EMRA*Cast: Recent Episodes
Emergency Medicine Residents' Association
The Emergency Medicine Residents' Association (EMRA) is the voice of emergency medicine physicians-in-training and the future of our specialty. EMRA*Cast is created "for Residents, by Residents."
A seemingly routine pediatric nosebleed quickly became one of the most frightening cases of my career when a five-year-old with undiagnosed immune thrombocytopenia (ITP) developed life-threatening epistaxis. In this episode, we walk through the case and explore why dissolvable hemostatic agents may be an underutilized first-line option, incorporating insights from ENT that may change your practice the next time pressure, Afrin, and traditional packing fail.
In this solo episode, Dr. Blythe Fiscella shares 11 hard-won lessons from the emergency department — covering everything from procedures and airway management to communication and clinical uncertainty. Whether you're a resident or a seasoned clinician, there's something here for everyone.
In this mini episode of our "Bridging Health and Humanity" series on EMRA*Cast, Dr. Natalie Hernandez speaks with EM:RAP's Dr. Matt Delaney about patient vulnerability during transitions of care, focusing on what clinicians should do when receiving sign-out.
The opioid epidemic has become supercharged in the past 10-15 years, first with the widespread replacement of heroin by the more potent fentanyl and more recently with the introduction of alpha agonists such as xylazine and medetomidine into the drug supply. Peter Lorenz, MD, sits down with EM/tox/addiction medicine-trained Rachel Haroz, MD, to discuss this ever-changing landscape and how to best provide lifesaving care to some of our most vulnerable patients in the emergency department.
Hand injuries may look minor, but missed diagnoses can mean permanent disability. In this episode, EMRA*Cast host Maiya Smith, MD, is joined by PGY-3 Orthopedic Surgery resident Dr. Tyler Thorne to break down the high-yield hand exam and walk through can't-miss cases like Seymour fractures, central slip injuries, and perilunate dislocations.
This episode of EMRA*Cast delves into the making of "MicroSkills: Small Actions, Big Impact," a powerful book by Drs. Adaira Landry and Resa Lewiss. Much like the book itself, the conversation breaks down a big topic (how to be successful at life) into snackable stories. Join host D'Monte Farley to learn some premium life tips.
In this EMRA*Cast episode of Bridging Health and Humanity, host Natalie Hernandez speaks with Dr. Maya Yiadom, MD, MPH, MSCI, an associate professor and director of Precision Analytics and Data Integration in Emergency Medicine at Stanford, about how artificial intelligence is reshaping emergency care.
They discuss practical AI already in use (predictive analytics and ambient AI scribes), how AI can be designed from clinical workflows to improve detection and timeliness (for example, speeding recognition of STEMI), and the promise of tools that reduce documentation burden and support decision-making.
Dr. Yiadom also grapples with real risks — biased training data, subgroup performance, privacy and cloud constraints — and emphasizes protecting trainee learning while teaching residents how to use AI responsibly. She closes on an optimistic note: AI as a fail-safe that augments clinicians' judgment rather than replaces the human art of medicine.
This week on EMRA*Cast, Dr. Jay Kaplan shares compelling insights on the evolution of emergency medicine and the art of being a 'people doctor.' Join host Blythe Fiscella, MD, for a heartfelt conversation that's sure to inspire! Get tips on overcoming moral injury, finding your fit in medicine, and running a marathon instead of a sprint.
Dr. Sean Nordt is an emergency physician, toxicologist, pharmacist, and educator with deep expertise at the intersection of clinical toxicology, addiction medicine, and frontline emergency care. As a former Poison Center director, he brings a wealth of insight to a discussion with host Dr. Lauren Rosenfeld. Let's get into it! Tune in as Dr. Nordt explains an increasingly common—and often misunderstood—ED presentation: kratom.
The CDC and ACEP both recommend opt-out screening for HIV in most emergency departments, though this practice is far from widespread. Host Peter Lorenz, MD, sits down with Emory University's Emma Sizemore, MD, MPH, to discuss the nuances of implementing an opt-out HIV and HCV screening program in the emergency department.
Buprenorphine is well-known for opioid use disorder—but what about for acute pain? Drs. Terry Ahern and Jon Lee join host Maiya Smith to discuss low-dose buprenorphine for pain management in the emergency room, covering pharmacology, dosing, patient selection, and why it may be a safer, underused analgesic.
One talk with Dr. Fred Kency, and you will appreciate not only a strong work ethic, but also ingenuity and a passion for all aspects of the field of medicine. Join EMRA*Cast host Dr. D'Monte "TP" Farley for a stimulating conversation on ways to stay inspired and motivated in your career.
Publisher's note: This conversation was recorded at the ACEP Leadership and Advocacy Conference 2025, where emergency medicine visits Capitol Hill en masse to advocate for patients and practitioners. The EMRA Representative Council will hold its Spring Representative Council meeting in conjunction with LAC in April 2026.
In this episode of EMRA*Cast's "Bridging Health and Humanity," host Natalie Hernandez interviews Dr. Jailyn Avila about the importance of gender-affirming care in the emergency department. Dr. Avila highlights the significant health disparities and challenges faced by LGBTQIA+ patients, including a reluctance to seek care in the ED due to fear of discrimination and past negative experiences. The conversation covers the critical aspect of treating trans patients with the same respect and care as cis patients, avoiding irrelevant medical questions, and implementing small changes in practice to create a supportive environment. Dr. Avila shares personal experiences as a transgender woman, emphasizes the necessity of advocacy, and provides actionable steps for clinicians to improve the care and trust of LGBTQIA+ patients. The episode also addresses the impact of recent restrictive policies on the health care of trans individuals and calls for education, advocacy, and systemic change to support this vulnerable population.
Whether you're days from becoming an attending or just trying to figure out how to get a BP on a pulseless patient, this episode will help you go from fear to confidence in managing LVADs in the emergency department. Join EMRA*Cast host Dr. Maiya Smith and guest Dr. Anna Ciullo as they review how to assess perfusion, manage complications, and decide on CPR. From pump thrombosis to GI bleeds, we help you stay calm and take control.
Laceration repair is not uncommon in the emergency department. In this episode, we get some expert tips for emergency physicians from a plastic surgery colleague. Join Dr. Kimberly Fiscella of Albany Medical Center and host Dr. Blythe Fiscella of ChristianaCare to pick up some essential pearls on suturing and skin/soft tissue injury management in the ER.
In this EMRACast episode, hosts Lauren Rosenfeld and D'Monte Farley sit down with Dr. Mel Herbert, emergency physician, educator, and writer/medical consultant for The Pitt, the hit TV drama inspired by life in the emergency department.
The emergency department offers critical access to health care in our broken system. An important skillset of the modern emergency medicine physician is a set of low-risk, low-time commitment, high-benefit interventions for the management of chronic diseases. In this episode, we discuss the diagnosis and management of hypertension, type 2 diabetes, asthma, alcohol use disorder, and tobacco use disorder from the emergency department.
Career-switching into medicine as a second profession might not be typical, but it’s not out of reach - just ask Dr. Rob Lowe, an aerospace engineer for 6+ years before trading in his flight simulator for a stethoscope. Dr. Lowe joins the show to detail his previous experiences, discuss commonalities between engineering and emergency medicine, and ultimately inspire any career-changers to keep pushing forward.
In this episode of “Bridging Health and Humanity,” hosted by Dr. Natalie Hernandez, the focus is on the effects of current immigration policies and enforcement tactics on the health of vulnerable communities. The discussion features Dr. Rose Diaz and Dr. Sarah Lopez, both advocates for immigrant health, who share their insights on changes in immigration policy, including the revocation of “sensitive location” protections and adjustments to the public charge rule. They delve into the broader impact of these policies on patient trust and public health, including delayed care and increased health care costs. The segment also explores how health care teams can support immigrant communities through advocacy, education, and understanding legal protections. The episode concludes with hopeful reflections and practical advice for medical professionals committed to supporting these marginalized populations.
July is the most exciting time of the year in the hospital - especially in the Emergency Department, when all of the new interns show up! Get 12 pieces of advice for interns reporting for their first shifts, courtesy of EMRA*Cast host Blythe Fiscella, MD, and guests Andrew Toron, MD (chief resident), Brielle Grote, DO, and Emerson Trimble, DO.
It was the tweet heard far and wide: When the NRA claimed doctors "should stay in their lane," physicians took aim at firearm safety as a matter of public health, policy, advocacy, and patient care. EMRA*Cast host Lauren Rosenfeld, MD, dives into this issue with author and policy guru Cedric Dark, MD, MPH, FACEP.
When it comes to the airway, roc rocks and succ sucks, right? You’ve heard it more than once. But EMRA*Cast host Peter Lorenz, MD, presents a nuanced argument in defense of succinylcholine, with guests Mike Perza, PharmD, and Patricia Simmer, MD.
In this episode of EMRA*Cast's “Vacation Gone Deadly: Toxins in Paradise,” hosts Maiya Smith, MD, and Lauren Rosenfeld, MD, speak with Kenneth Katz, MD, a toxicologist and practicing EM physician at Lehigh Valley Health, about toxins you might encounter while traveling, inspired by Season Three of The White Lotus.
Mental health concerns drive a large number of emergency department visits in the United States. When a patient presents with an acute crisis, it’s important for emergency medicine and psychiatry to work as a seamless team. Drs. D’Monte Farley and Caylon Pettis talk about how to ensure an effective psychiatry consult in the ED.
In this episode of EMRA*Cast's "Bridging Health and Humanity" series, host Natalie Hernandez, MD, MPH, speaks with Aslam Akhtar, MD, PhD, a fourth-year EM resident at Harbor UCLA, about his experience volunteering on a medical mission trip to Northern Gaza.
Navigating EM residency can be tricky and often difficult. EMRA*Cast host Nishant Gogna, DO, presents a group discussion navigating the tips, tricks, and pitfalls to watch out for in your EM residency, with Joanne Bethencourt, DO, PGY-3 and chief resident at UF Health Shands Hospital; Mario Hernandez, MD, PGY-3 at UF Health Shands Hospital; and Wade Chen, MD, PGY-3 at UF Health Shands Hospital.
This episode of EMRA Cast features Dr. Jody Kieffer, a pediatric EM attending physician at Nemours Children's Hospital. Dr. Blythe Fiscella, EMRA*Cast host, gets expert advice on examination strategies for pediatric patients. Learn about newborn-specific exams, strategies, and holding techniques to conduct ear and throat exams in toddlers; the use of metered dose inhalers; the appropriate use of ibuprofen and acetaminophen; and guidelines for discharge counseling for bronchiolitic patients.
In this bonus episode co-produced with Vital, we're talking patient satisfaction: how to create a meaningful connection in a short amount of time, and why it matters. (Spoiler alert: It's not all about metrics.) Join EMRA*Cast alumni Masood Mohammed and guest Gus Garmel for this practice-elevating conversation.
In this episode, @ucmax_show host and @embouncebacks author Dr. Michael Weinstock chats with EMRA*Cast's Dr. Lauren Rosenfeld, breaking down documentation to avoid litigation with a focus on a common presentation: chest pain. Learn how to use the HEART score and avoid a courtroom.
Refractory hypoxemia in the intubated patient is one of the scariest situations any emergency physician can face. In this episode of EMRA*Cast, Drs. Peter Lorenz and Steven Haywood discuss a stepwise approach to managing this worst-case scenario.
Mistakes are an unavoidable part of medical training. Yet, they're often under-discussed, contributing to feelings of burnout and isolation. In this episode, host Maiya Smith, MD, is joined by residents Lulu Weindruch, DO, Stephanie Michael, DO, and Jarred Millard, MD, as they share their personal experiences with errors and the strategies they've developed to grow from them.
EMRA*Cast’s D’Monte Farley talks to social EM leader Italo Brown, MD, MPH, of Stanford University, about how and why to build doctor-patient trust and make care more accessible at the community level. In the spotlight: T.R.A.P. Medicine and a unique barbershop initiative.
Decision-making capacity is a key component of patient autonomy. In this episode, host Natalie Hernandez, MD, MPH, and guest Ilene Claudius, MD, discuss potential challenges to assessing capacity and obtaining consent - particularly among the pediatric population.
There’s more to consider for your first EM job than just locations, hours, and pay. EMRA*Cast host Nishant Gogna, DO, presents a fireside chat about other things to consider on your first job hunt with Ryan Kirby, MD, market president for IES and former PD of John Peter Smith Hospital in Fort Worth Texas, and Marcus Nash, MD, chief resident at UF Health Shands Hospital, and currently on the job hunt.
Every great resuscitationist needs to understand the fine points of keeping your patients breathing - not only by securing an airway, but also by understanding ongoing ventilation. In this episode, EMRA*Cast host Blythe Fiscella, MD, reviews pearls and pitfalls of NIPPV with critical care expert Colin McCloskey, MD.
Known for candid perspectives and sense of humor, pediatric emergency guru Dr. Richard Cantor shares how PEM reminds residents to be present with patients. The organic nature of PEM requires us to use all five senses, engage with patients and their families, and see past burdensome EMRs. Dr. Cantor recalls his transformation from day one as an intern to life as an attending, and he reminds new practitioners to always do what's best for patients and their families.
Food is routinely withheld from patients entering the emergency department in order to prevent the theoretical risk of aspiration should they require operative intervention or procedural sedation. This practice is not evidence-based and does more harm than good. EMRA*Cast host Peter Lorenz, MD, and guest Chris Reilly, MD, dig into the literature, best practices, and the humanity behind denying patients food or water in the emergency department.
We're seeing a LOT more medications like Ozempic in the emergency department nowadays. In fact, 12% of U.S. adults have used a GLP-1 drug! So, what do we need to know about these drugs? Dr. Megan Boysen Osborn, Professor of Emergency Medicine at the University of California Irvine, discusses these GLP-1 agonists with host Maiya Smith.
The transition from being a resident to an attending may be daunting for some.
But have no fear, EMRA*Cast host Lizzii Le sits down with Gus Garmel, an Adjunct Clinical Professor of EM at Stanford University, author of multiple books on clinical education, to discuss this topic.
Students navigating the ERAS Application Cycle - or any residency application process - face a lot of stress and anxiety. Knowing the answer to every possible question is difficult, but having individuals with expertise in your corner is beneficial. Dr. Arlene Chung, current Vice Chair of Academic Affairs at the University of Vermont and previous Program Director at Maimonides Medical Center, joins host D’Monte Farley to provide valuable insight and helpful strategies to assist students while undergoing residency application season.
Being a leader in emergency medicine, whether in the department or on the administrative side, is easier said than done. So, what are the skills a good leader should have, and what practices should they absolutely avoid?
In this episode, host Masood Mohammed (@DocMooseEM) sits down with emergency medicine physician Dr. Azita Hamedani (@ahamedani) as she discusses her own journey as founding chair of an emergency department and shares wisdom on how to develop and grow as a leader within EM.
Acetaminophen is widely available over the counter in the United States, increasing the risk of overdose (both acute and chronic). Several factors contribute to the complexity of managing this tricky condition in the emergency department, but until recently, there has been no true standardized approach. Guidance issued in 2023 aims to establish a helpful framework for managing acetaminophen overdose.
EMRA*Cast host Kyle Duke, MD, breaks it down with EMRA Toxicology Committee Chair Mason Jackson, MD.
Atrial fibrillation can be a tricky thing to manage in the ED. Sometimes it is not always clear if you should treat it, how you should treat it, or if it’s even safe to treat. In this episode, Ray Isenburg and host Will Smith discuss the basics of AFib, how to treat it (both chemically and/or electrically), when is it safe to treat, and how to determine if this is something worth treating or if there is other pathology occurring that, once resolved, will resolve the heart rhythm.
Some pathologies are true can’t-miss diagnoses. Get into one such condition with EMRA*Cast host Will Smith, MD, and EM guru Matthew DeLaney, MD. In this episode you will learn a very simple and comprehensive workup for mesenteric ischemia.
Let’s hear it for the pharmacists who make every emergency medicine shift easier and safer. EMRA*Cast host Dustin Slagle, MD, picks up some pearls from Mike Perza, PharmD, BCPS.
A patient isn't breathing, 8 people are talking at once, alarms are alarming, and you have a whole roster of concerns and options running through your mind. How do you control your reaction, prioritize your response, and step up as a leader for your team and your patient?
