial donation, crucial to obtain “buy-in” from the local do differently on your next trip? Did Dr. Patel recommends those donations go community. Dr. Patel emphasized that you feel your experience had a positive, to an organization doing work in the area local professionals are the experts in negative, or neutral impact on the host as opposed to individuals. their system — not the visiting trainee. community? What are some parallels While on the topic of local As Dr. Yaffee stated, “Being deferential between the social determinants of health organizations, it is important to is important; realize that many times affecting your patients in the community consider any unintended consequences we are going to learn a lot more from you visited vs. your home setting? a global health activity can have on places we visit than we are giving back.” How will practicing medicine abroad those local organizations. For example, Listening and being deferential to influenced your work in the U.S.? Are a hypothetical medical mission M the host system will earn you respect there ways you can stay connected with starts going to town T twice a year for and buy-in from the community. An the host community and help from home? 2 years to provide free medical care intervention developed without the Conclusion and medications. Unfortunately, its input and active participation of a local International rotations can have a funding runs out at the end of year 2, community will often fail because it is profound impact on medical trainees. and program M stops. During those either ineffective in the local context or According to our interviewees, the 2 years the only medical clinic and the because it fails to gain the community’s experience will be enhanced by significant only pharmacy in town T closed because interest and trust. A trainee that feels preparation, good mentorship, allotting people stopped using their paid services superior to her local coworkers and enough time in the host community, in favor of mission M’s free mission patients will struggle to gain trust and be debriefing, and staying connected with the services. In the long-term, mission M left effective in her role. individuals at the host site. Some pitfalls town T worse than it found it — without Table 3 lists articles that discuss some to avoid are practicing outside of one’s its only permanent clinic and pharmacy. of the challenging ethical dilemmas that scope, disregarding the knowledge of the People from town T must now travel 2 healthcare workers encounter when doing local community, overconfidence, and hours by car to seek medical care. Thus, international work. All of our experts lack of respect for the local community. any global health project must have the recommended reading papers such as Above all, it is important that, as visitors, input of patients, community members, these before embarking on a global health we make every effort to familiarize local government, local businesses, rotation. ourselves with the host country’s history and any other stakeholders. Perhaps Reflection and medical system and not simply try if Mission M had delivered its services Our experts think working abroad to impose our own ideals. As Dr. Patel through the local clinic and pharmacy, has made them more resourceful in their stated, “We have this notion when doing these local businesses would have practices in the U.S. Dr. Yaffee shared global health work we want to go and become stronger and better able to serve that she has been able to solve problems make all these changes. We have all these the community when the mission left. more creatively, without relying as ‘wants’: ‘I want to teach them this, I want While trainees most often will not design heavily on as many resources. Dr. Patel to do that,’ without understanding the global health interventions themselves, mentioned the challenge of switching needs of the community. Instead we must they should choose to participate from treating serious, debilitating be humble, listen and be thankful to the in sustainable programs. Trainees illnesses in a low resource area to community for letting us be there, think should ask how a specific program is practicing in an emergency department about unintended consequences of well- strengthening local capacity, its impact in the U.S. that welcomes many non- meaning actions, and expect to learn much on local organizations, and how it will emergent complaints. It can be easy more than we can teach.” transition its activities to the local to feel judgmental of patients with low For more details, a checklist of global community when it leaves. Programs acuity complaints. rotation preparations, and additional should leave communities more self- However, he states we must not forget resources please see the expanded article sufficient than they found them. each patient deserves the same level on emresident.org. ¬

August/September 2020 | EM Resident 35 ADMIN & OPS Are You Satisfied with Your Patient Satisfaction Scores? Darian Arman, MD And most important, measuring patient often did doctors listen Mount Sinai St. Luke’s/Roosevelt satisfaction gives patients a voice in their carefully to you? @darianarman own healthcare, and is fundamental when 3. During this hospital stay, how s the U.S. health care system striving towards patient-centered care. often did doctors explain continues to transition to value- Measuring Patient Satisfaction things in a way you could based reimbursement, patient understand? A In 2002, the federal government satisfaction is becoming an increasingly became involved in patient However, the HCAHPS survey important metric for hospitals, clinicians, satisfaction scores with the creation also has several limitations that may and patients. From a hospital systems of the 27-question Hospital Consumer impact the scores. For example, taking standpoint, it can be used to compare Assessment of Healthcare Providers and care of critically ill patients may lower different health initiatives, evaluate Systems (HCAHPS) survey. Then in 2010, some scores due to low acuity patients the quality of care, and identify areas the Affordable Care Act tied hospitalized potentially grading you poorly as a result of improvement.1 From a financial Medicare pay-for-performance with of increased wait times as you were perspective, it can be an essential marker HCAHPS. As part of the Hospital Value- actively resuscitating and stabilizing of performance and compensation for Based Purchasing Program, hospital more sick patients. Another limitation hospitals, administrators, and physicians. performance on the HCAHPS survey is the lapse of time between a patient’s A study by Fullam et al. found can affect the hospital’s base operating ED visit and the receipt of a survey in that patients’ perceptions of quality Medicare payments by 2.0%, positively the mail, which may affect a patient’s explained nearly 30% of the variation or negatively. To aid in capturing the memory of their visit. And patients who 2 in hospital financial performance. This HCAHPS payment, roughly 50% of were unhappy due to a long wait or has led to senior health care executives’ hospitals use Press Ganey as the vendor because they did not receive requested compensation being tied to patient of the HCAHPS survey. In addition to medications or testing may be more satisfaction scores, which in turn prompts the financial benefit of the survey, it also inclined to show their unhappiness by administrators to incentivize (or penalize) provides feedback that guides hospitals down-grading all aspects of their care, 3 scores. Moreover, patient satisfaction is in policies and allows patients to have a even when other aspects of the care important from a malpractice standpoint, voice in their own healthcare. Informed they received were exceptional. As well, where studies have shown that positive by survey data, hospitals can develop certain patient dispositions may influence patient experience is associated with initiatives to make the patient experience the attention received from providers. lower medical malpractice risk. In one better in terms of effectiveness and For instance, patients who leave without study, they found that the likelihood of efficiency.5 being seen or who are admitted to the a provider being named in a malpractice The HCAHPS survey asks about: observation unit do not receive surveys, suit increased by 21.7% for each drop in ● communication with doctors leaving open the possibility that providers patient-reported scores along a 5-step ● communication with nurses can change how they manage these 2 6 scale of “very good” to “very poor”. ● responsiveness of hospital staff patients to minimize poor scores. Herein Patient satisfaction is also linked ● communication about medicines within this context, an opportunity to greater employee satisfaction, ● care transition presents itself for emergency physicians resulting in reduced staff turnover. For ● cleanliness of the hospital to gain awareness of the drivers of instance, a focused initiative to improve environment patients satisfaction. the patient experience at one hospital ● quietness of the hospital Determinants of Patient led to a 4.7% reduction in employee environment Satisfaction turnover.4 Not only is patient satisfaction ● discharge information Hospital Environment an important reflection of the quality ● overall hospital rating The hospital environment has a of work we’re doing as physicians, but ● likelihood to recommend large impact on patient satisfaction, it can also be impactful to the health In terms of doctor communication, the and facility improvement can lead to outcomes of our patients. Higher patient survey asks: improved patient scores. A systematic satisfaction has been shown to improve 1. During this hospital stay, how review by Batbaatar et al. found that the patients’ compliance with recommended often did doctors treat you with aspects of the hospital environment that treatments and will result in closer courtesy and respect? were associated with patient satisfaction patient follow-up with appointments.1 2. During this hospital stay, how included: pleasantness of the atmosphere,

