Is Moonlighting Right for You?

RResidentOfficial ePublication ofsident the Emergency Medicine Residents’ Association February/March 2020 VOL 47 / ISSUE 1 Is Moonlighting Right for You?

US-Guided Supracondylar Blocks The Heart of EM: A New Opportunity Pulmonary Hypertension in the ED RICHARD LOGUE, MD, FACEP EMERGENCY MEDICINE

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For more information, contact: 877.226.6059 [email protected] I still vividlyThe remember, as a second-year medical student, my attending gushing over EMRA and its resources being a benefit not only to medical students interested in emergency medicine,Heart but also to medical students interested in any specialty.of That EMwas my hook into EM. It started with EMRA.

Priyanka Lauber, DO advantage of residents and attendings. up and have made intentional actions, I Editor-in-Chief, EM Resident We need to have the hard conversations: see a positive change that not only benefits Lehigh Valley Health Network let’s talk about an accurate count of duty me, but also effects positive downstream @PriyankaLauber hours, fair and appropriate treatment, improvements unbeknownst to me. appy New Year to my EM and accountability when poor behavior is I have always said personal stories Resident family! The holiday demonstrated by staff/consultants/etc. and the written word are both incredibly Hseason is over. Christmas/ The latest survey by the American powerful. Hanukkah/Kwanzaa/Diwali has passed Medical Association (AMA) demonstrated Thus, I am starting a NEW and most of us have finally recovered that 2 in 5 physicians screen positive series in EM Resident where from our new year’s eve celebrations. for depression. Medical students were residents, medical students, Although many are a little disappointed also noted to be 3 times more likely to and attendings can share their the festivities have ended, there are die of suicide than their counterparts in stories: “Heart of EM.” I want to people out there who are not. Studies the general population. Why is this hear about your struggles, your have demonstrated that the holiday happening? Are we good advocates failures, and your triumphs. season can exacerbate the feelings of for ourselves, attendings, fellow co- Even if you tried and failed, I loneliness some individuals face on a residents, and medical students? welcome it. Please share your daily basis. Medical students, residents, How can we do better? experiences, even if you don’t want and some attendings are no strangers to Over the past several years, like many to share your name (requests feelings of desolation. We are often in of us, I’ve endured instances that positively for anonymity will be honored). a juxtaposition where, although we are and negatively affected my well-being. YOUR stories are humanizing and surrounded by people (hospital staff, Times I felt supported and others not. will help connect all of us globally patients, mid-levels, doctors) all day, we Times I have been quiet, as not to upset through shared experiences and do not encounter meaningful or quality the status quo, and others I have loudly emotional intermediaries. conversations that involve us. spoken up for myself and others. Serendipitously, we already had a When I ran for the EMRA Board, my The times I have been the most submission for this edition that will help speech involved talking about this subject proud, of course, are the times that I have kick-start this new series (“Grab a Shovel” in the context of “mental health.” Better demanded a change and actually witnessed — and your tissues, fair warning). Take mental health and wellness, it seems, and experienced the transformation. a moment to read it. Take a few more to involves increasing grit, utilizing deep Through these experiences, I have realized, add to the conversation. breathing, and incorporating yoga from residents have an innate power in our We are always looking for relevant what most of us have been told repeatedly. hospital systems. We have the combined content, so if you a compelling case you I believe we are missing some foundational support of our co-residents, faculty (core would like to share or a personal story, conversations involving the culture of and not), program directors, designated email me at [email protected]. medical training and organizational institutional officials (DIOs), ACGME, and I am looking forward to making our medicine — a culture that is ripe to take EMRA. I have realized that when I speak specialty feel more connected. ¬

February/March 2020 | EM Resident 1 B:8.75" T:8.5" S:8" B:11.25" S:10.5" T:11"

FOR SOME OF OUR MOST ELITE SOLDIERS, THIS IS THE FRONT LINES.

As an ofﬁcer working in Emergency Medicine for the U.S. Army health care team, you’ll be on the front lines of medical innovation, practicing in world-renowned hospitals, clinics and health care facilities with access to the most sophisticated medical equipment in the ﬁeld. With over 90 medical career specialties to choose from, you’ll have the opportunity to participate in humanitarian efforts, learn innovative techniques and make a real difference in the lives of Soldiers and their families.

To see the beneﬁ ts of being at the forefront of Army medicine call 800-431-6717 or visit https://www.goarmy.com/amedd.html

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TABLE OF CONTENTS

4 What Can We Do When The Echogenic Kidney EDITORIAL STAFF a Residency Closes? 26 RENAL/NEPHROLOGY EDITOR-IN-CHIEF PRESIDENT’S MESSAGE End the Glow! Priyanka Lauber, DO Emergency Medicine 28 CARDIOLOGY/RADIOLOGY Lehigh Valley Health Network 5 Residents Oppose Pediatric EDITORIAL TEAM the Sale of Graduate 29 Brian Freeman, DO Medical Education Slots Nasopharyngeal Tumor Lakeland Health PEDIATRICS LEADERSHIP REPORT Meghan Gorski, DO Albert Einstein Medical Center How to Fund Your 30 Tactical Medicine: 7 An Evolving EM Whitney Johnson, MD Program’s EMRA UCSF-Fresno Representative Subspecialty Jeremy Lacocque, DO LEADERSHIP REPORT PREHOSPITAL & DISASTER MEDICINE UCSF EMS Fellow 10 Ways You Can Mahesh Polavarapu, MD 9 Help End Trafficking 33 Lessons Learned ChristianaCare LEADERSHIP REPORT the Hard Way on Jason Silberman, MD International Expeditions University of Tennessee How Do You Know 10 INTERNATIONAL Daniel Bral, DO If You’re Ready University of Rochester To Moonlight? 35 Clinical Pathways CAREER TRANSITIONS in the ED MSC Editor B:11.25" S:10.5" T:11" ADMIN/OPS Samuel Southgate Gastric Perforation University of Connecticut 12 after Liquid Nitrogen Demystifying the EM 36 ECG Faculty Editor Ingestion to PEM Journey Jeremy Berberian, MD TOXICOLOGY CAREER TRANSITIONS ChristianaCare Ultrasound Guided 39 Grab a Shovel PEM Faculty Editor 14 Supracondylar Nerve HEART OF EM Yagnaram Ravichandran, MBBS, MD, FAAP Blocks for Reduction Dayton Children’s Hospital Pediatric ED Why EM Should Lead Clinical Asst. Professor of Pediatrics of Distal Radius Fractures 40 the Charge for Wright State University NEURO/ ULTRASOUND Foreign Policy Debate Toxicology Faculty Editor FOR SOME OF OUR MOST ELITE SOLDIERS, Defusing Ectopic OP-ED David J. Vearrier, MD, MPH, FACMT, 17 Pregnancy FAACT, FAAEM THIS IS THE FRONT LINES. EM Leaders of Tomorrow OB/GYN 42 As an officer working in Emergency Medicine for the U.S. Army health care team, you’ll LEADERSHIP REPORT be on the front lines of medical innovation, practicing in world-renowned hospitals, clinics CRASH-3: TXA for TBI EM Resident (ISSN 2377-438X) is the and health care facilities with access to the most sophisticated medical equipment in the 20 News & Notes field. With over 90 medical career specialties to choose from, you’ll have the opportunity CRITICAL CARE 45 bi-monthly magazine of the Emergency to participate in humanitarian efforts, learn innovative techniques and make a real ABEM Announces Advanced Medicine Residents’ Association (EMRA). difference in the lives of Soldiers and their families. Primary Cardiac Synovial Ultrasound Fellowship The opinions herein are those of the authors 22 Program Requirements, To see the benefi ts of being at the forefront of Army medicine call 800-431-6717 Sarcoma Complicated and not of EMRA or any institutions, or visit https://www.goarmy.com/amedd.html Upcoming Events and more organizations, or federal agencies. EMRA by a Malignant encourages readers to inform themselves Pericardial Effusion 47 ECG Challenge fully about all issues presented. EM Resident CARDIOLOGY INTERPRET AND DIAGNOSE reserves the right to edit all material and does not guarantee publication. Board Review 24 A Case of Pulmonary 51 © Copyright 2020 Hypertension in the ED Questions Emergency Medicine Residents’ Association PULMONOLOGY PEER ASSISTANCE February/March 2020 | EM Resident 3 ©2020. Paid for by the United States Army. All rights reserved.

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File Name ARMCOR_P5167_Front_Lines_F.indd Document Path DDB:US_Army:Active_Work:ARMCOR_US_Army:ARMCOR_P5167_McCann_Ad_resize:Mechanicals:Medical_Corp:ARMCOR_P5167_Front_Lines_F.indd Revision # 0 Links Fonts Inks Creative Date Created 1-9-2020 1:58 PM CNY_MCE-ARMY-HI-2355_V2.tif (CMYK; 377 ppi; 106.05%), ARMYAlrv4cwoTag_Patch_.ai (16.48%) Slug Font Myriad Pro Family Cyan Account Group Saved 1-10-2020 3:04 PM Minion Pro (Regular; OpenType), Magenta Print Producer [email protected] Printed 1-10-2020 3:06 PM Interstate (Regular, Light; OpenType) Yellow Lead Digital Artist matt holzman Print Scale None Black Digital Artist jenny smith InDesign 2020 Retoucher _ Notes MATS Due: 1/10/20 Proofreader PRESIDENT’S MESSAGE What Can We Do When a Residency Closes? Hannah R. Hughes, MD, MBA President, EMRA University of Cincinnati @hrh_approved “[I] moved across the country for a program that I really liked, bought a house, [and] began setting down roots...” As interview season ends and Match Day nears, the excitement of where to train and what that envelope will say is palpable. “...but now this wonderful program is closing at no fault of the program itself or the hard-working residents/staff that comprise it.” Craig Jones, DO, PGY-3 Ohio Valley Medical Center When the incoming class of EM residents open those envelopes this spring, how many will be plagued by the fear of a program’s insolvency? What are we — their seniors, their peers, and organized medicine overall — doing about it?

magine yourself 11 months away from medicine” at my first EMRA event. So Compendium and produce a Resident’s graduating residency when you find it certainly wasn’t because I envisioned Bill of Rights to address protections for Iout your hospital is closing. Instead of running for EMRA President. My answer residents. Similar resolutions were also gearing up for your first job interviews, is quite simple: I am an advocate — an passed through ACEP and AMA. The All- you’re now left trying to figure out advocate for increasing the diversity of EM Resident Organizations and Students where you can complete the rest of your emergency medicine, for pay equity, group (AEROS), which was convened training. Will you graduate on time? Will and for improving health care access for by EMRA in 2018, released a joint you have to sell your house? Will you still underserved communities. statement in this issue of EM Resident have a paycheck to cover bills? Perhaps terms such as “feminist” and because “having residents and fellows on Imagine the fear, the uncertainty, the “social justice warrior” have taken on staff at an institution is a privilege, not a anger. pejorative tones, but I am proudly both. commodity.” That’s what a number of emergency Being surrounded by other emergency Despite these efforts, along with medicine residents went through these physicians-in-training who are passionate those of other organizations such as past few months, not just at Drexel/ about improving the future of our ACGME, CORD, and the Pennsylvania Hahnemann University Hospital in specialty and medicine as a whole is my Medical Society, there is still plenty Philadelphia but also at Ohio Valley answer to “Why EMRA?” of work to be done, as Hahnemann Medical Center.1 The same occurred for Over the past several months with residents still face a potential gap in emergency medicine residents in 2017 the closure of both residencies, EMRA their medical liability coverage months at Summa Health in Northeast Ohio, has played an active role in advocating after displacement. following failed contract negotiations.2 on behalf of residents who have faced Get angry or get inspired; either More residents will be affected if interrupted training and financial, way, get involved. With 20 committees we don’t take action. Enter organized regulatory, and legal barriers to and more than 120 funded leadership medicine. continuing education. positions, EMRA has a place for you *** Through EMRA’s Representative to make a difference. We have a voice People often ask me why I got Council, which democratically represents that, when raised in unity, can lead to involved in EMRA. To be honest, I wasn’t all EM residencies in the country, a positive change for ourselves, our future even familiar with the term “organized resolution was passed to amend our Policy colleagues, and our specialty.

“I never thought I would have to cold-call programs to finish my residency but, here we are,” ended Craig’s email to me. His story is heart-wrenching, but this doesn’t have to be the future of emergency medicine. ¬

4 EMRA | emra.org • emresident.org References available online LEADERSHIP REPORT

PHOTO COURTESY OF WHYY Emergency Medicine Residents Oppose the Sale of Graduate Medical Education Slots Dhimitri A. Nikolla, DO Statement not a commodity. GME slots are Immediate Past President n June 30, 2019, Philadelphia scarce because of the 1997 cap on American College of Osteopathic Emergency Medicare support; however, residents Physicians Resident Student Organization Academic Health System, LLC (ACOEP-RSO) filed for Chapter 11 bankruptcy, and fellows play a critical role in the 5-8 @DhimitriNikolla O care of underserved patients. The which left 570 residents and fellows care residents and fellows provide Hannah R. Hughes, MD, MBA in training at Hahnemann University is billed for by their institution. President Hospital scrambling for new sites to Emergency Medicine Residents’ Association However, the primary responsibility of work and train.1-2 On Sept. 5, 2019, the @hrh_approved residents and fellows is to train in their sale of Hahnemann’s Graduate Medical Allison Beaulieu, MD chosen specialty to learn to practice Education (GME) slots for $55 million Resident Member-at-Large independently, not generate revenue. was approved by U.S. Bankruptcy Judge Council of Residency Directors Though GME slots are linked to their in Emergency Medicine Kevin Gross despite disapproval by the institutions and may be transferred Haig Aintablian, MD Centers for Medicare and Medicaid in the event of a change in hospital President Services (CMS), which considered it ownership, they are not an asset to be American Academy of Emergency Medicine illegal.3 After an appeal by CMS, on Sept. Resident and Student Association sold. (AAEM/RSA) 16, 2019, a federal judge temporarily Our organizations oppose the stopped the sale of Hahnemann’s GME commoditization of GME slots and Nehal Naik, MD 4 President slots. commend the efforts of CMS to halt Society for Emergency Medicine Residents Having residents and fellows on the sale of Hahnemann’s residency and and Medical Students (SAEM-RAMS) staff at an institution is a privilege, fellowship slots. ¬

February/March 2020 | EM Resident 5 SPONSORED

Making the Experience of Practicing Medicine Matter

Alicia Mikolaycik Kurtz, MD, is a Vituity Partner and assistant ED medical director at “ I didn't want more salads. Mercy San Juan Medical Center in Sacramento, Sometimes I just wanted CA. She was named one of EMRA’s 45 under 45, previously served as president of EMRA, and to make it through the completed Vituity’s Adminsitrative Fellowship. day without crying.”

As an Administrative Fellow with Vituity, I was able to further develop Real Talk as a program. In the Humans have been telling stories since the very past two years as a Vituity Partner, I’ve brought it beginning. It’s how we innately process our to healthcare teams across the country. And a few experience in the world — the joys, sorrows, months ago, I launched the Real Talk Podcast in the surprises, and humor. We tell our friends and hope of bringing the healing power of storytelling families our stories. And yet in medicine, we to physicians everywhere. rarely pause to talk about our experiences. Storytelling is especially powerful for healthcare Sure, we have plenty of opportunities to share our providers because so few people outside our profession cases, do quality review, and reflect on our mistakes. understand what our jobs are really like. By sharing our But we rarely talk about how it all feels. We don’t stories, we bring dignity, meaning, and significance to discuss what it’s like when our patient dies, when a our experience, honoring our human side without child is sick, when we witness a miracle, or what it’s seeing it as a sign of weakness — letting vulnerability like to be a part of a team that literally saves lives. be accepted and celebrated amongst our teams.

I was given a lot of wellness advice when I was a resident. Much of it involved eating healthfully, Impact of Real Talk doing more yoga, and taking advantage of the organization’s wellness program. How does Real Talk change the way we practice medicine? Anecdotal evidence suggests that the Meanwhile, I was working 80 hours a week in a very experience is a powerful one. When the 40 residents intense environment. I didn’t want more salads. in our program completed a survey that ranked the Sometimes I just wanted to make it through the wellness and social activities they valued most, day without crying. almost all of them put Real Talk at the top of the list. And while I can’t claim sole credit for this, surveys of Vituity clinicians show burnout symptoms at rates A Different Approach to“Wellness” 50 percent lower than national surveys.

My fellow chief residents and I saw a need for more In addition, Real Talk challenges the culture that emotional and existential forms of support. So, we doctors should be impenetrably tough and stoic and created Real Talk — a storytelling experience for bucks the old “go it alone” cowboy doctor mentality. It healthcare providers that gives airtime to those shows us that our stories — our experiences — matter, unique experiences we have working in medicine. and that the simple act of sharing them can heal us. It always amazes me how vulnerable people will be when we give them space and permission to do so.

Got a Story To Share?

Subscribe to the podcast or learn more about Real Talk at www.vituity.com/realtalk. 6 EMRA | emra.org • emresident.org LEADERSHIP REPORT Show Me the Money! How to Fund Your Program’s EMRA Representative Breanne Jaqua, DO, MPH Karina Sanchez, MD Mercy St. Vincent Medical Center Conemaugh Memorial Medical Center ACGME RC-EM Liaison Speaker of the Council @BreanneJaqua @KarinaSanchezMD

arly in my PGY-2 year, one of my ü Sample EMRA Program Impact chief residents said “Hey Brea, Representative Position Statement: During the RepCo Town Hall last year, Edo you want to be our program https://bit.ly/30jVaCJ attendees discussed how (or if) EMRA’s representative to EMRA?” I agreed, ü Sample Funding Proposal for EMRA resident moonlighting policy should be despite having no idea what that would Program Representative: revised. Resident representatives from across entail. A few months later, I wandered the https://bit.ly/2t5NOq4 the country debated the policy’s language, halls of ACEP18 in San Diego, looking for The Sales Pitch and it was obvious there was no “one-size-fits- EMRA’s Representative Council meeting Clearly outline why money should all” solution. Every EM program is different (RepCo). Resident representatives from be spent. The first argument I made (urban vs. rural, academic vs. community, every EM program in the country attend was that participation in organized small vs. big); given this diversity, RepCo, during which national resolutions medicine is increasingly important, but moonlighting needs and expectations are written by medical students, residents, and it is nearly impossible to transition from varied. Without giving residents equal fellows are discussed, modified, and voted ED pit doc to state representative at opportunities to speak on behalf of their on. Sitting quietly in the Ohio section, I ACEP Council without prior experience. programs, moonlighting may have become felt like an imposter holding my voting Attending EMRA’s RepCo meetings restricted to purely rural facilities, limiting card. I was responsible for my program’s is a great entry point to organized supported opportunities elsewhere. This is 40 votes, but I did not know how my medicine. Furthermore, the RepCo one example why having a seat at the colleagues back home felt about these environment fosters group learning about table is so important. resolutions, especially given that they parliamentary process and procedure. This could affect our practice for years to come. No Money? No Problem is an unparalleled learning opportunity. At that moment I decided change was Invariably, some programs will not fund Additionally, an officially funded EMRA necessary. Our program needed to discuss a resident representative to attend RepCo program rep provides an opportunity to these resolutions ahead of time, and we meetings in person. That doesn’t mean the introduce organized medicine to all of needed a democratically elected and program can’t be fully engaged; EMRA the EM residents. Resolutions must be funded representative to EMRA’s RepCo. accommodates virtual attendance and discussed with the whole program so the remote voting. Every program should elect Process representative knows how to vote on the a representative, discuss resolutions ahead To start, I drafted a position statement RepCo floor. I helped our representative of time as a group, and make sure their that outlined not only the representative’s lead a 1-hour discussion during protected vote is recorded during the biannual RepCo duties and responsibilities, but also the time at grand rounds, during which meetings. process to select the resident who would residents learned how to interpret speak and vote on our behalf. I discussed resolutions, participated in the debate Need Help? this plan with program leadership and process, and voted on issues that directly Please reach out! Dr. Sanchez is available secured their approval. affect them. This was a valuable learning at [email protected], and Dr. Jaqua can be Next, I wrote a funding proposal so experience for the whole program. reached at [email protected]. ¬ our representative could be reimbursed for travel and lodging at the EMRA RepCo SPRING REPCO MEETING @ CORDAA20 meetings that occur twice a year. I sent Monday, March 9 this proposal to our institution’s GME 8-11 am (check-in @ 7 am) office, and it was approved with minor Virtual meeting: ATTENTION, PROGRAM REPS! modifications. You will get an email with Virtual RepCo log-in and voting details. Follow those instructions. These templates can help you do the Review proposed resolutions at emra.org/repco same at your program:

February/March 2020 | EM Resident 7 INTRODUCING

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8 EMRA | emra.org • emresident.org LEADERSHIP REPORT 10 Ways You Can Help End Trafficking Office on Trafficking in Persons to potential local partners. Do you work colleagues to register for the SOAR to An Office of the Administration in a school? Propose anti-trafficking Health and Wellness training. for Children & Families protocols. Are you an attorney? Raise Your Voice Note: Per policy adopted in 2016, the EMRA Offer pro-bono services. Writing a Ask representatives how they are Representative Council continues to support story? Use media best practices. Work addressing human trafficking. Let them the need for human trafficking training, in hospitals or clinics? Encourage your know what your community needs. ¬ research, policy development, and collaboration with organizations that work with victims of human trafficking. OUT OF THE SHADOWS Know the Signs Learn the red flags and indicators of Exposing the Myths trafficking. Challenge common myths about trafficking with facts. of Human Trafficking Report a Tip Contact the National Human Trafficking Human Trafficking Hotline if you have any concerns about a MYTH TRUTH 68% FORCED LABOR potential trafficking situation. Call 1-888- IS ONLY SEX 22% sexually 373-7888, text HELP to BEFREE (233733), or OF THE 20.9 exploited 10% state-imposed email . TRAFFICKING MILLION VICTIMS [email protected] of human trafficking globally forced labor Spread the Word Share and display HHS Look Beneath the of VICTIMS had contact MYTH Human Trafficking TRUTH with a health care Surface and DHS Blue Campaign awareness 50% professional resources in your community. Let everyone know VICTIMS WILL that the National Human Trafficking Hotline is SELF NONE here to help. IDENTIFY were identified as a victim. Think Before You Shop Consider how you shop and eat. Who made MYTH Human Trafficking TRUTH your clothes? Who prepared your food? Calculate your Slavery Footprint, and know which goods IS NOT IN MY CASES of potential human may be produced by child or forced labor. 30,000+ trafficking REPORTED COMMUNITY IN ALL 50 states, Tell Your Friends: DC & US territories Demand Fuels Exploitation The U.S. Government has zero tolerance MYTH Human Trafficking TRUTH THE crime of human trafficking is a policies for employees, uniformed service symptom of a societal problem members, and contractors paying for sex. Learn ONLY AFFECTS more about the Federal Acquisition Regulations THE VICTIM HOW TO and human trafficking. HELP KNOW WHERE YOUR GOODS offer opportunities REPORT IT: CALL THE national & SERVICES COME FROM for at-risk individuals human trafficking hotline Volunteer Locally Ask anti-trafficking organizations in MYTH Human Trafficking TRUTH your community how you can support them. Perhaps they need volunteers or you could help ONLY HAPPENS SINCE 2012, NATIONAL HOTLINE 62% ADULTS with an awareness event. TO CHILDREN cases reported: Stay Informed Sign up for DOJ human trafficking news alerts, follow relevant organizations on social MYTH Human Trafficking TRUTH media, read reports as they are released, ONLY HAPPENS or check out OTIP’s newsfeed. SINCE 2012, NATIONAL HOTLINE 18% MEN Register for Training TO WOMEn cases reported: OTIP’s National Human Trafficking Training and Technical Assistance Center trains public health professionals and the Office for Victims National Human Trafficking Hotline of Crime Training and Technical Assistance Center supports the criminal justice system. 888-373-7888 | acf.hhs.gov/endtrafficking SOURCES ILO 2012 Global estimate of forced labour Executive summary. Accessed March 4, 2015. Use Your Skills https://polarisproject.org/facts CNN. “The CNN Freedom Project.” Accessed March 4, 2015. National Human Traﬃcking Hotline Statistics 2012-2016, https://humantraﬃckinghotline.org/states Can you train or hire survivors? Reach out https://www.acf.hhs.gov/otip/resource/publichealthlens

February/March 2020 | EM Resident 9 CAREER TRANSITIONS

How Do You Know If You’re Ready To Moonlight? David Beran, DO, MPH UMC New Orleans Every resident: When should I start moonlighting? Every Attending: Well, it depends. oonlighting is a rite of passage clarity from my attendings. I wanted appreciated. It has little to do with your for many residents. It’s the confirmation that I was safe to practice post-graduate year. Mexperience that signals a degree alone before I ventured out. I certainly The facility a resident is considering of readiness to be on your own. didn’t want to figure out that I was for moonlighting is a key determinant But the decision to moonlight means unprepared while alone at 2 in the of my answer. At one nearby facility, for knowing the difference between being morning, in a remote, single coverage example, a moonlighter is essentially ready and thinking you’re ready. You facility. the same as any other resident. The may ask your Attending physicians, but As a new attending, I realize the moonlighter sees and evaluates patients there’s always insecurity when you’re answer isn’t as absolute as I wanted but doesn’t make any major decisions or receiving direct feedback… If I were it to be. Are all upper-levels ready to dispositions without signing the patient unprepared, would they tell me to my moonlight? If so, are they all ready to out to staff. face? moonlight anywhere, or just at certain A resident may be ready to work in When I made the decision to locations? this setting by their second year. moonlight as a resident, I wanted Competency is more fluid than I At a different facility — a local critical

10 EMRA | emra.org • emresident.org access hospital, a moonlighter is the sole If you’re erring on the side of giving you independence, only seeking physician available. This is the other end admitting too much: You’re more you out at the time of disposition, of the spectrum. conservative than average — that’s that’s a good sign — it indicates your And in the middle of this wide fine, up to a point. You can’t overuse evaluations are being trusted. If spectrum is urgent care centers. resources or burn equity with attendings are letting you carry out A resident may be competent to consultants. If this is happening, ask plans that are stylistically different than work in one setting but not the others. yourself before admitting a patient: their plans, it’s a really good sign! So, when residents ask if they’re ready, What specifically do I want to occur as You’re waiting on your my answer is: Well, it depends. an inpatient that cannot happen as an attendings. This answer would have been outpatient? In residency, we had a fast track maddening to me as a resident. If you’re erring on the side of area that was staffed by an attending In retrospect, there were a few clues discharging too much: You’re more physician and a resident. In my third that could have helped validate my cavalier than average — that also may be year (I went to a 4-year program), I decision to moonlight, I just didn’t know fine, up to a point. Follow those patients reached a point where it took as much to look for them at the time. you would have discharged to see what time to see and dispo patients as it did to These are things to consider over the develops. Also, ask yourself — if I were have an attending sign the chart. After course of weeks to months — one shift working in Moonlighting Hospital X, multiple fast track shifts without will not give you enough information. would I still discharge this patient? significant dispo or patient plan changes Also, look for them with different There’s a good chance that when you’re when staffed with my attendings, I attendings and across different facilities, on your own, you’ll be less cavalier than knew I was ready to moonlight at especially in facilities similar to the place when you work under someone else’s urgent care centers. When the same you’re thinking of moonlighting. license! pattern emerged in the main emergency Your work-ups don’t vary from Also, discharging more may be department, I decided I was ready for your attendings’ work-ups. institution-specific. Moonlighting single coverage moonlighting. It was still There may always be some small, settings often have less resources than an intimidating transition, but I knew stylistic variations — you pick ibuprofen, your primary training institution. You from my experience in the ED that my they pick acetaminophen. However, may be accustomed to discharging plans were solid and I was procedurally are they ordering cardiac work-ups on people into an outpatient sector where competent. patients you want to send home after a they will be followed up by a system When you get to this point in GI cocktail? Did they rule out a PE in a that can support them. That may not residency, you start to get the itch for patient you said had bronchitis? be true where you’re moonlighting in the next step. You have the confidence If major variations occur between a hospital that has less clinic support. that you can manage an ED in residency your plan and your attendings’ plan, it’s You may find that you admit a little and want to know whether you can do it a sign you may not be ready to go alone. more as a moonlighter than you do as a alone. You’re ready to move, to see the There are more conservative resident. next patient, and you’re just waiting for attendings who work everything up, Are you receiving more or less your attending to sign off on what you’ve every time. But, if this is happening to oversight than your peers? done so you can keep things flowing. you with multiple attendings across Residencies have different Your motivations aren’t multiple facilities, chances are that it’s cultures when it comes to resident financial. not the attending. oversight. However, by the time you’re Moonlighting can be great money Explore your attendings’ plans thinking about moonlighting, you — but if that’s your motivation, you’re in thoroughly. What would have been the probably have a clear sense of your it for the wrong reasons. Remember that difference between yours and their plans residency culture and how they interact you do have peoples’ lives in your hands on patient outcome if they were both with residents. who are trusting you for your expertise. carried out? If you’re in your final year of Don’t moonlight prematurely just to Follow your patients throughout residency and still are being checked up make money. their inpatient course — it gives you on, having all of your orders reviewed, When you reach a point that your insight into how you can best serve being generally treated like an intern, plans are consistent with standard of your patients and will slowly lessen there’s an issue. If you’re being “pimped” care, minimal disposition and patient- the gap between your plans and your on topics that you find patronizing, care discrepancies are noted between attendings’. it’s not a good sign. If clinically liberal the attending physician and yourself, Your dispositions don’t vary attendings are micromanaging you, it’s and you feel comfortable undertaking from your attendings’ plans. also not a good sign. the responsibility for patients’ lives Do you and your attending want to You aren’t ready. without another physician overlooking admit and discharge the same patients? On the other hand, if attendings are your work, then you are ready. ¬

February/March 2020 | EM Resident 11 TOXICOLOGY Gastric Perforation after Liquid Nitrogen Ingestion A Scream after Ice Cream Natasha Brown, MD Carlos Dos Santos, MD Fiona Azubuike, MD Mount Sinai Medical Center — Miami Medical Student Pediatrics & Clinical Teaching Faculty @MiamiBeachEM Mount Sinai Medical Center — Miami

iquid nitrogen is used as a food or drink additive to provide rapid cooling or produce an aesthetic effect in which smoke seems to emanate from a prepared drink or food. Although potentially dangerous and currently Lunregulated, it has gained popularity in recent years and is used to make cocktails, cool ice cream, and create snacks for children in order to enhance presentation and consumer appeal. Few cases have been reported over the years describing gastric perforation secondary to liquid nitrogen ingestion. We report the case of a child who developed pneumoperitoneum secondary to liquid nitrogen ingestion. This case is relevant to emergency medicine because providers should be aware of this popular additive that may have deadly sequelae.

Case There were no visible signs of trauma A 9-year-old female with no or burns along the face, abdomen significant past medical history arrived or anterior chest wall. Lung sounds to the emergency department via fire were clear to auscultation bilaterally. rescue shortly after ingesting ‘dragon A portable chest x-ray demonstrated breath’ ice cream purchased on a extensive pneumoperitoneum (Figure 1), popular pedestrian street. Her mother highly suspicious for organ perforation. stated she had ingested the liquid which Laboratory results were significant had been left over at the bottom of for a white blood cell count of 16,400 / the cup. Her parents who witnessed uL, a potassium level of 3.3 MMOL/L, the event reported she immediately and a lactic acidosis of 2.5 MMOL/L. experienced pain, gripping her Remaining complete blood count, abdomen and seeming to have trouble chemistry and toxicology screen were breathing. A bystander believed the unremarkable. FIGURE 1. Portable upright chest patient to be choking and performed While in the emergency department x-ray demonstrating massive the Heimlich maneuver with minimal the patient remained lethargic and pneumoperitoneum. relief in symptoms. Fire rescue was exhibited multiple episodes of non- then called and transferred the patient bloody, non-bilious emesis. Treatment unit complicated by fever attributed to the emergency department in stable was initiated with intravenous fluids, 20 to aspiration pneumonia and treated condition. mg famotidine, 1 g of ceftriaxone and 8 with cefepime, vancomycin, fluconazole Upon arrival the patient continued mg of zofran. The patient was promptly and metronidazole. She was discharged to complain of abdominal pain. On transferred to a separate pediatric on oral antibiotics and followed up in examination she was hemodynamically facility where she was intubated the outpatient clinic with no further stable but lethargic and responsive to for airway protection and taken to complications. verbal stimuli. Initial vital signs were the operating room for exploratory temperature of 98.1 °F (36.7 °C), heart laparoscopy. The procedure was Discussion rate 85 bpm, blood pressure 120/83, converted to open laparotomy for better This case demonstrates liquid and oxygen saturation 96% on room exposure, and a 3-4 cm full thickness nitrogen to be a potentially fatal air. The patient weighed approximately perforation was identified along the substance if directly ingested. Even 54 kilograms. The patient was placed on lesser curvature of the stomach near if promptly treated, solid organ a cardiac monitor and end tidal carbon the gastroesophageal junction. This perforation may have a high morbidity dioxide for continued monitoring. area was repaired via Graham patch and mortality. Prior case reports She exhibited a distended abdomen closure. The patient was extubated involving liquid nitrogen detail similar which was tympanic, rigid and tender the following day and had a two week presentations in both adults and to palpation in the epigastric region. course in the pediatric intensive care children with sudden onset abdominal

12 EMRA | emra.org • emresident.org TOXICOLOGYAIRWAY pain and shortness of breath after ingestion. As in this case, other cases vapor layer that slows thermal transfer.6 ingestion,1-4 with the exception that reported no esophageal or oropharyngeal Interestingly, this patient presented our patient additionally presented with chemical burns with ingestion despite with altered mental status, initially marked lethargy and altered mental its potential to cause severe frostbite. suggesting another diagnosis such as status. Further, prior case reports also This can be attributed to the Leidenfrost accidental alcohol intoxication. The identified gastric perforation at the effect, wherein a liquid encounters a nitrogen may have caused displacement lesser curvature of the stomach as in temperature significantly higher than of oxygen and subsequent hypoxemia 5 this case. its boiling point and creates a protective leading to altered mental status. ¬ Liquid nitrogen has an extremely low boiling point of -196˚ C and an TAKE-HOME POINTS expansion ratio of 1:694.1 Proposed mechanisms of injury involve the In our case the child did well while ingesting the ice cream covered with accumulation of liquid nitrogen in liquid nitrogen. It was the act of drinking the remaining pooled liquid the stomach, which causes damage containing higher concentrations of liquid nitrogen that caused immediate by thermal burn to the epithelium pain and organ rupture. For emergency medicine specialists it should be or via barotrauma due to the rapid noted that such pediatric behavior is normal, just as a child might drink the volume expansion within the stomach causing rupture at anatomical regions remaining milk from a cereal bowl. Thus, such natural behavior increases the which are particularly susceptible to risk of caustic injury to this population with such toxic ingestions. barotrauma.3,5 The lesser curvature Considering the potentially lethal effects of liquid nitrogen ingestion, we of the stomach is held in place by the hepatogastric ligament, possibly suggest the implementation of regulations for the use and purchase of foods causing further traction on the gastric with liquid nitrogen additives. Liquid nitrogen as a food additive is gaining wall and facilitating gastric rupture at more popularity within American culture and emergency physicians should this site in the context of rapid volume be aware of this rare yet potentially fatal presentation. expansion secondary to liquid nitrogen Because someone always takes it one step too far. You’re there for them, we’re here for you.

ACEP AND EMRA’S OFFICIAL ONLINE CAREER CENTER

References available online February/March 2020 | EM Resident 13 NEURO/ULTRASOUND Ultrasound Guided Supracondylar Nerve Blocks for Reduction of Distal Radius Fractures Heather Roesly, MD Emergency Medicine Resident, PGY III Denver Health Emergency Medicine Residency Spencer Tomberg, MD Emergency Medicine/Sports Medicine Physician Denver Health Medical Center istal radius fractures are one of the more common fractures taken Dcare of in the ED. These occur in a wide variety of patients and often require manipulation or reduction in the ED prior to splinting. This reduction is one of the more painful procedures performed in the ED and, as such, has been associated with evolving analgesic procedures to assist in its successful performance. These procedures range from hematoma blocks to Bier blocks to procedural sedation. Reduction of distal radius fractures in the ED can be complicated if the patient has comorbid medical conditions such as polytrauma, FIGURE 1 hypotension, or traumatic brain injuries which can further complicate or limit the improvement in safety of procedural sedation (Smits et al., patient satisfaction 2017). Recently, the utility of performing (Blaivas, Adhikari, regional nerve blocks under ultrasound & Lander, 2011). (US) guidance has gained popularity as Cadaver studies it has the potential to combine adequate have shown that pain control with ease and efficiency in an the majority of ED setting. the distal radius While not widely studied, US guided is innervated Supracondylar Nerve blocks have been by the posterior shown to be easily performed by an US interosseous trained physician in an ED setting with nerve, a branch of success rates as high as 95% (Ünlüer et the radial nerve. al., 2016). When compared to hematoma Therefore, the blocks, US guided supracondylar nerve supracondylar blocks have been shown to significantly nerve block can decrease pain scores pre-reduction, theoretically during reduction, and post-reduction provide adequate FIGURE 2 (Aydin, Bilge, Kaya, Aydin, & Cinar, pain control for 2016). Although their utility in decreasing distal radius fractures. If adequate Koudstaal, Schuurman, Bleys, 2006) overall ED LOS has not been studied, anesthesia is not acheived, adding a (Ünlüer, Aslan, et. al. 2016). it can be inferred from many related median nerve block can address any Ultrasound guided supracondylar studies that utilizing regional anesthesia nerves (anterior interosseous nerve blocks provide a motor and sensory over procedural sedation may lead to and median nerve) not anesthetized blockade of the radial distal forearm. significant decreases in ED LOS and by the supracondylar nerve block (Pol, This anesthetic affect has been described

14 EMRA | emra.org • emresident.org as early as 15 minutes post-procedure facilitate appropriate identification of the ensure appropriate positioning with the with successful reductions taking place radial nerve, surrounding vasculature/ remaining amount administered upon anywhere from 15-30 minutes post- musculature and bony landmarks verification. (Figure 3) procedure (Frenkel, Herring, Fischer, (Figure 1). Median Nerve Block Carnell, & Nagdev, 2011). No serious Step Two: Landmark Identification: Step One: Positioning or long term complications have been This positioning allows for rapid The patient is placed in a position described to date. These procedures can identification of the radial nerve which where the supinated forearm can be be performed by a single EP and do not can be visualized as a hyperechoic accessed by the provider. This can be in require additional staff, monitoring, or triangular structure lying between a sitting position or a supine position. resources associated with procedural the hypoechoic structures of the The provider should create a clear line sedation. brachioradialis and brachial muscles, and of sight from the patient’s forearm to the The Procedure adjacent to the humerus. (Figure 2) ultrasound screen. (Figure 4) Materials Needed Step Three: Needle Advancement Step Two: Landmark Identification • US with linear probe and Anesthetic Administration The median nerve traverses the mid- • 5-10 mL (milliliters) Anesthetic The skin is prepped in a sterile volar forearm. The ultrasound probe is (Lidocaine, Bupivicane, or 1:1 fashion with chlorhexidine or betadine. placed so that a cross-sectional view of mixture) A sterile US probe cover should be the forearm is obtained from the volar • 27 G Needle applied and sterile US gel should be surface. The provider should locate the • 20 or 22 G needle used to help limit the risk of introducing nerve around the mid forearm (if you look • Sterile Gloves infection. With the radial nerve kept closer to the wrist the nerve is hard to • Sterile US probe cover in view under ultrasound guidance, an differentiate from the surrounding wrist • Chlorhexidine or povidone Iodine in-plane approach should be used to flexor tendons). The nerve appears as a These should be performed under visualize the needle thought its entire cluster of hypoechoic structures that are sterile technique with the use of povidone course as it approaches the nerve. wrapped by hyperechoic tissue: this has iodine or chlorhexidine, sterile gloves, After anesthetizing the tract using been described as a cluster of grapes, or a and a sterile US probe cover. lidocaine and a 27 gauge needle, a larger honeycomb. You should also identify the Supracondylar Nerve Block gauge needle (20-22G) is used for the ulnar and radial arteries on the periphery Step One: Positioning procedure as it tends to be visualized of the screen as these will need to be Patients should be placed in a better under ultrasound. The anesthetic avoided during the procedure. (Figure 5) supine position to help prevent any is introduced in a circumferential Step Three: Needle Advancement complications associated with anesthetic pattern around the nerve; this is done and Anesthetic Administration introduction such as vasovagal syncope. by injecting above and below the Again, the skin is prepped in a sterile The forearm should be flexed at 90 nerve, which will dissect it from the fashion, a sterile US probe cover is degrees at the elbow with the wrist held surrounding tissue and allow anesthetic applied, and sterile US gel is used. With in pronation. The linear US probe can to surround the nerve. A total of 5-7 mL the ultrasound probe in cross-section then be applied about 2-4 cm superior of anesthetic is infiltrated. Initially 1-2 and the median nerve centered in the to the lateral epicondyle of the elbow to mL of anesthetic can be introduced to screen, note the depth of nerve from the