Physician-led health care teams are a gold standard in emergency medicine. There’s an art to learning how to lead that team, especially in today’s climate. EMRA*Cast host Masood Mohammed, DO, MS, FAAEM, dives into the details with physician/attorney/national leader Ricky Dhaliwal, MD, JD.
Let’s talk about the crashing intubated patient. What’s your strategy? What if the nearest ICU requires transport? EM/intensivist Andrew Phillips gives EMRA*Cast host Kyle Duke some high-yield tips that you’ll want to hear, too.
EMRA*Cast host Chris Reilly, MD, and NYU Grossman School of Medicine's Stacey Frisch, MD, MS-HPED, discuss effective strategies and key considerations for EM physicians during contract negotiations, with insights on preparation, priorities, and potential pitfalls.
How many EKGs does an emergency doctor interpret per shift? How many seconds of undivided attention can be devoted to those readings? Let's go over 7 key findings you can't miss for occlusive myocardial infarctions, with EMRA*Cast host Will Smith, MD, and emergency physician Domenico Mastandrea, DO, of Nuvance Health.
Doctors deal with EMS providers on the daily, but do we really understand their world? Dr. Lizzii Le chats with Dr. Kelly Tillotson and Dr. Luke Wohlford, who worked as EMS providers before becoming emergency physicians, to give us a deeper dive into what exactly goes into the field.
EMRA*Cast host Dustin Slagle, MD, and NYU critical care cardiology fellow James Ciancarelli, DO, revisit the topic of a prior episode – dual synchronous defibrillation – to further explore the theory, logistics, evidence, and indications for its use.
As the first Latina physician in the United States Congress, Rep. Yadira Caraveo, MD, brings a unique voice to policymaking. Dr. Caraveo tells former EMRA President Jessica Adkins Murphy about how she decided to run for office, what she hopes to achieve, and how every doctor can impact patient care through advocacy.
Seizures are part of the bread and butter in emergency medicine. Most of the time when these patients arrive in the ED, the seizing has stopped and there isn’t much else for us to do. But in the cases where they seizures don’t stop or when the patient has multiple seizures, do you know what meds to give and how much? How about second line? Third? Perhaps, even fourth line? In this episode Dr. Rod Fontenette goes over the latest in seizure management when first line benzos don’t work, the appropriate dosing of those meds, and what to do in certain patient populations.
A crashing tox patient poses one of the most unique and challenging cases we face in the emergency department. Do you know all the tricks of the trade when it comes to managing them?
In this episode, host Dr. Masood Mohammed (@DocMooseEM and MedSchoolMoose) sits down with toxicology expert Dr. Gillian Beauchamp (EMRA and ACMT Medical Toxicology Guide senior editor) to break down some of the key points when it comes to navigating the unstable tox patient.
Palliative care can be difficult and confusing. How do we care for those at the end of their life, and how can we also care for their families? Today we discuss the conversational and medical sides of palliative care medicine with EMRA*Cast host Kyle Duke, MD, and Carrie Harvey, MD, an EM/intensivist at the University of Michigan.
In this episode, Dr. Chris Reilly and Dr. Lizzii Le co-host an interview with Dr. Adam Goodcoff to discuss the impact of social media in medical education. The conversation covers authenticity, transparency, professionalism, and the potential for social media to revolutionize medical education.
Orthopedic injuries might seem more straightforward than your average undifferentiated weak-and-dizzy presentation in the emergency department. But don't be fooled! Learn some key sports medicine tips from Washington Capitals physician Landon Mueller, MD, and EMRA*Cast's Will Smith, MD.
Medical errors are an unfortunate, but nearly unavoidable, part of medical training and practice. The key is knowing how to turn an honest mistake into wisdom. EM educators Laura Welsh, MD, and Ivan Zvonar, MD, have some tips you can put into practice today. Join EMRA*Cast hosts Dustin Slagle, MD, and Lizzii Le, MD, for this conversation.
Since the beginning of time, storytelling is how we would pass along information and learn new things. So why are doctors bad at it? EMRA*Cast host Kyle Duke, MD, joins Avir Mitra, MD, an EM doc who also has created stories for Vice, NPR, Radiolab, and more. We talk about what makes a good story and why storytelling is still relevant in medicine.
Performing a good neuro exam is arguably one of the trickiest areas of emergency medicine, but it’s need-to-know and doesn’t have to be such a headache! In this episode, host Masood Mohammed (@DocMooseEM) sits down with emergency medicine physician Dr. Rahul Bhat (@bhatgtown of @GtownEM) to discuss how to perform a higher quality neuro exam on your next shift.
The culture of medical training historically has not supported an easy pregnancy experience. But is that culture changing? CAN you start your family before you finish residency? EMRA*Cast host Lizzii Le, MD, talks to Melissa Nelson-Perron, MD, and Paige Reinfeld, DO, of Nuvance Health about the changing way the program approaches residents who are pregnant or planning family during training.
When Mark Cuban realized the "rebates" he was getting from his companies' PBM were actually paid for by his sickest employees, he couldn't opt out of the broken system fast enough. Now Mark Cuban Cost Plus Drug Co. is changing the game. What's next? And how can emergency medicine be part of this revolution? Find out with EMRA*Cast and EM Over Easy.
In this conversation with Dr. Anthony Mazarelli, co-author of “Wonder Drug: 7 Scientifically Proven Ways That Serving Others Is the Best Medicine For Yourself,” EMRACast host Dr. Chris Reilly dives deep into the idea of finding (and protecting) happiness through serving others. Tune in for a whole new approach to a healthy, happy attitude.
Many patients come and go through our trauma bays, but the goal never changes: Stabilize them, figure out what they need, then make that happen. In this episode, EMRA*Cast host Will Smith, MD, and Kyle Weant, PharmD, BCPS, BCCCP, FCCP, discuss the evidence (or lack thereof) behind some of the most commonly used resuscitation medications.
If you've ever thought critical care medicine might be an interesting career path, pull up a chair and join this conversation between EMRA*Cast host Dustin Slagle, MD, and three EMRA crit-care leaders who have reached various milestones in their critical care medicine journey: Jenelle Badulak, MD; Mark Ramzy, DO, EMT-P; and Brian Sumner, MD.
“I think we need better on-shift teaching.” This is a common quote from residents and med students alike in the emergency department. EMRA*Cast host Chris Reilly, MD, MS, talks with EM:RAP Deputy Director and EM educator Jessica Mason, MD, about different ways residents can take learning into their own hands and get the most out of their on-shift education. It’s as easy as a SNAPPS (punny if you listen).
The management of several common pediatric emergency medicine complaints have changed in recent years. Are you up to date on the new guidelines?
In this episode, host Masood Mohammed (@DocMooseEM) sits down with emergency medicine and pediatric emergency medicine physician Dr. Kristy Schwartz (@SchwartziEMPEM) to break down some need-to-know updates when it comes to taking care of kids.
Join Brittany Ladson, DO, and host Kyle Duke, MD, for some ToxTalk fun, talking about the differences between and the risks and dangers of tetrahydrocannabinol, Delta-9 THC, and Delta-8 THC. Be sure to check out Dr. Ladson’s article in EM Resident for a deeper dive.
Creating and maintaining a Curriculum Vitae (CV) can sometimes seem like a daunting task, but EMRA*Cast host Chris Reilly, MD, sits down with CV guru Dr. Saadia Akhtar to try to lessen the confusion and give you high-yield tips and tricks to make your CV stand out.
Imposter syndrome robs you of confidence - and it can imperil your team, especially in a moment of crisis. Learn how to down-regulate yourself and the whole team, with host Will Smith, MD, and physician/coach Rob Orman, MD. (Pro tip: Tune in to Part 1 first to learn how to recognize that inner critic.)
In this 2-part series, physician and coach Rob Orman, MD, explains how to deal with our inner critic so that we can be at our clinical best. He also touches on imposter syndrome and shares tips for dealing with the anxiety that sometimes comes with the territory for emergency physicians. Join host Will Smith, MD, to gain valuable insight from Dr. Orman.
The practice of medicine, especially emergency medicine, can be emotionally exhausting, even when things go well. Burnout is on the rise, and seeking help can be hard. Learn how to overcome the obstacles in your journey to well-being with these tips from Al’ai Alvarez and Amanda Deutsch, shared by EMRA*Cast host Lizzii Le.
Mental health is a key component of physical health. So why do so many health care workers keep their own mental health exercises in the shadows? Al’ai Alvarez and Amanda Deutsch share insight with EMRA*Cast host Lizzii Le.
Every year, July 1 marks a new academic year in medicine, when recent medical school graduates begin their journey as freshly minted physicians. This time can be exciting, terrifying, exhilarating, stressful – and everything in between. In this episode, host Dr. Masood Mohammed (@DocMooseEM) chats with Dr. Richard Church, program director of UMass Chan EM Residency (@umassEMresident), and Dr. Cameron Burke, UMass EM PGY3, who share their own intern experiences and provide advice on how to navigate this transition.
Early-career financial planning can make all the difference for physicians, but there is no cookie-cutter approach. Smart financial planning focuses on your individual circumstances and goals, and financial guru Tyler Olson of Olson Consulting LLC can help make sense of it all. He and host Chris Reilly, MD, MS, walk through some common questions, pitfalls, and concerns regarding medical school loans in the first of a 2-part episode.
In this interview-style podcast, Dr. Chris Reilly sits down with Dr. Thom Mayer, a real-life hero and EM doc, to discuss everything from his recent volunteering time in Ukraine to the NFLPA concussion protocol and the major topic of discussion: the staffing crisis in health care, particularly on the front lines in the emergency department.
Mentorship is a huge part of physician success in medicine. For as hard as we have worked and as much sacrifice as we have made, at some point, we have all had someone (or multiple people) play an integral role in our achievements. How can you be an effective mentee? And what, exactly, makes an effective mentor? EMRA*Cast host Will Smith, MD, speaks with one of the greats, Arlene Chung, MD, MACM.
When you are managing a patient in cardiac arrest, do you turn to bedside ultrasound? EMRA*Cast host Dustin Slagle, MD, talks to ultrasound guru Michael Gottlieb, MD, RDMS, about when you should, how it can be useful, and the best way to incorporate POCUS into the plan.
Although the first time ultrasound was used for clinical reasons was in 1956, the incorporation of ultrasound in the Emergency Department is relatively new. In this episode, EMRA*Cast host Dr. Lizzii Le (@LizziiLeMed) get tips from Dr. Avila (@UltrasoundMD @coreultrasound) on the best way to incorporate ultrasound in the ED.
ST-segment elevation myocardial infarction (STEMI) is a term that all emergency medicine residents learn and commit to memory early on. This term is far from perfect, however, and some physicians think it should be thrown out altogether. In this episode, host Masood Mohammed (@DocMooseEM) chats with Dr. Susy DeMeester (@SusyDemeester) about why ‘STEMI’ misses the mark and what we can do to fix it.
Is EM still cool? What happened in the 2023 Match? Tune in to EMRA*Cast for a special episode with EMRA President Jess Murphy, MD, and host Chris Reilly, MD, talking about the Match, the aftermath, and our best path forward.
The transition from the last day of medical school to the first day of intern year may be one of the biggest leaps in medicine. It’s not easy – but you’re not alone. If you just matched and you’re gearing up for intern year, this is for you. Join EMRA*Cast host (and almost-finished-with-intern-year) Kyle Duke, MD, and his guest, Noah Schammel, MD, current EM/IM intern at East Carolina University, to talk about the highs, the lows, and the in-between of intern year.
As emergency docs, anytime there is something in the chest cavity that should not be there, such as air, blood, or fluid, we often feel compelled to get it out. For many decades that barbaric task was done with a 40 French chest tube and some low-wall suction. But is that what is best for the patient?
Is there a doctor onboard? In-flight emergencies are not rare, supplies and resources are limited, and it is always good to be prepared. Dr. Amy Ho joins EMRA*Cast host Dr. Dustin Slagle to discuss what to expect and how to help.
Being a female in a profession that was previously dominated by males can present with some unique challenges. In this episode, Dr. Arlene Chung (@arlenesujin) and Dr. Diane Birnbaumer (@DianeBirnbaumer) discuss what it is like being a female emergency physician with EMRA*Cast host Dr. Lizzii Le (@LizziiLeMed).
How often do you add ZIP code to the risk factors you’re considering when building a differential? In this episode, Renee Salas (@ReneeNSalas_MD) and host Masood Mohammed (@DocMooseEM) discuss why you should. In short: Climate change is waiting in your ED.
Ever feel lost and confused when it comes to antibiotic choice? Feel like you are making a mistake by giving this instead of that? Giving too much? Giving too little? If so, you’re not alone. So let's branch out from just vanc and zosyn and dive into the top 10 antibiotic mistakes today with pharmacy guru Dr. Bryan Hayes.
Giving feedback is an art, and in this episode, med-ed all-star Christina Shenvi, MD, and EMRA*Cast host Chris Reilly, MD, take us on a deep dive into the psychology of feedback: what is it, why we need it, and how to give and receive feedback well. This conversation is packed with evidence, pearls, and a challenge you should strive to achieve every day. Go ahead and bookmark this; you’re going to want to listen more than once.
Giving feedback is an art, and in this episode, med-ed all-star Christina Shenvi, MD, and EMRA*Cast host Chris Reilly, MD, take us on a deep dive into the psychology of feedback: what is it, why we need it, and how to give and receive feedback well. This conversation is packed with evidence, pearls, and a challenge you should strive to achieve every day. Go ahead and bookmark this; you’re going to want to listen more than once.
Roughly 1 in 20 subarachnoid hemorrhages are missed during initial presentation in the emergency department – substantially increasing the risk of complications and mortality. That’s scary. But is it a reason to do a lumbar puncture every time a patient’s head hurts? EMRACast host Will Smith (@WTSmithMD IG/Twitter) shares some expert insight from Lt. Col. Roderick Fontenette* (@RodFontenette1).
There’s a laundry list of potential complications from using the subclavian vein to place a central line. But there’s also a growing number of reasons to make sure this procedure is part of your arsenal. Host Dustin Slagle, MD, and guest Gabriel Hoffman, MD, walk you through the evidence.
Unions have a long and storied history in the United States – but not within the house of medicine. Yet as the practice of medicine has become enveloped by business interests, unionization is taking root. More than 22,000 resident physicians are already union members. Where do you start if you want to organize? EMRA*Cast host Dr. Matt Dillon presents part 2 of this series on unions for medical residents.
Unions have a long and storied history in the United States – but not within the house of medicine. Yet as the practice of medicine has become enveloped by business interests, unionization is taking root. More than 22,000 resident physicians are already union members. Where do you start if you want to organize? EMRA*Cast host Dr. Matt Dillon presents part 2 of this series on unions for medical residents.
Statistics show 75% of emergency physicians are named in malpractice lawsuits during their career - and the only correlation with being sued is the number of years practiced and the number of patients seen over time. Being sued does not mean you are a bad doctor, but rather you are practicing in a high-risk specialty.
Join EMRA*Cast host Ranjita Raghavan, MD, (@DrRanjitaMD) and Camie Sorensen, MD, of St. Agnes Hospital (@AgnesEmr) in a discussion of the medico-legal realities of practicing emergency medicine.
Statistics show 75% of emergency physicians are named in malpractice lawsuits during their career - and the only correlation with being sued is the number of years practiced and the number of patients seen over time. Being sued does not mean you are a bad doctor, but rather you are practicing in a high-risk specialty.
Join EMRA*Cast host Ranjita Raghavan, MD, (@DrRanjitaMD) and Camie Sorensen, MD, of St. Agnes Hospital (@AgnesEmr) in a discussion of the medico-legal realities of practicing emergency medicine.
In the wake of this year’s Supreme Court positions, treating OB/GYN emergencies according to standards of care can now result in criminal or civil charges for you and your patients in some states. Major medical societies have come out against the Dobbs v. Jackson decision that overturned Roe and Casey. While EMTALA currently provides some support for emergency physicians, state laws and local prosecutors still might try to take you to court. Understanding your state’s law and interpretation by your institution is crucial. On this episode host Kate Joyce (@sceneisnotsafe) talks with attorney Carmel Shachar (@CarmelShachar), policy analyst Cat Duffy (@catduffy), EM resident Jessica Adkins Murphy (@DrAdkinsMurphy), and OB/GYN resident Andrea Contreras about keeping your job and patients safe in today’s legal and political landscape.