36 EMRA | emra.org • emresident.org room comfort, bedding, cleanliness, noise healthy. Conversely, religion, gender, and found that patients were more satisfied level, temperature convenience, lighting race have not shown to impact patient if the provider demonstrated more convenience, food service, bathroom satisfaction.1 interpersonal orientation, caringness comfort, clarity of sign and directions, Provider Characteristics and empathy, while negatively viewing arrangement of equipment and facilities, A provider’s physical appearance assertion or dominant behavior. For male and parking. Furthermore, patients is considered important for the patient physicians, satisfaction was greater when who were in appealing rooms evaluated experience. Physicians wearing glasses they showed more interpersonal distance, physicians’ actions and perceived positively affects perceived warmth and more expansiveness, less orientation 1 competence more favorably. competence, whereas beardedness has toward the patient, more looking at the Patient Characteristics a negative effect on perceived warmth.7 patient chart, and louder voice. It was The characteristics of a patient can For emergency physicians, studies have also found that female doctors attained influence whether a patient is more or less shown that patient satisfaction does not highest satisfaction ratings using a likely to be satisfied with your care. Older change whether a doctor wears a white consultative communication style with patients are generally more satisfied than coat or scrubs in the ED.8 younger and middle-aged patients, younger patients. Patients in rural areas The provider’s gender can also whereas male physicians reached the tend to be more satisfied than those in impact patient satisfaction. A study by highest satisfaction ratings using an urban areas. Health status can impact Mast et al. demonstrated that patients authoritative communication style with satisfaction, as patients reporting their have different expectations about female middle-aged and older patients.9 health as poor are generally less satisfied and male physicians in-line with gender Nonverbal Actions than those who describe themselves as stereotypes. For female physicians, they Nonverbal actions by the physician, such as smiling, eye contact and social contact can all influence a patient’s perception of their provider. Patients were more satisfied when physicians smiled more during interactions.9 As well, eye contact has been determined to be important, but the extent of its CHEAT SHEET effect changes with the length of the The Perfect Patient Satisfaction Score interaction. The degree to which eye The Introduction: What Matters To You? contact influences satisfaction increases q Address the patient formally: acknowledge they have been waiting when the visit length is short, but as the q Introduce yourself visit becomes longer, the effect of eye q Shake hands contact decreases.10 In terms of social q Stand or sit openly contact, patient ratings of likability and q Maintain eye contact connectedness increased with social Initial Interview: Making Patient Part of Team touch, to a point, but decreased when q Listen without acting rushed, setting expectations while planning to exceed them done in excess. The study by Mast et al q Make sure to address each concern without being dismissive or interrupting. hypothesized that two social touches Identify medical/ clinical diagnosis and customer service diagnosis in a consultation may be ideal.9 Other q Provide timeline: next sequence of events so the patient knows what to expect q Provide an honest timeline for results nonverbal techniques that were found to have a positive association with patient Continuation of Care satisfaction includes nodding, forward- q Reassess patient’s symptoms leaning, gesturing, gazing and eyebrow q Update patient on test results and the plan: try to have touch point every 20 minutes lowering. On the other hand, keeping a q Update the patient on delays of their care far distance to the patient and frowning had a negative association. And no Conclusion or Transition of Care q Use easy to understand language to explain diagnoses, cause of illness, association was found for talking while medications, and discharge instructions doing something else or the attractiveness q Allow for shared decision making when appropriate of provider.9 q Listen to Understand: “Sometimes I’m not as clear as I want to be; what is your For more information on patient understanding of what I just said?” satisfaction scores and other q Introduce the patient to the next provider during transitions of care areas of EM operations, consider q Explain specific and realistic return precautions when discharging the patient applying for the EMRA/ ACEP q Final opportunity to leave a legacy. Consider asking patients: How did we do today? Intervene on outstanding issues. Emergency Department Director’s Academy (EDDA) Scholarship! ¬

References available online August/September 2020 | EM Resident 37 LEADERSHIP TRAINING THE FRONT LINE Substance Use Disorder Education for EM Residents Lucinda Lai, MPhil, MD Substance Use Disorders Development of the Harvard Affiliated in the ED EM Curriculum Emergency Medicine Residency The prevalence of substance use The Substance Abuse and Mental Case Vignette disorders (SUDs) among the ED Health Services Administration aniel had overdosed, again. patient population is on the rise.1-3 The (SAMHSA) has awarded the American Someone must have noticed emergency department has become College of Emergency Physicians Dhim passed out on the street a critical point of access to the health (ACEP) a $220,000 grant to develop and called 911 because, before he care system for patients with SUD, and disseminate SUD curriculum to EM knew it, an ambulance crew had representing nearly half of all ED residency programs around the country. picked him up and dropped him visits in the US.4 And yet, the rates of With this grant funding, ACEP has off at the emergency department. treatment remain low. The National partnered with the American Board of He reminded me of dozens of other Survey on Drug Use and Health data Emergency Medicine (ABEM), Council patients that I have taken care of from 2016 revealed that of the 19.9 of Residency Directors in Emergency over the past 7 years in Boston — million American adults who needed Medicine (CORD), and EMRA to carry first as a medical student, then as treatment for a substance use disorder, out a two-year project, called “Training a resident training in emergency only 10.8% received addiction treatment the Front Line.” The goals of this project medicine during the height of the within the past 12 months.5 Why are are to teach residents about SUD disease nation’s opioid epidemic. He was a so many people left untreated? Lack processes and evidence-based treatment mid-30’s, white male who had grown of knowledge about evidence-based options, reduce stigma, and empower up in an economically depressed part treatment modalities, the pervasive emergency physicians to actively engage of the north shore of Massachusetts. stigma surrounding addiction, and patients in treatment. In the first phase From his first exposure to opioids at lack of a feeling of self-efficacy on the of the grant in the fall of 2019, ACEP age 14 to his eventual progression to part of clinicians to intervene may all convened a committee of experts in the IV heroin and cocaine use, Daniel’s* contribute to the missed opportunities field of SUD research to determine the medical history outlined the story of a to save lives.6 design the curriculum. The subject matter life upended by addiction: untreated Some would argue that the experts included Drs. Kathryn Hawk, hepatitis C, multiple ED presentations emergency department is actually the Alexis LaPietra, Ryan McCormack, and for opioid overdoses, hospital optimal setting to perform screening and Reuben Strayer. I had the privilege of admissions for complicated skin intervention for SUD. For example, EDs serving as the EMRA representative to abscesses from which he often left often serve the primary health care needs the committee and helped to shape a against medical advice, and one ICU for patients with opioid use disorder curriculum that would be practical and admission after getting intubated in (OUD), provide overdose reversal, focused on the needs of EM residents. the ED for excessive agitation while attention to injuries related to substance Together, we created a series of short, intoxicated with a bad combination use, and entry points into OUD 20-minute teaching modules organized by of opioids and cocaine. treatment.7 When patients present with topic: Introduction to Opioids, Treatment On this particular evening, Daniel an acute problem to the ED, physicians and Management of Opioid Use Disorder, had overdosed on heroin. By the time may be able to leverage their motivation Alcohol and Benzodiazepines, Cannabis he had arrived to the ED, he had to change and initiate buprenorphine, and Vaping, Stimulants, and Special become increasingly somnolent with distribute naloxone, counsel patients, Populations such as adolescents and pinpoint pupils and a respiratory and refer them to outpatient treatment pregnant patients. In the second phase rate that was dipping into the danger and follow-up.8 Because of the unique of the project, twelve residency programs zone. The nurse placed an IV and I role that emergency physicians are able served as the pilot sites for the rollout of gave him a tiny dose of IV naloxone to play in reducing overdose deaths this curriculum from January to June (0.04 mg, one-tenth of the standard and increasing linkage to addiction 2020. Faculty at those residency programs dose)—just enough to restore his treatment, it is essential that SUD delivered the modules to their residents, respiratory drive, but not enough to education be taught in every EM and residents provided feedback to ACEP send him into florid withdrawal. residency in the nation. about the quality of the curriculum. In the

38 EMRA | emra.org • emresident.org third phase, resident feedback will be used month. Approximately 20% of patients development of OUD, use of alternatives to to revise the curriculum. By the end of who died did so in the first month, and opioids for acute pain management, harm 2020, the revised curriculum will be made approximately 20% of those died in reduction techniques such as distribution available to all EM residencies in the U.S. the first two days following discharge of naloxone kits , and ED initiation of As the final output of this grant, the 2021 from the ED. With the median age at MOUD, we can significantly increase the In-Training Exam (ITE) will be updated to time of death of 39 years, the loss of life likelihood that patients will engage with include examination questions based on from those preventable overdose deaths health services and achieve long-term 11 this SUD curriculum. was astounding. On the other hand, if improvements in health outcomes. By creating a standardized SUD patients are provided with medication Case Resolution curriculum that is specific to EM for opioid use disorder (MOUD) — So, what happened to Daniel that residents, we hope to equip emergency specifically buprenorphine or methadone night in the ED? After giving him the physicians with the tools they need to maintenance treatment — one death small dose of naloxone, his breathing provide their patients with high-quality can be prevented for every 40 patients normalized and he did not go into and evidence-based SUD screening, treated, which would reduce the annual withdrawal. I kept an eye on him while assessment, and treatment. mortality from 5% to 2%.8,10 he slept through the rest of the night