FIGURE 3 FIGURE 4

References available online February/March 2020 | EM Resident 15 NEURO/ULTRASOUND

skin surface. Then at either the radial emergency medicine literature) point It is also important to consider or ulnar side of the forearm insert the toward equivalence between the action of anesthetic choice and the potential of needle into the skin directly below the the agents, with onset of both within 30 rebound pain upon patient discharge edge of the US probe at a depth that seconds and effects lasting over 6 hours which may lead to repeat visits or poor matches the nerve depth. This will also (Collins, 2013, Alhelail, 2008). Mixing pain control upon discharge. There is be an in-plane approach with a goal to the two has been shown to combine the limited evidence on rates of rebound visualize the needle thought its entire benefits of the individual anesthetics. pain in patients treated with regional course and the needle will run parallel to The literature supports success with anesthesia in an operative setting, but it is the US probe. multiple different medication choices theorized that up to 40% of patients may As above, the tract is anesthetized (Martin, Dumais, Cinq-Mars, & Tétrault, experience this effect (Lavand’homme, using lidocaine and a 27 gauge needle 1993). It is important to consider time to 2018). It is reasonable to assume that this and if better visualization of the needle is reduction, need for repeat neurovascular would translate to the ED setting. This required a larger gauge needle (20-22G) exams, and pain control upon discharge is an important consideration, especially is used for the procedure. The anesthetic in these patients; anesthetic choice is when providing return precautions and is introduced in a circumferential based on balancing these considerations. discharge pain control. pattern around the nerve; this is done Anesthesia during splinting may also by injecting above and below the Complications lead to tighter splint placement and limit nerve, which will dissect it from the Given the limited adoption of US diagnosis of compartment syndrome, surrounding tissue and allow anesthetic guided supracondylar nerve blocks, however, the safety of forearm splint to surround the nerve. A total of 5-7 mL the associated risks or their rates of placement under IVRA has been shown in of anesthetic is infiltrated. Initially 1-2 occurrence have not been widely studied, previous studies (Aarons et al., 2014). mL of anesthetic can be introduced to although they are important to consider Emergency Medicine is an ever- ensure appropriate positioning with the prior to shifts in practice. In theory, these evolving field and it is important that we remaining amount administered upon risks would be similar to other regional verification. (Figure 6) nerve blocks including neurovascular evolve with it. The addition of US guided The anesthetic of choice is provider damage, bleeding, and infection. The procedures has increased the safety and dependent, but generally ranges from a use of US guidance and sterile technique efficacy of many different procedures short acting agent such as lidocaine, to a can limit these risks, however more from vascular access to arthrocentesis medium-acting agent such as bupivacaine studies would be needed to show safety in and should be considered in the utility or ropivicaine, to a mix of the two. Studies practice. of regional anesthesia. While more data looking specifically at nerve blocks It is important to realize that the is needed, there is promising evidence (orthopedic and anesthesia literature) supracondylar nerve block is a motor and to suggest that distal radius fractures show that lidocaine has a significantly sensory block. This will limit the ability can be manipulated and splinted in a faster onset of action compared to that of to perform a neurovascular exam after pain-free setting with fewer associated bupivacaine or ropivicaine, but a shorter the reduction. Because of this, the use complications, shorter ED LOS, and with duration of action (Cuvillion, 2013, of a short acting anesthetic (lidocaine) improved patient satisfaction with the Vinycomb, 2008); while studies looking may be beneficial to facilitate the early use of ultrasound guided supracondylar at skin anesthesia (plastic surgery and recognition of any complications. radial nerve blocks. ¬

FIGURE 5 FIGURE 6

16 EMRA | emra.org • emresident.org References available online OB/GYN Defusing Ectopic Pregnancy

TICKING TIME BOMB

Blake Briggs, MD intrauterine pregnancy (IUP).3 Failure pregnancy test, vaginal bleeding, and/ Wake Forest Baptist Medical Center to appropriately manage this common or abdominal pain. 18% (376 patients) @emboardbombs pathology leads to significant morbidity had an ectopic pregnancy. Of those with Iltifat Husain, MD and mortality. In this article we will ectopic pregnancy, vaginal bleeding Wake Forest Baptist Medical Center review the presentation, diagnosis, was reported in 76%, and generalized 32-year-old female presents to and approach to managing ectopic abdominal pain in 66%.7 Importantly, the ED with 7 days of worsening pregnancy. there is no measured amount of bleeding Aabdominal pain. She appears in Risk Factors that is associated more with ectopic pain and refuses to lay on her back or The biggest risk factor is previous pregnancy. Bleeding can range from walk. She lays on her left side. Her vitals ectopic pregnancy. Other major historical scant to heavy. There is often non-focal on arrival pulse 97, BP 103/57. Her pain risk factors include uterine or tubal tenderness on abdominal exam. is 10/10, constant, and nothing makes it scarring from surgery (e.g. D&C, PID), Even more fascinating, a population- better. She cannot pinpoint one location increased maternal age, smoking, use of based study in France looked at 849 tubal where it hurts the most. She denies fevers assisted reproductive techniques (ART) ectopic pregnancies and found the rate of or chills. Upon chart review you find she like in vitro fertilization. tubal rupture to be 18% on presentation, is a G7P2032 with past medical history Despite the popular misconception, so a high suspicion is warranted for of treated PID. Her urine pregnancy test IUD presence does not increase the overall potential decompensation.8 is positive, she did not know she was risk of ectopic pregnancy, but a pregnancy Multiple resources state that the pregnant. What is your next step? with an IUD is more often an ectopic one.4 diagnosis of ectopic pregnancy should Introduction Presentation be considered in any female with vaginal An ectopic pregnancy is simply an Ectopic pregnancies can present in bleeding or abdominal pain- let’s expand extrauterine pregnancy, accounting a variety of ways. Symptoms typically on that. One must have a low threshold of 1 for 2% of all pregnancies. The vast develop around 6-8 weeks after the thinking about ectopic pregnancy in any majority (96%) occur in the fallopian last menstrual period. Women may female of reproductive age. Given the high tube, however other sites include misinterpret their vaginal bleeding as mortality and high rate of misdiagnosis, the cervix, hysterotomy, ovary, or “normal menses”. Typical symptoms of here’s some major complaints we always even abdomen. Very rarely, there pregnancy (breast tenderness, polyuria, order a urine pregnancy test (UPT) for: can be both an intrauterine and nausea/vomiting) can also occur but with syncope or near-syncopal symptoms, ectopic pregnancy, which is coined lesser frequency than IUPs, as the levels abdominal pain, chest pain, nausea/ a heterotopic pregnancy.2 Rates of of human chorionic gonadotropin (hCG) vomiting, dizziness, lightheadedness, or ectopic pregnancies have been steadily are often lower.5,6 any GU complaint. This is by all means not increasing, however at least 40% of A retrospective cohort study in 2009 a totally exhaustive list, but it does hit the cases are initially misdiagnosed as a analyzed 2,026 females presenting to a highlights. non-pregnancy condition or suspected US emergency department with a positive Important questions to ask a female

February/March 2020 | EM Resident 17 OB/GYN

FIGURE 1 (left). TAUS Transverse view of the uterus and R ovary. Note free fluid surrounding R ovary in the left aspect of the image, as well as pseudogestational sac in uterus (right side of image) FIGURE 2 (right). TVUS Sagittal view of the uterus demonstrating free fluid in the cul de sac

with a +UPT include gravidity and parity, Relevant physiology Option 2: Gestational sac with history of prior ectopic pregnancies, hCG is secreted into maternal or without yolk sac outside the birth control status, usage of in vitro circulation after implantation, about uterus or echogenic extraovarian fertilization, prior history of STIs 6 days after ovulation. Normally, hCG mass = ectopic pregnancy especially PID, and surgical history. should double ~48 hours during the Option 3: No pregnancy is Pelvic exam has come under fire first 30 days; decline is concerning for identified = nondiagnostic recently for suffering from relatively poor failed pregnancy. Traditionally, slower In confirmed ectopic cases, the most specificity and sensitivity, but it is still a rise is concerning for ectopic pregnancy common finding is an extraovarian necessary part of any GU workup. Your or early intrauterine demise, but hCG adnexal mass, at 89% of the time. primary goal during the exam is to assess alone it is not confirmatory and there It is critical to recognize that the for the presence of bleeding, its quantity, is no common predictable pattern of presence of an intrauterine gestational and confirm that the uterus is the source of hCG in certain pathologies.9 In short, a sac alone does not confirm an IUP! In bleeding. single serum hCG level has very limited fact, the presence of an intrauterine Diagnosis utility and it alone should not be used to “sac-like” structure could actually be Workup of ectopic pregnancy can make decisions (more on that below).10 a pseudogestational sac, which is a quickly get algorithmic and tedious. Here Hemodynamically unstable collection of blood and hypoechoic fluid is an overview to keep you grounded: in the uterus that can be seen in ectopic Here’s a shiny pearl: Females who pregnancy (Figure 1).12 Diagnostic evaluation Comments are hemodynamically unstable with A small amount of clear fluid in the 1. Confirm patient is If UPT is negative +UPT have an ectopic pregnancy until pelvis is physiologic, but echogenic free pregnant (+UPT) this conversation proven otherwise. fluid in a woman with +UPT is virtually is over. The most critical step is to perform diagnostic of ectopic pregnancy. In a 2. Is the patient Quickly perform a bedside basic gynecologic prospective study, finding echogenic hemodynamically a bedside Gyn ultrasound (uterus, ovaries, cul fluid has a sensitivity of 56% and stable? POCUS & FAST de sac) with a FAST exam to look specificity of 96% for predicting ectopic exam. for free fluid, ovarian pathology, or pregnancy.13 intrauterine pregnancy (Figures 1 & 2). 3. Order a serum hCG, The blood type From the TVUS, if Option 1 blood type, CBC, is the most All the while, you should follow occurs, ectopic pregnancy is effectively CMP commonly aggressive resuscitation algorithms ruled out as the risk of heterotopic forgotten test. (2 large bore IVs, blood products), and pregnancy is negligible in females not Rh-D status is promptly alert OB/GYN. critical to know in using assisted reproductive techniques. these patients. Hemodynamically stable If Option 2, proceed with medical In those hemodynamically stable, or surgical management of ectopic 4. Perform bedside there needs to be a complete, formal TVUS or order a pregnancy by contacting OB/GYN. formal study ultrasound. Transvaginal (TVUS) is Option 3 requires further workup. a. Determine the best test to effectively exclude an If no pregnancy is identified (either intrauterine vs ectopic pregnancy. IUP or ectopic), it is likely because ectopic pregnancy There are 3 possible conclusions gestation is too early to be visualized on b. Coordinate proper that can be drawn from the TVUS11: ultrasound. Transabdominal US (TAUS) management Option 1: Gestational sac with a can pick up an IUP at about 7-8 weeks; strategy with OB/ yolk sac or embryo in the uterus TVUS around 5 weeks. These patients GYN = IUP will need close Ob/Gyn follow up with

18 EMRA | emra.org • emresident.org repeat hCG measurements and likely evidence of heterotopic pregnancy contraindications that must be a repeat TVUS.14 typically includes complex adnexal mass reviewed, and OB/Gyn will obviously What about the magical or fluid. They are often falsely labeled as drive this discussion. 18 “discriminatory zone”? a corpus luteum cyst. Ob/Gyn should Case Conclusion be consulted early on to assist with this The discriminatory zone is You perform a pelvic exam which is complicated pathology. traditionally defined as the hCG level negative for bleeding or discharge. You above which one should see an IUP Treatment overview perform a bedside TAUS to look for IUP via US. On average, this is about 2000 If an ectopic pregnancy is and discover free fluid in Morrison’s mIU/mL for TVUS (about 6000 for confirmed, treatment discussion pouch as well as a pseudogestational TAUS). Traditional teaching was that should obviously involve Ob/Gyn. All sac. As Ob/Gyn is urgently called, her if a patient’s serum hCG was below the patients that are hemodynamically repeat BP drops to 95/73 systolic and cut-off value and the US showed no IUP, unstable, have significant free fluid on emergency blood products are hung. there was a “decreased risk” for EP. This US, or have symptoms of rupture go to You place a 2nd large bore IV via US- has been found to simply not be accurate emergency surgery. That’s easy enough. guidance. Ob/Gyn urgently takes the and there are even some studies to In stable patients, methotrexate patient to the OR where a ruptured suggest the opposite (i.e. increased risk therapy has been found to be quite ectopic pregnancy of the left ovary for ectopic pregnancy).15 Therefore, we beneficial at reducing surgical exposure is found with a small hematoma. She recommend not using the discriminatory and its associated complications. recovers well and was discharged zone alone to rule out ectopic pregnancy. There are strict indications and without incident. ¬ There is no standard hCG level ectopic pregnancies are expected to present at. FIGURE 3. Simplified algorithm to ectopic pregnancy work-up Remember, a single serum hCG level has +UPT very limited utility. For patients with an elevated Hemodynamically Hemodynamically hCG, but a nondiagnostic US, this is a stable unstable pregnancy of unknown location, and a wide range (8-40%) turn out to be TVUS ectopic. Call Ob/Gyn and arrange for Bedside Gyn US & FAST follow up. The patient will need repeat IUP Ectopic Nondiagnostic hCG measurement in about 48 hours Aggressive resuscitation, along with potentially repeating the Call OB/GYN TVUS (Figure 3). Serial hCGs that do Repeat hCG levels in 48-72 hrs (coordinate with Ob/Gyn) not rise by about 66% in 48 hours is coined an abnormal pregnancy (ectopic hCG doubles hCG does not double hCG plateau or decreases or nonviable IUP). Besides stressing close Ob/Gyn follow up with the patient, strict return precautions should be Suggests IUP, Abnormal pregnancy Failed pregnancy, given. Rcpeat TVUS Repeat TVUS Follow closely What about heterotopic pregnancies? TAKE-HOME POINTS By definition this is a simultaneous • Have a low threshold for ordering a urine pregnancy test, even if the chief complaint IUP and ectopic pregnancy. This is a isn’t “GU related”. feared pathology that very rarely occurs. • A single serum hCG level has very limited utility and it alone should not be used to In fact, it is estimated to occur in 1 in make decisions. 30,000 pregnancies.16 Therefore, in a • Females who are hemodynamically unstable with +UPT have an ectopic pregnancy female that has a confirmed IUP with until proven otherwise. no assisted reproductive techniques • The most critical step in an unstable female with +UPT is to perform a bedside basic being used (ART), no further workup for gynecologic ultrasound (uterus, ovaries) with a FAST exam. heterotopic pregnancy need occur. • If the TVUS is nondiagnostic in a stable patient, it is likely because gestation is too The risk of heterotopic pregnancy early to be visualized on ultrasound. Transabdominal US can pick up an IUP at about in those using ART is 1.5 per 1000 7-8 weeks; TVUS around 5 weeks. These patients will need close Ob/Gyn follow up pregnancies.17 We predict this number with repeat hCG measurements and likely a repeat TVUS • There is no standard hCG level ectopic pregnancies are expected to present at. Do not to increase in the future as more and let the “discriminatory zone” guide management. Remember, a single serum hCG level more patients are utilizing ART. Expect has very limited utility. similar symptoms of ectopic pregnancy. • Assisted reproductive technologies raises the risk of heterotopic pregnancies. In these patients, aside from an IUP,

References available online February/March 2020 | EM Resident 19 CRITICAL CARE CRASH-3: TXA for TBI Ryan Lee, MD severe trauma, including isolated head EM PGY1 trauma, even when the clinical course ChristianaCare was not complicated by hypotension.8 Raymond Green, DO, FACS Accordingly, if similar hemostatic Acute Care Trauma Surgeon ChristianaCare benefits seen in surgical patients are Michael Perza, PharmD, BCPS extended to trauma patients, TXA may Emergency Medicine Clinical Pharmacist offer a low-cost, low-risk treatment ChristianaCare option to impact outcomes in trauma @pillpushermike surgery. ranexamic acid (TXA) has received Over the past decade, multiple trials much attention over the past have investigated the usefulness of Tdecade secondary to its usefulness TXA in hemorrhage. Published in 2010, in treating hemorrhage. Released in CRASH-2 was a massive RCT with more October 2019, CRASH-3 is the latest trial than 20,000 patients, which showed a exploring the benefits of TXA, this time 1.5% decrease in mortality when TXA in traumatic brain injury (TBI).1 Each was given to trauma patients with year there are nearly 70 million cases of significant bleeding. This effect was time What did they do? traumatic brain injury worldwide2, and in dependent and only seen when given This brings us to the latest evolution the United States more than 2.5 million within 3h and increasing to 2.1% when of TXA research: CRASH-3. This was a patients seek care in the ED for TBI every given within 1h. There was no observed very large, pragmatic, double-blinded RCT year, accounting for approximately 2% increase in thromboembolic events. conducted at 175 hospitals in 29 countries of all ED visits.3 CRASH-3 evaluated the However, a subgroup analysis showed across a range of geographic and economic effect of TXA on 28-day head injury- there was an increase in death due to settings (although no North American related death in patients with acute TBI. bleeding when given >3h from injury.9 centers participated) from 2012-2019. Before diving into the study itself, The Military Application of Tranexamic Included patients were adults with TBI it may be useful to briefly review why Acid in Trauma Emergency Resuscitation treated within 3 hours of injury who had TXA has been so heavily investigated (MATTERs) study published in 2012 a GCS ≤ 12 or any intracranial bleeding as a pharmacologic tool to help control included 896 combat injuries treated in on CT (inclusion was originally within hemorrhage. Having been accepted Afghanistan in which the TXA group had 8 hours however this was changed in 2016 for the better part of two decades a 6.5% mortality benefit over placebo after data showed patients were less likely amongst the surgical community due despite being a more severely injured to benefit from TXA when given beyond to its reduction of peri-operative blood group.10 The WOMAN trial published that time point). Patients were excluded if transfusion requirements, TXA is an in 2017 studied the effects of TXA in they had any obvious major extracranial anti-fibrinolytic agent that works by postpartum hemorrhage in over 20,000 bleeding. The intervention was 1g TXA displacing plasminogen from fibrin to patients. This study showed a statistically given over 10 minutes followed by a 1g stabilize and inhibit clot breakdown. significant 0.5% reduction in death due infusion over 8 hours versus a matching In the case of trauma, hyperfibrinolysis to postpartum hemorrhage when given placebo regimen. has long been an associated component within 3h of birth as a secondary outcome The primary outcome in this study was of the coagulopathy of trauma. When with no increase in thromboembolic disease specific being head injury-related present, mortality has been observed to events, but no significant decrease death within 28 days in those treated within be in excess of 70%.4,5,6 Particularly in in the primary outcome of all-cause 3 hours. Notable secondary outcomes the case of severe, blunt trauma, tissue mortality with its use.11 Finally, The included early head injury-related death hypoperfusion stimulates the release of Tranexamic acid for hyperacute primary (<24 hours), all-cause and cause-specific tissue-plasminogen activator (t-PA) from IntraCerebral Hemorrhage (TICH-2) trial mortality, disability, vascular occlusive vascular endothelial cells, resulting in was released in 2018 which studied the events (MI, CVA, DVT, and PE) and seizure. fibrinolysis and impeding hemostasis.7 It effect of TXA on non-traumatic ICH when Of note, the authors had a pre-specified is the role of TXA to directly inhibit this given within 8h. This study showed sensitivity analysis that excluded patients process. While it may be intuitive then no benefit in the primary endpoint of with a GCS of 3 or bilateral unreactive to infer that the benefits of TXA may functional status at 90 days or secondary pupils as these patients were expected to only be limited to those in shock, it is outcomes of hematoma expansion, have a very poor prognosis regardless of important to note that hyperfibrinolysis however it did show a significant treatment and may bias treatment effect has been an identified component in reduction in early deaths at day 7.12 towards the null.

20 EMRA | emra.org • emresident.org Results groups (RR .98; 95% CI 0.74 – 1.28) and endpoint. One can also conclude that Of the 12,737 patients randomized, there was no observed increase in the risk earlier treatment is more effective than 9,202 were treated within 3h of injury. of seizures (RR 1.09; 95% CI 0.90 – 1.33). later treatment in patients with mild Baseline characteristics including sex, Of note, TXA did increase the relative risk to moderate TBI, a similar finding to age, time since injury, systolic blood for non-head injury related death, however previously published literature regarding pressure, GCS, and pupil reactivity were this too was not shown to be statistically the need for timely administration of TXA well matched at randomization. As for significant (RR 1.31; 95% CI 0.93 – 1.85). in hemorrhage. Thus, increasing delays the primary outcome, there was Finally, among survivors there was no in TXA administration would reduce the no statistical difference in head improvement in patient-centered disability potential for therapy to prevent expansion injury-related death within 28 days for TXA vs placebo as determined by two of intracranial hemorrhage in TBI. of injury with TXA compared to separate disability measures. Several limitations should also be placebo (TXA 18.5% versus placebo Discussion mentioned. These include quite wide 19.8%; RR .94; 95% CI 0.86 – 1.02). How should CRASH-3 be interpreted confidence intervals, making both a Similarly, there was no statistically and what are the takeaways? The primary substantial and little to no benefit possible, significant difference between TXA and outcome of this study may be considered a disease specific primary outcome which placebo in the pre-specified sensitivity negative, with no significant difference may be affected by misclassification analysis which removed patients with seen between head injury-related death of cause of death (although this was GCS of 3 or bilateral unreactive pupils within 28 days when comparing TXA vs blinded to trial treatment), and possible (TXA 12.5% versus placebo 14%; RR 0.89; placebo given within 3 hours. However, underestimation of DVT/PE. 95% CI 0.80 – 1.00). when looking at the data more closely The authors summarized their This brings us to the subset of there appears to be a subset of patients findings by stating “tranexamic acid patients receiving the most attention for which TXA has a definitive benefit. is safe in patients with TBI and that following the publication of the trial. A When excluding patients with a GCS treatment within 3 h of injury reduces subgroup analysis for risk of head of 3 or bilaterally unreactive pupils, head injury-related deaths.” A caveat injury related death in patients with those who are likely too sick to benefit could be made this applies most clearly mild-to-moderate head injury (GCS from any intervention are removed, to patients with a GCS of 9-15. With a 9-15) was significantly reduced a dilutional skew towards a negative now demonstrated mortality benefit in (5.8% vs 7.5%; RR.78; 95% CI 0.64 outcome is taken out. Patients with a GCS TBI following CRASH-3 combined with – 0.95; NNT 59). In this subgroup, of 9-15 are less sick on presentation, but the low cost and thus far proven safety of early treatment was also found to be more also have more room to decompensate TXA, it is certainly reasonable to include effective than later treatment (p=0.005). following their TBI. This is the subset of timely administration of TXA to more The benefit did not carry over to those patients where TXA was shown to have established interventions (elevating the with severe head injury (GCS 3-8; RR .99; the highest mortality benefit. It may be head of the bed to 30°, blood pressure 95% CI 0.91 – 1.07). that this benefit was simply not large control, avoidance of hypoxia, etc) as part As for the secondary outcomes, TXA enough to affect the mortality endpoints of the treatment regimen for patients was found to be generally safe with the risk for the entire patient population presenting to the emergency department of vascular occlusive events similar in both studied, resulting in a negative primary with acute TBI. ¬ Effects of tranexamic acid in patients with acute traumatic CRASH-3 brain injury The CRASH-3 Trail Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. 2019;394(10210):1713-1723. Methods RESULTS • 175 hospitals, 29 countries No significant difference in head injury-related death within 28 days for TXA vs placebo. • Randomized, double-blind, Effect of TXA on head injury-related death TXA Placebo RR (95% CI) Placebo-controlled All 18.5% 19.8% 0.94 (0.86-1.02) • 9,202 patients treated within 3h Excluding GCS 3 & bilateral unreactive pupils 12.5% 14% 0.89 (0.80-1.00) • Intention to treat, pre-specified Mild-to-moderate head injury (GCS 9-15) 5.8% 7.5% 0.78 (0.64-0.95) subgroup analysis Risk of vascular occlusive events 1.5% 1.3% 1.08 (0.71-1.64) Intervention • 1g TXA over 10 min followed 3h NNT = 59* by 1g TXA over 8h OR placebo *GCS 9-15 THE BOTTOM LINE 3-HOUR WINDOW When given within 3h of injury, TXA was shown to have a mortality benefit in head injury-related death in patients with acute traumatic TBI and a GCS of 9-15 with no significant increase in vascular occlusive events.