In the wake of this year’s Supreme Court positions, treating OB/GYN emergencies according to standards of care can now result in criminal or civil charges for you and your patients in some states. Major medical societies have come out against the Dobbs v. Jackson decision that overturned Roe and Casey. While EMTALA currently provides some support for emergency physicians, state laws and local prosecutors still might try to take you to court. Understanding your state’s law and interpretation by your institution is crucial. On this episode host Kate Joyce (@sceneisnotsafe) talks with attorney Carmel Shachar (@CarmelShachar), policy analyst Cat Duffy (@catduffy), EM resident Jessica Adkins Murphy (@DrAdkinsMurphy), and OB/GYN resident Andrea Contreras about keeping your job and patients safe in today’s legal and political landscape.
On June 24, 2022, the United States Supreme Court overturned the landmark decision Roe v. Wade, a legal precedent protecting a citizen’s constitutional right to abortion. The highly politicized decision comes with significant consequence for those of us in health care – especially in states with abortion trigger bans. EMRACast Host Shreyans Sanghvi, DO, joins EM Resident Editor-in-Chief Jessica Adkins Murphy*, MD, (@DrAdkinsMurphy) to explore this deeply personal, subjective, and contentious topic.
On June 24, 2022, the United States Supreme Court overturned the landmark decision Roe v. Wade, a legal precedent protecting a citizen’s constitutional right to abortion. The highly politicized decision comes with significant consequence for those of us in health care – especially in states with abortion trigger bans. EMRACast Host Shreyans Sanghvi, DO, joins EM Resident Editor-in-Chief Jessica Adkins Murphy*, MD, (@DrAdkinsMurphy) to explore this deeply personal, subjective, and contentious topic.
On June 24, 2022, the United States Supreme Court overturned the landmark decision Roe v. Wade, a legal precedent protecting a citizen’s constitutional right to abortion. The highly politicized decision comes with significant consequence for those of us in health care – especially in states with abortion trigger bans. EMRACast Host Shreyans Sanghvi, DO, joins EM Resident Editor-in-Chief Jessica Adkins Murphy*, MD, (@DrAdkinsMurphy) to explore this deeply personal, subjective, and contentious topic.
On June 24, 2022, the United States Supreme Court overturned the landmark decision Roe v. Wade, a legal precedent protecting a citizen’s constitutional right to abortion. The highly politicized decision comes with significant consequence for those of us in health care – especially in states with abortion trigger bans. EMRACast Host Shreyans Sanghvi, DO, joins EM Resident Editor-in-Chief Jessica Adkins Murphy*, MD, (@DrAdkinsMurphy) to explore this deeply personal, subjective, and contentious topic.
When you received your employment contract after matching into residency, did you read it? Was there any question you would sign it, no matter what it said? The structure of medical training and board certification creates an unequivocal power differential when it comes to residency employment contracts. EMRACast host Matt Dillon, MD, (@mdmd_8889) talks with UCLA union members Anna Yap, MD, (@annayap) and Kenneth Kim*, MD, about the power of a unified resident body.
Disaster medicine has long focused on how to prepare for mass casualty incidents - but there are special considerations for emergency physicians to take into account in the case of terror attacks. In this episode, host Kim Bambach, MD, and Sriram Venkatesan, FAWM, discuss the niche of counterterrorism medicine with Derrick Tin, MBBS, senior fellow in Disaster and Counterterrorism Medicine at BIDMC/Harvard Medical School.
The health care job market has been a roller coaster in recent years - especially in the nation's safety net of emergency medicine. What’s a soon-to-be-graduate to do? Host Ranjita Raghavan, MD, shares some job search pearls and perils from Saadia Akhtar, MD, FACEP, and Maria Moreira, MD, FACEP.
Some baked-in practices in medicine don't hold up to closer inspection. This episode of EMRACast turns attention to the use of sodium bicarbonate in cardiac arrest. Host Matt Dillon, MD, (@mdmd_8889) recently spoke with clinical ED pharmacist Mike Perza, PharmD, BCPS, (@pillpushermike) and Dustin Slagle*, MD, regarding sodium bicarbonate use during cardiac arrest and why you might want to think twice.
Congratulations on graduating residency! Do yourself a big favor and listen to this advice from Dr. Christina Shenvi and Dr. Nikki Binz, brought you by EMRACast host Dr. Kim Bambach*. Start off on the right foot with BHAG, ikigai, and proper spycraft at a new job. You got this!
Your patient has an arterial bleed and a tenuous airway. You've got 1 unit of blood, no vent, and no hospital within hours. Welcome to the world of austere medicine. Host Kate Joyce, MD, MPH (@sceneisnotsafe) and USAF Lt Col Regan Lyon, MD, FACEP, discuss the challenges of treating patients in the most extreme scenarios.
Hemorrhagic shock can be tricky to manage – yet there’s no shortage of (sometimes conflicting) guidelines regarding massive transfusion. When do you make the call to activate massive transfusion protocol? How early is too early? What happens if you wait too long? Dr. Sara Crager simplifies this crucial decision-making process with EMRA*Cast host Ranjita Raghavan.
EMRA*Cast Host Shreyans Sanghvi, DO, ventures into the abyss of life after residency to find out how to keep up your learning after training with street illusionist and veteran public speaker Salil Bhandari, MD. Completing his residency in emergency medicine at NYU Langone, Salil has trained hundreds of residents in public speaking, presentation design, and procedural competency. He is a passionate resuscitationist and educational philosopher who currently serves as the Director of Media and Communications and Assistant Program Director for the Emergency Medicine Residency at McGovern Medical School @ UT Health in Houston, Texas, among busiest Level 1 trauma centers in North America.
Have you ever felt like you're spinning your wheels in your emergency department? EMRACast host Kim Bambach, MD, (@KimBambach) explores how to work smarter, not harder. Guests Eric Blazar, MD (@eblazar) and Guy Carmelli*, MD (@GuyCarmelli) focus on how to improve efficiency so you can spend more time on the things that made you want to go into medicine in the first place.
On this week's episode of EMRACast, host Matt Dillon, MD, (@mdmd_8889) talks to Jim Dahle*, MD, FACEP (@wcinvestor) about physician finances. Now known as the White Coat Investor, Dr. Dahle shares how the school of hard knocks made him financially savvy - and able to offer advice via his book, website, and “White Coat Investor” blog.
This episode is directed at the resident and early attending.
EMRACast is talking about a range of unusual cases and thought-provoking perspectives from the February-March edition of EM Resident magazine. Join host Ranjita Raghavan, MD, and editor-in-chief Jessica Adkins Murphy, MD, to find out how a Blakemore tube featured in an LGI bleed, whether atraumatic splenic rupture is easy to spot (spoiler alert: not always*), and what medical students are advocating for this year.
The emergency department has been called an "operation existing on the edge of chaos." Join EMRA*Caster Kate Joyce (@sceneisnotsafe) and Henry Ford Hospital ED Medical Director and Vice Chair of Operations Dr. Seth Krupp as they walk that chaotic edge. We'll be talking about how EDs keep things moving and what residents interested in operations can do to get involved.
The emergency department has been called an "operation existing on the edge of chaos." Join EMRA*Caster Kate Joyce (@sceneisnotsafe) and Henry Ford Hospital ED Medical Director and Vice Chair of Operations Dr. Seth Krupp as they walk that chaotic edge. We'll be talking about how EDs keep things moving and what residents interested in operations can do to get involved.
What's the key to outstanding medical education? Host Kim Bambach, MD, showcases some pearls from The Ohio State University Wexner Medical Center's Allison Beaulieu, MD; Andrew Kendle, MD; Lauren Willoughby, MD; Ryan O'Neill, MD; and Geremiha Emerson, MD.
In our Med-Ed track, we discuss all topics related to learning and teaching EM. One way to take a deep dive into a topic is through small group learning. In this brief soundbite, we'll share a few pearls to make small group sessions more engaging and memorable.
What's the key to outstanding medical education? Host Kim Bambach, MD, showcases some pearls from The Ohio State University Wexner Medical Center's Allison Beaulieu, MD; Andrew Kendle, MD; Lauren Willoughby, MD; Ryan O'Neill, MD; and Geremiha Emerson, MD.
In our Med-Ed track, we discuss all topics related to learning and teaching EM. One way to take a deep dive into a topic is through small group learning. In this brief soundbite, we'll share a few pearls to make small group sessions more engaging and memorable.
EMRACast Hosts Shreyans Sanghvi, DO, and Ranjita Raghavan, MD, explore the budding but ever-so-important field of medical journalism with emergency physician, author, and renowned public speaker Amy Faith Ho*, MD, MPH. Early in her medical school days, Dr. Ho’s personal accounts of navigating the hard knocks of clerkship as a third-year medical student on an OB/GYN rotation would pave the way for a decorated career in journalism. From TED talks, to coveted pieces on NPR and Forbes, and even authoring her very own children’s book - appreciate Dr. Ho’s unique perspective on how to explore this niche cross-section between medicine and journalism.
It's the EM resident's responsibility to learn and perfect the basics of the airway - including those difficult cases. On this episode of EMRACast, host Matt Dillon, MD, shares insight and 4 key lessons from Colin McCloskey*, MD, board-certified in both anesthesiology critical care medicine and emergency medicine.
'Tis the season for winter trips - and for many people (especially in this pandemic era), that means heading to the mountains. EMRA*Cast host Dr. Ranjita Raghavan brings you top-notch advice from a top-notch wilderness medicine expert, Dr. Linda Keyes. Make sure you know how to recognize and manage altitude sickness this season.
Altitude sickness and its more serious altitude-related illnesses, High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE), are processes we may not see often, but when they appear we need to know what signs to look out for, how to manage treatment, and how to prevent the conditions from worsening. Especially as more Americans get outdoors throughout the pandemic, it's more relevant than ever before.
There are a lot of options when it comes to providing oxygenation and ventilatory support in the emergency department. With so many non-invasive options, host Dr. Kate Joyce sits down with Dr. Jeremy Greenberg to talk about nasal cannula options that may be helpful.
EMRACast Host Shreyans Sanghvi, DO, takes us on an innovative journey with Andrew Chu, MD, PGY4 at Harvard Affiliated Emergency Medicine Residency and fellow at Massachusetts General Hospital's Healthcare Transformation Lab, and Leland Perice, MD, Ultrasound Fellow at Maimonides Medical Center. Their first experiences with patient codes catalyzed their drive to explore the intersection of healthcare and digital innovation. In 2020, in the midst of the COVID-19 global pandemic, they embarked on a journey to create a digitalized treatment algorithm. Brandishing a Silicon Valley approach to mastering cardiac arrest management, Dr. Chu and MGH's Jared Conley*, MD, PhD, MPH, created the MGH ACLS.
EMRA*Cast host Matt Dillon puts MAP 65 under a microscope with sepsis researcher/CCM expert Emily Brant and EMRA CritCare Vice Chair Dustin Slagle in this #EMRACritCare + #EMRAcast journal club collab. Find out what we’re learning about the studies influencing the Surviving Sepsis campaign and critical care medicine in America.
With COVID surging, shifts in the emergency department have been rough, to say the least, and our wellness is more important than ever. This episode is all about burnout, self-compassion, and resilience - what we can do for ourselves, our patients, and each other. Host Kim Bambach gets insight from renowned wellness expert Al'ai Alvarez.
Dr. Ranjita Raghavan and Dr. Will Flanary - better known as “Dr. Glaucomflecken” - discuss everything and anything EM residents would want to know about the world of eyes! Dr. Flanary is a full-time ophthalmologist and comedian who has gained fame on the speaking circuit and social media. In this episode of EMRA*Cast he outlines key aspects of the history and physical that your ophtho consult wants to know.
EMRA*Cast Host Shreyans Sanghvi, DO, takes a deep dive on the entrepreneurial journey with Rich Park, MD (CityMD4All). Early in his emergency medicine career, Dr. Park turned an eye toward the patient experience; in 2007 he embarked on an entrepreneurial journey that led to a chain of urgent care centers now valued at more than $1.2 billion.
Being a parent is tough. Being a parent AND a doctor is real tough. Join these dads - host Matt Dillon and guests Geoff Comp, Drew Kalnow, and Alex Waggener - as they meander through tips and tricks about the when's and what-if's of starting a family during your medical training and career. No experts to be found here, just a handful of dads doing their best and sharing their experiences.
You crushed the written exam to become a board-certified emergency physician, and now the only thing standing between you and your ABEM certification is oral boards. How do you prep - especially for a virtual test? Host Kim Bambach, MD, reviews pearls & pitfalls with guests Krystin Miller, MD, and Jennifer Yee, DO.
Interactions with law enforcement in the emergency department can be confusing. What are the emergency physician's legal responsibilities? How can we ensure our patients are getting quality care? Dr. Hannah Janeway, Dr. Shamsher Samra, and attorney Ji Seon Song sit down with host Kate Joyce to discuss the philosophical and practical challenges faced by emergency physicians.
Early goal-directed therapy for fluid resuscitation in sepsis is a hotly debated and much-studied topic - and for good reason. Listen in as three emergency physicians discuss some of the landmark papers directing emergency care of these critically ill patients. Join host Dr. Ranjita Raghavan of Mount Sinai and guests Dr. Chad Meyers of Elmhurst Hospital Center and Dr. Dustin Slagle of ChristianaCare.
Fluid resuscitation in sepsis is a hotly debated and much-studied topic - and for good reason. Listen in as three emergency physicians discuss some of the landmark papers directing emergency care of these critically ill patients. Join host Dr. Ranjita Raghavan of Mount Sinai and guests Dr. Chad Meyers of Elmhurst Hospital Center and Dr. Dustin Slagle of ChristianaCare.
Every year thousands of clinical pearls are published in the emergency medicine FOAMed space. From podcasts, blog posts, to journal feeds - the novice EM resident is often overwhelmed by the vast amount of nuanced information these valuable resources provide. But how do you make sure you get the right content in front of your residents?
On this episode of EMRA*Cast, Drs. Benjamin Cooper, Jonathan Giordano, Catie Reynolds, and Tom Fadial discuss their journey developing ECG Stampede, a gamified medical education platform aimed at helping residents master the foundations of electrocardiography triage and interpretation.
Ever wonder why no one questions your opioid prescriptions, but when it comes to prescribing opioid withdrawal therapy there are miles of red tape? With legislative relief in sight, it's time to learn more about how to treat patients with substance use disorder. Find out about a new curriculum developed with a grant from SAMHSA and hear what "MAT" is meant to be.
This topic never gets old! Whether you realize it or not, geriatrics is probably a large part of your practice, especially when it comes to high-complexity, high-acuity emergency medicine. Dr. Lauren Southerland will teach us what we can do to better care for older adults. We’ll also discuss how to get involved at the national level and how to pursue a career in geriatric EM if you want to go a step further.
Patients who are homeless visit the emergency department more often than the general population, yet emergency physicians get minimal formal education about homelessness and the impact of housing on health. In this episode, we talk with three physicians about how we can best support our patients struggling with housing issues.
Host: Kate Joyce, MD, MPH
Guests:
- Richard Bryce, DO; Chief Medical Officer, Community Health and Social Services Center; faculty advisor for Street Medicine Detroit and Detroit Street Care; faculty at Michigan State University, Wayne State University and Henry Ford Hospital
- Ryan McCormack, MD, MS, FACEP; Assistant Professor, Emergency Medicine and Addiction Medicine, Bellevue Hospital, NYU School of Medicine
- Katherine Chen, MD; National Clinician Scholars Program, Internal Medicine/UCLA
In medicine, one thing you cannot avoid is giving presentations. It is both exciting and nerve-wracking to present to colleagues, attendings, and friends. Yet some doctors are extremely talented at holding captive audiences. Host Dr. Ranjita Raghavan chats with the incomparable Dr. Anand Swaminathan (aka Swami) to give us the scoop on how to make an excellent, engaging lecture in person and on Zoom.
So you've got a handle on the medicine, but have you got a handle on your personal finances? Take a deep dive into financial education and learn about the most common mistakes, questions, and fears young physicians encounter with physicians/personal finance gurus Sotirios Keros and Dalton Haslam.