Evidence-based Interventions By training emergency medicine connected to end-tidal CO2 monitoring What kind of evidence-based residents in evidence-based practices such and made sure that he didn’t need further interventions are we talking about? In as reduced opioid prescribing to prevent doses of opioid reversal. By the morning, a randomized control when he had sobered, trial by Yale University one of our ED social in 2015, patients who workers talked to him presented to the ED with about treatment options. opioid withdrawal were Ultimately, he wasn’t ready randomized to one of to start buprenorphine or three treatment arms: other MOUD treatment 1) referral to outpatient that day, but I left my shift treatment, 2) referral knowing that I had treated and brief counseling him with respect and intervention, and 3) understanding. referral, counseling, and One day he may be initiation of buprenorphine ready to come back for from the ED. The results help. I hope that when were impressive: being that day comes, the next given a buprenorphine emergency physician “starter pack” from the ED to care for him will be increased a patient’s 30-day empowered by resources retention in treatment to such as this SUD 78%, nearly double the rate curriculum to counsel of the group who received and guide him towards brief counseling and effective treatment options. referral alone (45%), as well That indeed should be our as compared to the group standard. ¬ who received referral alone 9 Funding for this initiative was (37%). made possible (in part) by In a study published in grant no. 1H79FG000021-01 the Annals of Emergency from SAMHSA. The views Medicine in January 2020, expressed in written Weiner, et al, determined conference materials or publications and by speakers that patients treated in and moderators do not the ED for overdose had necessarily reflect the official a one-year mortality rate policies of the Department of of over 5%.8 They found Health and Human Services; that a large number of nor does mention of trade names, commercial practices, patients discharged from or organizations imply the ED after an opioid endorsement by the U.S. overdose died in the first Government.

References available online August/September 2020 | EM Resident 39 LEADERSHIP COCKTAILS WITH CHAIRS Pearls for EM Physicians-In Training Nicholas Cozzi, MD, MBA Our chairs gave insight into their experience, day-to-day roles, and career trajectory from Spectrum Health/Michigan State University resident physician to leader of their respective departments and our field. EMRA Administration & Operations Committee Chair-Elect 10 Pearls Gleaned from the Event that You Can Use @NickCozziMDMBA in Your Journey of Becoming an Emergency Physician Adrian Cotarelo, MD, MHS St. John’s Riverside Hospital Secret Sauce: Failure is necessary Remember that not every idea, project, or initiative will be successful. Something may Wendy Sun, MD seem better in theory than it turns out in practice. Part of leadership is learning from Yale New Haven Medical Center these experiences, taking setbacks in stride, and moving forward. hile the COVID-19 pandemic Imposter Syndrome continued to affect each corner Many students and residents face imposter syndrome — EM department chairs are no Wof the world, emergency exception. Many of the chairs noted feeling inadequate compared to their colleagues medicine physicians were leading on the during their residency training. They reported imposter syndrome as a driving factor in front line while also meeting together to working hard to develop their clinical knowledge base. imagine the future of our specialty. EMRA “Planting Trees Under Whose Shade You May Never Sit” and SAEM RAMS collaborated alongside Being a chair is like being a maestro. One of the key tenets of being a chair includes EM department chairs across the nation advocating for your department, junior learners, and the field of emergency medicine. as part of the May Virtual SAEM Meeting. Some of our panelists were founding department chairs. The success of your colleagues Our “Cocktails with Chairs” event sought is a reflection of your success. Part of the goal of a chair is building up the next to reduce the power distance between generation of leaders in our field. residents and EM department chairs High Reliability Culture and afforded an intimate session with Our chairs described the importance of establishing a highly reliable culture of residents, attending physicians, and continuous improvement, trust, and consistency. This triad helps accelerate the process of building trust and can help you starting day one of residency. medical students — over cocktails! The Power of Radical Candor Our Chairs Honest, professional, and direct conversations build relationships that hold people ● Dr. Andra Blomkalns is the founding Chair of the Department of Emergency accountable. Be candid, but with compassion, as you lead your department and in your Medicine at Stanford School of Medicine. residency. ● Dr. Michael Brown is the founding Portfolio of Skills Chair of the Department of Emergency Cultivate skills that will make you an effective leader including listening, understanding Medicine at the Michigan State and being approachable. Be intellectually flexible. Be a learner and take advantage of University College of Human Medicine and Immediate Past President of the various developmental and national opportunities within EMRA and SAEM. Association of Academic Chairs of Go First Emergency Medicine. Raise your hand to help in the time of need. Often leadership roles occur serendipitously ● Dr. Bo Burns is the George Kaiser when a person steps up to do what they feel is right. One of our chairs described Family Foundation Chair of the obtaining 165 brand new N-95 masks for each member in his department. Follow your Department of Emergency Medicine at ambition, pursue the changes that you feel are necessary, and your career will follow. the University of Oklahoma School of Community Medicine and current CORD Introverts Board Member. Leaders come in all shapes, sizes, and personality types. Introverts can and do succeed ● Dr. Gabe Kelen is the founding Chair of in leadership at every level in emergency medicine. the Department of Emergency Medicine Practice makes Permanent at Johns Hopkins University and current Consistent, intentional and deliberate effort leads to progress. No one develops ACEP Board Member. ● Dr. Ian Martin is the Chair of the competency overnight. Improvement comes with having a growth mindset. Department of Emergency Medicine at Send the Elevator Back Down the Medical College of Wisconsin and An EM department chair is inherently a mentor to many, and each panelist described Immediate Past President of SAEM. the impact mentors had on their careers. As a resident physician, you have the ability to ● Dr. Angela Mills is the founding Chair mentor countless medical students, undergraduates, and students in high school. Take of the Department of Emergency Medicine the first step today. Repeat often. Doctor’s orders.¬ at Columbia University Vagelos College of Physicians and Surgeons, the Chief Thank you to both EMRA and SAEM RAMS for hosting this collaborative event. Special recognition of Emergency Services of New York — goes to our participating EM department chairs; Cathey Wise, CAE (Executive Director of EMRA); Presbyterian — Columbia, current SAEM Holly Duncan, (SAEM Director of Membership and Meetings); Hannah Hughes, MD, MBA (EMRA Board Member, and 2019 EMRA Inaugural President); and Nehal Naik, MD (Immediate Past President of SAEM RAMS). For the full Cocktails EM Chair of the Year. with Chairs event, please see the video available on SAEM’s Youtube Page.

40 EMRA | emra.org • emresident.org MEDICAL EDUCATION Medical Education Fellowship Director Interview Series Frances Rusnack, DO, MS he EMRA Education Committee is excited to bring you our newest project, Mount Sinai Morningside – West, PGY-3 the Medical Education Fellowship Director Interview Series, which will allow EMRA Education Committee Medical Education Fellowship Directors a platform to describe their fellowship Vice Chair of Resident Education T program, highlight different medical education career paths, and provide resources for Moira Smith, MD, MPH University of Virginia Health System, PGY-2 potential fellows. We are excited to showcase the first interview for you here within EM EMRA Education Committee Resident’s August/September issue, and we encourage you to visit EMResident. Vice Chair of Resident Education org for a collection of these Q&A format articles from other programs. The Erin Karl, MD interviews will also be linked to each fellowship’s profile on EMRA Fellowship Match, University of Nebraska Medical Center, PGY-3 EMRA Education Committee Chair serving as a valuable resource to applicants. This is particularly timely given the loss of Sarah Ring, MD many conferences and other networking opportunities for prospective fellows. If you Mount Sinai Hospital, PGY-2 are a MedEd Fellowship Director interested in submitting a profile on your program, EMRA Education Committee Chair-Elect please email [email protected].

