Talledega nights – Key to Schedule Call for photos! get ER done! recognizing of meetings EMRA’s hyperkalemia and events 2nd Annual Photo Contest EDITOR’S FORUM NEW FEATURE: CAN’T MISS ECGs EMRA ACTIVITIES AT SAEM EM REFLECTIONS Page 6 Page 31 Page 33 Page 37 June/July 2010 VOLUME 37, issue 3 Resident EMThe Offi cial Publication of the Emergency Medicine Residents’ Association Vice report Critical decisions – advice to our graduating seniors Angela Fusaro, MD, Carolinas Medical Center, Charlotte, NC, Vice Speaker of the Council s another new class of interns Prioritize your family. Find time to be “Hopefully the Aagonizes over what to wear for their with each of your children for a least a fi rst day of school, our senior residents few minutes each day. You never want Canadians are working are preparing for life in the real world. them to resent your commitment to this on an algorithm for And while they have become accustomed profession. happiness, but in the to dealing with diffi cult decisions in the ED, they might not have considered some Don’t stress about your loans--you can meantime, here is challenging crossroads that lay ahead and will actually pay them off! No matter what your quantity of debt, take that some advice from both in their personal and professional lives. Hopefully the Canadians are working fi rst pay check and spoil yourself. And attending and fellow on an algorithm for happiness, but in spoil those who have helped you survive residency. If you don’t have time to learn residents regarding the meantime, here is some advice from both attending and fellow residents to be fi nancially savvy, seek the advice of how to thrive after regarding how to thrive after graduation. those you trust. And always check in with your lenders--many of us are working in graduation.” Congratulations on completing a long underserved communities and don’t realize journey! that we are eligible for fi nancial incentives. Friends, family, and fi nances One of the biggest decisions you have Choosing your mate is the most important to make is deciding where to live. Your decision of your life. You must always overall satisfaction is based on multi- protect and nurture the sanctity of that factorial criteria, and a big piece of that relationship. Spend uninterrupted time puzzle is geography. You will not stay in with your spouse, and have a retreat or a place if you and your partner are not honeymoon at least every 2 years. continued on page 8 Hurry, sale ends June 30, 2010! Here are just a few of the titles you’ll fi nd and the savings you can realize if you hurry: SAVE SAVE SAVE SAVE SAVE SAVE $10 $20 $20 $23 $25 $40 Contact the ACEP Bookstore by phone, 800-798-1822, ext. 4; or e-mail, [email protected]; or mail your order to ACEP Bookstore, PO Box 619911, Dallas TX 75261-9911. Upcomingevents Table June 3-6, 2010 SAEM Annual Meeting of Phoenix, AZ June 5, 2010 EMRA Representative Council Meeting Contents Phoenix, AZ June 12-16, 2010 AMA MSS / YPS / RFS and House of Delegates Meeting Chicago, IL July 7, 2010 Annals of Emergency Medicine Resident Editorial Board Fellowship Application President’s Message Deadline 4 July 15, 2010 EMRA/ACEP Health Policy Mini-Fellowship Application Deadline Board Update 5 August 12-18, 2010 ACEP Teaching Fellowship Dallas, TX Editor’s Forum 6 August 15, 2010 EMRA Travel Scholarship to ACEP’s Scientifi c Assembly Application Deadline Vice Speaker Report August 15, 2010 EMRA Fall Awards Application 8 Deadline August 15, 2010 EMRA Fall Representative Council Resolutions ACEP Rep Update 10 Deadline August 30, 2010 EMRA Board of Directors Candidate Application Tech Talk 12 Deadline September 10-11, 2010 RRC-EM Meeting Advocacy Corner 15 Chicago, IL Sept 26-30, 2010 EMRA Events at ACEP’s Scientifi c Assembly Las Vegas, NV Clinical Case 16 Sept 28-Oct 1, 2010 ACEP’s Scientifi c Assembly Las Vegas, NV Guest Feature 18 September 29, 2010 EMRA Representative Council Meeting at ACEP’s Scientifi c Assembly Las Vegas, NV Medical Student News 20 October 29, 2010 ACEP Medical Student Professionalism & Service Award Application Deadline October 9-11, 2010 ABEM Oral Certifi cation Exams Talking with Taku 24 Nationwide November 1-8, 2010 Emergency Medicine Basic Research Skills (EMBRS) Meeting EM Pediatrics 26 Dallas, TX November 6-9, 2010 AMA House of Delegates Interim Meeting Resident Life 29 San Diego, CA November 15-20, 2010 ABEM Qualifying Exams Nationwide Resident Research 30 Can’t Miss ECGs 31 Advertisingguidelines EMRA Party 32 Thank you very much for your interest in advertising with EM Resident. As the largest organization to represent the needs of the emergency medicine resident, we are able to reach a unique and important niche of our specialty. EMRA’s mission statement is to promote excellence in patient care through the education EMRA Activities at SAEM 33 and development of emergency