OverviewNew to emergency medicine residency and trying to take that first step toward building your knowledge base? Maybe you're trying to optimize your study strategy? Look no further! The great thing about EM is that we LOVE medical education. Today we take a look at a variety of educational resources to help build a solid foundation of your medical/clinical knowledge.
Key PointsTopics we cover include:
- EM gear to bring to shift
- Podcasts to listen to on the way to shift
- The most valuable on-shift mobile apps
- Pocket guides for every clinician
- Textbooks that won't collect dust
- Question banks that will be the work-horse of your study plan
- The best way to keep up with current medical literature
- How to solidify your knowledge
Resources and References
- Best EM Podcasts: https://www.emra.org/emresident/article/best-podcasts-for-the-student-em-nerd/
- Textbook suggestions by Scott Weingart: https://emcrit.org/recommended-reading/
- EMRA's on-shift guides:
https://www.emra.org/apps
https://www.emra.org/amazon
https://www.emra.org/about-emra/publications/bookstore/
OverviewIn this episode originally released in 2019, Drs. RJ Sontag and Andrew Meltzer interview fellow emergency physician Rep. Raul Ruiz, D-CA, to explore how medical students, residents, and recent grads can become advocates for their patients and their profession outside the emergency department. As EMRA's 2019 Congressional Health Policy Fellow, Dr. Sontag worked with Dr. Ruiz on Capitol Hill to turn medical and policy research into legislative solutions on a wide range of topics, from firearm violence prevention to surprise billing to youth nicotine use.
HostsRJ Sontag, MDPresident, EMRA
Residency: UT Health San Antonio
Medical school: Wright State University
EM Resident Articles
Twitter: @RJSontagMD
Andrew Meltzer, MD, MS
Associate Professor of Emergency Medicine, George Washington University
Director, Urgent Matters
Fellowship: Clinical Research, University of Maryland Shock Trauma Center
Residency: University of Maryland Shock Trauma Center
Medical School: SUNY Downstate School of Medicine
Twitter: @ACMeltzer
Guest
Raul Ruiz, MD, MPH, MPP
United States Congressman (CA-36)
Fellowship: International Emergency Medicine, Brigham and Women’s Hospital
Residency: University of Pittsburgh
Medical School: Harvard University
Twitter: @CongressmanRuiz
Key Points
- Being an emergency physician provides a unique perspective on governing
- Our understanding of the needs of underserved and underinsured populations can influence policy decisions
- Patient health involves more than just the care we provide in the emergency department
- Social determinants of health, drug pricing, insurance status, and many other factors affect our patients’ health
- To truly improve our patients' health, students, residents, and young physicians must learn the language of advocacy by getting involved at every level of policy creation: from hospital administration to local, state, and federal government
- Emergency physicians are better equipped than other specialties to advocate for our patients and our profession because of our experience standing up for our patients to guarantee they get the care they need every single shift
- Government can play a role in incentivizing technology and alternative payment models to improve health care access and affordability
References
- Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity
- Biography, Congressman Raul Ruiz, MD
- EMRA Advocacy Handbook
- EMRA Congressional Health Policy Fellowship
- Urgent Matters
The emergency medicine job market has been tight this year, there's no doubt. COVID has caused some groups and hospitals to cut back or even lay off EM physicians. So what's a resident or fellow to do? In this episode, host Kate Joyce, MD, MPH, gets a few perspectives on the job landscape from Washington Post reporter Ben Guarino, US Acute Care Solutions chief clinical recruiting officer Travis Ulmer, MD, FACEP, and NYU/Bellevue chief resident Michelle Romeo, MD. Learn some tips on navigating the job market this year and in the years to come.
Key Points * COVID has added stress to the EM job market, making finding jobs more difficult. * Applicants are encouraged to apply broadly in terms of setting and geography. * Recruiters can be especially helpful in the job hunt. * Talk to your attendings to learn their experience and to find networking opportunities. * Collaborating with fellow residents can help everyone find work. * Reaching out to departments directly may reveal jobs not posted on hospital websites. * Your first job does not have to be your last job.
Host: Dr. Isaac Agboola, MD, MS
Guest: Dr. Sheryl Heron, MD, MDP, FACEP
Assistant Dean of Medical Education and Student Affairs at Emory University School of Medicine
Vice Chair of Administrative Affairs
Professor of Emergency Medicine
OverviewDrs. Agboola and Heron discuss the intricacies of cognitive bias and cultural competency and the role it plays in the emergency department. They discuss ways that individuals and residency programs alike can ensure they are rendering more culturally competent care - and model that for medical trainees. Additionally, they spend time addressing communities at risk for such biases such as undomiciled populations, individuals from lower socioeconomic status, and racial minorities.
Key Resources
- EMRA Diversity and Inclusion Committee
- Implicit Bias: What Can We Do?
- Implicit Bias and ED Overcrowding
Key Points
-
Cognitive bias, microaggressions and cultural humility should compel us to think more deeply on how we can deconstruct the "-isms".
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It is important to create and nurture an environment that allows for open dialogue in a safe space.
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As a health care provider there are critical steps that need to be taken:
-
- Appreciate and understand that we are all different - diversity is a good thing!
-
- Be prepared to "call the card" if you experience a discriminatory comment/action. It is important to address it. Do not ignore it.
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Eliminating bias is not an individual effort; it is institutionally and systemically driven.
-
Patient populations with common negative biases include those with cardiovascular disease, high utilizers/low socioeconomic status, and the incarcerated.
- There is a large amount of research that demonstrates disparities and inequities in care but more work is still left to be done.
References
-
Martin ML, Heron SL, Moreno-Walton L, Strickland M. Diversity and Inclusion in Quality Patient Care: Your Story/Our Story: a Case-Based Compendium. Cham: Springer; 2019
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Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Academic Emergency Medicine. 2017;24(8):895-904. doi:10.1111/acem.13214.
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ACEP Implicit Bias and Cultural Sensitivity Paper
Let's discuss a few hot topics: How do rising temperatures affect emergency medicine and the health of your patients? In this episode we sit down with Dr. Caitlin Rublee to discuss bugs, drugs, plants, and people. We connect the dots to show how climate change relates to social emergency medicine and what we can do as leaders to engage in health policy and take action to protect our patients!
Key Points
- Climate change affects bugs, drugs, plants, and people! Rising temperatures mean increased vector-borne/zoonotic infections, decreased efficacy of medications and patient access to medications, as well as increased potency of plant-borne illness and decreased biodiversity. Most important, it means poor health outcomes for our patients.
- Addressing health care equity is crucial when it comes to climate change. Vulnerable populations are disproportionately affected, and social determinants of health are front and center.
- Start a conversation about climate change in your program or medical school
- Incorporate health policy education into your curriculum, research, or QI projects
- Seek multi-disciplinary collaborators
- Get involved with organizations within your hospital or on the national stage
- COVID-19 has exposed our fragile health care system. There are many steps we can take to build climate-smart, climate-resilient health systems to prepare for when disaster strikes. You can:
- You can talk about climate change with your patients! For example, for your patients with asthma, discuss risks stemming from pollen and air pollution. For your patients who work outside, talk about heat index and cooling measures.
- You are a leader: what can you do to inspire and engage? Channel the fierce urgency of now into action!
Guest: Jess Mason, MD, FACEP, director of the Medical Education Fellowship at UCSF-Fresno and deputy editor of EM:RAP, EM:RAP HD videos, and creator of EM:RAP’s C3
Hosts: Ranjita Raghavan, MD, of The Mount Sinai Hospital EM Residency, and Shreyans Sanghvi, DO, of Northwell Zucker School of Medicine (North Shore/LIJ)
OverviewEmergency medicine offers an exciting yet staggering number of career paths. In this episode, we explore what it takes to find your niche in the specialty. Get the inside track from Jessica Mason, MD, FACEP, who knew early on what motivates her and has established herself as a leader in FOAMed.
Key Points
- If you are looking for inspiration for what niche to pursue, ask yourself, "What bothers you?" The answer to this question usually will lead to something you are passionate about.
- You do not need to be at a residency that directly fits your passions; you can find mentors and pursue opportunities anywhere you go. You just need to reach out to people; they will generally be willing to help.
- When reaching out to someone, do NOT ask "What should I do?" Instead, come with an idea or plan; this is more helpful and shows you are motivated and inspired, and people will find it easier to help you execute your ideas.
- "Everything is already taken" – except it's not. There is always room for another voice, a different perspective, or a fresh approach. Just because it's been done before does not mean there is no room for you.
- Everyone is always hiring. Remember this; every interaction is a connection, and you never know when an opportunity will pop up suddenly, so reach out to people and places you are interested in.
- Whatever you do, 10% of people are not going to like it – and that is good; it means you made an impression. The most inspiring people usually have strong opinions.
- Say yes to opportunities and be willing to take a leap of faith.
In part 2 of her interview with Dr. Haney Mallemat, Dr. Jessie Werner finds out how to manage the ventilator in the ED and reviews some real-life cases with Haney!
Overview: As Emergency Medicine physicians we’re tasked with taking care of the sickest of the sick, often before we even have a diagnosis to clarify the clinical picture. Stabilizing critically ill patients may require placing a definitive airway and providing hemodynamic support with pressors. When faced with these challenging situations, what do you do? So you decide to intubate. Now what? What are the different ventilator modes and how do we choose? What does it mean when the vent is alarming? Find out how to select vent settings and troubleshoot problems in Part 2 on becoming a critical care beast in the ED!
Key Points * There’s no difference between pressure and volume control + If you’re giving a certain pressure, you monitor the volume, and vice-versa * Remember 6-8cc/kg of volume (using ideal body weight) for lung protective strategy * Peak pressure is the sum of resistance and compliance * Plateau pressure measures compliance * High peak pressure indicates a resistance problem * High peak AND plateau pressure indicate the lungs are stiff * To diagnose a ventilator problem think DOPES: + D: displaced tube or cuff problem + O: obstructed tube + P: pneumothorax + E: equipment problem + S: breath stacking * To fix a ventilator problem think DOTTS: + D: disconnect from the ventilator and allow for full exhalation + O: oxygenation - are they bagging okay? + T: tube in the right place + T: tweak the vent to prevent breath stacking + S: ultraSound
References / Resources * Weingart, Scott D. "Managing initial mechanical ventilation in the emergency department." Annals of emergency medicine68.5 (2016): 614-617.
EMRA*Cast host Dr. Shreyans Sanghvi takes a deep dive on the history, current practice, and future direction of cardiac arrest management and advanced resuscitation medicine with research pioneers Dr. Lance Becker and Dr. Sam Parnia.
OverviewEach year hundreds of thousands of Americans suffer from cardiac arrest out of the hospital. CPR has been a core tenet in the rescue algorithm for patients in cardiac arrest, but how do we transform this age-old treatment with today's advances in technology, and to where do we turn when CPR alone is ineffective?
Dr. Lance Becker, chair of Emergency Medicine at Northwell Health North Shore - LIJ, and Dr. Sam Parnia, director of Critical Care Research at NYU Langone Medical Center, discuss lessons they've learned along the way dedicating their lives to the research and treatment of patients in cardiac arrest.
Key Points
- CPR is the single most-effective measure in the resuscitation of patients in cardiac arrest.
- CPR when used in tandem with real-time biomarkers such as end tidal CO₂, arterial line pressure, and ultrasound can be utilized to monitor CPR efficacy in real time.
- A team-focused, multi-disciplinary video review of cardiac arrest management can help improve outcomes in patients and identify barriers to achieving adequate reperfusion.
- Upon achieving ROSC, provider efforts should be dedicated to minimizing the amount of reperfusion injury patients incur.
- Providers should resist the urge to correct acidosis (in the immediate post-ROSC phase) by increasing the ventilator respiratory rate, as decreased CO₂ levels can precipitate cerebral vasoconstriction and worsen brain ischemia.
Dr. Jeremy Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada and ARVD.
Lumps and Bumps: Can't-Miss Diagnoses in Syncope
Host: Alex Kaminsky
Guest: Jeremy Berberian, MD
- Associate Director of Resident Education, ChristianaCare
- Editor-in-chief: EMRA EKG Guide, EMRA Ortho Guide, and the upcoming Emergency ECGs: Case-Based Review and Interpretations, with Amal Mattu and William Brady
- Faculty editor: EM Resident Monthly ECG Challenge
- Creator: ECG Greeting Cards©, a collaboration with MPP and JerBer Productions
EPISODE OVERVIEWResidents are well-programmed to recognize cardiovascular emergencies such as STEMIs at a glance. However, during a busy shift it can be easy to overlook dysrhythmias and other electrophysiologic urgencies and emergencies. Syncope is a prime example of a chief complaint that may be uncovered with an EKG alone -- however, syncopal emergencies are often subtle and nuanced. Dr. Berberian joins EMRA*Cast with Alex Kaminsky to delve deeper into the pathophysiology and electrical findings associated with diagnoses such as WPW, Brugada, ARVD and more.
KEY POINTS
Wolff-Parkinson-White (WPW)
Prevalence: 0.7 to 1.7 per 10000
OverviewAccessory Pathway Connecting the atria to the ventricle. In some instances, this can cause the accessory pathway to travel FASTER than through the AV node.
- Orthodromic (Narrow): Travels down the AV node (can bypass)
- Antidromic (Wide): Bypasses AV node and UP the his-purkinje system.
Courtesy of CardioNetworks: Free use image
Key Features:
Image: Courtesy of EMRA EKG Guide
- Short PR (less than 120ms)
- “Delta” wave -- which is a “slurring” of the QRS complex
- QRS might be “a little” wide (still <120ms)
- Often secondary ST-T wave changes.
Most common presentation is SVT. But also can present as atrial fibrillation.
TreatmentOrthodromic (Narrow): Treat like SVT
Key Point: Procainamide is the most safe chemical cardioversion in WPW as it does not directly affect the AV node. Use of AV-nodal blockers in WPW (including Amiodarone) increases the risk of VT/VF.
*Blocking the AV node in a WPW patient in Atrial Fibrillation can precipitate bad ventricular rhythms. If you see A-fib GREATER than 220 minus age -- consider WPW.***
Antidromic (Wide): Treat Like V-Tach
Brugada SyndromePrevalence: 5 in 10,000. Traditionally taught more common in Southeast Asian populations.
OverviewSodium Channelopathy, which can lead to unstable dysrhythmias and ultimately cardiac death
Key Features
Diagnosis is made both by EKG and clinical criteria
Images: Courtesy of EMRA EKG Guide
Type 1:
- “Coved” ST-Elevation >2mm with a negatively deflected T in right precordial leads (V1-V3)
- Potentially diagnostic as isolated EKG finding.
Type 2:
-
ST elevation in right precordial leads (V1-V3) with a “saddleback.” Within the STE.
-
Not completely diagnostic but concerning fr workup.
Clinical Criteria (EKG Findings PLUS one or more):
- SYNCOPE
- Nocturnal Agonal Respirations
-
- Brugada gets WORSE with parasympathetic stimuli.
- Family member with known Type 1
- Observed/Documented VT/VF
- Sudden cardiac death in family member <45 (Take that history!)
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD)
Prevalence: Unknown, likely more than we thought. Mean age is 31. Also we don't have great clinical criteria to full encompass this -- yet. Multiple genes linked to disease process. Variable inheritance patterns.
OverviewFibro-Fatty infiltration of the myocardium that replaces good "conductive" tissue with fibrinous infiltrates. Think: "Kinda like cirrhosis of the heart."
Causes paroxysmal ventricular rhythms. Can present as CHF.
Key Features
Image: Courtesy of EMRA EKG Guide
-
Epsilon wave -- AKA "The Ditzle or Nubbin" (only in 30% of patients)
-
T-wave inversions in right precordial leads (V1-V3) -- (85% of patients)
-
Long S-wave repolarization delay >55ms (in 95% of patients)
-
Slightly prolonged QRS >110ms (Right precordial leads)
-
VT looks more like a Left-bundle morphology -- Appreciate that AFTER the patient is out of VT.
Key Resources: If needed and/or different than references
- EMRA EKG Guide
- Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope: Huff J.S., Decker W.W., Quinn J.V., Perron A.D., Napoli A.M., Peeters S., Jagoda A.S.( 2007) Annals of Emergency Medicine, 49 (4) , pp. 431-444.