References available online February/March 2020 | EM Resident 21 CARDIOLOGY Primary Cardiac Synovial Sarcoma Complicated by a Malignant Pericardial Effusion All authors are with UT Health San Antonio Ryan Joseph, DO, DTM&H Assistant Professor of Emergency Medicine Global Emergency Care Curriculum Director @DocJoseph08 she leaned forward however her physical later the cytology on the pericardial fluid Charles Kennedy exam was unremarkable and all vital signs came back positive for synovial sarcoma. UT Health San Antonio were within normal limits. She then had a She was awaiting follow-up with both Meera Gebrial, MD bedside TTE performed by the emergency Cardiothoracic Surgery and Hematology/ Department of Emergency Medicine physician which revealed a large pericar- Oncology. dial effusion and an 8cm mass adjacent to Shane Jennings, MD, FACEP Background Associate Program Director, Emergency Medicine the right atrium (Figures 1-2). On exam, Primary cardiac neoplasms are she clinically had no signs of cardiac tam- 26-year-old female presented to extremely rare with an incidence of ponade and was well-appearing. the ED complaining of 2 weeks of 0.0001%. Primary cardiac synovial A subsequent CT of the chest showed a progressively worsening shortness A large low-density pericardial effusion with sarcomas (PCSS) account for < 5% of of breath and left sided chest pain. The a large heterogeneously enhancing mass cardiac sarcomas and < 0.1% of all primary patient had been seen at a private clinic 3 likely arising from pericardium (Figure cardiac tumors. Prognosis is extremely the week prior due to cough, congestion, 3-4). The mass was located at the base of poor in cases of PCSS with a median chest pain, and intermittent shortness of 4 the heart abutting the inferior vena cava survival rate of < 9 months. PCSS is a breath. A chest x-ray was done at that time (IVC) and right atrium and was favored to rapidly progressive tumor which can which showed an enlarged heart and she represent a pericardial angiosarcoma. The present with non-specific symptoms such was subsequently instructed to follow-up patient was admitted to the cardiology as chest pain, shortness of breath, weight with her primary care physician (PCP) for service where a pericardiocentesis and loss, and fatigue. Patients usually remain a cardiology referral. She was seen in her biopsy were performed and 1100cc of asymptomatic until the tumor increases to PCP’s office one week later where an EKG bloody fluid was removed. The pericardial a certain size or until spread and metastases was performed which revealed no acute fluid was primarily composed of red occur. Additionally, pericardial effusions abnormalities and an outpatient transtho- blood cells and mixed inflammatory cells and subsequent cardiac tamponade are racic echocardiogram (TTE) was ordered. suggestive of a hemorrhagic effusion. possible complications. Advanced tumors The next day she presented to the ED due Ultimately, the patient had an uneventful may spread to the opposite side of the heart to worsening chest pain and subjective hospital course and was discharged from by the time they are discovered. Symptoms fevers. She stated that her chest pain was the hospital with a plan for her to follow usually present when mass effect of the worse when lying flat and alleviated when up to discuss her biopsy results. A few days tumor or obstruction of blood flow from the

FIGURE 1. Parasternal transthoracic echocardiography in the short axis (PSAX). The arrow indicates a large mass adjacent to the right FIGURE 2. Parasternal transthoracic echocardiography in the long atrium. The two stars indicate the large pericardial effusion. axis (PSAX). The star indicates a large pericardial effusion. LV = Left Ventricle. RV= Right Ventricle LV = Left Ventricle. RVOT = Right Ventricle Outflow Tract

22 EMRA | emra.org • emresident.org pulmonary veins occurs.1 Diagnosis of PCSS PCSS can also be associated with Because of the rapidly progressive is often achieved later in the disease course significant pericardial effusions and signs course of PCSS and the risk of metastases due to the generalized symptoms associated of congestive heart failure. Obstruction of in primarily right-sided cardiac with it and the rarity of the disease. However, blood flow within the heart and infiltration tumors, early detection is paramount in with increasing use of TTE in clinical and of the myocardium is often the cause of accelerating diagnosis and initiating the emergency department settings, a more death in these patients. Because of the high treatment process. Previous literature rapid diagnosis can be made. Furthermore, fatality rate of these malignancies, rapid has shown that echocardiography is the transesophageal echocardiography (TEE), detection and early resection of PCSS, primary method of evaluating the tumors, which has a sensitivity of 97% for detecting before invasion of the heart or metastasis with a 97% sensitivity. Specifically, a TTE cardiac masses, is also becoming more can occur, offer the best chance of can assess location, shape, size, degree of common in specialty clinics and inpatient extending life expectancy. However, due to adherence, and mobility of the tumor,6 settings. TEE can be used to gain more the rapid infiltration and aggression of the whereas TEE provides information information about the tumor’s characteristics malignancy it is often detected when it has about the specific insertion point of the such as shape, size, and precise location.5 already advanced into the myocardium, tumor. In addition to echocardiography, In this article we describe a case in which complicating complete resection. When CT should be used to gain a better the diagnosis and treatment of PCSS was compared to left sided PCSS, right sided understanding of the complexity of the expedited by the use of point-of-care TTE. PCSS appear more infiltrative and are mass and to check for metastasis.6 In the Discussion more likely to metastasize. This suggests case described here, TTE has been shown to be a relatively quick and effective way Primary cardiac neoplasms are that neoadjuvant chemotherapy may to evaluate for a cardiac mass with an extremely rare, with an incidence of be of some benefit to help shrink the associated pericardial effusion. 0.0001%.3 Because of the nonspecific tumor before complete resection. Cases clinical signs and symptoms associated with of right-sided PCSS that were treated Conclusion the disease, diagnosis can be challenging; with neoadjuvant chemotherapy along Diagnosing a primary cardiac often, preliminary detection first occurs with surgical resection reported a median synovial sarcoma can prove challenging through imaging techniques such as X-Ray survival time of 27 months.8 Unfortunately, because of the nonspecific nature of or CT scan. complete resection is often not achievable the symptoms and rarity of the disease. According to a review of the literature because of tumor inaccessibility and the Furthermore, the risk of complications of PCSS, patients presenting with cardiac risk of affecting other cardiac structures. associated with the disease and the high synovial sarcomas have a mean age of 32.5 However, even in cases of partial tumor mortality rate make early detection years with a range of 13 to 66 years old. It resection, surgical intervention has proven and intervention essential. By utilizing is more common in males than in females, to increase prognostic survival time and bedside echocardiography in the with a ratio of 3.5:1, and it has previously has shown some benefit in regard to tumor ED, we can expedite workup, help demonstrated a predisposition for young control.8,9 Patients who underwent surgical guide treatment options, and most adults and adolescents. Also, the right side intervention showed a median survival importantly, identify life-threatening of the heart is more commonly affected, time of 14 months compared to 9-12 emergencies that would benefit from with a ratio of 2:1. months for medical therapy alone.8,9 immediate intervention. ¬

FIGURE 3. Coronal CT scan of chest. The straight red line is showing the size of the mass. The star indicates the large FIGURE 4. Sagittal CT scan of chest. The straight red line is showing pericardial effusion. the size of the mass. The star indicates the large pericardial effusion. LV = Left ventricle

References available online February/March 2020 | EM Resident 23 PULMONOLOGY A Case of Pulmonary Hypertension in the ED Sophia Ahmed, MD, MS (PH). These include: pulmonary arterial prothrombotic state by aggregating at the UT Health San Antonio hypertension (PAH — group 1), PH level of the injured endothelial cells. Maci Chapman due to left sided heart disease (group In group 2 PH, left-sided heart UT Health San Antonio 2), PH secondary to chronic hypoxic disease leads to pulmonary venous Class of 2020 lung disease (group 3), PH secondary congestion; eventually producing Nurani Kester MD, FACEP to chronic thromboembolism (group increased pulmonary arterial pressure. Assistant Professor UT Health San Antonio 4) and PH secondary to unclear/ Group 3 results from chronic hypoxemia- multifactorial pathogenesis (group 5).2 induced pulmonary vasoconstriction 63-year-old female with past Pulmonary arterial hypertension (group and thus hypertension.5 Group 4 medical history of COPD (on 2L 1) is often idiopathic or occurs as a result involves chronic thromboembolism, home oxygen), hypertension, A of a connective tissue disorders. Of the which impedes normal blood flow “some remote heart surgery,” presents to groups above, pulmonary hypertension within pulmonary vessels. This results the emergency department by EMS with secondary to left sided heart disease in vascular congestion, pulmonary acute, increasing shortness of breath (group 2) is the most common. Our hypertension, and right ventricle strain. over the past 12 hours. Patient denies patient would fall into group 3 due to her Group 5 is by definition unclear, and fever, increased cough or recent travel. history of COPD, and PH is important to often has no clear pathophysiology.4 Initial vital signs were HR 118, RR keep in mind when evaluating patients Signs and Symptoms: Approx 35, SpO2 61% on 2L and BP 124/86. presenting with presumed COPD imately 86% of patients with PH will On physical exam the patient is alert exacerbations. It is vital to be able to present with shortness of breath. As and in severe respiratory distress, with identify and begin appropriate treatment a nonspecific symptom, PH is often diminished but clear breath sounds for PH sooner rather than later, as it overlooked.6 Additional associated bilaterally. vastly improves patient outcomes and symptoms can include fatigue, chest pain, The patient’s respiratory status fails their quality of life. exertional syncope, light-headedness, to improve with non-rebreather mask Pathophysiology: The exact edema and palpitations. Initially, a loud or Bi-level Positive Airway Pressure and pathophysiology varies based on the S2 may be the only discernable sign on ultimately is intubated. underlying mechanism. In the case of examination. However, as PH progresses, Laboratory work reveals no PAH, it is characterized by vascular signs may include a pansystolic murmur leukocytosis, no lactic acidosis, remodeling and accompanied by of tricuspid regurgitation, diastolic normal hemoglobin and VBG with fibrosis, inflammation, and abnormal murmur of pulmonary insufficiency, pH 7.28 and CO2 >115. Chest-x-ray proliferation of endothelial and vascular left parasternal lift, jugular venous shows cardiomegaly with prominent smooth muscle cells.3 The mechanism is distension, hepatomegaly, peripheral pulmonary vasculature. Computed thought to be secondary to endothelial edema and ascites.2 These signify right tomography pulmonary angiography dysfunction with an imbalance ventricular failure due to increased reveals no pulmonary embolism, but between endogenous vasodilators (eg, pressure in the pulmonary system. marked dilation of the pulmonary trunk. prostacyclin) and vasoconstrictors Diagnosis: Definitive diagnosis The patient required medical (endothelin-1) resulting in a net effect is established via right heart intensive care unit admission and was of vasoconstriction and thrombus catheterization.3 However, in the discharged 3 weeks later on her baseline formation. There are three major emergency department we rely on oxygen requirement. pathways (nitric oxide, endothelin more accessible modalities to indicate Discussion and prostacyclin) playing a role in the the presence of PH such as EKG, labs, Introduction: Pulmonary development and progression of PAH.4 and imaging. Evidence of right heart hypertension can be a complicating factor Pulmonary vascular smooth muscle strain on EKG, such as a right bundle in many patient presentations, especially cells that normally have a low rate of branch block or t wave inversions and in the acute setting. It is defined as a multiplication undergo proliferation and ST depression in the anterior leads are resting mean pulmonary artery pressure hypertrophy leading to intimal narrowing associated with PH.7 The most common (PAP) at or above 25mm Hg, and is and increased resistance to blood flow. electrocardiogram finding is right axis typically diagnosed via right heart cardiac Furthermore, circulating platelets in deviation (Figure 1). Right ventricular catheterization.1 There are currently five patients with PAH are in a continuous hypertrophy may also be noted, with V1 categories of pulmonary hypertension state of activation and contribute to the and V2 having large R waves and smaller

24 EMRA | emra.org • emresident.org S waves. V5, V6, I and aVL may also increased myocardial stretch.2 Chest and provide key information to expedite display smaller R waves than normal. x-rays (CXR) can offer further evidence the diagnosis. An RV: LV ratio >1 on Prolongation of the QTc interval or QRS of pulmonary hypertension, as they the apical four-chamber view indicates complex likely indicate more advanced may show cardiomegaly or prominent right ventricular overload (Figure 4). 7 disease. (Figure 1) central pulmonary arteries (Figure 2). The “D” sign may be visualized in the Specifically, right ventricle and atrium parasternal short-axis view (Figure 5). enlargement can be seen in advanced This is produced when the right ventricle cases. Chest x-ray can also offer evidence is enlarged, leading to interventricular of underlying disease processes leading septum flattening during diastole, to pulmonary hypertension; for example, which in turn results in a D-shaped left 9 hyperinflation as seen in COPD or ventricle. Ventricular wall thickening will interstitial lung fibrosis.8 (Figure 2) differentiate chronic vs. acute right heart. A computed tomography (CT) In acute strain, as seen with a pulmonary FIGURE 1. scan of the chest can also be useful in embolism, we would see a thin, free wall; Although not emergently indicated, diagnosis if the main pulmonary artery however, the chronic strain characteristic a troponin level may be useful, especially diameter is >29mm and/or the ratio of PH would produce a thickened wall. if there is any concern for ischemia due of the main pulmonary artery to the Like CT, ECHO can also be useful in to poor right coronary artery perfusion. ascending aorta diameter is >1.7 CT determining whether there is another An elevated troponin in the setting of will reveal enlargement of the right disease process playing a role in the pulmonary hypertension is associated ventricle, mediastinal abnormalities, and patient’s presentation. (Figure 4 and 5) with increased morbidity and mortality. other findings that will help clarify the Management: Outpatient A brain-natriuretic peptide level may diagnosis (Figure 3). management may include a combination also prove useful if it is elevated from Bedside ultrasound and of calcium channel blockers, digoxin, the patient’s baseline, as it reflects echocardiogram, can be performed quickly continued on page 27

SAG DORSAL BASE OF PENIS AOC ML FIGURE 2. FIGURE 3.

FIGURE 4. FIGURE 5.

February/March 2020 | EM Resident 25 RENAL/NEPHROLOGY The Echogenic Kidney Bryn Dhir, MS IV a size of 9.5x5.2x3.7 cm (Figure 1, 2) to be attributed to the developmental International American University and 10x3.5x4.4 cm of the left, and was abnormality between the ureteral-bud College of Medicine negative for hydronephrosis or focal and the metanephric blastema in utero.2 Colin Ireland, DO masses, bilaterally. The right kidney was Nonetheless, investigations for the Todd Britt, DO marked with a 5 mm stone in the lower proteomic biomarkers responsible for the Alan Janssen, DO Ascension Genesys Hospital pole, without focal masses. There were defects or genetic transmission is limited, no stones in the left kidney. On careful and patients will often present with a ltrasound in the emergency inspection, diffuse increased echogenicity negative family history and phenotype. As department can reveal the of the renal pyramids was visualized medical referrals and consults for MSK are echogenicity of the renal pyramids U bilaterally. increasing at a rate out of proportion to the in Medullary Sponge Kidney. Despite The patient was given Toradol IV prevalence of the disease,3 understanding previous episodes and presentations, it with improvement of pain. The patient MSK in the emergency department (ED) is often undiagnosed or overlooked by also received IV fluid hydration to aid can allow for appropriate patient care physicians, and chronic presentations can in calcium stone management. Labs and management. Further, although the cause diagnostic dilemmas for emergency were drawn and results remained with renal pathogenesis of MSK is associated physicians. normal limits. The patient indicated with Beckwith-Widemann syndrome and Case. A 31-year-old female with a she had approximately five previous renal hemihypertrophy, it is important to history of nephrolithiasis and hematuria episodes of similar pain over the years. differentiate MSK from polycystic kidney presented to the emergency department However, these episodes did not require disease and tubulointerstitial kidney with a chief complaint of right flank pain hospital admission. The diagnosis of disease as these can present with similar and hematuria for the past three days, medullary sponge kidney was made imaging results despite the unrelated unrelieved by over the counter ibuprofen from assessment of the case and medical pathophysiology.4 or acetaminophen. The patient reported history, and discussion with the patient MSK is often asymptomatic. However, pain, which was dull and constant in for management with oral hydration clinical presentation is often among adult nature, which fluctuated to a sharper pain at home as well as pain management wo5men between 30 to 50 years of age does associated with movement. The pain was was recommended. The patient was demonstrate a history of recurrent painless localized to the right flank, with radiation discharged approximately five hours after hematuria, increased frequency of urinary to the right lower pelvis. presentation. tract infections, and recurrent calcium Investigation of the abdomen, Discussion. Medullary Sponge Kidney stones.6,7,8 As there is no gold standard pelvis and kidneys with an ultrasound (MSK), also known as Cacchi-Ricci for the diagnosis of MSK, emergency was unremarkable, except for bilateral disease, is an uncommon and benign physicians in the ED can use ultrasound renal echogenicity. Focused renal congenital disorder affecting less than for renal vascular flow analysis to visualize examination of the right kidney measured 1% of the population1 and is thought the renal architecture for the dilation of the

FIGURE 1. Ultrasound investigation of the right and left right kidney in FIGURE 2. Ultrasound investigation of the right and left kidney in 2D long views, reveal diffuse echogenicity seen here. The right kidney a 2D long view doppler flow. Diffuse echogenicity is seen. measured a size of 9.5x5.2x3.7 cm, whereas the left kidney measured a size of 10x3.5x4.4 cm. The right kidney was further marked with a 5 mm stone in the lower pole.