Medical Education Scholarship Fellowship at the pre-residency boot camp, developed residency curricula, and Department of Emergency Medicine at the Alpert been on the planning committee for the Program in Educational Medical School of Brown University Faculty Development — the medical school’s professional development arm for educators. In addition, fellows have taught Director: Chris Merritt, MD, MPH, MHPE at regional and national conferences. Title: Associate Professor of Emergency Medicine & Pediatrics III. Scholarship: Scholarship may take many forms, from Institution: Department of Emergency Medicine at the Alpert dissemination of newly developed curricula to scholarly Medical School of Brown University application of educational evidence to primary education Social Media Tags: www.brownmeded.org, @chris__merritt research in the health professions. Within the Department Tell us about you and your program of Emergency Medicine, the Education Section is an Our program’s philosophy is to create a network of colleagues, active network of educators and education scholars collaborators, mentors and teachers around each fellow with cooperating in regular collaborative efforts. Fellows have the goal of positioning our fellows to achieve their educational access to this body of shared expertise and mentorship and professional development goals. Rather than fit a fellow into with BrownEM, and to the broader community of educators a program, we work to build a program around the individual’s throughout the institution. Whether fellows seek support identified needs and goals. in traditional research, or opportunities to engage in more Medical education at Brown focuses on understanding, non-traditional scholarly pursuits such as podcasts or digital opportunity, mentorship, and scholarship. Fellows are fully privileged health, we will build a program that meets their professional faculty in the Department of Emergency Medicine at Brown. development goals. IV. Mentorship: One of the greatest joys as an educator is Our 2-year program is built around 4 pillars: to engage in the sort of mentorship relationship that our I. Building a background in educational understanding: To fellowship offers. Our faculty are dedicated to engaging with achieve this, we offer a fully-funded master’s degree in medical fellows, identifying individual and shared goals, and helping to or health professions education. Fellows can choose from build the personal learning networks that we hope can enrich among dozens of programs, finding a graduate program that not just a fellowship program but an academic career. meets their needs. We find that the combination of didactic learning gained through the master’s degree process provides How did you get involved in medical education, a broad base upon which a career in education can be built. and what is your career path that led you to your Our most recent graduate completed the MEHP program from Fellowship Director position? Johns Hopkins. Brown’s program mentors work together with I’ve been drawn to education since medical school, but it graduate program leaders to align the goals of fellowship with wasn’t until I joined the faculty at Brown that I realized that it could the goals of graduate work. become such a significant part of my career. I started by directing II. Opportunities to teach: There is no shortage of opportunity here a month-long rotation for EM residents. I got to know every EM at Brown. Because our faculty and colleagues have connections resident in our program on a 1:1 basis, each over the course of a across the entire spectrum of medical education, our fellows are month, which remains one of my most memorable and fulfilling afforded the chance to dip their toes in the water at any level, roles as an educator. It was then that I recognized that if I were from undergraduate university students to ongoing professional going to really pursue med ed as an academic niche, I would need education with experienced faculty, and everywhere in between. to strengthen my foundation. Through a faculty development Fellows have participated in the preclinical doctoring course grant, I was able to pursue a master’s degree in health professions at Brown’s medical school, taught in the EM clerkship and education, during which time I recognized the importance of

August/September 2020 | EM Resident 41 MEDICAL EDUCATION

mentorship and sponsorship. The mentoring relationships I for example. Seek opportunities within your own program — maybe developed then have stood to this day, and the network of there’s a rotation curriculum that needs to be revamped? These educators and colleagues I began to build have strengthened over local curricula can even be shared and presented at regional or time. I’ve had roles in education across the spectrum — directing a national meetings. Is there a residency committee that needs your short course for preclinical medical students, running a residency voice? Elective time might be an opportunity to learn simulation or rotation, spending time as a residency director, and planning and another med ed skill. And look to your national organizations — teaching in Brown’s faculty development program. I currently am EMRA, of course, but CORD, SAEM, ACEP all have resident sections a longitudinal mentor to more than 30 medical students at Brown, and committees, and many have state or regional arms that might which has been a whole new adventure! Through my role as just be looking for a voice like yours. fellowship director, I hope to help new faculty find this same joy What qualities does your program look for in through education and education scholarship. potential fellows? What are the benefits to completing a fellowship We really look for a passion for teaching — of course! — but in medical education? also for individuals with a vision for how their passion for education More and more, education is becoming professionalized — and can contribute to both their own careers and to the community of by this I mean that learners and program leaders have begun to academic emergency physicians. I love to see people’s eyes light expect that their education leaders have a deeper understanding of up when they talk about their hopes and aspirations, and how they the many facets of education, including education theory, education see a Med Ed fellowship as a step toward the future they hope for. scholarship, and leadership. The “see one, do one, teach one” What is the application and interview process like mantra no longer applies. By identifying education as a niche, fellows signal that they have sought this deeper understanding. at your program (ie, application requirements, Fellowship provides the protected time to really sink your teeth into timeline, match process, participation in CORD all the aspects of what it means to be an educator within emergency universal offer day)? medicine. Graduates go to the head of the line when it comes to The application is pretty straightforward — we ask for a letter seeking faculty jobs, leadership positions, and other opportunities. of intent, a CV, and three letters of reference. These can be sent to Simply put, a med ed fellowship is a short investment in a long career. me and our fellowship coordinator, Wendy Wesley (wendy.wesley@ brownphysicians.org). Does your program have a particular niche within We’ve historically invited applicants to come visit us and medical education or unique aspects potential fellows interview in the fall — typically in October. We love the chance to should be aware of? show off our city — trust us, if you’ve never been to New England We’ve prided ourselves on building individualized programs in the fall, it’s amazing. Providence is a great little city, with so much for each of our fellows and helping each of them build the career more to offer than its size might suggest. they desire. We don’t try to shoehorn anyone into a one-size-fits- We’re hopeful that we’ll still be able to bring folks to us to all approach. interview, but travel may be tricky depending on how the COVID What are the different career paths that fellowship pandemic progresses — we’ll be offering virtual interviews as well. graduates from your program have taken after The CORD universal offer date was met with mixed reviews last graduation? year — we’re definitely involved in the conversation about how it will Our fellowship grads have been really well-positioned to take evolve for the coming year. Med ed fellowship directors met at CORD on leadership roles in medical education, from sitting on residency this winter, and we continue to stay up to date with that dialogue! committees, medical school curriculum committees, all the way to What are your thoughts on the value of a master’s positions in the medical school Office of Medical Education and degree in medical education? Does your program even deans! require it or accommodate fellows who want to A sample of positions/titles held by our graduates: pursue one? • Director of clinical skills training (4-year longitudinal “doctoring” A fully funded master’s degree is built into our fellowship course) program. We believe that this has high value in establishing • Chair of AAMC’s Northeast Group on Educational Affairs the foundation of understanding medical education theory and • Chair of AAMC’s Group on Educational Affairs national Grant practice, as well as in helping fellows develop a wide-reaching Award Program personal learning network and a robust professional identity • Assistant Dean for advising, Program in Liberal Medical as an educator. A master’s degree program helps augment the Education mentorship relationships we form with fellows. The combination • Course leader of formal education in health professions education plus the • Chair, SAEM Education Research Interest Group components of the fellowship program itself is really a win-win. What advice do you have for residents who are Together, this helps us develop education leaders. just starting to get involved in medical education, If a resident is interested in getting to know more especially residents who may not have a lot of about your program, what is the best way for them resources at their own program? to get in touch with you? Be on the lookout for opportunities to be involved! Medical Please reach out to me directly! I’m always happy to share schools in particular often love to have residents on board everything great we’ve got going on at Brown. I can also put as clinical skills teachers or mentors. Volunteer or campaign prospective fellows in touch with alumni of our program, faculty, or to represent residents and trainees on hospital or university others who might be helpful. [email protected] / @chris__merritt committees — graduate medical education committees or senates, on Twitter / brownmeded.org ¬

42 EMRA | emra.org • emresident.org HEART OF EM When Medicine Robs You Tiffany Proffitt, DO EMRA*Cast Host Spectrum Health Lakeland @ProMammaDoc