- Epidemiological profile of Wolff-Parkinson-White syndrome in a general population younger than 50 years of age in an era of radiofrequency catheter ablation. Lu C.-W., Wu M.-H., Chen H.-C., Kao F.-Y., Huang S.-K. (2014) International Journal of Cardiology, 174 (3) , pp. 530-534.
- Reference, G. (2019). Brugada syndrome. [online] Genetics Home Reference. Available at: https://ghr.nlm.nih.gov/condition/brugada-syndrome#statistics [Accessed 14 Feb. 2019].
- McNally E, MacLeod H, Dellefave-Castillo L. Arrhythmogenic Right Ventricular Cardiomyopathy. 2005 Apr 18 [Updated 2017 May 25]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1131/
OverviewDo you ever get overwhelmed with all the ED analgesic options? In part 2 on ED Pain Management, Dr. Sergey Motov helps break things down, reviewing a few cases and finishing with Sergey’s 10 Commandments of ED Pain Management.
Key PointsSergey's 10 Commandments of ED Pain Management
- Titrate opioids regardless of initial dosing regimen: weight-based, fixed, or nurse-initiated.
- Use alternatives (to IV) routes of analgesic administration: PO, PR, IN, SubQ, nebulized, topical.
- Utilize sub-dissociative dose ketamine for selected acute and chronic painful conditions.
- Educate patients about appropriate expectations of pain course and management.
- Embrace a concept of channels/enzymes/receptors targeted analgesia.
- Use NSAIDs based on their analgesic ceiling dose.
- Attempt to use non-opioid analgesics whenever possible.
- Promote nerve blocks for a variety of acute painful conditions (trauma, infection, inflammation).
- DO NOT prescribe long-acting opioids, SR/ER opioids, or fentanyl patches in the ED or at discharge.
- If indicated, DO prescribe a short course of immediate release opioids (preferably morphine sulfate IR) at discharge and arrange proper follow-up.
Resources and References
-
Cisewski DH, Motov SM. EMRA Pain Management Guide. EMRA. Dallas, Texas:2020.
• App version available within MobilEM at iTunes and Google Play. -
Motov SM. PainFreeED.com.
In part 1 of her interview with Dr. Haney Mallemat, Dr. Jessie Werner discusses using pressors in the ED. Stay tuned for part 2 on managing the ventilator!
Overview: As Emergency Medicine physicians we’re tasked with taking care of the sickest of the sick, often before we even have a diagnosis to clarify the clinical picture. Stabilizing critically ill patients may require placing a definitive airway and providing hemodynamic support with pressors. When faced with these challenging situations, how do you choose the right pressor? What’s the dose? When do you add another agent? What about fluids? We answer all these questions and more in this episode of EMRA CAST. Also, stay tuned for the follow-up to this episode which covers vent management in ED. We’ve got you covered with all the tips you need to become a critical care beast in the ED!
Key Resources: * The RUSH protocol (which includes the HI-MAP technique Dr. Mallemat mentions) – Rapid Ultrasound for Shock and Hypotension.
Key Points * Perfusion is composed of the tank (preload), the pump (cardiac output), and the pipes (systemic vascular resistance). Hypotension or shock can be caused by ANY of these, so consider performing ultrasound using the HIMAP protocol: HEART, IVC, MORISON’S POUCH, AORTA, and PULMONARY to determine the cause of the hypotension and tailor your resuscitation. * Pressor Algorithm: + As long as there is not evidence of a decreased EF or another cause of hypotension, Haney recommends starting with fluids to resuscitate a hypotensive patient. + If a patient is critically ill and/or not responsive to fluids, consider starting norepinephrine. It’s okay to start it peripherally! + If the patient is profoundly vasoplegic and norepinephrine is not working, consider adding vasopressin at a dose of 0.03 mg/kg. + After that point, you can consider starting epinephrine at a higher dose, or greater than 0.05 mcg/kg/min to get the most vasopressive effect. There is no known maximum dosing, but organ ischemia - particularly gut ischemia - can occur. + Dopamine has fallen out of favor due to concern over arrhythmogenic properties; however, you could consider using dopamine if a patient is bradycardic AND hypotensive (for example, if they’re beta-blocked). If a patient has a “pump” problem with a significantly reduced EF, you should consider dobutamine in conjunction with cardiology or an intensive care specialist.
References / Resources * Rezaie S. RUSH protocol: Rapid Ultrasound for Shock and Hypotension. ALiEM Website. https://www.aliem.com/2013/06/rush-protocol-rapid-ultrasound-shock-hypotension/. Updated 6/1/2013. Accessed 12/13/2018.
**Host** Jessie Werner, MD Alpert Medical at Brown University
PGY3
@JessWernerMD
EMRA Cast Episodes
**Guest** Haney Mallemat, MD Associate Professor of Emergency Medicine at Cooper Medical School
Triple boarded in EM, IM, CritCare Medicine.
Internationally recognized educator in CC Medicine.
Hospital Affiliation: Cooper Medical School
@CriticalCareNow
EMResident Articles
Host: Alex Kaminsky, MD PGY-3
UCSF-Fresno (@Alex_KamskyEM)
Guest: Stephanie Benjamin, MD (@StephBenjaminMD)
EMS/Disaster Fellow, UC-Davis
Author: “Love, Sanity, or Medical School”- https://www.thirdyear.org/
Overview:
In this episode Dr. Kaminsky sits down with veteran journal writer, award winning author, lecturer and current EMS/disaster fellow Dr. Stephanie Benjamin to discuss tangible ways to combat burnout: beyond the buzzwords and by actively building resiliency via personal or medical journaling. Dr. Benjamin discusses the strong medical origins to journaling, her own path and experiences into writing, the evidence-based physical and mental benefits of writing and how residents can delve into combating burn-out in a meaningful and realistic way. What we do is HARD. What we see is difficult. We need outlets to cognitively offload and unpack. Journaling is one way to actively (or passively) practice mindfulness outside of meditation and yoga.
Key Points:
- Journaling has deep roots in medicine. From Queen Victoria’s personal physician, to modern day
- Medical culture and education have deep roots in separating emotion from patient interactions and experiences. Journaling and having meaningful and purposeful reflection go against the way we are trained, even today.
How to Journal:
Step 1: There are no rules. This is for YOU, not public consumption
Step 2: Be HONEST with yourself. This is a time for reflection and cognitive off-loading. You’re human. Recognize your own success, experience and shortcomings.
Step 3: Avoid the existential questions at first. Start small, work your way up.
Step 4: Writer’s Block? Find a prompt. Answer a pointed question. Doodle. It doesn’t matter.
Remember, just a couple times per month is enough to reap the physical and psychologic benefits of journaling. Do it!
References and Works:
- https://www.acep.org/who-we-are/50Years/WhatsYourMoment/first-place-stephanie-b-benjamin-md5/
- Baikie K. A., Geerligs L., Wilhelm K. Expressive writing and positive writing for participants with mood disorders: An online randomized controlled trial. J Affect Disord. 2012; 136: 310–319. 10.1016/j.jad.2011.11.032
Baker JR, Moore SM. An opportunistic validation of studies on the psychosocial benefits of blogging. 2011; 10.1089/cyber.2010.0202. Epub 2010 Nov 3. PMID:21117978
Do you ever get overwhelmed with all the ED analgesic options? Dr. Sergey Motov from Maimonides Medical Center in Brooklyn helps breaks down ED pain management. We cover everything from topical NSAIDs to ketamine infusions. Curious which opioid to go with or what dosing? Look no further.
Key Points:
- Remember to set appropriate pain management expectations. The goal is to make the pain tolerable, not to eliminate it. The more you include your patient in your decision making, the more in control they will feel.
- NSAIDs are a go-to first option. If a patient doesn’t respond to one class, try another. And don’t forget about topical NSAIDs like diclofenac! Reasons to avoid this class would be history of GI bleed or CAD.
- Ketamine is a great option for acute pain. 0.3mg/kg in a bolus over 30 minutes followed by 0.1mg/kg/hr during their ED stay. Use these slow infusions to avoid dysphoric reactions. Don’t be afraid to use ketamine in combination with other analgesics for optimal pain management.
- Neuropathic pain is difficult to manage. Options include antidepressants, lidocaine infusion, gabapentin.
- Nerve blocks are amazing. From a greater occipital nerve block for migraine to serratus anterior block for rib fractures. There are so many more applications. “If there is a nerve, it can be blocked.” Shout out to my favorite: a hematoma block!
- Opioids are dangerous but they have a definite role in acute pain management. Morphine is less associated with euphoria and is a good start if choosing to treat with opioids. Oxycodone and hydromorphone are weaker alternatives and have a higher risk of substance abuse; avoid them if possible.
Resources and References:
- https://www.emra.org/books/pain-management/painmgtguide/
- http://www.painfree-ed.com/
Do you ever feel like a fake, a fraud? Imposter syndrome can make you feel a pervasive sense of intellectual fraudulence, despite all the evidence to the contrary. In this episode, Dr. Kim Bambach discusses imposter syndrome with Dr. Jamie Hope including strategies that you can use to combat it.
Host:Kim Bambach, MD
Ohio State University, PGY3
@kimbambachhttps://twitter.com/kimbambach
Guest:
Jaime Hope, MD
Assistant Professor
Beaumont Hospital, Royal Oak
@DrHopeHealth
Key Points:
- Watch out for the typical signs and symptoms: These include devaluing your accomplishments, attributing your accomplishments to external causes, constantly comparing yourself to others, and a negative inner “bully” monologue.
- Go first: Be the first to speak up about imposter syndrome, because acknowledging those feelings gives others a chance to feel understood and helps you recognize that you are not alone.
- Put your name in the hat: Don’t let imposter syndrome hold you back when it comes to professional development. Apply for that award, leadership position, or job even if you don’t feel 100% qualified. Imposter syndrome can cloud your ability to see your own value and strengths.
- Lift as you climb: When you recognize imposter syndrome in others, use your voice and your social capital to advocate for them. Focusing outward on lifting up others can help you combat imposter syndrome. You can do this at any stage of training.
- Does it pass the “why” and “who cares” tests?: When you are thinking of all the things you “should” be doing, ask yourself if you can articulate a good reason why you should take on that project and the larger impact of why it is important to YOU. There is no single path to success.
- Change the channel: When you notice that your inner bully podcast is playing on full blast, change the channel to a different topic. Ask yourself- would you say those things to a friend?
Resources and References:
https://feminem.org/2018/01/30/overcoming-imposter-syndrome-dont-fake-youve-made/
https://feminem.org/2018/06/07/imposter-syndrome-part-2/
In this episode, Dr. Tiffany Proffitt talks with Dr. Esther Choo about tangible ways to view and address gender disparities in emergency medicine.
Description: Recorded at ACEP 2018 on the Expo floor. A discussion with Dr. Esther Choo on overcoming gender disparities in medicine as well as advice to residents and core faculty for implementation of techniques to encourage change and advancement. Introduction to Dr. Choo’s new start up Equity Quotient.
Content of Show Notes: Dr. Choo’s Top 3 for Overcoming Gender Disparities in Medicine:
- Find your support network - there are local and national groups!
- You are NOT alone!
- Continue to work to improve the problem as you move up.
Just a Few Support Networks:
- Your own hospital’s women’s group – if it doesn’t exist, reach out to your faculty and start one!
- EMRA
- Academy for Women in Academic Emergency Medicine
- American Association of Women Emergency Physicians
- FemInEM:
- Dr. Choo
Citations for Any Relevant Articles
- Anna S. Mueller, Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O'Connor, and Vineet M. Arora. Gender Differences in Attending Physicians' Feedback to Residents: A Qualitative Analysis. Journal of Graduate Medical Education: October 2017; 9(5): 577-585.
-
Dayal A, O’Connor DM, Qadri U, Arora VM. Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training. JAMA Intern Med. 2017;177(5):651–657.
Host Tiffany Proffitt, DO Lakeland Health
PGY3
@ProMammaDoc
EMRA CAST Episodes
EMResident ArticlesGuest Dr. Esther Choo, MD Associate Professor of Emergency Medicine at the Oregon Health & Science University (OHSU)
Former president of AWAEM
FemInEM Advisory Board member
Co-founder of Equity Quotient
@choo_ek
Overview:
With an upcoming election, social unrest and a global pandemic - there’s a lot to get fired up about. But what’s our role as residents? PGY2 Kate Joyce talks with Dr. Marina Del Rios, Dr. Dara Kass and Dr. Alister Martin about a program that registers patients to vote in the ED, social emergency medicine, policy and advocacy. We’ll round things out by talking about how to get involved - without putting your career in jeopardy.
Key Points:
Social Emergency Medicine recognizes the importance of addressing the social determinants of health in the Emergency Department through direct practice, community engagement, advocacy and research.
Many of our patients have not been introduced to the political process. For others, it may not be safe for them to go to the polls. VotER is a nonpartisan project that allows patients to register to vote or request absentee ballots while they wait, without adding to the work burden of providers.
Drs Del Rios, Kass and Martin lay out a few examples and suggest ways to get involved in advocacy responsibly as residents.
Without addressing issues like housing, hunger, addiction, poverty and health disparities, we will continue to play “whack a mole” in the ED with problems that we cannot treat medically. Getting involved in upstream approaches gives providers an avenue to get at these issues.
10 tips for getting fired up without getting fired
- VOTE on November 3 and in EVERY election.
2) Hold elected officials accountable and SHOW UP to local and community events.
3) Find arenas where your position as a resident can add value to the discussion.
4) INVEST in your time as a resident - that’s why we’re here!
5) Be aware that your decisions on HOW you practice advocacy can seriously impact your career.
6) Avoid sharing ANY kind of identifying information about patients.
7) Know your institution’s rules about in-person advocacy, publications, social media, lobbying and especially talking to the press.
8) Don’t feed the trolls! Keep it classy and do your research so you know your stuff.
9) Have conversations with people outside of your silo.
10) Remember that getting involved at a LOCAL level can have the biggest impact.
Resources and References:
- Register to vote, check your registration status, and find what’s on your ballot https://www.vote411.org/
- American College of Emergency Physicians Section on Emergency Medicine https://www.acep.org/how-we-serve/sections/social-emergency-medicine/
- The Andrew Levitt Center for Social Emergency Medicine https://www.levittcenter.org/
- Download or order your free VotER kit to start providing voter registration information in your hospital https://vot-er.org/
- National Conference of State Legislatures: Find information about same-day voter registration, early voting, or requesting absentee ballots. https://www.ncsl.org/
- Information on fellowships in social EM and population health from the EMRA Fellowship Guide https://www.emra.org/books/fellowship-guide-book/20-population-health-and-social-emergency-medicine/
Dr. Jessie Werner hands over the mic over to our five new EMRA*Cast hosts. Take a listen and get to know them before they go live with their own episodes.
**Overview: Imagine being one of a few dozen Emergency Medicine trained physicians responsible for the lives of millions in a vulnerable country. This is the practice and training environment faced on a daily basis by the noble Doctors who represent the first classes of Emergency Medicine Residents in Haiti. Take a moment to hear their stories and please continue to support Haiti’s first Emergency Medicine Residency program!
Host:** Tiffany Proffitt DO, MABS Attending Honor Health
Guest Panel:
Jacqueline Tin, MD, MPH, Vice Chair of the EMRA International Committee
Wesner Jacotin, MD, Emergency Medicine Resident at the University Hospital of Mirebalais, Haiti
Jose Moncricket, MD, Emergency Medicine Physician and former resident at the University Hospital of Mirebalais, Haiti
Suggested References:
The Hôspital Universitaire Mirebalais Residency will be the first EM training program in Haiti
Reach out to the EMRA International Committee: internationalctte@emra.org
Key Points:
- You can make a difference supporting the next generations of Emergency Medicine trained physicians on a global scale!
- Think beyond your own boarders and boundaries, join the International Committee!
Host: Dr. Isaac Agboola, MD, MS
Guest: Dr. Zach Jarou, MD, MBA
Overview: On this episode, Dr. Agboola and Dr. Jarou venture into the oftentimes convoluted task of applying to Emergency Medicine residency. They discuss common pitfalls and misconceptions, giving evidence-based advice on how to increase success in applying whether it be to a community or educational setting. This episode is primarily geared towards medical students applying as well as advisors for these individuals.