26 EMRA | emra.org • emresident.org terminal collecting ducts and/or diffuse medullary cysts, as was done in TAKE-HOME POINTS the management of this case. Other imaging studies include a preference of non-contrast computed tomography scan, as well as intravenous • Patients with a recurrent history of nephrolithiasis and hematuria may have undiagnosed medullary sponge pyelography though rarely used, and magnetic resonance imaging with kidney. Although a benign disease, the management 3 gadolinium. Although ultrasound is less specific than other imaging of sequela associated with MSK, such as antibiotics modalities, it’s benefits with time and cost effectiveness make it a favorable for urinary tract infections, and analgesics for pain imaging candidate, which can reliably show a uniform echogenicity of the management, is recommended. corticomedullary junction and hydronephrosis due to stone obstruction, • The awareness and understanding of the pathophysiology seen in MSK.9 and presentation of MSK in the ED, where ultrasound imaging is frequently used for screening and diagnostic Initial treatment of MSK involves hydration for calcium stones, purposes, is valuable in establishing a management plan as well as the management of sequela (UTI, pain). Thorough case consisting of a diagnostic work up, potential medical investigation with patient history further allows for cost-effective consults and other invasive investigations. management and patient education. As seen in this case, effective • Patient education to understand the pathogenesis of MSK management and awareness of this benign disease resulted in a can alleviate anxiety and frustration and can allow for cost effective management. favorable outcome. ¬ A Case of Pulmonary Hypertension in the ED continued from page 25 and additional fluids can stretch thereby increasing the work of the diuretics, home oxygen, anticoagulation, the myocardial fibers and cause right ventricle. Dopamine is also endothelin receptor antagonists, decreased cardiac output due to not ideal due to increased risk of phosphodiesterase inhibitors and right ventricle failure (Figure 6). tachydysrhythmias and elevation in prostacyclin analogues. However, our Additionally, in chronic PH, right peripheral vascular resistance and chief concern is acute management. ventricle remodeling leads to elevated pulmonary artery pressure.3 1. Airway management can prove transmural pressures, impairing RCA 6. Next steps: consider prostanoids, challenging because positive pressure perfusion, which may lead to right endothelin receptor antagonists, and ventilation (PPV) and intubation ventricular ischemia. Intravenous PDE-5 inhibitors. These agents have increase the risk of cardiovascular fluids should only be used if the half-life of 30 minutes to one hour, collapse. The increased intrathoracic patient is obviously dehydrated, and and patients may develop severe pressure from positive pressure even then should be used in small rebound pulmonary hypertension if ventilation puts additional strain boluses with frequent re-evaluation.3 their infusion is stopped. Consider on the heart by decreasing preload, Hemodynamic stability in these starting these agents with expert which worsens cardiac output.3 patients is precarious, and can easily consultation. Nitric oxide (NO) If intubation cannot be avoided, be disrupted. (Figure 6) should be utilized as an inhaled Etomidate should be used for 4. Right ventricle support is critical. medication when available. Patients induction due to minimal effects The main agents include dobutamine with PAH typically have low levels on systemic vascular resistance, and milrinone. Dobutamine operates of NO, and the severity of disease pulmonary vascular resistance and via beta-2 mediated systemic inversely correlates with NO cardiac contractility. Lung protective vasodilation, causing decreased reaction products. Nitric oxide settings should be embraced with a pulmonary and systemic vascular causes systemic vasodilation and tidal volume of 6mL/kg ideal body resistance and increased contractility. helps to reduce the stress placed weight and the lowest PEEP to Milrinone works as a PDE-3 inhibitor, on the right ventricle by decreasing maintain oxygen saturation >90%.10 and reduces peripheral vascular preload.3 Monitor serial plateau pressures, as resistance to augment right ventricle 7. If all else fails, consider right these should be kept low.3 function.11 However, it is important ventricular assist devices and 2. Oxygenation: hypoxemia and to note that these agents may cause extracorporeal membrane hypercapnea cause vasoconstriction hypotension, and vasopressors may oxygenation. of the lungs and worsening be necessary to offset this effect. 8. Disposition: most patients will pulmonary vascular resistance. A 5. Vasopressors: norepinephrine is the require inpatient admission, if for goal of SaO2>90% is preferable, vasopressor of choice, and reduces no other reason than to identify as these patients cannot tolerate the 28-day mortality from cardiogenic the underlying mechanism of permissive hypercarbia and shock.12 Other agents that may be their pulmonary hypertension. hypoxemia.3 considered include epinephrine Additionally, intensive care unit 3. Circulation: fluids must be used and vasopressin. Phenylephrine admission should be considered for judiciously. The right ventricle is should be avoided since it causes patients with right ventricular failure already under a great deal of strain direct pulmonary vasoconstriction, at the time of presentation.3 ¬

References available online February/March 2020 | EM Resident 27 CARDIOLOGY/RADIOLOGY

Apply ADD-RS criteria**

End the Glow! ADD-RS <= 1 ADD-RS >1 Roli Kushwaha, MD HCA West Division Brandon Regional Hospital Anthony Furiato, DO, FACEP HCA West Division Brandon Regional Hospital D-dimer testing @medbrew16 Justin McNamee, DO, FACEP D-dimer D-dimer HCA West Division Brandon Regional Hospital <500 ng/ml >500 ng/ml CTA @jjmcnamee ortic dissection (AD) is part of a ADD-RS Criteria** Any high risk condition (+1): Marfan syndrome, family h/o aortic disease, known aortic group of acute aortic syndromes valve disease, recent aortic manipulation, or known TAA consisting of intramural aortic AAS Any high risk pain feature (+1): Chest, back, or abdominal pain described as abrupt A onset, severe intensity, or ripping/tearing hematoma, penetrating aortic ulcer, and ruled out Any high risk exam feature (+1): Perfusion deficit (pulse deficit, systolic BP differential, aortic rupture. On its own, the incidence or focal neuro deficit + pain). new aortic insufficiency (with pain), hypotension/shock is approximately 3-8 cases per 100,000 per year, and up to 25% of cases are 46.6% studied on AD patients.3,4 Although negative D-dimer showed a sensitivity missed. The in-hospital mortality when a rapid, economical, and accessible of 98.8%, NPV 99.7%, and LR-0.02. An treated is 27%, with a 2% increase in biomarker, it is also nonspecific with a ADD-RS=0 had a sensitivity of 99.6%. mortality/hour. Imaging modalities like low specificity and PPV and a poor (+) Furthermore, application of this rule CT angiography, TEE, and MRA have LR.2 The possibility of excessive advanced could potentially spare ~3 in 5 conclusive made improved diagnosis of the disease, imaging is increased when used alone on imaging exams in all patients with AAS, but are costly, potentially harmful, time- a low-risk patient population. Therefore, and could avoid up to 1 in 2 CTA exams in consuming, and require patient stability when coupled with a decision rule like the patients with suspected AAS.1 when in use.1 The key concern in the ED Aortic Dissection Detection Risk Score For perspective, a 65-year-old male is if there is a way to risk stratify patients (ADD-RS), it can provide better utility with known history of TAA presenting with for AD and if so, is there a test with high with increased sensitivity. abrupt onset of chest pain radiating to back enough sensitivity and negative likelihood Risk Stratification Tool who appears diaphoretic and hypertensive ratio (-)LR to rule out AD. Smooth ADD-RS is a set of 12 clinical markers would immediately receive a CTA based on muscle myosin heavy chain is a proposed of aortic dissection released in 2010 by risk factors and presentation alone. Howev- modality, which is released from injured American Heart Association and the er, a 56-year-old with history of HTN aortic media at the start of AD, but there American College of Cardiology.5 This presenting with chest pain radiating to is a lack of observational studies testing scoring system was developed using back, but well-appearing and stable vital 2 its efficacy as biomarker in diagnosing. the International Registry for Aortic signs can be appropriately risk stratified Hence, an algorithm to help reduce both Dissection, comparing common historical with this tool. Her ADD-RS of 0 indicates misdiagnosis and overtesting is much and clinical features. The strength of D-dimer can be obtained. If the level is needed. the ADD-RS scoring system is that its negative, and she remains hemodynam- Literature Review retrospective analysis of IRAD showed ically stable, we can safely rule out AAS while reducing cost and radiation exposure. Plasma D-dimer, a degradation that low risk scores of 0 had a sensitivity This strategy could aid in standardizing product of cross linked fibrin by the for AD of 95.4%. Of the 4.6% that had decisions on advanced imaging for sus- endogenous fibrinolytic system, is found AD with a score of 0, 48.6% of these pected AAS, while balancing the risks of to be elevated in states like cancer, MI, patients had abnormal chest radiographs, misdiagnosis and over-testing. This could pregnancy, sepsis, or disorders where including things such as widened become an essential tool analogous to Wells there is indiscriminant activation of the mediastinum. If considering that these Criteria, PERC, and D-dimer. The authors coagulation cascade.2 Meta-analysis patients would be worked up anyway due suggest further prospective studies for reviews of D-dimer studies have shown to an abnormal chest radiograph, the validation but are optimistic for its future. that a cut-off level 0.50 ug/mL has miss rate of the ADD-RS would be 2.23%. proven to have high sensitivity, (-) The ADvISED Trial1 evaluated the Notice LR, and negative predictive value.2,3 ADD-RS combined with D-dimer testing This research was supported by According to the IRAD-Bio study, when by conducting a multicenter, prospective HCA and/or an HCA affiliated entity. utilized in the first 24 hours of symptoms, observational study which enrolled 1,850 The views expressed in this publication D-dimer can reliably rule out pulmonary consecutive chest pain patients, 241 represent those of the author(s) and do not embolism (PE) and acute AD with (13%) of which were diagnosed with acute necessarily represent the official views of sensitivity of 96.6% and specificity of aortic syndrome (AAS). ADD-RS<=1 and HCA. ¬

28 EMRA | emra.org • emresident.org References available online PEDIATRICS Pediatric Nasopharyngeal Tumor Ashlee Davis, MD spur malignant transformation of nasal Prisma Health – Upstate epithelium.2 While rare in the continental @EDThisIsAshlee US, incidence is highest in Tunisia, China, Sarah E. Fabiano, MD, FACEP, FAAEM Southeast Asia, Alaska, and the Mediter- Clinical Assistant Professor ranean basin.2 Nasopharyngeal carcinoma University of South Carolina Medical School/ Greenville Health System arises from epithelium of the fossa of Prisma Health Rosenmuller in the lateral nasopharynx 14-year-old male presented to and may metastasize to cervical lymph 2 the ED with a chief complaint of nodes, bone, lung, and mediastinum. vision changes. For three months Like the tumor in this case, A neuroendocrine and neuroectodermal he had been seen by his pediatrician and diagnosed with recurrent sinusitis tumors of the nasopharynx are even less common. These are characterized as and upper respiratory infections. Imaging may include CT of the head, facial small, round blue cell tumors.3,4 Primary Upon ED presentation, he reported left bones, sinuses, and orbits.2 Depending on neuroendocrine neoplasms typically eye swelling with blurred vision. He availability MRI is a useful modality for involve the lungs but rarely originate in denied eye redness or pruritus, fever, or evaluation of soft tissues of the head and the head or neck.3 These tumors have a photophobia. His mother insisted that his neck if tumor is found on CT.2 penchant for highly aggressive behavior left eye was swollen and “different” than ED management of nasopharyngeal and prognosis is typically poor.3 the right eye. Vital signs were T: 36.5 tumors consists of a two pronged Neuroectodermal tumors, such as C, HR: 83, BP: 129/81, RR: 19, SpO2: approach: stabilization and early esthenioneuroblastoma (ENB), arise 100% on room air. Physical exam was consultation. Airway must take first from the olfactory nerve and can extend remarkable for left eye proptosis, left eye precedence. Theoretically, in the case upward into the orbit and anterior cranial discharge, limited upward and lateral of large and possibly hemorrhagic fossa.4 Peak incidence is in the second movement of the left eye, and bilateral nasopharyngeal masses, ED physicians decade of life with a pediatric incidence of maxillary sinus tenderness. A CT of the must include an airway management plan 0.1/100000.4 These historically follow an orbits with and without contrast revealed in addition to timely consultation. indolent course or are aggressive with fast a heterogenous mass in the left nasal Malignancies of the nasopharynx growth and early metastatic spread.4 cavity which extended upward into the are often high-grade and aggressive.2,3,4 Nasopharyngeal tumors are exceed- anterior cranial vault and left maxillary Therefore, prompt consultation to ingly rare but their clinical presentation sinus. He was admitted to the pediatric hematology-oncology and ENT must often includes symptoms commonly seen inpatient service with consultations to in the ED. These may include symptoms of be made. If there is invasion into the pediatric neurosurgery and pediatric more benign conditions, such as rhinitis or anterior cranial fossa, as seen in this case, hematology-oncology. sinusitis. Many patients with tumors of the discussion must be held with neurosurgery. Discussion nasopharynx experience nasal obstruction, Final diagnosis depends on formal biopsy. Nasopharyngeal tumors are rare and eye discharge, and rhinorrhea, which is Treatment includes a combination of their ED presentation is variable, ranging often unrelieved by antihistamines. Benign chemotherapy and radiation with surgical 2,3 from benign symptoms such as rhinorrhea tumors and carcinoma may present with resection. to more insidious clinical findings, recurrent epistaxis.1,2 Mass effect may Case Conclusion including facial asymmetry or neurologic contribute to more advanced symptomatol- Pediatric ENT and oncology were sequelae. ogy. Patients may experience voice changes consulted. Biopsy revealed a small, round Tumors of the nasopharynx as the tumor grows and begins to affect air blue cell tumor of neuroendocrine or may be benign or malignant. Benign movement through the involved nare. In neuroectodermal origin. He received tumors include angiofibroma and patients with ENB, facial asymmetry may combination chemotherapy and was craniopharyngioma.1 These primarily occur as the tumor enlarges as well as pro- diagnosed with Li-Fraumeni syndrome, a occur in children or young adults with the ptosis and visual field changes if the orbit rare familial cancer syndrome that occurs most common presenting symptoms being or optic nerve are affected.4 due to loss of function mutations in tumor epistaxis and nasal obstruction.1 A tumor of the nasopharynx may be suppressor genes. After chemotherapy Malignant nasal tumors include naso- considered in patients presenting with tumor mapping revealed that the tumor is pharyngeal carcinoma and may, even more multiple ED visits for rhinorrhea, epistaxis, necrotic. ENT/neurosurgery team believe rarely, be of neuroendocrine or neuroec- facial asymmetry, ocular symptoms, and that surgical intervention is not necessary. todermal origin. Risk factors for carci- cranial nerve palsies. Diagnostic work He is followed by pediatric-oncology and noma include EBV infection, which may up should be guided by clinical exam. continues to receive chemotherapy. ¬

References available online February/March 2020 | EM Resident 29 PREHOSPITAL & DISASTER MEDICINE Tactical Medicine: An Evolving EM Subspecialty Insights from a Tactical Medicine Pioneer Cameron Justice, OMS IV Pacific Northwest University College of Osteopathic Medicine John Wipfler III, MD, FACEP, is an attending emergency physician at OSF Healthcare Saint Francis Medical Center, a Level I Trauma Center in Peoria, Illinois. He is board-certified and teaches as a clinical professor of emergency medicine at the University of Illinois College of Medicine (UICOMP). Dr. Wipfler served in the U.S. military for 14 years, attaining the rank of Major in the U.S. Army Medical Corps before transitioning to a support role for law enforcement tactical operations in 1994. Dr. Wipfler is involved in prehospital Urban Search & Rescue, Wilderness Medicine, and Technical Rescue; volunteers with IMERT (the primary Illinois disaster response team); and served as the medical director of Life Flight air medical program. Dr. Wipfler was instrumental in forming the first tactical EMS unit in the state of Illinois (called mention plenty of space to be involved as STATT) certified by the Illinois Department of Public Health in 1998. His unit supports 3 a resident. tactical operations teams in central Illinois and has been directly involved in more than CJ: How would you describe 220 SWAT callouts. In addition, he has supported callouts or training with the U.S. Secret tactical medicine? Service, U.S. Marshals Office, Illinois State Police SWAT, FBI, and DEA in central Illinois. In 1999, Dr. Wipfler developed one of the first formal 2-week electives in tactical medicine JW: Tactical medicine is a division of for EM residents at UICOMP/OSF St. Francis Emergency Medicine Residency. He continues medicine where the prime objective is to work closely with the Illinois Tactical Officers Association as Tactical Emergency Medical the support of the tactical officers of the Services (TEMS) co-chair, and he serves nationally as chair-elect of ACEP’s Tactical SWAT team, also called Special Response Medicine Section. Teams, Emergency Response Teams, or Dr. Wipfler is the lead author of “Tactical Medicine Essentials,” a textbook endorsed by similar names. In my region, I primarily ACEP and developed with the help of more than 140 reviewers and editors. support three groups; ILEAS 6/7, Peoria City Police SRT, and CIERT (Central treatment in active battlefields and allow Primer on Tactical Medicine Illinois Emergency Response Team). A for the successful extraction of patients to actical Emergency Medical Support Special Weapons and Tactics (SWAT) a higher level of definitive care. Civilian (TEMS) is a rapidly evolving Team is a special group of highly trained law enforcement agencies took note of Tarea of emergency medicine that athletic individuals with specialized the success of TEMS in the military and focuses on prehospital emergency care skills in assessing and resolving high risk its potential application in the civilian specifically designed to support high-risk situations in our communities that have world; in 1994, the National Tactical law enforcement operations and operators. significant threats to citizens. The goal is to Officers Association (NTOA) issued Tactical medicine aims to enhance law resolve the crises with minimal morbidity/ formal positions supporting the wide enforcement operations by assisting in mortality as possible. As a tactical implementation of a well-trained and Medical Threat Assessments, training law medicine provider (TMP), my primary equipped TEMS element into all tactical enforcement officers (LEOs), providing objective is to provide comprehensive on-scene casualty care, and overseeing teams. medical support to the tactical officers, preventive health care maintenance of the Today, tactical medicine is an with the secondary objective being operators. increasingly essential element of law providing necessary care to others on TEMS can be dated to19th century enforcement missions. Tactical medicine scene, ie, other first responders, hostages, physician Dominique Jean Larrey, the providers are involved in all aspects of innocent bystanders, and suspects. surgeon-in-chief for Napoleon’s Army, tactical operations, including pre-mission who was known for his innovative use planning, training, and implementation CJ: What is the physician role of surgical teams dispatched on the of clinical protocols tailored to the tactical in tactical medicine? battlefield to provide immediate lifesaving environment. The goal of tactical medicine JW: Tactical physicians are there for many treatments.[needs a citation] In more is to help ensure mission success and reasons — comprehensive team support, recent years, TEMS has been utilized by safety via preventative as well as acute preventive medicine during training and the United States military in the form of care medicine. TEMS is a rapidly evolving ‘callouts’ (deployments), close up medical specifically trained medical and tactical and widespread practice with exciting support with the goal of having TMPs and support personnel who provide critical opportunities for EM physicians — not to their advanced life support interventions

30 EMRA | emra.org • emresident.org rapidly available when needed, along à The East Coast: Many East Coast of these physicians simply feel that with leadership, EMS medical direction, tactical medicine physicians are anyone who enters the inner perimeter training of team members, and many dedicated to support LEOs, but many of a tactical operations callout should other functions. There are several ways of choose to not become sworn LEOs be armed for self-defense and for accomplishing this goal, and a variety of (reserve officers or deputized, etc.), defending the casualties they are team structures are utilized in our country. are not armed, and choose to function caring for. As in other areas of life, à Some physicians choose to remain in advisory roles from incident things are sometimes controversial, at the Incident Command post with command. The patients get treated and physicians certainly will want to the brass and not attempt to provide and extracted from the scene by the sort through this and other topics in warm or hot zone medical care. They imbedded EMTs / paramedics / nurses deciding when and how to become can mostly provide oversight and and the tactical medicine physician involved in tactical medicine. backup support of the tactical medics will be able to provide advanced à You really have a lot of options as that go inside the warm or hot zone medical care when a casualty is far as being a tactical medicine perimeters. brought to the CCP (casualty collection provider depending on the level of à Some physicians choose to be a fully point), or they may go to the point of involvement you are interested in as sworn law enforcement officer (LEO), injury if the scene is rendered safe. well as the level of participation your obtain the training and qualification They may also provide medical care local agencies are willing to have you to carry a sidearm for protection, and during MedEvac / transport to the involved in. You can be the Medical deploy with the tactical team inside hospital. Director of a Tactical Emergency the warm or hot zone. Some tactical à The West Coast: Many tactical Medical Service unit, where you paramedics and physicians may go medicine physicians in central and primarily function as the primary inside with entry teams if fully SWAT- western USA choose to be more physician for the team members, as trained and competent, but most will involved with warm and hot zone well as write medical protocols and remain nearby — behind hard cover operations, and depending upon the lead trainings for your team. You and within a 30-second response politics and administrative support of can choose to be more hands-on as time — to be ready to respond to LE / Fire / EMS, they may be sworn well, imbedding within the team and medical emergencies if needed. For LEOs who are trained and authorized participating in the same trainings as most SWAT callouts, there is a single to be armed with a pistol or other the tactical operators as well as being house or small building and the firearm. Achieving law enforcement in charge of the medical aspects of TEMS element can move close to but status can require part-time school, your unit. EMS Medical Directors not inside the structure due to high a standardized firearm course, also help support their local Tactical threats. However, if there is a large and an agreement with a local/ Medics and Rescue Task Forces and building with multiple stories, then regional law enforcement agency in can choose to be more or less involved. the TEMS element may deploy and order to be deputized or sworn in Just be aware that the medical legal accompany the rear portion of the as a peace officer with all the rights coverage for tactical medicine can be SWAT entry team or rescue team, or accompanied with the title. There is a significant barrier, especially for Rescue Task Force element, which variability throughout the country and resident physicians, so check with your allows the benefit of being close throughout the rest of the world. Many hospital and local/regional teams. to the team during all movement. CJ: What are the job prospects Most SWAT callouts have a Tactical of the tactical medicine physician? Operations Center (TOC), which is JW: There are a couple of paths currently, where all the operators are completing but this is a continually growing field as the mission planning and gearing up states and counties slowly begin to expand for the mission itself. Participating their goals and funding for TEMS units. at this point involves much more You could be a paid EMS Medical Director tactical training with the team in order who supports local TEMS units, and again, to be a safe and effective operator make sure you check into malpractice on scene with the rest of the team. coverage for your area. Medical Threat Assessment (MTA) is You could also become a faculty formulated and communicated, and member at a residency program that has emergency medical response plans a tactical medicine elective and get paid to are determined and planned and teach the elective. But a large majority of prepared for. physicians who provide tactical medicine There are also regional differences in are unpaid volunteers who have decided to the abilities to participate in these roles, contribute towards our community’s well- and in general: being using God-given talents in a helpful