Induction Day books. But I did have my Step 1 book. I am fortunate to have them. But hen you are 38 weeks pregnant I didn’t open it, but it nagged me all medicine assumes that because I want to with twins, this day comes through the night, as I waited to bring my be a doctor, I don’t want to be a mother. with mixed emotions. But even children into the world. Medicine thinks I wanted to abandon my W The next morning, my OB/GYN children when they were tiny; 2 weeks more so when you are a second-year medical student about to sit for the first, discussed my failed induction, how my son old was the last time I was able to focus entirely on them. and most important, of your medical was having late decelerations and it would Medicine is more than dehumanizing. licensing boards. Step 1 determines which be safest if I underwent a c-section. I was Some days I cry to myself, some days I cry specialty you will match into and, often, secretly relieved because after finals week to my husband because I missed it all and your potential future earnings and career I was exhausted. After a night of no sleep I wish I could go back. I wish I could have longevity. At 38 weeks people would — made impossible by the uncomfortable position required to make sure the toco been present. I don’t think real maternity often ask, “Aren’t you ready to deliver?! monitors worked — I was exhausted. leave is too much to ask. You must be tired of being pregnant!” Then they were there, my son and It makes me so angry — actually, My answer: “Yes. No.” Yes, I was tired of daughter, the most important people in that’s not a strong enough word. carrying around 2 babies and not being my life next to my husband. And when Infuriated, enraged. They robbed me of able to sit behind a computer, steering they were 2 weeks old, when I was still the first month of my children’s lives. The wheel, stand up without a forklift, plus trying to figure out how to breastfeed, powerlessness of being a medical student I couldn’t remember the last time I saw how to pump, how to hold my 4 lb son, (whom medical schools and residencies my feet or was able to tie shoelaces. No, I had to leave them. Step 1 and clinical exploit) prevents us from asking for what because I had so much to do. I was glad rotations loomed; I had to study. we need. I had made it through my rigorous finals My mother and husband, who are What we need is an accommodating week, which consisted of 5 exams, 3 of ceaselessly supportive and loving, took system. I’m tired of being forced to be which addressed 2 years of cumulative over my role. grateful for scraps of humanity and equity. information in 1 week. But I digress. Now that I’ve finished residency, I I had made it. To 38 weeks. To my look forward to focusing on my family last final. It was a 7 am psychiatry exam; again. But I am infuriated and enraged by I woke up at 5 am, and my mother drove what I have lost. It eats away at me every me the hour each way to campus because day. The pain is palpable, physical, it tugs I didn’t fit behind the steering wheel. at the very fibers of my soul. It comes Then there was a clerkship orientation, unexpectedly and without conscious which I attended because I didn’t want thought. And then I have to go work a to give anyone a reason to dismiss me. shift or attend didactics or journal club THEN I was ready for my induction. I or a mandatory residency event when all exchanged my exam study materials for I want to do is hold my family. Breathe my maternity “go bag,” which included in my children. Feel the fine, soft hairs of my Step 1 prep book. their heads run through my fingers and This is how medicine robs you of the read them a bedtime story. most important moments of your life. This is not just my story. This is From before the moment my twins the story of being a parent in medical were born, I was distracted by medicine. training and an example of how Who brings a Step 1 prep book to labor/ medicine tries to rob us of what we delivery when they’re the patient? I didn’t cherish. Things are changing, but there have a birth playlist. I didn’t have baby is more work to be done. ¬

August/September 2020 | EM Resident 43 HEART OF EM Lord NRMP Match

“We are sorry, you did not match to any position.”

Matthew Caviness, MD to myself. I turned his oxygen up to 6L considered an alternative. While Saint Louis University School of Medicine and told him we would do everything we applying I had focused on programs near Class of 2020 could to make him more comfortable. my home in the Midwest. I had hit my ood morning, Matt. We I went to find my senior resident to number of interviews recommended. admitted 2 new patients discuss my concerns about abdominal I thought I had done all of the “right “G overnight. Why don’t you compartment syndrome, then prepared things” during the application and see this patient who presented last for rounds. interview season. night with pancreatitis?” My ICU senior It was an hour before match results “How could I have not resident suggested early on the Monday were set to be released. prepared for this? I don’t know of March 16. As we were rounding, results of where to apply. I don’t even know “Sure!” I responded, realizing this testing ordered by my resident after our what positions to apply to. Should I would be an excellent learning case. The discussion were back: our patient with switch fields and apply to a categorical ICU had been enlightening for furthering alcoholic pancreatitis had a bladder internal medicine position? Surgical or my understanding of emergency pressure of 25. A subtle, congratulatory medicine prelim? What the hell even is medicine. I had found myself immersed fist bump and a “Good job man, you a transitional year?” I asked myself as I in my cases. GI bleeding from esophageal called that one” made me feel like a furiously began familiarizing myself with varices, acute respiratory failure contributing member of the team. the SOAP. secondary to opiate overdose complicated Then the clock reached 10 am sharp. My phone rang and I was relieved by aspiration pneumonia, stroke in a My sense of success was short-lived. to see my advisor’s name flash onto the young female with Graves’ disease. Caring screen. “Hey Matt, it’s Dr. T. I heard the for these high acuity, and medically “We are sorry, but you did not news. I wanted you to know that everyone complicated patients was captivating. match to any position.” here in the department is shocked. This I went to see my new patient, a I heard the sound of the ice cracking was unexpected, but you should know we gentleman in his 50s with a past medical beneath my feet as I plunged into the are all here to help. Do you know Dr. C? history of alcohol abuse. He came to the cold depths of the unknown. “Is this a You may not have been aware of this, but ED overnight with abdominal pain and mistake? Surely, this wasn’t meant for he didn’t match during his first attempt shortness of breath, and was diagnosed me. Not even one program? I had hit the and went through the same process. I with pancreatitis secondary to alcohol recommended number of interviews. My think he would be a great help.” abuse; appropriate treatments were advisors had assured me of my chances. “Dr. C didn’t match? Dr. C, the administered. Immediately, as I walked We were never concerned.” The thoughts fellowship trained, POC ultrasound into the room, I became concerned. raced through my mind as I became educator and clerkship director?” I My patient was tachypneic, unable to increasingly pale and tachycardic. thought to myself. speak in full sentences, but was still But there was no time to process; the Within minutes I was on the phone maintaining adequate O2 saturations. clock had already started ticking on the with Dr. C. “Hey. Sorry to hear the news, Additionally, he had profound 3-hour window to apply to a maximum of Matt. I want you to know that a career abdominal distention. 45 programs listed in the SOAP process. in EM is still an option. I initially didn’t “This is the largest and most firm I realized I had put everything match and was able to successfully belly I have ever mashed on,” I thought into matching EM and hadn’t even reapply. Don’t lose hope on this. A career

44 EMRA | emra.org • emresident.org in EM is still a definite possibility for materials and prefilled program contact conversational manner than I had you. We think the best option for you is emails was ready. I was prepared for my previously experienced over the past to apply to surgery preliminary position final trial: the post-SOAP scramble. week. By the end of the interview I was or transitional year position and reapply I contacted my advisors about left with a good impression. next cycle.” the results of the final SOAP round. “What do you think about the idea I took a deep breath, mentally Everyone was standing by to advocate that when we get off the phone, I’ll have preparing for my next steps. I was not for me. my coordinator send you an offer and we going to drown... and I was not Then SOAP officially ended, the can both call it a day?” alone. laws of the Match were lifted, and the “I am ready to sign.” The next few days were a blur. I floodgates opened. Myself and my team It was Thursday, March 19, 4:35 pm. reviewed the 45 programs, submitted of superiors sprang into action. I made it. I was in. I was going to be my applications, and kept researching During the scramble, I received a included in tomorrow’s Match Day. the 45 possibilities while I waited. Phone waitlist offer, meaning I was next in line My transitional year at HCA interviews could happen at any time if another applicant declined during Healthcare West will be a welcome after application submission. This was an agreed-upon 1-hour timeframe. As experience in my journey to EM. not the type of “being on-call” I had I left voicemails, (and brightened the I was drawn into emergency pictured for myself. day of ERAS and American Express medicine for the same reason that I “Why do you think you stockholders by even paying more needed to share my story. This story didn’t match?” application fees) I received a call from is about the PEOPLE in emergency I began ruminating my answer to the waitlisted offer. medicine, where going above and beyond this standard question for people in my “We’re sorry, the other applicant is the norm. Throughout all of the chaos, position. “The match had failed me. accepted the position and we are now turmoil, fear, and uncertainty, I was Or maybe, I had failed the match.” I filled.” never alone. Emergency physicians thought as I recounted every decision I “We’re sorry, but you did not match embody the greatest heroes of fiction, had ever made. to any position” echoed in my overly venturing into chaos headstrong with I was standing before the all- caffeinated and sleep-deprived state of bravery. They are leaders fighting on the powerful judge, Lord NRMP Match. consciousness. front lines amongst a team of residents, My Judgment Day had arrived, and I realized it was time to go home scribes, nurses, students, social workers, I had been deemed unworthy. Exiled as the afternoon came to an end. I had law enforcement officers, pharmacists, uncaringly to the Underworld of the called programs, left voicemails, and EMS workers, and, thankfully, Unmatched. If Lord Match could be so emailed every program with unfilled unmatched EM applicants. callous, how could I hope for mercy from positions. Time to regroup and ponder Whether working against a his crony, Mr. SOAP? my promising future as a well-educated worldwide pandemic or rushing to the But then I got a phone interview for a Uber driver. aid of a code blue, emergency medicine preliminary position! It lasted 6 minutes That’s when I received a text from providers serve to keep the fibers of life, and 32 seconds. Brief, straightforward, Dr. C. “I just spoke to a program director humanity, and order from tearing apart. and formal. The questions were for a transitional year position. The PD While my journey is still uncertain, my standardized. My ambitions were framed is an EM doc and he’ll be calling you story and gratitude must be shared. around this snapshot interview. soon. Also, he mentioned the hospital is To me (and others in my position) the I checked my phone every few working on opening a new EM program. future is simple. Continue the fight seconds for some sort of contact. I hoped Hopefully, this is an opportunity for you.” through failure, chaos, and uncertainty. for an offer, an executive pardon, from “Is Dr. C really still advocating and Continue to learn and grow. Continue Mr. SOAP. The offer rounds passed making calls to programs for me? It’s so to exemplify these values inherent in as I commiserated with other lost, late in the day.” I had tried everything emergency medicine. And when the time unmatched souls in internet forums. without success. I had also started comes... look straight back into the cold My phone was silent. warming up to the idea of my life as Dr. eyes of Lord NRMP Match. My pleas to the Lords of the Match Uber. But Dr. C still had hope. I allowed Special Acknowledgment went unanswered. When the final round myself a brief, half-hearted flash of a I can hardly express my sincerest of offers concluded and I was not offered smile. gratitude, respect, and admiration a position, I turned to my spreadsheet of During the phone interview, I to the emergency medicine faculty at remaining unfilled positions. conversed with the program director Saint Louis University, but hopefully The spreadsheet was fully equipped for some time. I explained my thoughts this was a start. A special thank-you with program contact information, color on why I had failed to match and spoke to my advisors, Dr. Tina Chen and coding, and sectioning for programs of my ideas for the future. We talked former EMRA Board member Dr. Kene based on personal interest. My “spam” about the excitement of EM as a career. Chukwuanu, for their unwavering template email with my application I was able to ask questions in a more guidance and support. ¬