Key Resources:
-
EMRA & Cord Advising Guide https://www.emra.org/books/msadvisingguide/msag/
-
EMRA Match Tool https://webapps.emra.org/utils/spa/match#/search/map
-
EMRA Student-Resident Mentorship Program (program helped to find mentors for medical students interested in EM residency) https://www.emra.org/students/advising-resources/student-resident-mentorship-program/
-
Program Director Interview Series - Various PD’s give an inside look into what they are looking for in an applicant for their programs
https://www.emra.org/emresident/articles/categories/topics/medical-students/match/program-director-interviews
Key Points:
-
Plan your application based on your personal situation.
-
You are probably applying to more programs than you need to.
-
When it comes to away rotations, rotate in an environment that is the best for you, given what you want to get out of residency.
-
The three-year vs. four-year program discussion should be less about the training time and more about how that particular program is structured, but most importantly about how it can help you to achieve your goals long term.
-
Statistically speaking the things that have been shown to be most important to applicants are: (1) Geography, (2) Practice Environment, (3) Step 1 cutoffs, and (4) Time (shift length/shift amount, three years vs. four years).
-
Applicants that are IMG, DO, or other special circumstances should take careful consideration when applying.
-
An average applicant (i.e., average board scores, SLOEs, research experiences) should be applying to approximately 30 programs.
-
There is no perfect equation for success in the Match; it’s important that you meet with trusted advisors and find a plan that best suits you and your competitiveness.
References:
- EMRA & Cord Advising Guide https://www.emra.org/books/msadvisingguide/msag/
Transitions of care are one of the most dangerous activities in medicine. Numerous studies highlight the rates of medical errors which occur at the time of sign-outs. Formalized sign-out processes have been shown to significantly decrease breakdowns in communication and reduce adverse events. In this episode, Dr. Kaminsky sits down with residents from across the country to dissect and discuss different sign-out styles and share some insights regarding bias and areas for improvement.
Host:
- Alex Kaminsky, MD -- UCSF, Fresno
Guests:
- Rosemarie Diaz, MD – University of Michigan
- Mary McLean, MD – St. John's Riverside Hospital
- Nicholas Robbins, MD – John Peter Smith Hospital
Key Resources:
-
Safer Sign Out Protocol: Available at ACEP.
-
EMRA: Transitions of Care
-
https://www.emra.org/students/advising-resources/transitions-of-care/#:~:text=Improving%20transitions%20of%20care%20%E2%80%93%20also,transfer%20of%20patient%20care%20information
Key Points:
-
In a prospective multi-center study (>10,000 patients) communication error occurred at a rate pf 24.5 per 100 admissions. Preventable errors were found to be 4.7 per 100 admissions.
-
Effective sign-out strategies have been shown to reduce overall medical errors by ~23% and preventable adverse events by ~30%.
Hand-Off Tools:
Remember CODE STATUS!
IPASS:
Illness severity: Stable, “watcher,” unstable
Patient Summary: HPI, ED course/Ongoing assessment, Plan
Action List: “To-do”
Situation Awareness and Contingency Planning: “If this, then do that.” Give your colleagues an idea of what to do if an event occurs.
Synthesis by Receiver: Person taking the sign out does a “readback” of what they heard. Restate key actions. Also, the time to ask questions.
SBAR
Situation: Clearly and briefly define the situation
Background: Provide clear, relevant background information that relates to the situation.
Assessment: A statement of your professional conclusion.
Recommendation: What do you need from this individual? What to do and contingencies.
SHOUT
S: Sick or not Sick
H: History and Hospital Course
O: Objective Data
U: Upcoming plan, disposition
T: To do
(note: This is by no means a comprehensive list)
References:
- Brady P, Gorham J, Kosti A, et al "SHOUT" to improve the quality of care delivered to patients with acute kidney injury at Great Western Hospital. BMJ Open Quality 2015;4:u207938.w3198. doi: 10.1136/bmjquality.u207938.w3198
- “SBAR a Powerful Tool to Help Improve Communication.” The Joint Commission, www.jointcommission.org/resources/news-and-multimedia/blogs/at-home-with-the-joint-commission/2013/11/sbar--a-powerful-tool-to-help-improve-communication/?_ga=2.175033826.1924301882.1600033523-2075193987.1600033523.
- Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-12.
- Heilman JA, Flanigan M, Nelson A, Johnson T, Yarris LM. Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs. West J Emerg Med. 2016;17(6):756-61.
- Cheung DS, Kelly JJ, Beach C, Berkeley RP, Bitterman RA, Broida RI, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171-80.
Overview: On this EMRACast, Dr. Agboola sits down and talks to Dr. Dajer* about his experience working as a physician during 9/11. Additionally, he gives his personal approach to disaster planning.
Key Resources:
- EMRA Pre-Hospital and Disaster Committee https://www.emra.org/be-involved/committees/prehospital-and-disaster-medicine-committee/
Key Points:
- Collaboration between EMS and ED staff is critical
- Adapt to your own circumstances
- In a disaster do not go into a disaster mode mentality
- Establish clear and central leadership
- You can always make more clinical spaces in a disaster situation
EMRA*Caster Dr. Alex Kaminsky sits down with Dr. Adam Rosh of Rosh Review to cover timelines, mindset, and strategies into successful preparation for both written boards and in-service examinations. Additionally, Adam imparts his wisdom as a passionate educator and former program director.
Overview: In this episode of EMRA*Cast, Dr. Jessie Werner and Dr. Jessica Whittle discuss high flow nasal cannula. Unsure of the difference among nasal cannula, a venti mask or a non-rebreather? Sick asthmatics? Pedi patients? Pneumonia? Learn when to use this modality to improve patient comfort and help stave off intubation.
Key Points:
- Regular nasal cannula goes up to 15L/min but patients are really only getting about 6L/min because of outside air mixing in
- The progression of FiO2 goes nasal cannula🡪venti🡪non-rebreather
- High flow nasal cannula goes up to about 40L/min of flow and is humidified so it’s more comfortable for patients
- Evidence points to a mortality benefit using high flow nasal cannula in pneumonia patients
References:
- Jentzer, Jacob, Cameron Dezfulian, and Lillian Emlet. "High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure: the FLORALI study." F1000Research 5.41 (2016): 41.
- Frat, Jean-Pierre, et al. "Preoxygenation with non-invasive ventilation versus high-flow nasal cannula oxygen therapy for intubation of patients with acute hypoxaemic respiratory failure in ICU: the prospective randomised controlled FLORALI-2 study protocol." BMJ open 7.12 (2017): e018611.
- Milési, Christophe, et al. "High flow on the rise—pediatric perspectives on the FLORALI trial." Journal of thoracic disease 7.8 (2015): E230.
Host: Tiffany Proffitt DO, MABS PGY-4 Lakeland Health
Guest Panel:
Michael Gisondi, MD, FACEP – Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University School of Medicine, Former Program Director at Northwestern.
Tarlan Hedayati, MD, FACEP – Chair of Education, Assistant Professor and Associate Program Director in the Department of Emergency Medicine at Cook County Hospital in Chicago
Andy Little, DO: Core Faculty, Research Director, Medical Education Fellowship Director at Doctors Hospital Emergency Medicine Residency, Co-founder and Host of EM Over Easy Podcast
Overview:
In this episode, Tiffany talks with a panel of expert interviewers on how to conduct an interview. The panel provides tips and tricks to the resident interviewer when it comes time for interviewing medical student candidates for a spot in their programs. They discuss everything from putting interviewees at ease, to canned speeches to present to the unengaged interviewee, and some unexpected questions to set yourself apart as an interviewer. Our panel also reminds the resident interviewers of the honor it is to be a part of the interview process. Your program chose you as an interviewer because it values your opinion; don’t waste the opportunity.
References:
10 Tips to Become a Successful Interviewer: Do’s and Don’ts, ALiEM, Medical Education, Sep 15, 2016, Meg Pusateri, MD and Nicole Battaglioli, MD
https://www.aliem.com/2016/09/10-tips-become-successful-interviewer /
EM Match Advice: Interviewing Strategies, ALiEM, EM Match Advice, Aug 29, 2014, Dr. Michael Gisondi, MD
https://www.aliem.com/2014/08/em-match-advice-interviewing-strategies/
Collings J. Residency Interviews (PDF handout from Dr. Jamie Collings https://www.aliem.com/wp-content/uploads/Collings-Interview-Tips.pdf)
.
Questions:
-
Who was your favorite teacher ever – from nursery school to now - and why?
-
What’s the last book that you read? What is the book about, why did you pick that book, what do you like about the book?
-
Ask about a flaw in the application.
-
Ask about recent travel or a favorite trip.
-
For four hours you will be placed on a monitored bed and you get to experience any illegal substance without risk of negative side effects or addiction, which would you try?
-
Favorite movie.
-
What is your biggest failure—can be non-medical. If your candidate struggles, then the interviewer shares one of her or his failures.
Key Points:
- To the senior residents - your program chose you as an interviewer because it values your opinion; don’t waste the opportunity.
- When all else fails, play the tape.
- To the interviewees – we’re not out to get you, except maybe Dr. Little.
Does double defib work? Does it improve your chances of walking out of the hospital? What’s your CPC score? What is a CPC score? And how exactly do you conduct this procedure. In this episode, recorded live at ACEP 2019, Dr. Tiffany Proffitt discussed the ins and outs of double defibrillation with Dr. Mark Ramzy.
Host: Tiffany Proffitt DO, MABS Attending Physician, Honor Health, Scottsdale, AZ
Guest Panel: Mark Ramzy, DO, EMT-P, Critical Care Fellow at University of Pittsburgh, Chair of the EMRA Critical Care Committee.
Suggested References:
Dr. Ramzy’s very own presentation and sources on Double Defibrillation: https://docs.google.com/document/d/1VlkBhMOYT5oi93fPD8Q1B-JOMETkrY_vDl7r3zq2-JQ/
- El Tawil C, et al. Double sequential defibrillation for refractory ventricular fibrillation. Am J Emerg Med. 2017; PMID: 28978402
- Hajjar K et al. Dual defibrillation in patients with refractory ventricular fibrillation. Am J Emerg Med 2018. PMID: 29730094
- S. Cheskes, et al. Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation 2020; PMID: 32084567
- Ramzy M, "The DOSE VF Pilot RCT: Double Sequential External Defibrillation for Refractory Ventricular Fibrillation", REBEL EM blog, March 26, 2020. Available at: https://rebelem.com/the-dose-vf-pilot-rct-double-sequential-external-defibrillation-for-refractory-ventricular-fibrillation/.
- Hamilton R, Ramzy M. Dual defibrillation is highly variable: an analysis of pulse interval delivered in dual defibrillation. Prehospital Emergency Care. 2019 PMID 31116612
Additional Readings:
- EmCrit.org - Double Defibrillation
- REBEL EM - Double Defibrillation
Key Points:
- Make sure the case is appropriate for the use of Double Defibrillation.
- Two defibrillators of the SAME brand.
- Pads, like your kids, do NOT TOUCH EACH OTHER!
- Completely anterior or anterior and posterior approach.
- Hit the buttons at the same time.
- Try not to shock yourself or ruin your defibrillator.
Dr. Isaac Agboola along with a group interns from across the country approach how to navigate the challenging parts of residency outside of just the basic science.
Overview: On this episode, Isaac is joined by an illustrious cast of interns from all across the country to discuss the other side of residency outside of the science. This is the Resident Survival Guide, addressing the new and challenging aspects of transitioning from being a medical student to now being someone’s physician. “How to deal with uncertainty?”,“Resident wellness”, “Disposition indecision”, “How to deal with a difficulty attending”, “End of life discussions” etc.
Key Points * Residency is hard…. for everyone. * Sometimes the best lessons come from people who aren’t your attendings. * Every shift make a goal of something to improve on. * Wellness is as wellness does. Do what makes you happy and keeps you balanced. * Lean on your co-residents they can be your greatest support system.
References / Resources
- ALiEM
- EMRA
-
LITFL - Life In The Fast Lane
Host Isaac Agboola, MD Yale New Haven Medical Center
PGY1
EMRA Cast EpisodesGuests Adrian Haimovich, MD, PhD Yale, PGY-1
Erin Karl, MD Nebraska, PGY-1
@erinkarl_md
EMResident Articles
Aadil Vora, DO Emory, PGY-1
EMResident Articles
Host: Miguel Reyes, MD
Guest: Aga De Castro, MD
Overview: We discuss what events led Dr. De Castro to be interested and eventually pursue a simulation fellowship, what it’s like being a sim fellow, what the fellowship looks like, the various kinds of sim fellowships, and different career possibilities you can pursue with the fellowship.
Key Resources:
-
https://www.emra.org/fellowships/simulation-fellowships/
-
https://www.emra.org/books/fellowship-guide-book/23-simulation/
-
https://www.saem.org/simulation
Key Points:
-
Sim fellowships are non ACGME accredited - thus follow the pay rate.
-
Fellowship length varies, 1 or 2-year tracks
-
Sim fellowship varies quite a bit, look into what kind of sim interests you
Host: Jessie Werner, MD
Guest: Amal Mattu, MD
Overview: In this episode, Dr. Jessie Werner hears Dr. Amal Mattu’s 10 Pearls for Success in Residency. These pearls were developed for Interns but will benefit any level of training. Follow this advice and you’re sure to be a star resident.
Key Resources:
Check out Dr. Amal Mattu’s White Board Teaching with his 10 Pearls for Success below:
- https://drive.google.com/open?id=0BzGTqddnb96vVWo1ZWY4a01tazRTTGJKUjExZlRKeUFLVzBV
Key Points:
-
Learn the names of the Nurses and Techs! Thank them often. Let’s face it, they spend more time with the patients than we’re able to. They know when something’s not right and they will catch things that will help you.
-
Don’t manage sick patient’s on your own. EM is a team sport. Always notify your senior or attending about a sick patient. They’ll respect your good judgment and trust you more!
-
Don’t judge patients or consultants without walking a mile in their shoes. Everyone has their own story. Be empathetic and compassionate - it will make you feel better too.
-
Peter Rosen “Nobody woke up this morning and decided to ruin YOUR day.” Happiness is you choice. Be happy, stay positive. Enough said?
-
Nobody expects you to know much (yet). But we do expect you to be 100% reliable. Residency is a time of learning! It’s ok to not know things but show up on time (or early), follow through on tasks, and give everything your best effort.
-
Never ever, ever lie. If you don’t know something (or didn’t do something), be honest. This is where your reputation is made. You will gain the trust of your colleagues and attendings by always being honest. We don’t care that you don’t know or forgot to do something. Just admit it and offer to fix it!
-
Want to get smart? Do two things:
-
Read up on at least one patient per shift
-
Ask lots of questions
Learning in residency can feel overwhelming. A great and manageable way to learn is by taking it one step at a time by reading about one thing you saw after every shift. Take advantage of your attending’s and consultant’s knowledge! Ask why they chose Roc over Succs or keppra over phenytoin…
-
Never be arrogant. You’ll be wrong many times in your career. Learn humility now. Even the best, most seasoned physicians have to look things up. Overconfidence leads to errors. Stay humble.
-
Eat and hydrate during every shift. You won’t be able to be the best for your patients if you haven’t taken care of yourself. We promise you won’t lose points for having a snack or going to the bathroom. Eat, drink, pee!
-
Never forget what a privilege and responsibility it is that people who don’t know you ask for your help on the worst day of their life. You went into medicine to help people. Hold onto your compassion and empathy. Remember what an honor it is to have people place their trust and confidence in you as an Emergency physician.
EMRA*Cast Host Dr. Miguel Reyes sits down with Dr. Kevin Baumgartner to discuss Toxicology Fellowships. Listen in as they discuss what events led Dr. Baumgartner to be interested and eventually pursue a toxicology fellowship, what its like being a tox fellow, what the fellowship looks like, and different career possibilities you can pursue with the fellowship.
Key Resources:
-
https://www.acmt.net/
-
https://www.emra.org/be-involved/committees/toxicology-committee/
-
https://www.emra.org/books/fellowship-guide-book/27-toxicology/
Key Points:
-
Tox fellowships are ACGME accredited - thus follow the pay rate.
-
All are 2-year fellowships
-
If no local tox contacts use the links listed above for job opportunities and guidance
EMRACast host Dr. Alex Kaminsky takes a deep dive on the topic of Acute Respiratory Distress Syndrome (ARDS) with Dr. Sean Hickey and Dr. Evan Leibner*.