February/March 2020 | EM Resident 31 PREHOSPITAL & DISASTER MEDICINE

and challenging way. It is a ‘mission’ or your pistol and very little medical care, least 1 or 2 shooting courses. Become safe passion for most of the tactical physicians, then that will not work in your favor. Be and reliable with weapons handling and and many can benefit from this. quiet and modest and start out slowly with safety. Don’t be that ‘doc’ who accidently ‘flashes’ fellow shooters with the muzzle. CJ: What advice do you have a sincere desire to be there for emergency Incompetence on the shooting range will for residents or new attending medical care and preventive medicine and be quickly noted, and you’ll lose respect physicians who want to get team support. Ask about vaccinations, and they won’t want you around. Start involved in tactical medicine/local medical histories and allergies of team thinking through injury prediction based SWAT teams? members; take blood pressures; and worry about the guns and shooting later, at an on the environment of mission and learn JW: The biggest thing is to get training appropriate time. the medical knowledge and skills necessary and experience, meaning take courses to deal with them in the field when it’s CJ: In what ways could medical on tactical medicine, prehospital medical rainy and dark and you’re providing students get more involved in skills, firearms safety, shooting courses, medicine on your knees in the mud or on this field? tactical medicine courses, and other broken glass. instruction. A lot of different courses JW: Go ahead and check out the ACEP CJ: How do you see the role of are out there that vary in length, depth, Tactical Medicine Section website, which the physician evolving in tactical and cost. You could start with 1-3 day lists the EM programs that have tactical medicine in the future? awareness courses (TEMS / TCCC / medicine education. We are preparing to TECC), then look at some 5-day to 2-week revamp the webpage to include some cool JW: Right now many of the tactical courses. Some I would recommend looking new resources, but there are currently medicine physicians are volunteers into are ISTM-International School of some helpful resources such as the and unpaid. Many county and local law Tactical Medicine, CONTOMS, and others. Tactical Medicine tool kit. There is also enforcement agencies have very limited Use the internet and talk with experts to a list of training and education sites for budgets and don’t have money to pay for get further information. various courses as well as a list of some tactical medics or nurses or physicians. Read some tactical medicine books, of the EM residency programs that offer Will this change as tactical medicine look at state/regional agencies to get an tactical medicine electives. I am working becomes recognized as the ‘standard of idea of their structure and curriculum. on creating a comprehensive list of all the care’? Yes, eventually it will be, and there Out of all of the states, California has done residency tactical medicine training at the will be a budget for it, because SWAT the best job of setting up a standardized EM programs in the country, and currently teams without formal TEMS support organization for tactical medicine, so most EM residencies do NOT offer some will be successfully sued in court due the California EMSA website (search for level of tactical medicine training. I would to deliberate indifference in providing Tactical Medicine) is a great resource! suggest starting by reading, completing close-up medical care. We have not quite Basically, I would say to build up your courses if you can, and trying to choose reached that point in the USA but it will prehospital medical knowledge and skills a residency program that offers tactical arrive someday. Meanwhile, fortunately with firearm safety, shooting, and tactical medicine training. there are medical professionals out medicine courses and then approach there who are interested in the tactical your local law enforcement agency about CJ: In what ways could residents medicine field and support the women getting involved. One of the big things is get more involved in tactical and men in blue and camo who protect the firearms competency; you likely will medicine? our communities. I feel there is a deep have the medicine down, but you need to JW: Kind of similar to the previous amount of satisfaction in volunteering and be competent and safe with a weapon to question, but basically try to choose an EM supporting the incredible professionals be respected by law enforcement, so go program that teaches tactical medicine, working to provide these critically to a shooting school or two. And don’t act work on getting baseline training, and then important public services. For me, it is like a Rambo wanna-be. If you show up at approach the local team. an honor, and a privilege, to support SWAT training with a black tactical vest my community through tactical medical on that has 3 knives and 5 magazines for CJ: How would you suggest folks support. ¬ interested in this sector of EM get more experience if they lack a Helpful resources and links specific military or law enforcement ACEP Tactical Medicine Section: https:// background? www.acep.org/how-we-serve/sections/ JW: Really work on building a solid tactical-emergency-medicine foundation of the basic skills and CONTOMS Course: https://contoms. knowledge. Get familiar with law chepinc.org/EMT-TRegistration.html enforcement, SWAT tactics, weapons, Special Operations Medical Association: and how to treat injuries associated with http://www.specialoperationsmedicine.org/ those lethal and less-lethal weapons. Go Pages/default.aspx take some 2-day and 5-day courses and at

32 EMRA | emra.org • emresident.org INTERNATIONAL THINK LIKE A GUIDE Lessons Learned the Hard Way on International Expeditions

Tate Higgins, FAWM Will Hockett Oregon Health & Science University Oregon Health & Science University Class of 2020 Class of 2020 @emigcast

hether you are heading out climbing or international medicine, or SIM card with prepaid minutes for on an international research your gear will add up quickly. Consider voice calls. When I first started guiding Wproject, volunteer medical wearing your boots on the plane. Once in East Africa and Nepal, I would buy mission, CME adventure travel trip, you pass security, switch to flip flops a local cell phone for both in-country or just a vacation to a new corner of and put those boots overhead. Luggage communication and to call home because the globe, think like a professional restrictions can be more flexible abroad. the rates were so much cheaper than my guide. These lessons from international However, if you find yourself needing to U.S. carrier’s international plan. wilderness expedition leaders will make take a bush plane or helicopter, weight WH: Moving at altitude takes time you more independent, capable, and limits can become very strict and you may and you’ll need more than just your confident on your next adventure. be asked to leave gear behind if they are medical kit in the event of a medical Tate Higgins and Will Hockett were overweight. emergency. Make sure you have the layers full-time expedition guides before medical TH: Travel is a great place to you need to survive, plus some extra school and have 2 decades of experience disconnect from electronics. However, layers for the patient. If you do have to between them in leading remote and when you’re a guide, communication is package a patient for evac, make sure to international excursions. Learn their essential for safety and logistics. I usually use their gear and not your own. Take it hard-earned tips for making the most out change my cell phone into airplane from someone who lost a new ArcTeryx of your international rotation, medical mode and use it to connect to WiFi for jacket, if you send something with the mission, or off-the-beaten-path vacation. email, messaging, and Facetime only. patient you won’t get it back. TH: Write down important contact Just be sure to stay in airplane mode to TH: Luggage gets lost! Pack essentials information on paper — actual paper! avoid accidentally connecting to local like hiking boots, medications, eye Carry the paper with you in a gallon-sized cell service and incurring international glasses, and electronics in a carry on. In water-tight bag, along with a paper copy roaming fees. WiFi is becoming more a city like Kathmandu, Nepal, Arusha, of your passport. Once while working in and more widespread across the world Tanzania, you can find a huge market — which came in handy when I needed of slightly used outdoor and travel gear. India, I got off an all-day train ride and to coordinate an emergency helicopter Items like broken-in boots or medications realized I had gotten off at the wrong evacuation in Nepal. may be more difficult to replace. station! My phone was dead, no WiFi, Consider buying a local cell phone Book your return flight with a little and no open shops. Luckily I had written down the contact info of the driver who PEARLS: 6 ITEMS GUIDES ALWAYS HAVE IN THEIR BACKPACK was supposed to pick me up. I asked some locals for help and they called the number 1. Foul weather gear: Guides don’t even check the weather forecast, they just assume that it’s gonna get worse, and pack for it. on my paper and explained to my ride. Pack the snacks you can’t live without and have a method such Keep a paper backup of all the 2. Snacks and water: as chemicals or UV to treat your drinking water while traveling. important things. Your phone is a good 3. TP/personal hygiene kit: If you need toilet paper then you should carry it with you. place to store tons of information. 4. Buff or bandana: Multipurpose dust shield, sun shield, and headband. However, you need a hard copy of lodging 5. First aid kit: Have a kit and carry it with you. Doesn’t do any good if you leave it at addresses, tour operators, plane tickets the hotel. because your phone is going to die when 6. “Sacred socks”: Reserve a pair of socks (or T-shirt or base layer) only for sleeping. you need it most. At the end of a long day, being able to change into one semi-clean item of clothing WH: Most international flights have can feel like a huge luxury and boost your entire outlook. 22 kg baggage limit. For expedition

February/March 2020 | EM Resident 33 INTERNATIONAL

buffer whenever possible, especially if you bag and oxygen tanks. No matter what is Plan for the worst. In the comfort of are traveling in remote parts of a foreign provided, have your own basic kit so you your home, it’s easy to imagine committing country. Weather and travel delays are don’t have to go to the guides for every to sitting through a storm. At high camp, common. In the mountains of Nepal, blister or headache. with -40 wind chill and a tent that needs I’ve been socked in by fog that meant an WH: Try out all of your gear before to be dug out around the clock, it’s a lot extra 2 nights in the mountains and a you leave home. A big trip is a great harder to wait for a weather window. Bring chartered helicopter to finally get back excuse to upgrade your gear and buy the best chocolate, book, or card games to civilization. This can be a fun bonus something new, but test it before you can and keep your mind happy. adventure if you’ve budgeted a buffer at traveling. Load backpacks with all of the TH: Read the pre-trip information the end of your trip, but devastating if you gear you expect to carry and then take packet. Do not skim it; read it all! Things miss your international return flight. some laps around the neighborhood to like strict weight limits for luggage are WH: “In the event of an emergency, get the fit adjusted. A little bit of effort important; pack and weigh your gear stop and roll a cigarette.” I’m not before you leave can make a big difference before you leave, and count on the limits advocating smoking, but this was the in comfort during your trip. being enforced. best advice an older guide gave me. On a The primary reason I have seen Be flexible. Be humble. Remember trip, you might see an accident or hear a clients turn around are blisters. I had that it’s about the journey, not the cry for help. Pause and take stock of the a Denali client spend a year training, a summit. It’s easy to get super-focused situation. Take a deep breath, exhale, and month acclimating in Ecuador, but no on a specific goal, but it’s often the in- check your own pulse. When you’re first time in his new boots. He lasted 2 days on between days that are the most magical on the scene you need to be a rescuer, not the trail before he needed to turn back. and rewarding. ¬ an additional victim. Tate Higgins is a river TH: Get training guide, high altitude in wilderness trekking leader, and medicine and carry wilderness medicine a personal first instructor. His recent aid kit at all times, research centered stocked with any around wearable technology and sleep medications that changes in the high you need or expect altitude traveler. to need. In addition, add othre basic Will Hockett taught supplies such as leadership skills and tape for blisters, mountaineering education on several bandages, etc. For continents. The best an organized trip, part was never the find out what type summit, but about of expedition first the people he shared aid kit is supplied. If time with along the headed to extreme way. The adventure is high altitude ask reaching new heights about a Gamow with medical school.

34 EMRA | emra.org • emresident.org ADMIN/OPS Clinical Pathways in the ED To Use or Not to Use? Paula Diaz, DO By doing so, they can theoretically in medicine today, the implementation Emergency Medicine Department reduce over-utilization of resources of CPWs has yet to be standardized, ChristianaCare Hospital and redundancy in work-up. Pathways and their effect hasn’t been objectively Benjamin Golden, MD can also help identify systems issues proven as the variables remain ill- Emergency Medicine Department ChristianaCare Hospital that interfere with effective patient care defined. While certain metrics may Mahesh Polavarapu, MD and facilitate the resolution of system be realized, the core tenets of cost, @Mpolavarapu problems that can be irritating to both length of stay, and patient and provider Instagram: MahiMahi_86 clinicians and patients. As such, CPWs satisfaction have yet to be adequately ising health care costs and the can simultaneously be used as investigated. In fact, some investigations move towards a value-based vehicles for quality assurance and report no direct relationship between health care system has fueled the process improvement — which is using a CPW and the quality of care R 5 growth of clinical pathways (CPWs). invaluable in an industry constantly provided. While they may seem like a fad, CPWs looking to enhance safety, effectiveness, Additionally, CPWs are usually not have actually been used in health care and efficiency. developed to serve the interests of an since the 1980s and are now widespread As with any vehicle for change in individual patient, but rather a patient in the U.S., Australia, Canada, Europe, health care, CPWs have their share of cohort. Practices that are suboptimal and Asia.1 As a result, there is now critics. One major concern is that they from a patient perspective might be extensive literature about their design, are robotic and depersonalized, going recommended as a way to control costs implementation, and utilization. away from patient-centered care. While or protect special interests.6 Guidelines Despite this, there remains limited data this might be the case in other practice that are inflexible can harm by failing regarding their true impact on patient settings, CPWs offer a tremendous to address the unique patient’s case. In care. benefit for both patients and providers fact, CPWs are not designed for unusual So, in the field of emergency in the ED. In an environment where or unpredictable cases, nor do they medicine where increasing pressures there is a constant struggle to manage respond well to unexpected changes in threaten the ability of ED providers to cognitive burden, CPWs allow providers a patient’s condition. Therefore, when deliver high quality care, the question to offload some of this burden by used by providers who may not have the remains: Can clinical pathways help making certain aspects of patient care expertise to adapt to variability, CPWs acute care providers deliver safe, algorithmic. This, then, allows clinicians can increase risk. valuable, and standardized care to their to spend intellectual capital on the Last, but not least, many patients patients? To help provide an answer, undifferentiated sick, thereby increasing view pathways as an unacceptable this article presents arguments for and the overall quality of care delivered. intrusion into the doctor-patient 7 against their use in an ED setting. Close but No Cigar relationship. This is especially Best Thing Since Sliced Bread Make no mistake that CPWs can troublesome when patient-centered care and shared decision-making are There is extensive literature, serve to simplify decision-making. considered inalienable rights in the ED. and not just in emergency medicine, Nowhere is that more valuable than demonstrating the value of CPWs. First the ED. However, the distillation of Summary and foremost, they have been shown to the art of medicine to a series of binary There is no denying the theoretical improve cost-effectiveness and reduce choices can result in impersonal and benefit of CPWs in an acute care setting. length of stay by up to 22%.2 With the inappropriate care. This “set it and But reality is much harder to decipher, direct relationship between hospital forget it medicine” also creates a form of and evaluation of CPWs is particularly length of stay and ED boarding, this anchoring bias and reflexive compliance, challenging given the wide variability can have a significant downstream which can blind providers to alternative in their implementation and use. So effect on ED care. Additionally, CPWs or rare diagnoses.4 In a setting where don’t consider CPWs a panacea, but have been shown to reduce excessive providers are trained to practice within rather an additional tool to help deliver variation in patient care.3 In a practice the constricts of limited data, anything high-quality patient care, and be aware environment where work-up is driven that has the potential to create bias and that they must be customized to each by variable risk thresholds, CPWs reflexive thinking consequently has the practice setting and allow for flexibility established using evidence-based capability to introduce harm. in the ED where the uncommon is, well, medicine can decrease this variability. Furthermore, while nearing ubiquity common. ¬

February/March 2020 | EM Resident 35 CAREER TRANSITIONS Demystifying the EM to PEM Journey A Conversation with EM to PEM Attendings Gwen Hooley, MD UCSF. Dr. Carolyn Holland (CH) is the EP: I started off like many medical The Mount Sinai Hospital Pediatric Emergency Medical Director students, with no specialty in mind. I @GwenHooleyMD and Division Chief at the University of found interest in all my rotations, but Zaza Atanelov, MD Florida. the ER seemed like home. I loved the North Florida Regional Medical Center @Zatanelov Q: Briefly tell us about your career staff, acuity, undifferentiated patients, procedures, team-centered approach, and pon completion of residency trajectory. ability to treat anyone no matter their training we are expected to be MGH: While in medical school I was background or status. I decided to pursue well-equipped to handle whatever U very interested in virtually every subject, PEM out of a commitment to providing walks into the ED. However, many but my heart had been set on a pediatric excellent care to patients of all ages and emergency medicine graduates will feel specialty. I had originally thought that out of a nagging fear of sick children. uncomfortable caring for the critically I’d be a pediatrician but then became During PEM fellowship I was immersed ill pediatric patient.1 The most common very interested in orthopedic surgery in a busy pediatric ED where I became reason for this is a lack of exposure to and applied to an orthopedic surgery comfortable with the sickest pediatric critically ill pediatric patients. A lot residency with the thought that I’d do a patients. Fellowship also nurtured of us may choose to practice in an ED pediatric fellowship. Once I had started an interest in teaching, simulation, that sees very few pediatric cases, but my internship in general surgery at adult learning theory and curriculum it is hard to completely avoid pediatric Harbor-UCLA Medical Center, I realized development. Academics seemed like a patients, especially when they represent I had a real love for emergency medicine. great fit, affording me the opportunity up to 22% of our patient population.2 I spent a great deal of time in the ED to combine all my interests and easily Also, up to 90% of these patients are and decided to change my specialty in split shifts between adult and pediatric seen in non-speciality facilities without February of 1984; this was the last year emergency departments. Currently I am pediatric emergency medicine (PEM) that I could enter emergency medicine, heavily involved in the development of trained physicians, where both adults and having done an internship in another PEM education for both EM and pediatric children are treated.3 field. I then applied to and thankfully residents. Pursuing a fellowship in PEM can matched in emergency medicine at CH: I did my residency in EM provide expertise in caring for children Harbor-UCLA Medical Center. at the University of Cincinnati and in a shorter time frame than practicing During my last year as a resident, I then I pursued a fellowship in PEM at in the community for several years. had worked with faculty to establish a Cincinnati Children’s Hospital. I then Furthermore, studies have shown that Chief Resident year; however, there was stayed on the faculty there for 2 years PEM physicians have some of the highest no funding available at that time. James prior to coming to my current position at 4 job satisfaction in medicine. Despite Seidel, MD, PhD, who was on faculty UF. I have spent the past 7 years at the these benefits of PEM fellowship training, at Harbor, successfully competed for a University of Florida in Gainesville where most fellowship applicants come from grant with the Health Resources Services I was recently named the medical director pediatric residencies compared to Administration on Emergency Medical of the PED and Division Chief of Pediatric emergency medicine. There are multiple Services for Children. Within that grant, Emergency Medicine. reasons for this trend including perceived he funded a fellowship position and I differences in salary compared to adult became his fellow in Emergency Medical Q: Why did you choose to train in emergency medicine, duration of training, Services/Pediatric Emergency Medicine, PEM after completing EM training? and the fact that emergency physicians during my last year of residency. I worked MGH: I was very much interested can treat children without further on the grant as a fellow for 2 years in the in improving care for pediatric patients training, among several other reasons. Pediatric Emergency Department. At that in the emergency department. I realized To address some of these concerns, time, there were no other fellowships during my residency that there were we interviewed EM to PEM attendings that accepted emergency physicians many gaps, in terms of quality and about their journey towards pediatric in pediatric emergency medicine. So, methodology of care, and that emergency emergency medicine. Dr. Marianne after my 2-year fellowship in EMS for physicians were often ill-equipped to care Gausche-Hill (MGH) is the medical children/PEM, I became the first board for critical illness in pediatric patients. director of Los Angeles County EMS and a certified, fellowship-trained emergency During my fellowship, I was able to PEM faculty member at UCLA. Dr. Evelyn physician in the United States to be sub- participate in training the first national Porter (EP) is the assistant residency boarded in Pediatric Emergency Medicine faculty in pediatric advanced life support director and PEM faculty member at (1992). (PALS). Furthermore, my research during