August/September 2020 | EM Resident 45 EMRA @ ACEP20 UNCONVENTIONAL

Leaving behind the limitations of travel, we’re going big! Join EMRA at ACEP20 for our regularly scheduled programming, with a twist!

EXCLUSIVELY FOR OUR ALL-EMRA PROGRAMMING ALL-EMRA PROGRAMMING (CON’T) REGISTER TODAY MEDICAL STUDENTS Mix and mingle with residents and faculty by taking For a full conference experience, we COMPETITIONS & MEDUTAINMENT Fall Medical Student Forum part in our all-EMRA programming! encourage registration to ACEP20. Note that ACEP20 registration is not Saturday, August 15 @ 9:30 am EMRA 20 in 6 Resident Lecture Competition required to sign up for EMRA events Register at emra.org/student-forum JOB SEEKERS October 28 @ 9 am and programming. Sponsored by Laurel Road Nobody predicted this current climate, and it’s an See emra.org/20in6 for watch party information ever-changing landscape. We’re here to help you Sponsored by Hippo Education EMRA Residency Program Fair navigate it, whether that means nding your rst for medical students seeking to job out of residency or your new job after a career Resident Case-Con acep.org/sa match at an EM residency change. October 27 @ 9 am September 26 – 27 #ACEP20 Check emra.org/case-con for event details Registration opens soon at emra.org/acep #EMRAatACEP20 EMRA Job & Fellowship Fair Sponsored by Laurel Road Dates coming soon EMRA Resident SIMWars

Registration opens soon at emra.org/acep October 29 @ 9 am Virtual Mock Interview Practice Sponsored by emCareers.org, TeamHealth, Vituity, Check emra.org/SIMWars for competition Dates coming soon and Laurel Road updates Visit emra.org/student-forum for information COMMITTEE PROGRAMMING Airway Stories October 27 @ 6 pm Stay tuned for event speci c details posted to Medical Student Case-Con Competition emra.org/acep Check emra.org/airwaystories for event details October 25 @ 9 am Check emra.org/case-con for event details EMRA ELECTIONS Sponsored by Vituity & REPRESENTATIVE COUNCIL October 26 Participate in our Representative Council and elect Programming Updates Times and dates are subject to change. members of the EMRA Board of Directors. All times listed are Central Time. @emresidents See emra.org/repco For more information, visit Sponsored by ACEP/PEER https://www.emra.org/acep EMRA @ ACEP20 UNCONVENTIONAL

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ABEM News ACEP Section of Medical Exam Updates Humanities Writing and Exam dates have been set for the 2020 online ConCert Exam administrations: July 27–Aug. 16 and Nov. 2–22 Visual Arts Awards The exam is online, open book, and taken without collaboration. The Section of Medical Humanities is It can be taken anywhere, anytime within the three-week testing period. View soliciting submissions for its 13th annual ABEM Exam Dates and Fees and Frequently Asked Questions on the ABEM Writing Awards. Eligible pieces are creative, website at abem.org for additional information. not scientific, works related to emergency Due to the ongoing COVID-19 pandemic, ABEM has made the difficult decision medicine published in print or online to postpone the fall Oral Certification Examination. It will not be offered at all in between September 2019 and August 2020. ABEM is discussing options for administering the examination in 2021 and 2020. Word count limit is 2500. Blog entries will share that information as soon as possible. will only be eligible if reconfigured and ABEM has developed a letter that physicians may provide to employers to submitted as an independently publishable verify they have successfully completed the Qualifying Examination and states that piece of creative writing. Self-nominations they are awaiting assignment to take the Oral Certification Examination. The letter or nominations of another ACEP member’s explains that ABEM has canceled the 2020 exams due to COVID-19 and deferred writing are both welcome. Poetry and prose the Oral Exam to 2021. Letters will be available in mid-July. Physicians can contact will be considered in separate categories. [email protected] to request a letter. ¬ Limit 2 pieces per person. The Section of Medical Humanities is ABEM Selects Inaugural Members of Resident Ambassador Panel also soliciting submissions for its 7th annual • Haig K. Aintablian, MD Visual Arts Award. This is an opportunity • Alaa M. Aldalati, MD for artists to show off their paintings, • William Spinosi, DO photography, etc. Submit a digital image or Panel members will provide a resident perspective to certain ABEM activities, such file of the visual art (photograph, sculpture, as applying for certification, the Residency Visitation Program, and the ABEM website. textile, pottery, painting, etc). Limit 2 pieces They serve 2-year terms beginning July 1, 2020. per person. Additional information about the Resident Ambassador Panel is available on the Submissions for both awards are ABEM website. ¬ accepted from any member of ACEP or affiliated organization (EMRA, SEMPA). EMRA to Elect 5 New Board Members Submissions will be voted on by the The EMRA Representative Council elects new members to the Board of Directors members of the Section of Medical each year, and applications are now open for the 2020 elections. Humanities. Nominations should be emailed Anyone who is a resident member in good standing on the day of elections to Tracy Napper ([email protected]) before is eligible to seek a board position. The deadline to declare candidacy is Sept. Sept. 14. Submissions will be blinded before 12. Apply online at www.emra.org/be-involved/be-a-leader/become-a-board- being sent to the judging panel. ¬ member/guide-for-emra-elections/#applytobod. In 2020, the following board roles will be up for election: • President-elect: This is a 3-year term, with one year spent in each successive role (president-elect, president, immediate past president/treasurer). Prior leadership experience is strongly encouraged. • Vice Speaker of the Council: This is a 2-year term, with one year spent as vice speaker and the following year as Speaker of the Council. In this role you work closely with the Representative Council and the policy-making procedures of the association. • Resident Representative to the ACEP Board of Directors: This 2-year term requires As emergency physicians, residents, nurses, presence and participation not only at EMRA Board events, but also as an ex-officio physician assistants, and medical students, member of the ACEP Board of Directors. Prior leadership experience is strongly we are servant leaders in our communities. encouraged. We care and advocate for our patients while • Director of Leadership Development: This is a 2-year term, during which the board member works closely with EMRA’s 20 committees and EMRA representatives to working clinically. We also respond to the call ACEP Sections, helping develop leadership opportunities for residents within the to give back to the communities we serve. association and the specialty. The EM Day of Service was created with this • Director of Health Policy: This is a 2-year term focused on representing EMRA in essential concept in mind. policy circles, keeping EMRA members apprised of and engaged in policy initiatives, The EM Day of Service is a specialty-driven and serving as an organizer of the annual EMRA/YPS Health Policy Primer that kicks event where emergency care providers identify off the ACEP Leadership & Advocacy Conference each year. community needs and volunteer to address Serving on the EMRA Board requires support from your program. Clear expectations those needs. and descriptions of the time and travel commitments connected with board service Events take place throughout September. can be found at www.emra.org/be-involved/be-a-leader/become-a-board-member. Please share your efforts and tag us with Elections will be held during the Fall RepCo Meeting, Oct. 26. Make sure your #EMDayofService. For ideas and details visit program is represented; sign up your voting rep at emra.org/repco-program- https://www.emra.org/be-involved/events-- update-form and get meeting details at emra.org/repco. ¬ activities/em-day-of-service. ¬

48 EMRA | emra.org • emresident.org CARDIOLOGY ECG Challenge Brett Jennings, DO Jeremy Berberian, MD ChristianaCare Associate Director of Resident Education Dept. of Emergency Medicine, ChristianaCare @jgberberian

CASE. A 57-year-old male presents with AMS. He is minimally responsive and there is no additional history available. His initial heart rate was 25 with a blood pressure of 80/30. What is your interpretation of his ECG.