Host:
- Alex Kaminsky MD: PGY-3 UCSF Fresno
Guests:
- Sean Hickey MD: PGY3 Mt. Sinai Hospital, NYC
- Evan Leibner MD: ED/Crit Care Asst. Prof Mt. Sinai Hospital, NYC
Overview:
Broad Strokes: ARDS is diffuse interstitial pulmonary edema secondary to increased pulmonary vasculature permeability. This causes a disruption in gas exchange.
More precise definition: Acute Respiratory Distress Syndrome (ARDS) is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue with hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance.
Etiology of injury pattern must be from a non-primary cardiopulmonary source.
Phases of Histologic Patterns:
Broad Strokes: Histologically in the lungs "diffuse alveolar damage" (DAD)
Initial response to injury:
Exudative phase, immune cell mediated damage to alveoli.
-
Protein rich fluid buildup in the interstitium and alveoli.
-
Inflammatory cytokines released leading to recruitment of macrophages/T-cells
-Any injury during this stage is worsened by stretch on alveoli by mechanical ventilation
Second phase is proliferative phase
-
Beginning of healing process.
-
Edema begins to be reabsorbed.
-
Alveoli gradually regains integrity and function.
Third phase:
-
Fibrotic phase
-
Does not occur in all ARDS patients; linked with higher mortality
MOST COMMON CAUSES:
- Sepsis
- Aspiration (Hamman Rich Syndrome)
- Pneumonia
- Trauma
- Massive Transfusion
- TRALI
- Drug Overdose: ASA, Opioids, Cocaine,
- Pancreatitis
Diagnosis:
The Berlin Criteria
- Respiratory symptoms within ONE WEEK of clinical insult.
- Bilateral opacities on imaging – Not fully explained by effusion, lobar/lung collapse, or nodules.
- Respiratory Failure not fully explained by cardiac failure or volume overload. An objective assessment to rule out hydrostatic pulmonary edema is required. *
- A moderate to severe impairment of oxygenation is present while on >5 of PEEP
*Either objective assessment (echo) which excludes hydrostatic edema, or risk factors for ARDS (sepsis, pancreatitis, trauma, pneumonia).
Primary Literature:
- The ARDS Definition Task Force. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA.* 2012;307(23):2526–2533. doi:10.1001/jama.2012.5669
- Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. JAMA. 2018;319(7):698‐710. doi:10.1001/jama.2017.21907
Evaluation of Oxygenation: The P:F Ratio
- PaO2/FiO2 ratio is the ratio of arterial oxygen partial pressure to fractional inspired oxygen
- At sea level normal is > 500mmHg
-
- Mild ARDS: PF 200-300
- Moderate ARDS: PF 100-200
- Severe ARDS: PF < 100
Can be used as a rough guide to whether there is a significant A-a gradient present.
PaO2 should = FiO2 x 500 (e.g. 0.21 x 500 = 105 mmHg)
Treatment
Mild ARDS (PF 200-300): Consider BiPAP in patients who are awake, alert, protecting their airway and oxygenating/ventilating.
Majority Will Require Mechanical Ventilation
Key Point: Goal is to optimize gas exchange, but avoid barotrauma, volutrauma, atelectotrauma and biotrauma. This is accomplished by low tidal volumes and dry volume status as tolerated.
ARDSnet and Clinical Considerations
http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
http://www.ardsnet.org/studies.shtml
- Tidal Volumes at 4-6ml/kg of IDEAL body weight.
Pro-tip from Evan: Pick your ideal vent mode based on comfort. There are lots of fancy and potentially optimal ventilator modes, such as Bi-level, oscillatory modes, and otherwise. Unfortunately, these are nuanced and can leave to harmful outcomes if doctors and RT’s are not intimately familiar.
-
High vs low PEEP tables have not been shown to affect mortality. Must be careful as high PEEP can reduce cardiac output.
-
To maintain the minute ventilation with LTV you must increase the RR.
However, by increasing the RR too much you can cause auto-PEEP. Thus, permissive hypercapnia can be tolerated unless acidotic (pH <7.15)
- Auto-PEEP can be measured by measuring the pressure during an expiratory hold and calculating by subtracting the provided PEEP by the total pressure.
- Maintain plateau pressures below 30. This reduces the amount of volotrauma on patients. Can be accomplished by providing an inspiratory hold and measuring the pressure.
- Maintain driving pressure below 15. It has been shown to improve mortality. Most likely reduces atelectotrauma.
Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747–55.
- Keep patients DRY – Early pressers as needed. The FACTT trial targeted a CVP <4 lead to an improvement in ventilator free days, an improvement in oxygenation index, less time in the ICU without an increase in shock.
Wiedemann HP, et al. "Comparison of two fluid-management strategies in acute lung injury". The New England Journal of Medicine. 2006. 354(24):2564-75.
- Consider paralyzing patients with long-acting paralytics (cisatracurium) if desynchrony with the ventilator. The ROSE trial showed no benefit, this is controversial and still a practice by some intensivists.
National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. "Early neuromuscular blockade in the acute respiratory distress syndrome". The New England Journal of Medicine. 2019. 380(21):1997-2008.
- Can consider APRV which was shown by Zhou et al to improve mortality.
APRV: Essentially a persistent inspiratory phase by ventilator, with “exhallation” phase where the vent triggers “off.” To allow for passive exhalation. Theory is it keeps alveoli open for longer to participate in recruitment and gas exchange and then gives longs a “break.”
https://emcrit.org/squirt/aprv/
- Traditional recruitment maneuvers do not improve mortality according to the ART trial.
Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017;318(14):1335–1345. doi:10.1001/jama.2017.14171
- Proning patients substantially improves mortality. Increased recruitment of atelectatic lung according to the Proseva trial
Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159‐2168. doi:10.1056/NEJMoa1214103
- Consider EARLY for VV-ECMO. ECMO is believed to be potentially a cost-effective measure that increases survival without severe disability at 6 months in patient with severe ARDS. CESAR trial.
Especially Consider if single organ system is affected in otherwise non-terminal patients
Peek GJ, et al. "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial.". The Lancet. 2009. 374(9698):1351-1363.
Host: Jessie Werner, MD
Guest: Alin Gragossian, DO, MPH
Overview:
In this episode, Dr. Jessie Werner interviews one of EMRA’s 45u45 winners, Dr. Alin Gragossian. As a senior EM resident Alin was diagnosed with heart failure and required an emergent heart transplant. This is the inspiring story that every person should hear!
Special thanks goes to Dr. Shyam Murali (@smuramed), resident at Mercy St. Vincent Medical Center in Toledo, Ohio, for editing this episode!!
Key Resources:
- Check out Alin’s blog: https://www.achangeofhe.art/
In this episode, Drs. Agboola and Jubanyik discuss Palliative Care in the Emergency Department. They cover a wide range of subjects including: How to deliver “Bad News”, navigating surrogate decision makers, and the “Surprise Question”.
Host: Isaac Agboola, MD, MS
- Yale New Haven School of Medicine, PGY-2
Guest: Karen Jubanyik, MD
- Academic Advisor in the Dean of Student Affairs Office
- Past National Chair of SAEM Palliative Care Interest Group
- Associate Professor at Yale New Haven School of Medicine
Key Points:
- “Treat bad news conversations, just like you would a procedure”
- Palliative Care is an ER doctor’s responsibility because sometimes palliative care is an emergency
- In regards to code status, only offer what options you feel are medically indicated
- Empower surrogate decision makers to make the decision their loved one would want
- There are over 130 ACGME Hospice and Palliative Care Fellowships that are available if you desire further education in the subject
References/Resources:
- EMRA Palliative Care Fellowship guide https://www.emra.org/books/fellowship-guide-book/18-palliative-care/
-
SAEM Palliative Care https://community.saem.org/communities/community-home?CommunityKey=fc4c2027-6ee3-4bfb-ada7-e1d9e84990ba
-
Academic Life in Emergency Medicine- PV Card http://www.aliem.com/pv-card-palliative-care-screening/
Host: Tiffany Proffitt DO, MABS PGY-4 Lakeland Health
Guest: Ken Katz MD, FACEP, FAAEM, FACMT, Editor-in-Chief of the EMRA Toxicology Guide, Emergency Medicine Physician with Lehigh Valley Health Network, Professor at the Philadelphia College of Osteopathic Medicine.
Overview:
Seeing an uptick in bleach ingestions? Wondering how to manage that hydroxychloroquine overdose? You are in luck, in this episode, Tiffany talks with Dr. Ken Katz, Editor-In-Chief of the EMRA and ACMT Toxicology Guide. They discuss everything from why and how it was created, the user friendly way it was designed and how it teaches you to think like a toxicologist. We finish up on some advice if you are interested in toxicology and considering a toxicology fellowship. Everything you need to master every tox ingestion.
Suggested References:
- EMRA and ACMT Toxicology Guide
- Goldfrank’s Toxicologic Emergencies
- Tox and the Hound
Key Points:
- The poisoned patient goes hand and hand with the new COVID era; this guide can help you get past those first few steps of resuscitation with confidence.
- Know how to speak to poison control.
- No such thing as medical clearance.
- If you’re interested in toxicology and have that moment where you think, ‘I might want to be a toxicologist,' DO IT!!! It can open doors and career opportunities that you never knew existed.
Dr. Miguel Reyes sits down with EMRA 45 Under 45 winner Salim Rezaie, MD, to discuss how he was nominated and awarded this recognition. How REBEL EM came to be and the future plans for the website, podcast and conference. Additionally, we discuss how to be productive and the power of being 1% better everyday.
Host: Miguel Reyes, MD
@miguel_reyesMD
Guest: Salim Rezaie, MD, FACEP
@srrezaie
Key Resources:
- RebelEM.com
Antibiotics are one of the center pillars of medical management both within and outside of the emergency department (ED). Diagnostic momentum and treatment is established early within a patient’s presentation and is typically initiated in the ED. This places a particular responsibility on us both to initiate adequate treatment for our patients, which is appropriately broad and disease-specific, but also to keep with appropriate antibiotic stewardship.
EMRA*Caster Alex Kaminsky sits down with Dr. Bryan Hayes, ED clinical pharmacist to discuss pearls and pitfalls regarding antibiotic use in the ED - meanwhile dispelling common antibiotic myths and misconceptions along the way.
COVID-19 is affecting all of us in different ways. It can be a challenging time for residents, but you’re not alone. In this episode, your EMRA*Cast hosts share their thoughts and stories as they navigate the constantly changing landscape of ER Medicine during the COVID-19 pandemic.
Host: Jessie Werner, MD
Guests: Isaac Agboola, MD. MS; Tiffany Proffitt, DO, MABS; Miguel Reyes, MD
Key Resources:
- https://rebelem.com/covid-19-the-novel-coronavirus-2019/
- https://emcrit.org/ibcc/covid19/
- https://covid.emrap.org/
- https://www.cdc.gov/coronavirus/2019-ncov/index.html
- https://www.who.int/emergencies/diseases/novel-coronavirus-2019
- https://www.emra.org/external-search/?queryString=covid
Dr. Jessie Werner speaks with Professor and Chair of Emergency Medicine at UC Davis, Dr. Nathan Kuppermann, about ground-breaking research in Pediatric DKA. Learn the dos and don’ts of management and learn to embrace those fluids!
In this episode, EMRA*Caster Dr. Tiffany Proffitt talks with Dr. Andy Little and Dr. Brian Milman about how to mentor junior residents and medical students as a resident. They discuss everything from small gestures that make a big impact to having difficult conversations and setting boundaries with mentees. The challenges and rewards of mentoring are broad but worth the extra effort and time. To those mentor hopefuls out there, just remember: Your mentee matters. If you decide to mentor, keep your mentee in mind; mentor with purpose and intention.
Dr Miguel Reyes sits down with Dr. Wall to discuss pediatric fellowships. Why decide to do it? How does one apply and what how do you know for sure if its the right fit for you.
In this episode, Dr. Jessie Werner and Dr. Tiffany Proffitt talk with some of the best medical podcasters in the field about the use of podcasts for teaching and learning. Can podcasts replace books? Supplement conference? Which ones are the best? Find out here.
Dr. Miguel Reyes meets with Drs. Sara Paradise Dimeo, Guy Carmelli, and Michael Shamoon to discuss medical education fellowships and all they entail.
Overview:
We sit down with three guest panelists all involved in medical education fellowships in different phases of their fellowship career to discuss its ins and outs. We talk about why they chose MedED, why their programs, what the application was like and what you can do to be best the applicant.
Key Resources:
- https://www.emra.org/fellowships/education-fellowships/
- https://www.emra.org/books/fellowship-guide-book/7-education/
Key Points:
- MedEd fellowship gives you a leg up for academic positions
- Learn novel and engaging teaching techniques!
- Network with a lot of academic folk! It’s a small community
- Mentorship matters and can help your significantly career
Host: Dr. Agboola MD, MS
Guests: Dr. Arelene Chung MD, Dr. Chris Doty MD, Dr. Alicia Kurtz MD
Overview:
On this episode, Doctors Agboola, Chung, Kurtz, and Doty discuss the topic of “The Elephant in the Room: ‘Burnout’”. They spend time discussing: Defining the term of burnout, How to recognize symptoms of burnout in others, Getting past the platitudes of “yoga & exercise”, Moral injury, The Unspoken Curriculum, and Models of Wellness.
Key Resources:
-
EMRA Wellness Committee : https://www.emra.org/be-involved/committees/wellness-committee/
-
EMRA Wellness Handbook : https://www.emra.org/books/emra-wellness-guide/cover/
-
Airway Stories : https://airwaystories.org/author/airwaystories/
-
Real Talk : https://www.vituity.com/realtalk
Key Points:
- “Adversity is coming for all of us”
- We operate in a specialty that lends itself to “burnout”
- Moral Injury is better terminology to use than burnout because “burnout” puts the impetus on the individual rather than on the system that causes it
- It’s critical to find an outlet, whether that be in the curriculum of your program or elsewhere through modalities online.
- Online modalities such as these include Airway Stories and Real Talk
- “Burnout” ≄ Depression
- Recognizing burnout is often difficult because each person manifests it in different ways. Look for acute changes in a person’s behavior or mood.
- “Burnout” is a moving target, there are a variety of different ways to approach it
References:
-
Stanford Model of Wellness : https://wellmd.stanford.edu/content/dam/sm/wellmd/documents/2017-wellmd-status-report-dist-1.pdf
-
National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience : https://nam.edu/initiatives/clinician-resilience-and-well-being/
-
Medscape National Physician Burnout Depression and Suicide Report 2019 : https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#1
Overview: In this episode of EMRA*Cast, Dr. Jessie Werner discusses medical education with researcher and educator, Dr. Jeff Riddell. We cover adult learning theory, the current state of medical education and new developments. If you’re wondering where the CCC report came from, how to give and receive better on-shift feedback, and what we can do to improve medical education, then this episode is for you!
Key Resources:
- Norman, Geoffrey R. "The adult learner: a mythical species." Academic medicine (1999).
- Gottlieb, Michael, Jeff Riddell, and Sara E. Crager. "Alternatives to the conference status quo: Addressing the learning needs of emergency medicine residents." Annals of emergency medicine 4.68 (2016): 423-430.
- Telio, Summer, Rola Ajjawi, and Glenn Regehr. "The “educational alliance” as a framework for reconceptualizing feedback in medical education." Academic Medicine 90.5 (2015): 609-614.
- Telio, Summer, Glenn Regehr, and Rola Ajjawi. "Feedback and the educational alliance: examining credibility judgements and their consequences." Medical education 50.9 (2016): 933-942.
Key Points:
- Adult Learning Theory:
-
- Malcom Knowles’ Theory of Andragogy has 5 main assumptions:
-
- Adults are self-directed learners
- Adults learn experientially
- Adults approach learning based on tasks and social roles (adults want to know what they NEED to know)
- Adults approach learning as problem-solving
- Adults are intrinsically motivated to learn
- Geoffrey Norman argues against these ideas as being largely untested
- Adults and kids are actually more similar than different in how they learn
- When asking a question, or “pimping,” make sure you come at it with the right intent so as not to alienate learners. That being said, emotional activation (a little fear) can help you learn, as can the practice of retrieval (remembering)
- “Flipped Classroom”: lecture material is learned at home, asynchronously, and reviewed in conference
-
“Interleaving”: mixing up topics rather than blocked topics i.e. when talking about pulmonary embolism you address it in multiple ways and emphasize varying concepts so that learners remember multiple aspects about it and how it ties in with various presentations or alternate diagnoses (not all PEs present with pleuritic chest pain!)