36 EMRA | emra.org • emresident.org my fellowship made it clear that a lot of EP: Fellowship training took into level. This can be negotiated both in work was needed to improve pediatric account my expertise as an emergency private practice and in academic settings. readiness at the pre-hospital and ED medicine trained physician and offered In addition, PEM physicians, as pediatric settings. experiences to improve my blind spots. I emergency medicine specialists, can also EP: When I chose emergency was able to dig deeper into the pediatric work and have leadership in not only medicine as a specialty I was fully subspecialties and procedures while academic centers but also community committed to learning how to address practicing emergency medicine in a hospitals where they are models of any and all emergencies. Although I had community ED to maintain my hard- PEM trained individuals who can assist quite a bit of exposure to PEM through earned EM skillset. I was also trained community hospitals in improving my rotations in two separate pediatric by and with pediatricians and have their pediatric emergency care service emergency departments, both NICU and always found value in their perspectives line. Finally, EM physicians who are PICU rotations, international experiences and experiences. At the end of the sub-boarded in pediatric emergency and through critical care transports, day I’m capable of practicing in any medicine have the opportunity to work I lacked confidence when it came to pediatric ED alongside pediatric and EM in children’s hospitals, unlike their EM the care of the critically ill pediatric trained physicians. My current practice trained colleagues. Overall, I feel PEM patient. I needed more volume and houses the division of PEM within the offers expanded opportunities for the exposure. I chose fellowship as a means department of emergency medicine. emergency physician to contribute to the of getting the exposure and expertise in specialty. Additionally, I’m one of several EM a concentrated way as opposed to having Being happy in your career is so trained, so I have colleagues who have EP: these experiences parsed out over the important. At the end of the day if it’s traveled a similar path. course of my career. I also wanted to PEM you love then you should consider CH: The skills and knowledge that explore academic emergency medicine fellowship training. Compensation is have to be acquired in fellowship are and knew that fellowship would offer me variable depending on, but not limited different. I had to do pediatric primary that opportunity. to the type of group practice, location, care, NICU, pediatric specialty clinics, but CH: I wanted to be as good at taking and position/title you hold within your got to skip trauma, orthopedics and adult care of sick kids as I was taking care of department. You should also moonlight EM. The programs that I had interviewed sick adults. The number of critically ill regularly in a general ED to maintain your with all had plans for the pathway pediatric patients I saw in residency skillset (and supplement your income) if differences for Pediatric primary trained was significantly less than critically ill you plan to continue caring for adults. It fellows and EM primary trained fellows. adults — even though I rotated through is a very personal choice and is a sacrifice one of the busiest pediatric emergency Q: How would you advise EM of time and money so make a thoughtful departments in the country as an EM residents who are thinking of a decision that’s right for you and your resident. PEM fellowship but are concerned family. Knowing what I do about personal finances, retirement and job satisfaction I Q: How do you navigate being an about being compensated less would make the same decision if I had to EM to PEM physician when the financially throughout their do it all over again. majority of PEM trainees primarily career and the extra 2-3 years CH: The key in academics is to get a trained in pediatrics first? of fellowship when most EM fellowships are 1-2 years? job under the Department of Emergency MGH: Navigation in the specialty Medicine instead of the Department of MGH: Going into pediatric is easy if one embraces the concept that Pediatrics. My fellow PEM providers and emergency medicine provides the we are all emergency physicians. Peds- I get paid on par with the general EM EM trained physician additional PEM trained physicians have similar providers. As for the extra time, in the big opportunities post fellowship training. goals and perspectives as emergency picture, another year or two is not really There are PEM fellowship programs physicians. In other words, we are more a big deal. I did moonlighting during my that allow for a 2-year PEM fellowship alike than we are different. I find that my fellowship to keep up my adult EM skills versus a 3-year. I will state that many PEM colleagues are problem solvers just and functionally doubled my salary. like me, and are very much interested academic programs are very interested in improving care for children in our in PEM trained physicians as they can Q: What strengths and nation’s EDs and in the pre-hospital immediately lead a division of PEM, can contributions do you think EM environment. I have been active both assist in establishing pediatric EDs within trained physicians going into PEM in AAP and ACEP and I believe that academic centers and provide a niche that bring into the field? has helped create mutual trust and other faculty cannot provide. Regarding MGH: I believe that PEM trained respect with both organizations. It also the compensation, a PEM trained EM individuals have a unique opportunity has resulted in a full career for me with physician would be compensated equally to improve care locally, regionally and exposure to PEM colleagues with a to his/her EM colleagues and, in fact, nationally. At a local level serving on different training background and skill because of fellowship training, often committees for state chapters for ACEP set, yet with a common vision. could start at a higher compensation as well as EMS agencies, these individuals

February/March 2020 | EM Resident 37 CAREER TRANSITIONS

can help improve the pediatric care of the general EM trained physician is fellowship, but it would take a lot more services provided locally and regionally. critical. time and individual footwork. There are data to suggest that improving CH: While ABEM only requires 2 pediatric readiness improves mortality Q: What do you like best about years of fellowship there are still some within a region and a PEM trained working in PEM? What do you like institutions that require 3 years, just like individual is the perfect thought leader least? the primary Pediatric trained candidates. to enter these communities and begin MGH: Well, it’s hard to say what I like Keep that in mind when choosing the process of collaboration with other least about it as I’ve enjoyed a full career programs to apply to. of over 32 years in the field. What I like stakeholders to improve pediatric Q: How can an EM resident stand the most about working in PEM are the emergency care. Leadership can also out in a fellowship application? occur at a state and national level as all patients, the nurses and my colleagues. The way they can stand out states have EMS for children programs We are all joined by a singular vision MGH: is through their personal statement and and state partnership grants. The PEM to provide the best care possible to our demonstration of their desire to have physician can get involved on that level patients and I enjoy very much working the training and leverage to better care on technical advisory committees and with nurses and my colleagues to achieve for pediatric patients in emergency even as the Medical Director for these just that. I do love children and their very settings. I believe doing research, some programs. Also at a national level, the positive way of looking at the world. I love type of scholarly work, and/or project PEM physician can be active in the their joy, their desire to play, and admire centered around the care of children AAP as a member of the Emergency their inherent trust of the world. For me, would demonstrate their sincere interest Medicine section or on the Committee for being around patients such as those is an in addition to their attestation of their Pediatric Emergency Medicine (COPEM). honor. Lastly working with the team that intent to utilize their training to better For ACEP, the PEM trained physician I do is one of the greatest joys I have in care for children. I do believe aligning may wish to join the Pediatric section my life. themselves with current experts in the for ACEP as well as seek leadership EP: My favorite aspect of working in field so that these experts can get to know opportunity on the Pediatric Emergency PEM is witnessing the resilience of sick them and write them a strong letter for Medicine committee. In addition, there kids. My least favorite thing about PEM their fellowship application also would are lecturing opportunities both at is seeing how the shortcomings of our be extremely useful. However, most the state and national level for ACEP. society affect kids. importantly the applicant should aim to Furthermore, the emergency physician CH: Best part of PEM is the kids and having the chance to help them feel better excel in their residency. trained in PEM can develop a focus area on a regular basis. My least favorite part is EP: Demonstrate that you have for doing other continuing education parents who come to the ED for evaluation seriously explored PEM life and be able lecture opportunities with the many of their not-ill child who may have had a to articulate why fellowship is of value in providers wanting to expand their fever for 60 minutes and the child has not your career trajectory. This can be done EM knowledge. There are also unique received any antipyretics. Then, I have to through research, activities, curriculum opportunities to train advanced practice spend lots of extra time convincing them development, or leadership activities. providers (APPs) in the care of children. that their child doesn’t need any tests, Know that your residency training is not a EP:: As a minority participant you blood work or x-rays. It always takes more deficiency, but an asset. Your professional bring a different vantage point that is likely time face to face time to disposition a well interests will likely be different from not represented. You know what it’s like to child who the parents think is sick. those coming from pediatrics just by take care of sick kids without the expertise virtue of the differences in training and can speak reality into any questions or Q: What’s one thing you’d like requirements. Letters of recommendation concerns that lack perspective. EM trained people considering PEM fellowship from a PEM trained physician, clinical physicians are masterful at task switching, to know? excellence, intellectual curiosity and running a department and immediately MGH: The one thing that I would accomplishments are typically well prioritizing the care of sick patients. These want them to know is entering a career in received. Ultimately you want to find skills are valued in PEM. EM is also an PEM will provide a full career and allow a program that fits your needs so be amazing field that allows for a huge variety the physician to feel the strength of their thoughtful in where you apply. of niche interests which can also be useful training in ways that they never knew CH: Demonstrate enthusiasm for in PEM. possible. pediatric patients early in residency. CH: EM primary trained physicians EP: Fellowship is a ready-made Do research related to pediatric bring their well-honed sick/not-sick network of experts who are invested in patients. Perform well in your pediatric detector from the years of training in your success. It’s intended to develop rotations so you can get good letters of EM. Also, as more and more “adult-type” your clinical expertise, but expose you to reference. Consider getting involved illnesses occur in pediatric patients due the variety of different interests that exist in pediatric emergency medicine on a to childhood obesity (like type 2 diabetes, within PEM in a short period of time. regional or national level to help make cardiovascular disease) the expertise This could technically be done without connections and build your network. ¬

38 EMRA | emra.org • emresident.org HEART OF EM Grab a Shovel Jeremiah White, MD ChristianaCare “Your aorta might and the atypical, the worried-well and rupture.” the sick and dying, often with the same chief complaint headlined on their hese aren’t words you ever expect chart. And yet that uncertainty doesn’t to hear, and surely not at the age faze us. On the contrary, for me and of 26. But there it was. I stared at T probably others, it’s exactly that idea of my dilated aorta on the echocardiogram, “anything and everything” that drove us and it stared back at me — defiantly into this specialty. So how then, with this denying me the luxury of denial. uncertainty, can we be so comfortable Symptoms had not brought me here. with the unplanned when the stakes are What was supposed to be a routine so high? test had now become a life-altering At the end of the day, it’s all about diagnosis. And when the whistle of who you have in the trenches beside you. the train that had just blindsided me At our program, we have something dissipated, I could finally hear its called a “Golden Shovel Award.” To name: Loeys-Dietz syndrome, a genetic every day. We work long hours, paraphrase a former chief of mine, disorder that can cause aneurysms holidays, and weekends. We deal with it’s an award for a resident who anywhere in your body. We don’t come difficult patients, outcomes, and social has demonstrated the mindset of, across that much in the emergency circumstances. We see, smell, and “when you’re deep in the mud and department, but even this emergency hear things daily that would make the drowning, I’ll bring the shovel.” It’s this medicine resident knows the basic layperson squirm. And yet we are asked mentality that enables us to function premise of connective tissue disorders, to do these time and time again, and the when faced with the overwhelming particularly ones that balloon the task can be seemingly insurmountable. biggest blood vessel in the body: high and the unknown. Some may say it’s We cannot do it alone. We must risk for sudden death. As these words our proclivity for adrenaline or the recognize those around us who need us were repeated from primary care to culmination of our medical training that to grab a shovel and help them through cardiologist to surgeon, I understood one keeps us grounded when we face the the muck that comprises our daily thing. This had to be repaired. Soon. unexpected. But those things only take grind. And one day they will return the Sitting there, staring down the you so far. Even the most experienced favor when you need the extra shovel. barrel of the unexpected, all the medical and hardened provider would flounder Recently, an unforeseen diagnosis knowledge in the world couldn’t resolve in a busy ED alone. To be able to has encompassed me, and several the gut-wrenching concerns this news function efficiently and competently with questions remain unanswered. I don’t had prompted. Countless hours of whatever comes through the door, you know how this disease will progress training and study proved useless to need the support of your colleagues. over my lifetime. I don’t know if there silence all the questions that persistently I saw this in action recently as we will be issues with the repair. I don’t echoed in my mind that cannot yet drilled for a mass casualty incident. know if I will pass this burden to my be answered. What will come of this We practiced what it would be like if a children or how this will impact my connective tissue disorder? Will there tragedy resulted in countless patients career. be complications from the surgery? How flooding your doorstep from the back of But I count myself fortunate because will this affect me and my wife down the pickup trucks, police cars, and frantic I realize that I am not alone. Much road? My kids? My career? ambulances. In a situation like this, like the job I love, I do face certain Facing the unexpected is not new to any one provider would be utterly uncertainty, but I have a team beside me. It’s the very nature of emergency debilitated. Answering medic calls, me ready to share the burden. A selfless medicine. Every day, each emergency coordinating resources, triaging and wife, loving family, gracious colleagues medicine resident walks into the treating patients — it’s an impossible and faculty leaders. And although department knowing that they will thing to ask someone to do alone. But, as I often feel that I’m neck deep and assess, stabilize, and treat whatever a team, everyone plays a vital role. And drowning, not knowing what the future comes through those double doors, but the task, although daunting, becomes a may hold, I look beside me and take we have no idea what to expect. We are bit more bearable. heart. the frontline that sees both the mundane We as residents face the daunting They’ve all brought their shovels. ¬

February/March 2020 | EM Resident 39 OP-ED The Emergency Physician’s “DERELICTION OF DUTY” Why EM Should Lead the Charge for Foreign Policy Debate William Bruno, MD prosperity at home and abroad, and education,7 which is understandable on a LAC+USC Medical Center promote democracy…”4 personal scale. But ignoring U.S. foreign he presidential race is in full swing, There is an interesting discussion to policy is a perilous mistake when it comes and health care is a major focus. be had about what role U.S. foreign policy to presidential politics. TFrom a single payer, Medicare-for- could have in alleviating or exacerbating Emergency physicians should use their all system to mild Obamacare reforms, these public health crises — but no one is influential voices to advocate for a robust almost all the candidates have voiced having it. And that’s not new. During the foreign policy debate. We should demand an opinion. As an EM resident, I share 2016 presidential primary, moderators that our leaders articulate their plans for the enthusiasm of many in the medical asked, on average, only 2 foreign policy America’s role in the world and challenge profession who find encouragement in a questions per Democratic Party debate. them to take ownership of the health field of candidates engaged in a serious The 2020 debates are on track to see only consequences of those plans. Obviously, debate on how to improve our health a mild improvement.5 we are not all global health experts, but care system. U.S. foreign policy, on the Unilaterality of Foreign Policy that doesn’t absolve us of the responsibility other hand, has been a second-tier issue to be informed and engaged. When it comes to presidential politics, at best, and as a physician, I find this Other health care professionals the neglect of substantial foreign policy incredibly disheartening. But perhaps have heeded the call. The American debate in favor of domestic issues is even more disheartening is the disinterest Public Health Association, the World exactly backwards. Making or changing and apathy I’ve noticed in my fellow Federation of Public Health Associations, domestic laws requires Congress to do physicians vis-à-vis American foreign the International Federation of Medical the heavy lifting; the president just signs policy — an issue that desperately needs Students’ Associations, and the on the dotted line. Foreign policy, on our profession’s voice. International Council of Nurses have the other hand, is an area in which the all passed antiwar resolutions on public U.S. Foreign Policy: president takes the lead. health grounds.8 Where is EM? A Neglected Global Health Issue S/he could choose to pursue a Since starting residency I’ve been In today’s world with unprecedented bombing campaign or enforce an inspired by witnessing the real impact forced migration — according to United embargo, restricting access to desperately emergency physicians can have on Nations High Commissioner for Refugees, needed medicines, inflaming a public society. We’re in journals, magazines, we are witnessing the highest levels of health crisis. S/he could, for example, use 1 news outlets, and social media. Our displacement on record — U.S. foreign a phony polio vaccination campaign as a voices are heard on a range of issues, policy is inseparable from unprecedented means of intelligence gathering, putting global health challenges, making it well from health care reform and gun violence public health workers’ lives in jeopardy, within the physician’s purview. to human trafficking and domestic abuse. compromising legitimate vaccination Take the example of Yemen. The But when it comes to foreign policy and campaigns, and exacerbating polio’s U.S. is supporting Saudi Arabia’s role its profound impact on the public health, spread through one of the last vestiges as combatants on one side of the fight we’ve been shamefully silent. It is up to us of this eradicable epidemic (this is not a in Yemen’s civil war. As a result of this to change the narrative and to ensure our hypothetical; it was a strategy employed conflict, every 5 minutes a child under specialty’s relevance continues to grow in by the CIA while in pursuit of Osama age 5 dies of a preventable illness.2 an increasingly globalized society. bin Laden).6 The Commander-in-Chief Or Venezuela, where, in the backdrop It’s time we pushed for a robust could mobilize resources to stifle the next of political unrest that includes U.S. foreign policy debate. I don’t expect ebola crisis, lead vaccination campaigns, supporting an opposition leader’s claim everyone to agree with my politics. I’m or pressure allies to end wars — all with that the current president is illegitimate, not asking for us all to endorse the same the stroke of a pen or a phone call. No outbreaks of measles and diphtheria are presidential candidate. But I do expect Congressional input necessary. rampant.3 each and every one of us to be informed In a report aptly titled Why Health The Emergency Physician’s Duty and engaged. To quote the Jesuit peace Is Important to U.S. Foreign Policy, the There is a reason Democratic primary activist and poet Daniel Berrigan, when Council on Foreign Relations proclaimed candidates are ignoring foreign policy. it comes to U.S. foreign policy, all I’m “Supporting public health worldwide will American voters prioritize other issues: asking is that you “know where you stand enhance U.S. national security, increase the economy, health care costs, and and stand there.” ¬

40 EMRA | emra.org • emresident.org SPONSORED BY LAUREL ROAD

A Financial Guide to Surviving Residency For many, becoming a doctor and choosing a career helping others is an innate calling. For others, it may be a family tradition. Or for some, the lure of being at the forefront of medicine is irresistible. But whatever your motivation, becoming a skilled medical professional is expensive.

According to the Association of American So while there is the potential to make have a number of different repayment Medical Colleges (AAMC), 75% of the more in the future, you should budget options at their disposal, including; direct graduating class of 2018 reported leaving based on your current financial situation. consolidation, income-driven repayment medical school with student loan debt. and public service loan forgiveness. In fact, 51% of medical students that Consider Location graduated with student loans in 2018 Remember, cost of living varies based on Another attractive option available to had loans of $200,000 or more.1 location. When budgeting for expenses physicians is student loan refinancing like transportation, groceries, and housing – which is what Laurel Road does. With graduation in May, a move in June, be sure to research what these costs With student loan refinancing you and residencies beginning in June/July, are near your residency program. can refinance all or some of your there will be less free time available for federal and private student loans. dealing with finances than you might Save for Retirement Refinancing gives you the opportunity to do one or more of the following: think. So, what should you do once It’s never too early to start saving you’ve been matched to a program? for retirement. If your workplace • Lower interest rate(s) In this article, we’ll explore ways to provides retirement savings options, improve your finances and make your take advantage of these plans and • Pay off loans faster residency a little more manageable. any contribution matching offered. • Lower monthly payments Get Organized • Move from a fixed rate to a Get Insurance variable rate (or vice versa) Gather the records of all your debt— Disability, life, and umbrella student loans, car payments, mortgage, liability preserve your investment • Reduce number of loans in repayment personal loans, credit cards, etc.—and in yourself, your assets, and your To learn more about the different keep it in one safe place. Include the capacity to earn future income. amount, terms, payments, interest federal repayment options and rates, and any other key information. student loan refinancing, check out Have an our latest publication, A Financial Know What you Owe Emergency Fund Guide to Surviving Residency, at See the full picture of your debt so you Since insurance can’t cover every laurelroad.com/residency-guide. can make informed financial decisions. eventuality, having a financial This should encompass how much cushion can help get you through you owe, monthly payment due dates, an unexpected challenge. and your current payoff dates, even if they are 10, 15, or 20 years away. Maximize Your Deductions You may be eligible to deduct up to $2,500 Map Your Goals of student loan interest paid in a given year. House, kids, private practice, lifestyle— There are some restrictions, so check the include it all. Even if plans and income requirements each tax year and be circumstances change, thinking about sure to consult a tax professional for help. As an EMRA member or alumni, where you want to go now will help you you can get a 0.25% rate discount be better prepared for the future. Set a Student Loan when refinancing.3 To apply, visit Repayment Strategy laurelroad.com/EMRA and Live Like a Resident To set the best repayment strategy for see personalized rates in The average yearly salary for a resident is you, you’ll need to know your options. less than five minutes. $59,300 according to a Medscape survey.2 Physicians with Federal student loans

1. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card, AAMC, October 2018 2. https://www.medscape.com/slideshow/2018-residents-salary-debt-report-6010044 3. The 0.25% EMRA member rate discount is offered for student loan applications from EMRA members in good standing. The rate discount will end if EMRA notifies Laurel Road that borrower is no longer in good standing. Offer cannot be combined with other Laurel Road offers, except any discount for making automatic payments. The partner discount will not reduce the monthly payment; instead, the discount is applied to the principal to help pay the loan down faster Laurel Road is a brand of KeyBank National Association offering online lending products in all 50 U.S. states, Washington, D.C., and Puerto Rico. All loansFebruary/March are provided by KeyBank 2020 National| EM Resident Association, 41 a nationally chartered bank. ©2020 KeyCorp® All Rights Reserved. Laurel Road is a federally registered service mark of KeyCorp. Member LEADERSHIP REPORT Welcome, EM Leaders of Tomorrow! EMRA provides a leadership pipeline for every facet of the specialty. Please welcome the incoming EMRA committee chairs, chairs—elect, and vice chairs who are poised to make progress in 2020—2021. Please see EM Resident online for full recognition of the committee leaders of 2019–2020.