What is your interpretation of his ECG? See the ANSWER on page 50

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August/September 2020 | EM Resident 49 CARDIOLOGY ECG Challenge This ECG shows an irregular wide complex rhythm with an average ventricular rate of 72 bpm, right axis deviation, no discernable P-waves, and a prolonged QRS duration at 200 ms with an intraventricular conduction delay. These findings, in particular the very wide QRS complexes with bizarre morphologies, are consistent with hyperkalemia Hyperkalemia Presentation and Etiologies Hyperkalemia is a common and a potentially life-threatening electrolyte disorder in patients presenting to the Emergency Department. Although severe cases may be associated with paralysis and cardiac arrest, symptoms in the majority of cases are nonspecific, including muscle pain/weakness, nausea, vomiting, and abdominal pain.1

The major causes of hyperkalemia potassium influx into cells, and enhancing • Dose: 10 units regular insulin IV with can be categorized into two groups: potassium excretion. 25-50 g (1-2 amps) 50% dextrose solution conditions which impair the Calcium • Onset of action: 10-30 min elimination of potassium, such as renal • Temporarily stabilizes the cardiac • Duration: 2-6 hours insufficiency or medications interfering membrane by counteracting with urinary excretion (spironolactone, potassium’s depolarizing effects Albuterol NSAIDs, ACEI) and those conditions • Calcium gluconate via peripheral IV • Shifts potassium from serum into that cause the extracellular shift of or calcium chloride if central venous cells potassium, such as digoxin or beta- access is obtained • Usually given via a nebulizer and can blockers, acidosis, diabetes induced • Dose: 1 amp of calcium gluconate be administered prior to obtaining IV insulin decrease, and the tissue (10 mL of 10% solution) every 3-5 min access breakdown seen in rhabdomyolysis. until ECG normalizes • Dose: 10-20 mg nebulized over Hyperkalemia ECG Findings • Onset of action: < 3 min 10-30 min The earliest electrocardiographic • Duration: ~20-50 min • Onset of action: 15-30 min • Duration: 2-4 hours finding in hyperkalemia is typically Insulin and Dextrose peaked T waves. As serum potassium • Shifts potassium from serum into cells Diuretics and Dialysis levels rise, the PR interval lengthens, • Effect is dose-dependent, and the • Both eliminate potassium from the P waves flatten and can eventually dosage of dextrose should be adjusted body disappear entirely, and the QRS per the patient’s serum glucose level • Dialysis is the most effective and widens with the development of and risk factors for hypoglycemia reliable method for the definitive bizarre QRS morphologies. Severe (renal insufficiency, use of medications treatment of hyperkalemia, especially hyperkalemia can lead to bradycardia, for diabetes, etc.) for patients on dialysis loss of SA nodal conduction, the development of the classic “sine wave” morphology, and, ultimately, Repeat ECG after Treatment asystole. In short, the ECG changes seen with hyperkalemia progress as if the entire P-QRS-T complex were being pulled at both ends like a string. It is important to note that although the most severe cardiac manifestations of hyperkalemia have been shown to regularly occur at serum potassium concentrations greater than 9 mEq/L, ECG abnormalities do not always correlate reliably with serum levels and clinical decompensation can occur without profound changes in potassium concentration.1 Hyperkalemia Treatment The initial goals in the treatment of hyperkalemia are stabilizing the cardiac membrane, promoting

50 EMRA | emra.org • emresident.org VISUAL DIAGNOSIS

• Loop diuretics, such as furosemide, promote potassium excretion via the HYPERKALEMIA LEARNING POINTS kidneys and can be considered in the • EKG is specific but not sensitive for — Conduction abnormalities (AV blocks, appropriate clinical scenario hyperkalemia fascicular and bundle branch blocks) Cation Exchange Resins • EKG changes are not always — Sinoventricular rhythm (loss of • Includes sodium polystyrene sequential/progressive and include: P-waves, extremely widened QRS) with sulfonate and patiromer — Tall, narrow, peaked T-waves normal or slow rate • Bind potassium in the GI tract to (best seen in precordial leads) — Ventricular dysrhythmias prevent absorption — P-wave flattening and PR • Treatment goals include: • Onset of action is hours to days, so interval prolongation — Stabilization of the cardiac membrane not indicated for acute hyperkalemia — Widened QRS with bizarre — Promote potassium influx into cells treatment morphology — Enhance potassium excretion Of note, though bicarbonate was traditionally considered an element of the hyperkalemia treatment regimen, Case Conclusion there is no literature to suggest a benefit The patient’s initial labs were notable for a potassium of 7.9 mEq/L. This was treated when used in patients with hyperkalemia with 3 g of calcium gluconate, 10 units of insulin, 1 amp of dextrose, and a 15 mg with normal pH. Bicarbonate infusions albuterol neb, after which his mental status and vital signs improved. A repeat ECG may have a role in the treatment was obtained (see image) and showed resolution of the multiple abnormalities seen of academia in patients who are on his initial ECG. The patient was admitted to the hospital for further treatment of his concurrently hyperkalemic. hyperkalemia. ¬

What is your diagnosis?

Frances Rusnack, DO, MS Emergency Medicine Resident Mount Sinai St. Luke’s Roosevelt @FrancieRusnack

A 42-year-old female with a history of bipolar disorder and genital herpes presents with a diffuse rash for 1 month. She reports the rash is red, nonpruritic, and nontender. It started on her chest and spread to now involve her face, trunk, extremities, palms, and soles. She endorses associated diffuse joint pain as well as fevers, sore throat, nausea, vomiting, mild headache, and intermittent blurred vision. Current medications include clonazepam, haloperidol, and clozapine without recent changes. She is sexually active with multiple partners. Physical exam is notable for a diffuse non- blanching papular rash, lateral tongue ulceration, and minimally reactive pupils to light and accommodation. There are no genital lesions and her neurological exam is otherwise unremarkable.

See the DIAGNOSIS on page 52

August/September 2020 | EM Resident 51 VISUAL DIAGNOSIS Assessment Syphilis Her ED presentation was concerning for secondary, and possible tertiary, syphilis with neurologic manifestations. She had biopsy results from a week prior that confirmed a syphilitic rash. HIV testing was negative. Rapid plasma reagin test (RPR) was reactive, as well as serum fluorescent treponemal antibody absorption test (FTA-ABS). Cerebrospinal fluid Venereal Disease Research Laboratory (VDRL) tear was negative. Ophthalmologic examination was negative for ocular complications of syphilis. The patient was treated for secondary syphilis and discharged to follow up as an outpatient. Discussion Syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum and is known clinically to be “the great pretender” or “imitator.”1 Syphilis is categorized into 4 stages: primary, secondary, tertiary, and latent.1 Primary syphilis is characterized by a painless chancre.1 Secondary syphilis develops weeks later and includes a papulosquamous rash that can involve the palms and soles.1-3 This stage can also have systemic symptoms of sore throat, malaise, fever, and headaches.2 Tertiary syphilis occurs years later and can involve multiple organ systems, notably the nervous and cardiovascular systems.2 Latent syphilis indicates positive testing without clinical manifestations. This is further subdivided into early latent phase if infection occurred within the past 12 months and late latent phases if infection occurred more than 12 months prior.2 Treatment Primary, secondary, and early latent stages of syphilis are treated with a one-time intramusuclar dose of penicillin G benzathine, 2.4 million units.3 Doxycycline 100 mg BID for 14 days can be used as an alternate therapy if patients have penicillin allergies. 3 Pregnant women that have penicillin allergies require desensitization.3 Late latent syphilis, latent syphilis of unknown duration, or tertiary syphilis with normal CSF studies should be treated with intramusuclar penicillin G benzathine, 2.4 million units weekly for 3 weeks.3 Neurosyphilis and ocular syphilis are treated with parenteral/aqueous crystalline penicillin G 3-4 million units every 4 hours (18-24 million units per day) for 10-14 days.3 Repeat serologic testing should be done to ensure improvement.3 ¬

