ResidentOfficial Publication of the Emergency Medicine Residents’ Association August/September 2017 VOL 44 / ISSUE 4 Post- Intubation Sedation p. 10 Pediatric Drowning p. 18 Fishhook Removal p. 20 New EMRA Splint Guide p. 26 Physician Flexibility with EmCare! EmCare is hiring residents and physicians! • Earn While You Learn monthly stipend program • Opportunities for professional development and career advancement • A network of more than 14,000 EmCare affiliated clinicians • Rural or urban, low or high volume locations • More than 40 years of physician practice management experience • We are committed to your success and finding you the right fit Contact our dedicated recruiters today to discuss all that EmCare has to offer! Contact the us today at: 727.507.2526 [email protected] Letter from the Editor Abby Cosgrove, MD Editor-in-Chief, EM Resident Washington University in St. Louis St. Louis, MO very year as interns don their long why these attitudes exist, I found myself we must truly believe that we are all white coats for the first time ever, simply accepting them. It was easier to equally important. We are all in the Eswipe their glossy name badges, excuse rude or condescending behavior same boat, after all. and figure out where the bathrooms are, I by rationalizing that these so-called Last month, I delivered a very have flashbacks to my first few shifts as a “colleagues” were overworked, or sleep- premature neonate in a community “real doctor” in the emergency department. deprived, or that their personal lives were hospital that had neither pediatrics nor For the most part, I knew what to expect: falling apart. It was much more difficult obstetrics. Like a brand-new intern, I was to constantly feel sick to my stomach and to accept that certain behaviors might simultaneously exhilarated and terrified. completely overwhelmed, while wondering just be the result of inherent feelings of At the end of the shift, however, the what I had actually learned in medical superiority. adrenaline rush had dissipated and it felt school. And while I found it simultaneously Sometimes we don’t see eye-to-eye with like just another day at work. That is, I had liberating and terrifying to be able to our colleagues. This can create an “us vs. simply done what I was expected to do. write orders, make medical decisions, and them” mentality that stems from a more Three days later, I received a call perform procedures that I had only dreamt primal need to identify with and stay loyal from the neonatal ICU attending at the of as a medical student, I was disheartened to a certain social group or community. children’s hospital, commending us on our to discover a much darker side to medicine. But emergency physicians interact with work. Three specific words rung in my ears No, it wasn’t the endless administrative more physicians in more specialties on any like the Liberty Bell: “I appreciate you.” tasks, the nagging fear of litigation, or the given day than anyone else in the hospital. This recognition by a physician I waning empathy. It was surprisingly the We simply cannot afford constant clashes had never met, but with whom I way physicians treat each other. between our “social” groups, or else we risk shared a very special patient, trumped One day I found myself fighting back disgracing the entire profession. every negative interaction from the tears in fluorescent bathroom lighting What we too often forget is that every preceding months — maybe even years. after having been mocked and berated single doctor provides an important Unbeknownst to that physician, in that by the chief of a consulting team. As I aspect of patient care that complements moment, those 3 words made everything stared at myself in the mirror, desperately the work of others. We need our primary seem worthwhile. trying to wipe off what remained of my care colleagues to continue working hard to Each time I prepare another issue mascara (wasn’t this stuff supposed to be keep their patients out of the hospital. We of EM Resident, I am astounded by the waterproof?), a nurse was calling my phone need our surgical subspecialists to be able breadth of knowledge and experience of for a medication order. My pager was to take patients emergently to the operating my colleagues. It saddens me to think beeping with another Level 1 trauma. Just room, something far beyond our own scope that somewhere out there, hiding in a 30 more seconds and I was expected to of knowledge or practice. And they need bathroom, is a resident who feels as though walk out looking fresh and eager, excited to us to care for their patients when they are they have given so much of themselves for rejoin the educational utopia that was the not available, 24 hours a day, 365 days a so long, yet seemingly for so little in return. ED. More like a war zone, to me. year. Like well-trained professional athletes Whether s/he is a fellow EM resident or In that