Administration & Operations Chair–Elect Sarah Ring, MD | Mount Logan Ramsay, MD | University of Chair Ynhi Thomas, MD | Baylor Sinai School of Medicine — New Cincinnati College of Medicine York Informatics Chair–elect Nick Cozzi, MD, MBA | Vice Chairs Chair Chris Libby, MD | North Florida Spectrum Health/Michigan State Jon Brewer, MD | UT Southwestern Regional University Shannon Burke, MD | University of Chair–elect Fran Riley, MD | Vice Chairs Wisconsin Maimonides Medical Center Nicholas Stark, MD | UCSF — San Kathryn Fisher, MD | McGovern Vice Chair Morgan Carlile, MD | UC Francisco General Hospital Medical School at UTHealth San Diego Phillip Tseng, MD, MBA, MEd | The Frances Rusnack, DO | Mount Sinai International Ohio State University Wexner St. Luke’s—Roosevelt Hospital Medical Center Chair Colleen Laurence, MD, MPH | Center University of Cincinnati College of Critical Care Moira Smith, MD, MPH | University of Medicine Chair Mark Ramzy, DO, EMT—P | Virginia Chair–elect Travis Wassermann, MD, Maimonides Medical Center Jessie Werner, MD | UCSF—Fresno MPH | Loyola University Medical Chair–elect Mina Ghobrial, MD | Center Government Services Emory University Vice Chair Jacqueline Tin, MD | Mount Chair Danielle Wickman, MD (LT MC Vice Chairs Sinai School of Medicine — New USN) | LAC+USC Medical Center Sean Hickey, MD | Mount Sinai School York of Medicine — New York Chair–elect Katherine Lee, DO (LCDR MC USN) | Naval Medical Center — Pediatric EM Ally Hynes, MD | Hospital of the San Diego Chair Jessica Li—Yan Chow, MD | University of Pennsylvania UCSF—San Francisco General Timothy Montrief, MD | Jackson Vice Chairs Hospital Memorial Hospital Haley Dodson, MD (LT MC USN) | Naval Medical Center — San Diego Chair–elect Gwen Hooley, MD | Mount Diversity & Inclusion Sinai School of Medicine — New Zachary Hampton, DO (CAPT USAF) | Chair Jessica Faiz, MD | Boston York Doctors Hospital/OhioHealth Medical Center Vice Chairs Chair–elect Tatiana Carrillo, DO | SBH Health Policy Kellan Etter | Des Moines University Health Systems Bronx Chair Sushant Kapoor, DO | COM Vice Chairs ChristianaCare William White Jr., MD | Harbor UCLA Sandra Coker | McGovern Medical Chair-elect Kirstin Woody Scott, MPhil, Medical Center — Peds EM Fellow School PhD | Harvard Prehospital & Disaster Medicine Jeremy Collado, MD | Denver Health Vice Chairs Chair Kristen Kelly, MD | Mount Sinai Medical Center Miriam Bukhsh, MD | Beaumont School of Medicine — New York Arthur Pope, MD, PhD | University of Hospital — Royal Oak Chair–elect Sarayna McGuire, MD | Chicago Owais Durrani, DO | UT San Antonio Mayo Clinic School of GME Education Clifford Marks, MD | Mount Sinai NY Vice Chairs Chair Erin Karl, MD | University of Valerie Pierre, MD | Brookdale Hajirah Ishaq, DO | Doctors Hospital/ Nebraska Medical Center University Medical Center OhioHealth

42 EMRA | emra.org • emresident.org Rebecca Mendelsohn, MD | Florida Chair–elect Michael Simpson, MD | Osteopathic: Ryan Lucas | Rocky Vista Atlantic University Vanderbilt University University Research Vice Chair Katelynn Baska Student Advising: Ashley Penington | Philadelphia College of | Pacific Northwest University of Chair Joshua Davis, MD | Penn State Osteopathic Medicine Health Science COM Health Milton S. Hershey Web/Tech: Spencer Rushton | Kansas Chair–elect Chet Zalesky, MD | Ultrasound City University Medical College of University of Cincinnati Chair Akash Desai, MD | Mount Sinai Osteopathic Medicine Vice Chair Nathan Dreyfus | University School of Medicine — New York Northeast: Katelynn Baska of Vermont Larner College of Chair–elect Sam Southgate | | Philadelphia College of Medicine University of Connecticut Osteopathic Medicine Immediate Past Chair Aadil Vora, Vice Chairs Southeast: Erron Fritchman | Arkansas DO | Emory University School of Jacob Freudenberger | UNT Health College of Osteopathic Medicine Medicine Science Center Eric Lieu, MD | ChristianaCare Midwest: Rich Dowd | Ohio University Simulation COM Katie VanNatta, DO | Midwestern Chair Alex Tran, MD | Mount Sinai University — CCOM West: Lenexa Morais | UT Galveston School of Medicine — New York International: Shelby Wood, MPH, Chair–elect Evan Strobelt, MD | Yale Wellness EMT—P | St. George’s University New Haven Medical Center Chair Taryn Webb, MD | Mount Sinai AMA—MSS Primary Rep: Matthew Vice Chairs School of Medicine — New York Christensen | Rosalind Franklin John Peacock | University of Texas Chair–elect Allie Lockwood, MD | University — Chicago Medical School – Houston Mount Sinai School of Medicine — AMA—MSS Alternate Rep: Alysa Joseph Ponce | University of Texas New York Edwards | University of Colorado Medical School – Houston Vice Chair Leena Owen | Nova Southeastern University COM Regional Representatives Social Emergency Medicine Northeast 1: Brendan Miccio | Lake Chair Hannah Gordon, MD | Mount Wilderness Erie College of Osteopathic Sinai Medical Center/Miami Chair Yevgeniy Maksimenko, MD | Medicine Boston Medical Center Chair–elect Tehreem Rehman, MD | Northeast 2: Alexander Gallaer | Advocate Christ Medical Center Chair–elect Elaine Yu, DO | SUNY University of Connecticut Downstate/Kings County Hospital Vice Chairs Mid—Atlantic: Alexa Van Besien | Vice Chairs Victor Cisneros, MD | UC — Irvine University of Maryland Kathryn Kammert, DO | Spectrum Medical Center Great Plains: Kellan Etter | Des Moines Health Lakeland Hayley Musial | FIU Herbert Wertheim University COM Michelle Skuba—Gray | Tulane College of Medicine Great Lakes: Chiamara Anokwute University School of Medicine Alex Ulintz, MD | Indiana University | Indiana University School of Lee Wood, DO | Baylor College of School of Medicine Medicine Medicine Southeast 1: Alexa Peterson | Nova Sports Medicine EMRA Medical Student Council Southeastern University COM Chair Eric R. Friedman, MD | University Chair Jazmyn Shaw | University of Southeast 2: Tori Ehrhardt | FIU of Maryland Mississippi Medical Center Herbert Wertheim College of Chair–elect Breanna Kebort, MD | Vice Chair John Alex Cook | Medicine University of Maryland University of North Carolina School South—Central: Christian Casteel | Vice Chairs of Medicine Kansas City University Medical Danielle De Freitas, MD | University of Editor David Wilson | Sidney Kimmel College of Osteopathic Medicine Chicago Medical College Southwest: Luke Wohlford | University Nico Ramsay | FIU Herbert Wertheim Coordinators of Arizona College of Medicine — College of Medicine Legislative: Kenneth Kim | David Phoenix Toxicology Geffen School of Medicine at UCLA Pacific: Katherine Rodman | Oregon Chair Jon Meadows, DO, MS, MPH, Mentorship: Lorena Rodriguez Perez | Health & Science University CPH | Merit Health Wesley Nova Southeastern University COM Medical School

February/March 2020 | EM Resident 43 REGISTER BEFORE FEB 27 Make Your Voice Heard on Capitol Hill WITH PROMO CODE CONNECT with ACEP’s Leadership and Advocacy Conference (LAC) ONLY $100 Residents and Students acep.org/lac Join us to celebrate emergency medicine accomplishments while continuing to work for a better political environment for our specialty ADVOCATE ENGAGE CONNECT and patients. Send a stronger message to the for Emergency Medicine with Members of Congress with EM Leaders United States Congress – we will train you on the issues so you can help educate Members of Congress.

Approved for AMA PRA Category 1 Credit™

April 26 -28, 2020 Leadership & Grand Hyatt | Washington, DC Advocacy Conference 1942_0120

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

1942_0120

44 EMRA | emra.org • emresident.org NEWS & NOTES ABEM Announces Advanced JACEP Open Ultrasound Fellowship Accepting Program Requirements Submissions ABEM continues to develop special recognition for emergency physicians with ACEP’s new peer-reviewed, open-access expertise in advanced emergency ultrasonography (AEMUS). Program requirements journal is officially open for business! for AEMUS fellowship training are now available on the ABEM website. Approval of As a companion journal to Annals of fellowship training programs under a focused practice designation falls outside of Emergency Medicine, the focus of JACEP the purview of ACGME. The Emergency Ultrasound Fellowship Accreditation Council Open is to publish high-quality original (EUFAC) accredits training programs based on AEMUS Program Requirements. peer-reviewed research, across the Additional information is available on the EUFAC website. Questions can be addressed spectrum of basic and clinical research, in to [email protected], or [email protected]. ¬ an open-access format to the worldwide community. Henry E. Wang, MD, MS, has been named editor, after serving as a New Opportunity! Combined deputy editor for Annals of Emergency Subspecialty Training in Addiction Medicine. Article publication charges, deadlines, and submission requirements Medicine and Medical Toxicology can be found at https://onlinelibrary.wiley. ¬ ABEM is expanding career opportunities for emergency physicians. Combined com/journal/26881152. subspecialty training in Addiction Medicine and Medical Toxicology has been approved by ABEM and the American Board of Preventive Medicine (ABPM). Wellness & Normally, an Addiction Medicine fellowship is 1 year in length and a Medical Toxicology Assistance Program fellowship is 2 years; however, the combined fellowship training requires just 2.5 years The ACEP Wellness & Assistance of training. Program guidelines and application are available on the ABEM website. The Program offers ACEP members exclusive ¬ application must be submitted to both ABEM and ABPM. access to three free counseling or wellness sessions in partnership with Mines & Associates. Sessions are EMRA/YPS Health Policy Primer: available 24/7 by phone, text or online messaging, or you can schedule a face- Get Ready to Rock to-face appointment near your office, Advocacy newcomers, first-time LAC attendees, and all those interested in prepping home, or school. Learn more at https:// for this year’s issues should join the EMRA/YPS Health Policy Primer on Sunday, www.acep.org/life-as-a-physician/ACEP- April 25. Wellness-and-Assistance-Program. ¬ Hosted by YPS Legislative Advisory Puneet Gupta, MD, FACEP, and EMRA Director UPCOMING EVENTS of Health Policy Angela Feb. 26: NRMP Rank Order List Cai, MD, MBA, this 4-hour certification deadline event features Cleavon MD’s March 7: EMRA Spring Medical Student “Schoolhouse Rock” rap Forum explaining the legislative March 7: EMRA Committee Events at process. You’ll also learn: CORD Academic Assembly • Basics of health policy March 8: EMRA Quiz Show and advocacy March 8: Public Hearing & Resolution • Politics of policy Review • How to advocate March 9: Spring Representative Council effectively Meeting & Town Hall In addition, the 2020 Drop March 9: EMRA Party The Mic contestants will take April 25: Health Policy Primer at ACEP the stage during the Health Leadership & Advocacy Conference Policy Primer, and attendees will participate in a point/counterpoint discussion of how April 26-28: ACEP Leadership & to solve the health care coverage dilemma. Advocacy Conference Find details at https://www.emra.org/be-involved/events--activities/leadership- May 21-23: Essentials of EM 2020 advocacy-conference/, and register for LAC at acep.org/lac. ¬

February/March 2020 | EM Resident 45 46 EMRA | emra.org • emresident.org ECG ECG Challenge Paul Smyser, MD Jeremy Berberian, MD ChristianaCare Associate Director of Resident Education @p_smys ChristianaCare @jgberberian

CASE. A 62-year-old male presents with 1 hour of crushing chest pain radiating to the right shoulder.

What is your interpretation of the ECG and what would you do next?

Case continued on page 49

See the ANSWER on page 50

CORD ACADEMIC ASSEMBLY 2020 March 8 - 11, 2020 REGISTER TODAY! DON’T MISS EMERGENCY MEDICINE’S LEADING ACADEMIC CONFERENCE IN THE BIG APPLE.

www.cordem.org/aa #CORDAA20

February/March 2020 | EM Resident 47 WHO KNOWS IT ALL? It’s never too early to study for boards — but it doesn’t have to be painful.

Sponsored by Rosh Review, the Quiz Show is the perfect mashup of board prep and bar trivia. Compete or heckle from the audience, it’s all fun and games!

Sunday, March 8 2020 5:30 – 7:30 pm CHECK OUT THE 2020 COMPETITORS! CORD Academic Assembly TEAMS ARE ANNOUNCED AT in New York City EMRA.ORG/QUIZ-SHOW

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• Panel Discussion with Program Leaders • Breakout Sessions by Year of Training • FREE for EMRA members! Saturday, March 7 Westin Times Square New York City

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48 EMRA | emra.org • emresident.org ECG ECG Challenge Paul Smyser, MD Jeremy Berberian, MD ChristianaCare Associate Director of Resident Education @p_smys ChristianaCare @jgberberian

CASE CONTINUED. This EKG shows sinus rhythm at 72 bpm with a PVC (8th QRS complex followed by compensatory pause) and STD in I, aVL, and V2-V6. The STD in V2-V3 are concerning for a posterior MI, so a posterior EKG was obtained. What is your interpretation of the following EKG and what would you do next? What is your interpretation of the ECG and what would you do next? See the ANSWER on page 50

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February/March 2020 | EM Resident 49 ECG CHALLENGE ECG Challenge Anteroseptal STD This EKG shows atrial fibrillation with a ventricular rate ~130 bpm, STE in aVL, V3, and V7-V9 with STD in III and V1-V2. The STE in V7-V9 meets AHA criteria for an acute posterior MI so the cath lab was activated. Discussion Isolated posterior, also called inferobasilar, MI is an important and easily-missed diagnosis. Infarctions in this territory are typically seen with either an inferior or lateral MI, and in such cases portend a worse prognosis due to the larger area of ischemia. However, an estimated 3.3% of STEMIs are isolated posterior MIs and therefore do not show evidence of ST-elevation with standard lead placement.1 Diagnosing an isolated posterior MI requires using posterior leads (see Learning Points below). The criteria differ from traditional STEMI criteria in two important ways: there only needs to be 1 posterior lead with STE and the STE only needs to be ≥0.5 mm. The classic findings in leads V1-V3 on a standard ECG (i.e., no posterior leads) that are concerning for a posterior MI include deep horizontal STD, upright T-waves, and tall R-waves (which are equivalent to q-waves in an anterior MI, and are not present in our case above).

LEARNING POINTS

Posterior MI • Obtain a posterior EKG on any patient with a concerning story and isolated STD in V1-V3 • ≥0.5 mm STE in ≥ 1 posterior lead (V7, V8, or V9) diagnoses a posterior STEMI2 • Posterior lead placement (see image) is at the fifth intercostal space, parallel to the placement of V6, and moving lateral to medial: — V7: left posterior axillary line — V8: left mid-scapular line — V9: left paraspinal border3

Case Conclusion The patient had a 100% occlusion of the distal RCA which was stented, and after a prolonged course in the cardiac ICU, the patient made a full recovery. ¬

50 EMRA | emra.org • emresident.org References 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. For a patient with vaginal bleeding, which risk factor could indicate endometrial cancer? A. Anorexia B. Anovulatory cycles C. More than three lifetime pregnancies D. Multiple sexual partners

2. Which treatment option is recommended to prevent recurrences of pericarditis? A. Anti-inflammatories B. Colchicine C. Narcotics D. Steroids 3. A 14-year-old boy presents with acute shortness of breath and altered mental status 2 days after he fractured his lower leg. Petechiae are noted on his chest. His vital signs are BP 95/45, P 130, R 33, and T

38.6°C (101.4°F); SpO2 is 85% on room air. Which intervention should be performed first? A. 1 L normal saline fluid bolus B. Heparin bolus at 80 units/kg C. Intralipid infusion D. RSI and endotracheal intubation 4. A 30-year-old man presents complaining of chest pain. He says he has used “a lot” of cocaine over the past 2 days. His vital signs include BP 170/120, P 120, and T 39.9°C (103.8°F). He appears very agitated. Laboratory test results include creatinine 2.6 and CPK 8500. Which treatment should be avoided? A. Active and passive cooling B. Intravenous haloperidol C. Intravenous lorazepam D. Intravenous normal saline 5. A 22-year-old man presents by ambulance after a high-speed crash. His car hit a concrete barrier, and he was ejected. On arrival, his GCS score is 5. He has bilateral periorbital ecchymosis. Which concomitant factor significantly increases the likelihood that he will die or have a poorer outcome? A. Heart rate B. Hypertension C. Hypothermia

D. Hypoxia ¬

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

February/March 2020 | EM Resident 51 The Emergency Medicine Residents' Association is the voice of emergency medicine physicians- in-training and the future of our specialty. With a membership of over 16,000 residents, medical students, and alumni, EMRA provides a like-minded community of your peers for a lifetime!

EMRA Takes Care of You • Bedside Resources • Podcasts • Publications • Educational Events • EMRA Match • Leadership Opportunities • Awards • Scholarships

EMRA Is Your Community • Networking • Advising • Mentorship • Friendships

EMRA helps make you the EMRA For a Lifetime best doctor you can be, the • Medical Students • Fellows best leader you can be, and • Residents • Alumni helps EM become the best specialty it can be!

#EMRAFamily CLASSIFIED ADVERTISING NOW INTERVIEWING! EMERGENCY PHYSICIANS IN DAYTONA BEACH AREA CALIFORNIA LIVE Ventura: Newly constructed hospital and ER department BY THE OCEAN 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 physician. Main facility is a STEMI Center, CONTROL Stroke Center with on-call coverage of all specialties. This is a teaching facility with residents in Family Practice, Surgery, Orthopedics and Internal Medicine. Admitting YOUR hospital teams for Medicine and Pediatrics. 24-hour OB coverage in house and a well-established NICU. Annual volume is 48K patients with nearly 70 hours of coverage daily and 12 hours of PA/NP coverage. All shifts and providers have scribe services 24/7. Affiliated hospital is a smaller rural facility 20 minutes from Ventura in Ojai. SCHEDULE... Malpractice and tail coverage is provided. New hires will Join EMPros in Sunny Central Florida! • Private EM group staffing 5 hospitals work days, nights, weekends and weekdays. and Daytona International Speedway • Shareholder Opportunities Come work with a well-established high caliber group with • Employee Option with Full Benefits or expected volume growth potential at our new facility. Enjoy Independent Contractor • Flexible Scheduling the life style of a beach community yet outside the hustle • Camaraderie with Fellow Physicians of the LA area. FOR MORE INFORMATION, VISIT EMPROSONLINE.COM OR FACEBOOK.COM/EMERGENCYMEDICINEPROFESSIONALS Please send a resume to Alex Kowblansky, MD, FACEP, at [email protected].

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February/March 2020 | EM Resident 53 When you become an owner in one of the largest, fastest -growing physician- owned groups in the nation, you get the support you need with the culture and benefi ts you want. • Highly competitive fi nancial/ WORK WHERE YOU WANT TO LIVE. benefi ts package • Physician equity ownership for all LOCATON NATONDE full-time physicians • Industry-leading and company funded 401(k) (an additional 10%) • Yearly CME/BEA (Business Expense Account) • Student loan refi nancing as low as 2.99% • Groundbreaking Paid Parental Leave • Pioneering Paid Military Leave • Short- and long-term disability (own occupation) • Comprehensive medical, dental, vision and Rx coverage • The best medical malpractice including tail coverage • Outstanding professional development programs • Location fl exibility and career stability of a national group

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AdventHealth System Doctors Hospital Sharon Regional Medical Center Tampa, FL | 7-113,000 pts./yr. Columbus, OH | 72,000 pts./yr. Sharon, PA | 32,000 pts./yr.

Allegheny Health Network Fairfi eld Medical Center Springfi eld Regional Medical Center Emergency Medicine Management Lancaster, OH | 49,000 pts./yr. Springfi eld, OH | 62,000 pts./yr. Western, PA | 14-55,000 pts./yr. Lake Health System St. Catherine Hospital Atrium Health System Cleveland, OH | 10-33,000 pts./yr. Garden City, KS | 16,000 pts./yr. Charlotte, NC | 15-79,000 pts./yr. Lifebridge Health Stamford Health Baptist Emergency Hospitals Baltimore, MD | 62 - 66,000 pts./yr. Stamford, CT | 56,000 pts./yr. San Antonio, TX | 5 - 37,000 pts./yr Mercy Health System Summa Health System Children’s Hospital of Nevada (PEM) Cincinnati, OH region | 9-53,000 pts./yr. Akron, OH | 7-80,000 pts./yr. Las Vegas, NV | 26,000 pts./yr. MedStar St. Mary’s Hospital Valley Children’s Hospital (PEM) Leonardtown, MD | 49,000 pts./yr. Coastal Carolina Madera, CA | 109,000 pts./yr. Morehead City - 39,000 pts./yr. Saint Francis Health System University Medical Center New Bern - 68,000 pts./yr. Tulsa, OK | 10-108,000 pts./yr. Las Vegas, NV | 80,000 pts./yr.

eoe a acaec leaerp poo

54 EMRA | emra.org • emresident.org 7 Distinct Locations in Norfolk, Virginia Beach, and Suffolk

Since 1972, Emergency Physicians of Tidewater has delivered emergency care to Southeastern Virginia EDs. Our seven locations allow our physicians to choose a location based on patient acuity, ED flow, Talking about the resident coverage, and trauma designation. EPT employees enjoy the coastal living in Virginia Beach and Norfolk as well as the perks of issues that matter. having plenty US history, quaint towns, and mountains just a short drive away.

Opportunities: Listen today! Flexible Schedule Leadership & resident teaching (bedside emracast.org teaching, SIM lab, mock oral boards, lectures) Many options of involvement within the group (board representation, committee membership, etc.) Supported by Employees have the option to pursue our 2- year track to partnership Top Ranked Regional Retirement Plan

7 Hospital Democratic Group | Partnership Track | Teaching & Leadership Opportunities

Please send your CV to [email protected]

EMERGENCY MEDICINE

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

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

February/March 2020 | EM Resident 55 Exciting opportunities at our growing organization

• Emergency Medicine Faculty Positions • PEM Faculty Positions • EM Medical Director • Vice Chair, Research

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

TeamHealth Emergency Medicine Presence

At TeamHealth, we start with you. Where do you want to work? Do you aspire to be a leader? We go the extra mile to create a supportive environment for you to enjoy your work, hone your practice and shape your goals. Learn about the practice types TeamHealth makes available to physicians.

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Join our team at teamhealth.com/join or call 877.709.4638

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Our culture rocks. Here’s how we roll.

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

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

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