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52 EMRA | emra.org • emresident.org Reference available online PEER Board Review on IXsale! Questions

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” at emresident.org Order PEER at acep.org/peer . 1. A 54-year-old man with a history of diabetes, hypertension, and smoking presents complaining of dizziness since he woke up this morning. He says he feels like the room is spinning. He is also nauseated and cannot stand or walk without falling to the right. He denies numbness or weakness and is unable to complete finger-to-nose testing. Which vessel is most likely occluded? A. Anterior cerebral artery B. Cerebral venous sinus C. Middle cerebral artery D. Posterior inferior cerebellar artery

2. What is definitively seen in cardiac tamponade? A. Electrical alternans B. Inferior vena cava collapsibility C. Pulsus paradoxus D. Right ventricular diastolic collapse 3. Which condition is the most likely cause of widened mediastinum in a patient who has been experiencing weight loss and fatigue for several weeks? A. Burkholderia cepacia B. Pseudomonas aeruginosa C. Staphylococcus aureus D. Streptococcus pneumoniae 4. Systemic toxicity is most likely to occur after topical dermal exposure to which acid? A. Acetic acid B. Hydrochloric acid C. Hydrofluoric acid D. Sulfuric acid 5. Which physical examination finding indicates a cribriform plate fracture as a serious complication of trauma to the face and nose? A. Clear nasal discharge B. Epistaxis C. Hemotympanum

D. Septal hematoma ¬

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

August/September 2020 | EM Resident 53 OCTOBER 26-29•2020 Join Us for a Unique Digital Experience REGISTRATION NOW OPEN! These unprecedented times call for an unconventional ACEP20. After thoughtfully considering many different options and ideas, ACEP has made the decision to move ACEP20 to an exclusively digital experience. Join us online this year for a fully virtual event with education, engagement and excitement, culminating with a digital emergency medicine experience that will be so much more than a convention this October! More details will be released soon as the ACEP annual meeting evolves in exciting new ways. And while the delivery may be different, you can expect the same expert education and CME credit from the world-class faculty you respect. We are thrilled to embrace the innovation and are committed to keeping ACEP20 the best educational experience, bar none.

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54 EMRA | emra.org • emresident.org CLASSIFIED ADVERTISING The COVID Corner: CALIFORNIA Ventura: Newly constructed hospital and ER department Managing Money, functioning since December 2018. Practice with a stable ER group on the central coast of California and only 70 miles from LAX. Positions available in two facilities for BC/BE emergency in the Midst of Mayhem physician. Main facility is a STEMI Center, Stroke Center with on-call coverage of all specialties. This is a teaching facility It’s not all doom and gloom, with residents in Family Practice, Surgery, Orthopedics and Internal Medicine. Admitting hospital teams for Medicine and there are practical opportunities Pediatrics. 24-hour OB coverage in house and a well-established NICU. Annual volume is 48K patients with nearly 70 hours of for house staff on the front lines: coverage daily and 12 hours of PA/NP coverage. All shifts and providers have scribe services 24/7. Affiliated hospital is a smaller rural facility 20 minutes from Ventura in Ojai. Malpractice TAXES and tail coverage is provided. New hires will work days, nights, weekends and weekdays. Come work with a well-established Tax Deadline pushed back to 9/15/2020 high caliber group with expected volume growth potential at our new facility. Enjoy the life style of a beach community yet OPPORTUNITY: Extended time to fund 2019 outside the hustle of the LA area. Please send a resume to Alex SEP IRA and reduce 2019 tax liability, fund Kowblansky, MD, FACEP [email protected]. Roth or Back Door Roth for 2019 and 2020, Mammoth Lakes: Small independent group looking for a full- time night doctor. Amazing place to work. World-class skiing, accumulate funds to pay for 2019 tax bill mountain biking, climbing, fishing, hiking, and lakes in the if necessary. beautiful eastern sierra mountains. Very flexible scheduling options in a nice friendly ED that is not that busy most of the time. Low patient volume at night. Reasonable pay. Contact STUDENT LOANS David Bassler at [email protected]. Must be BC/BE. Federal payments and interest suspended for six months OPPORTUNITY: Redirect former payments to higher interest debt, building cash savings or funding that 2019 Roth IRA that you didn’t WASHINGTON DC The Department of Emergency Medicine at the think was possible! George Washington University is offering FELLOWSHIP positions beginning July 2021 DISABILITY INSURANCE Clinical Research Operations Research Disaster & Operational Medicine Simulation in Medical Education Insurance companies are working to Emergency Ultrasound Sports Medicine adapt to changing conditions Health Policy Telemedicine/Digital Health International Emergency Medicine Ultrasound for Family Medicine OPPORTUNITY: Most companies allowing Medical Leadership & Operations Wilderness Medicine up to $10,000/month without any medical Medical Toxicology Wilderness & Telemedicine exam. Discounted House-staff programs still Combined Fellowship The George Washington University Medical Faculty Associates, an available. Take advantage of this! independent non-profit academic clinical practice group affiliated with The George Washington University, is seeking full-time academic Emergency Medicine physicians. The Department of Emergency Medicine (http:// Let us help you, help yourself. smhs.gwu.edu/emed) provides staffing for the emergency units of George Washington University Hospital, United Medical Center, the Walter Reed National Military Medical Center, and the Washington DC Veterans Administration Medical Center. The Department’s educational programs include a four-year residency program and ten fellowship programs. Fellows receive an academic appointment at The George Washington University School of Medicine & Health Sciences and work clinically at a site staffed by the Department. The Department offers Fellows an integrated, interdisciplinary curriculum, focusing on research methodologies and grant writing. Tuition support for an MPH or equivalent degree may be provided, as www.emra.org/benefits/Integrated-WealthCare/ per the fellowship’s curriculum. Complete descriptions of all programs, application instructions, and Fellowship Connect with us @IWCAdvisor Director contacts can be found at: https://smhs.gwu.edu/emed/education-training/fellowships

August/September 2020 | EM Resident 55 Academic & C o m m u n i t y Whatever professional experience you’re looking for, you can find it with the Department of Emergency Medicine, all backed by the support and prestige of the University of Maryland. Our hospitals are located across the state of Maryland, offering cutting-edge care in rural, urban, and suburban communities.

Practice Regions and Ann ual Volumes B altimore City 32,000 - 66,000 North of Baltimore 32,000 - 65,000 The Suburbs of DC 34,000 - 60,000 The Eastern Shore 15,000 - 37,000

We offer a very generous compensation and benefits package, including: Additional incentive compensation Medical, dental, vision, and life insurance Employer-paid CME, PTO, and 401K safe harbor retirement plan Employer-paid malpractice insurance with full tail coverage Contact us at: [email protected] or (667) 214-2060

Are you prepared? Physician’s Evaluation and Educational Review in Emergency Medicine PEER questions and Personalized learning Subcribe today at Visual learning aids answer explanations are Continually updated content acep.org/PEER “closest to the boards.” Claim-as-you-go CME credit

“I have used the PEER series for both my initial board certification and my ConCert. I have never been 100% a great test taker, but the practice, layout, and questions helped me feel ready for test day. PEER is an Money-Back integral tool in the preparation process.” – Ryan Stanton, MD, FACEP Guarantee*

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

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56 EMRA | emra.org • emresident.org THANK YOU for the remarkable work and sacrifices you are making during the COVID-19 pandemic. You refused to indulge fear as you put the needs of others before your own.

Join our team teamhealth.com/residency 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

In the turbulent sea of healthcare one thing will never change.

We are the captains of our ship. Always have been and always will be. At USACS, every full-time physician that comes aboard our ship becomes an owner. Our mutiny-proof ownership model ensures patients will always come first, and we’ll be well equipped with everything we need for the best voyage: outstanding benefits, incredible work-life balance, and legendary camaraderie. Best of all, physicians maintain majority control.

At USACS, we love what we do and the crew we’re sailing with.

See why ownership matters at USACS.com

Positions available now. Visit USACS.com or call Darrin Grella at 844-863-6797. [email protected]