moment, I could not have felt on an Olympic crew team, every person an orthopedic consultant, let that resident more alone. is integral to the stroke of sound and safe know how much you appreciate them. I Yet over the years, instead of asking clinical practice. In order to succeed, promise it will make their day. ¬ August/September 2017 | EM Resident 1 TABLE OF CONTENTS EDITORIAL STAFF Categories EDITOR-IN-CHIEF Abby Cosgrove, MD Washington University in St. Louis COVER STORY CRITICAL CARE SECTION EDITORS ECG 10 Zachary S. Wilson, MD Post Icahn SOM at Mt. Sinai Intubation EMS Jeremy Lacocque, DO Sedation Midwestern University Bridging the Gap HEALTH POLICY Between the Emergency Nathan Vafaie, MD Department and the Baylor College of Medicine Intensive Care Unit MEDICAL STUDENT Morgan Bobb PRESIDENT’S MESSAGE WILDERNESS MEDICINE University of Iowa Carver College of Medicine 4 Keep on 14 Improvised Medicine Rockin’ PEDIATRICS Kaia Knutson, MD in EM Kyra Reed, MD Indiana University ULTRASOUND Leah McDonald, MD LEADERSHIP REPORT Lessons from the Wilderness NYU Langone Medical Center 5 Anatomy of an EMRA Resolution ULTRASOUND EDITORIAL COMMITTEE 16 Floaters Jennifer Beck-Esmay, MD Tanya Belle, MD MEMBERSHIP REPORT Retinal Marvinia Charles, MD 7 EMRA detachment, Trudi Cloyd, MD Alumni posterior vitreous Lucia Derks, MD Membership detachment, or vitreous Brian Fromm, MD hemorrhage? Andrew Helt, MD Cameron Justice, OMS Priyanka Kailash, DO PEDIATRIC EM Aryeh Lapin, MD HEALTH POLICY 18 In Over Your Head Beatrice Leverett, MD Kathryn Lupez, MD 8 Affordable Care Act vs. Saira Mehmood, MD American Health Care Act Sean Nardi, DO Jennifer Rabjohns, MD Katherine Laurinda Staats, MD Danny VanValkinburgh, MD Kathleen Yip, MD A Comparison of Central Principles Pediatric Drowning CLINICAL EM Resident (ISSN 2377-438X) is the bi-monthly EVENTS AT ACEP17 magazine of the Emergency Medicine Residents’ 20 Angling Association (EMRA). The opinions herein are those 13 EMRA Party of the authors and not of EMRA or any institutions, for Success organizations, or federal agencies. EMRA encourages Techniques for readers to inform themselves fully about all issues presented. EM Resident reserves the right to edit all Fishhook Removal material and does not guarantee publication. © Copyright 2017 Emergency Medicine Residents’ Association UPCOMING EVENTS August 11 CLINICAL EMPOWER SIMWars Call for Teams Due 22 Is There a Doctor 34 Sharing Our August 31 on Board? Stories EMF/GE Healthcare Grant Jeffrey M. Goodloe, MD, Applications Due NRP, FACEP, FAEMS Month of September EM Day of Service September 1 EDITORIALS ACEP Section of Medical Humanities 36 Your Thoughts Writing & Visual Arts Awards Entries Due Letter to the September 15 Answering the Call for Help Editor: Naloxone NRMP Main Residency Match Registration Opens Resident INFORMATICS October 5 Editorials EM Resident Magazine Articles Due 25 Taking a Cue from October 14–17 Netflix, Priceline ABEM Fall Oral Certification Exam CONSULT CORNER and more October 26–November 1 The Sustainable ED Looks 38 Otolaryngology EMRA Events @ ACEP Scientific to Other Industries for Tech Help when seeking Assembly, Washington, D.C. input from other specialists. November 6-11 SPORTS MEDICINE ABEM Qualifying Exam 26 Splinting Techniques NEWS & NOTES 40 EMRA Awards: Critical Care Medicine Conference First Thursday of every month Scholarship EMRA Match Wins EVENT MEDICINE “Power of A” Silver Award EMRA-Cast: 30 and more Listen at your On Doctoring convenience at the Olympics VISUAL DIAGNOSIS 41 Diagnose this Condition ADVERTISE WITH US PRINT AND ONLINE MARKETING OPPORTUNITIES AVAILABLE Contact Cynthia Kucera | 201-767-4170 An Insider’s View of Event Medicine [email protected] Download EM Resident Media Kit MEDICAL STUDENTS ECG CHALLENGE emra.org/advertise 32 Telemedicine 41 Be sure to check EMResident.org for exclusive online content! Want to improve your CV? Write for EM Resident! BOARD REVIEW Submit online at emresident.org. The Doctor Will See You Now 43 Questions PRESIDENT’S MESSAGE Keep on ockinEmergency Medicine´ R Alicia Kurtz, MD EMRA President CEP America Administrative Fellow @aliciakurtz_md irst and foremost, a huge welcome and offer the rest of the world willing to deal adeptly with this to all of our new members! We are a re-frame. struggle in the first place. Fso excited to have this year’s interns We don’t “have to” see everyone; We do not and will not simply suffer up an at ‘em in our departments already. we GET to. We are privileged as in a system with many broken parts; we While you may have years of training providers to not have to worry about advocate for our patients every left ahead of you and a ton to learn, you what a person’s insurance is or if they day on the local, state, and national bring such a great energy to work and are have pre-authorization before we levels, and we will work tirelessly a palpable reminder of the excitement so begin treatment.