medicine residency-trained physicians. It is our belief that this provides the best patient care in an emergency department setting. Money Matters 34 To support our mission and provide the greatest advantage to our residency-trained members searching for jobs, we welcome you to advertise in EM Resident, but require that all positions advertised in our publication be addressed only to board-certifi ed/board-prepared, residency-trained emergency physicians. Board Review Questions 36 For the sake of consistency, the use of the terms “ED,” “emergency department,” and “emergency physicians” are preferable to using “ER” or any such derivation. EM Refl ections 37 Your support is very important to us, and we appreciate your compliance with these guidelines. Please respect this policy and refl ect its sentiment in your advertisements. EM Resident has the right to refuse any Pediatric Pearls 40 advertisement that does not meet these guidelines. Thank you again for advertising in EM Resident. Pitfalls to Avoid 41 To place a classifi ed or display ad in EM Resident, contact Leah Stefanini, 866.566.2492, ext. 3298, e-mail [email protected], or fax 972.580.2829. Information for advertisers can also be found at www.emra.org. Back at You 62 EM Resident is published six times per year. Ads received by July 1 will appear in the August/September issue. EM Resident subscriptions are available only to individuals and institutions that are not considered eligible for EMRA membership as per the EMRA bylaws. For information on how to subscribe please contact Leah Stefanini, 866-566-2492 ext. 3298 or email [email protected]. June/July 2010 3 President’smessage The pulmonary embolism: A historical prospective r. Virchow was among the most prominent presentation, imaging is often required with CT Dphysicians of the 18th century. He angiograms being the most common modality. was a formidable proponent of cell theory The perceived severity of illness, improved in pathophysiology, and is credited with imaging, increased availability of CT scanners, describing many cellular substances including and the medical legal climate in which we myelin and disease processes such as leukemia. practice have prompted a drastic increase in Among his notable claims to medicine was the CT angiogram utilization and irradiation of fi rst description of thromboembolic disease. patients – the affects of which we may see later He coined the terms venous thrombosis and in our careers. Couple this with our perceived pulmonary embolism (PE), describing their acceptable miss rate of zero. But there are relationship in a landmark 1856 publication Edwin Lopez, MD certainly early signs that the pendulum is which preceded any form of medical imaging. Loma Linda Medical Center now starting to swing back the other way. X-ray imaging in fact, was not invented until Loma Linda, CA This is largely driven by concerns regarding President 1895 by Wilhelm Conrad Roentgen. cumulative lifelong radiation, healthcare In keeping with old traditions, Dr. Virchow resource utilization and the cost to society. wore many hats. He was a physician, This surge in CT angiograms has also prompted pathologist, anthropologist and politician the evolution of a collection of clinical “The detachment among other things. But it was his contributions decision instruments, geared to assess clinical of larger to medicine for which he would become most probability and curtail CT utilization. Among or smaller famous, earning him the name of a triad that he the most recognized are the Well’s Criteria fragments did not himself describe – “Virchow’s Triad.” and PERC Rules. Interestingly, there are from the end It includes endothelial damage, altered venous suggestions that they may in fact increase CT of the softening thrombus blood fl ow, and hypercoagulability. which are carried along by utilization leading to more radiation and false the current of blood and Approximately 150 years later and long after positives. his death, the origin of the term “Virchow’s driven into remote vessels. Next is the issue of treatment, which adds yet Triad” remains as elusive as the condition This gives rise to the very another level of complexity. Remember the which it seeks to describe. Furthermore, frequent process on which I oath, “Primum non nocere” or “First, do no despite medical achievements, the overarching have bestowed the name of harm”? The pathophysiology of pulmonary question is now when to pursue the diagnosis Embolia.” emboli has been well described and extensively in patients without clinically signifi cant emboli. Rudolf Ludwig studied since Virchow’s early discoveries. The reasons for posing this question are several Karl Virchow Treatment has similarly evolved and currently and require a brief review in order to better (13 October 1821 – consists of anticoagulation therapy, and understand.