-
Feedback:
-
- Formative: designed to help the resident improve (given directly to the resident in the moment)
- Summative: a summary of how the resident is doing overall (this is usually in your CCC report or an evaluation you see 6 months later)
- The Educational Alliance: Residents make credibility judgments about feedback in the context of a relationship (i.e. if you have a relationship with your resident then the feedback goes over better)
- Directions of Graduate Medical Education
-
- Technology is going to play a big role!
- There are a lot of resources out there now. Curating those resources will be important! Educational resources are not just in textbooks or from large academic centers. FOAMed, podcasts, blogs, etc are coming from multiple places.
Host: Alex Kaminsky MD: PGY-3 UCSF Fresno
Guest: Jerry Hoffman MD: Professor Emeritus UCLA
Deputy Editor/Contributor: Mat Goebel MD: PGY-1 Baystate
Overview:
In this inaugural Journal Club episode, we discuss the over-utilization of cervical spine imaging in traumatic patients via landmark papers from the NEXUS group.
X-radiography of the C-spine has been widely replaced by CT-radiography, but the principles remain the same. Patient with low mechanism injuries are often over-irradiated due to physician fears of a statistically small percentage of true clinically significant C-spine injuries. Physicians often neglect to recognize the number needed to harm during diagnostic studies. This is particularly important in C-spine imaging as the anatomic target is directly adjacent to the radiosensitive thyroid gland.
With the Assistance of Dr. Hoffman (Primary Author), we will delve into the overall study with some advanced pearls.
Key Resources:
- Initial Paper: Hoffman JR, Wolfson AB, Todd KH, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-469. PMID:9774931
-
- https://www.ncbi.nlm.nih.gov/pubmed/9774931
- Hoffman JR, , Mower WR, Todd KH. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343(2):94-1. PMID: 10891516
-
- https://www.nejm.org/doi/10.1056/NEJM200007133430203?url_ver=Z39.88-2003𝔯_id=ori:rid:crossref.org𝔯_dat=cr_pub%3dwww.ncbi.nlm.nih.gov
-
https://www.mdcalc.com/nexus-criteria-c-spine-imaging#evidence
Key Points:
- NEXUS C-Spine is an INSTRUMENT designed to augment clinical judgement. It was designed to support common-sense practices.
Criteria – 99.6% Sensitive (If all negative, reassured no significant fracture)
- No Focal Neurologic Deficit
- No Altered Consciousness
- No Intoxication – Requires Judgement (common sense)
- No Distracting Injury – Requires Judgement (common sense)
- Is a finger fracture? Is a corneal ulceration?
- No Midline Tenderness
Study Highlights:
34,000 Patients over 21 hospitals in 4 geographic US regions
800 true positive C-spine injuries identified
Sensitivity reported at 99.6%
Two clinically significant “misses” identified
-
One likely chronic injury. No change in outcome at follow-up. Patient asymptomatic.
-
One patient underwent surgical intervention
-
Of note authors suggest patient actually did not meet NEXUS criteria as he had paresthesias
NEXUS C-spine: Overall 12.6% reduction in C-spine imaging
Host: Miguel Reyes, MD
Hackensack University Medical Center
Year: PGY-3
@miguel_reyesMD
Guest: Alicia Kurtz,MD
Assistant Medical Director at Mercy San Juan Medical
Mercy San Juan Medical
@aliciakurtz_md
Overview: We discuss with former EMRA president, and current EMRA 45 Under 45, Dr. Alicia Kurtz about her decision and why people would choose to go into an administrative fellowship and what that entails.
Key Resources:
- https://www.emra.org/fellowships/
Key Points:
- If interested in admin try to get involved as a resident on committees
- Look up fellowships on the EMRA website!
- Some groups don't advertise their administrative tracks well, always ask!
Host: Tiffany Proffitt DO, MABS PGY-4 Lakeland Health
@ProMammaDoc
Guests: Dr. Anita Rohra: Assistant Professor at Baylor College of Medicine, residency at New York Hospital in Queens, Ultrasound Fellowship at Baylor, upcoming speaker at FIX 2019
@RohraAnita
Overview:
In this episode, Tiffany discusses gender disparities in the evaluation of female residents in the context of the 2017 JAMA study with Dr. Anita Rohra. The study compared the ACGME milestone data collected over 2 years from 8 emergency medicine residency programs across the country of male versus female residents. It demonstrated that both male and female residents started residency at a similar competency level according to milestones, however, female emergency medicine residents were evaluated 0.15 milestones, equivalent of 3-4 months of training, lower than their male counterparts at graduation. The study further found that both male and female attendings evaluated the female residents lower, oftentimes counter to the expressed beliefs of the attendings.
References:
- Dayal A, O'Connor DM, Qadri U, Arora VM. Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training [published correction appears in JAMA Intern Med. 2017 May 1;177(5):747]. JAMA Intern Med. 2017;177(5):651–657. doi:10.1001/jamainternmed.2016.9616October 2017
- Mueller, Anna S., Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O’Connor, and Vineet M. Arora. 2017. “Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis.” Journal of Graduate Medical Education 9(5): 577–85.
- The Delta Factor: Overcoming Gender Disparities https://traffic.libsyn.com/secure/emracast/530117925-emresidents-overcoming-gender-disparities-with-dr-esther-choo-and-dr-tiffany-proffitt.mp3
Key Points:
- Overcoming gender bias requires constant diligent evaluation of ourselves and our behavior.
- Change will only come with speaking out and awareness.
- The attainment of equality is an active, not a passive, process.
On The Brink of Chief
Hosts:
- Tiffany Proffitt DO, MABS PGY-4 Lakeland Health
- Miguel Reyes MD, PGY-3 and Chief Resident NYU Hackensack
Guests:
- Maddi Massa – Chief at Lakeland in St. Joseph, MI
- Chris Evans - Chief at Doctors in Columbus, OH
- Greg Tanquary - Chief at Doctors in Columbus, OH
- Manavjeet Sidhu PGY - Chief at UCSF-Fresno, CA
Overview:
In this episode, Tiffany and Miguel talk with a panel of newly elected chiefs about their hopes, fears, and plans in their chief year. They share when they knew they wanted to be chief and who influenced that decision. The panel shares the legacies they hope to leave and how they think the chief roll will influence their careers after residency. The episode finishes with some tips for future chiefs and a promise to join EMRACAST for a debrief when this chief year culminates. If you think you might want to be chief, start finding ways to be involved and lead early but be honest with yourself and do it for the right reasons.
References:
EMRA's The Chief Resident Survival Guide
Key Points:
- The Chief role isn’t just for residents hoping for a career in academics and a fellowship spot – it’sabout learning how to lead.
- Be prepared for anything – who knows what will shape your chief year.
- Seek Feedback. Be Humble. Lead by Example.
- And if nothing else… it’s all about the fame and fortune.
Host: Miguel Reyes, MD PGY-2 Hacken University Medical Center
Guest: Maxwell Thompson, MD
Overview: If you’re interested in ultrasound and want to do a fellowship then this is the podcast for you! We discuss the process of applying, what its like, what to look for in a program.
Key Resources:
- https://eusfellowships.com/
- https://www.emra.org/books/fellowship-guide-book/28-ultrasound/
Key Points:
- Get started ultra sounding early
- US fellowships are 1 year long
- Not ACGME accredited but go through the NRMP match
Dr. Agboola talks with Dr. Tomas Diaz about the complex topic that is diversity and the role it plays in medicine and specifically EM.
Host: Dr. Isaac Agboola MD, MS PGY-1 YALE
Guest: Dr. Tomas Diaz MD PGY-4 UCSF @tomasrdiaz
Overview: On this episode, Dr. Agboola and Dr. Diaz discuss the complex topic of diversity and the role that it plays in medicine, highlighting its role in EM. They discuss what programs can do to foster diversity and recruit diverse individuals in the future. They delve into a discussion of how imagery can become expectations and define terms such as minority tax, microaggression, and stereotype threat. Interspersed throughout this discussion, they open up about their personal experiences as providers of color at their respective training sites.
Key Resources:
- https://issuu.com/sfmedsociety/docs/sf_marin_medicine_sept_2018-issuu (page 25 features Dr. Diaz)
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https://implicit.harvard.edu/implicit/takeatest.html (Harvard implicit bias test)
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“Understanding why some ethnic minority patients evaluate medical care more negatively than white patients: a cross sectional analysis of a routine patient survey in English general practices” https://www.bmj.com/content/339/bmj.b3450
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“Does Diversity Matter for health?” chrome-extension://oemmndcbldboiebfnladdacbdfmadadm/https://www.nber.org/papers/w24787.pdf
-
EMRA diversity and inclusion committee
Key Points:
-
Diversity is not just about having colored faces in a space; it is about creating an environment that cultivates and supports diversity.
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Everyone has implicit biases. It is important to be aware of these implicit biases and utilize that information to invoke intrapersonal change.
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Just like allies are useful in overcoming the barriers faced by the LGBTQ community, allies are also important in overcoming the barriers faced by underrepresented minorities in medicine.
Dr. Kaminsky focuses on practical teaching strategies with Dr. Liu and Dr. Gallegos, covering topics from self-directed learning opportunities, debriefing and brief pearls in the form of digestible teaching moments.
Residents play an important role in medical education to our peers, students, nurses and patients. Internal medicine, surgery and just about every other specialty enjoys the luxury of down-time to reflect on recent presentations or formal didactics, often after rounds. The continuous and often frantic nature of emergency medicine limits our ability to plan for formal teaching. As emergency physicians we are obligated to know the worst of the worst in all medical specialties. But when do we find the time to teach and learn while at work?
Medicine has long embraced the Socratic method of teaching at the bedside -- however there is way more to teaching than “PIMP” questions!
Host: Alex Kaminsky, MD, PGY-2, UCSF - Fresno
Guests:
Moises Gallegos, MD, MPH, Faculty Attending, Baylor College of Medicine, @moyinscrubs
Jeff Liu, MD, Chief Resident, Baylor College of Medicine
Key Points:
Rule number one: Teaching on-the-fly, while fluid, requires some pre-planning or forethought.
Strategies for teaching on the fly
Courtesy of Dr. Liu and Dr. Gallegos CORD 2019 Hand-out):
- Focus teaching session into digestible moments. Micro-learning can facilitate teaching in a fast paced environment that may encounter multiple interruptions.
- Making simple patients sick – the “what if…” game. This is useful when the flow or acuity of patients is low.
- Debriefing – what just happened and why. This is helpful for highlighting important and critical actions.
- Setting your learner up for success – using focused directions, pausing for effect, getting a commitment from your learner. By creating a welcoming environment, the learning opportunity solidifies key concepts.
- Visual pearls around the department – whiteboards, post-it’s, diagrams, etc. These quick ways of highlighting pearls and creating focused learning points can be used to interject teaching into a busy shift that does not allow for dedicated time.
- Self-directed learning activities/challenges – when you really can’t make the time, facilitate the learner’s practice of searching for answers in evidence-based manners and allow them to be the teacher.
Teaching on the fly isn’t always about creating material “on the fly.” Preparation to develop areas of focus, create a repository of teaching points, and exploring of different teaching styles can facilitate deciding to teach on the spot.
Make a commitment to yourself: Reflective Questions/Thoughts
- Write down at least one skill to work on that you believe can help you improve on-shift education in your department.
- What are some topics that you feel comfortable enough with to convey select learning points/pearls if that type of patient encounter were to take place?
Key Resources and Suggested Reading:
-
Wolff et al. Not Another Boring Lecture: Engaging Learners with Active Learning Techniques. The J of Em Med. Vol 48, No 1. 2015.
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EMRA Guide: Resident as Educator -- A guidebook by residents for residents. By Guth MD et al.
Dr. Proffitt talks with a panel of Super Doctor Mammas about the art and challenge of mamma docing. The panel openly discusses challenging topics in an attempt to demystify and destigmatize the daily struggles all of us mammas in medicine face throughout medical school, residency and beyond. Listen as we discuss topics such as when to disclose your pregnancy, the lack of firm maternity leave policies in residency, and touch briefly on dealing with miscarriage and infertility during medical training.
Host: Tiffany Proffitt DO, MABS PGY-3 Lakeland Health @ProMammaDoc
Guests:
Meenal Sharkey: Core Faculty at Doctors Hospital Core Faculty @MdSharkattack
Tatiana Moylan: PGY-1 at Yale @tatianamoylan
Mackensie Yore: PGY-2 at UC Fresno
Leah Bauer: PGY-3 at UC Fresno
References:
ACGME Institutional requirements: https://www.acgme.org/Portals/0/PFAssets/InstitutionalRequirements/000InstitutionalRequirements2018.pdf?ver=2018-02-19-132236-600
Greenfield NP. Maternity and medical leave during residency: Time to standardize?. Int J Womens Dermatol. 2015;1(1):55. Published 2015 Feb 20. doi:10.1016/j.ijwd.2014.12.009
Humphries, LS, Lyon, S, Garza, R, et al. Parental leave policies in graduate medical education: A systematic review. American Journal of Surgery. 2017; Oct;214(4):634-639.
Key Points:
- In the era of Times Up Healthcare, I hope concrete ACGME policy change to accommodate moming in medicine is on the docket.
- You need to sit down with your PD and make a concrete policy for your individual pregnancy and maternity leave because there are few well laid out policies in general in GME.
- When planning maternity leave during residency, do not just look at it as the short time frame of delivery to first few months post-partum. Plan it in the context of your entire 3-4 years of residency (depending on the program) and have early discussions with your PD on how to arrange your blocks over those 3-4 years.
- MAMMAS IN MEDICINE: YOU ARE AMAZING!!!! AND YOU ARE NOT ALONE!!!
This is the first episode in our Fellowships series. Listen in as Dr. Jessie Werner speaks with our EMRA Fellowship Guide Editor-in-Chief, Dr. Krystle Shafer, about EM fellowships. Why should you do one? Which one is right for you? What should you expect from the application process?
Stay tuned over the next few months as we continue the series and cover the details of specific EM fellowships.
Host: Jessie Werner, MD
Guest: Krystle Shafer, MD
Key Resources:
- EMRA Fellowship Guide: https://www.emra.org/books/fellowship-guide-book/i-title/
Key Points:
-
There are a number of different fellowships in Emergency Medicine. Each one has different requirements and sets you up for a unique career.
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When choosing a fellowship, make sure you’re following your passion and have an “end goal” in mind
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Strong applicants will have an proven track record in that specific area of interest
-
It’s never too late to apply for a fellowship
This episode we talk to Dr. Ordonez about what it’s like to be an academic attending and what it felt like the first year out. Why go into academics, how to best go about obtaining an academic position and other survival tips are all discussed in this podcast!
Host: Miguel Reyes, MD
Guest: Edgar Ordonez, MD
Key Points:
- Find a niche and go with it, that can be your key to success.
- Find a mentor and ask for advice, be honest with them and yourself.
- Stay humble, you won’t always know the answer.
- Transcutaneous before transvenous pacing!
EMRA*Cast Host Dr. Isaac Agboola speaks with the authors of the EMRA Transgender Care guide to provide residents with helpful advice on the approach to the care of transgender patients in the ED.
Host: Dr. Isaac Agboola, MD, MS PGY-1 Yale
Guest: Dr. Julia Paris and Dr. Aiden “Yoshi” Shapiro
Key Resources:
- EMRA Transgender Care Guide
Key Points:
-
Best practice is to ask the patient upfront what pronouns they prefer and use those.
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It is important to ask patients what body modifications has the patient taken in order to feel more comfortable with their appearance. Be it surgical, non-surgical or hormonal because that may affect your differential and treatment algorithms.
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Transgender patients are at increased risk for intimate partner, substance abuse and sexually transmitted infections it is very important to take a thorough social history.
-
Understand that this is an area where there hasn’t been much formal education as far as most medical schools and residencies are concerned; So be comfortable in your discomfort.
References:
- https://www.emra.org/books/transgender-care-guide/trans-care-guide-intro/
EMRA*Cast Host Dr. Jessie Werner talks to Dr. Brian Levine about the EMRA Antibiotic guide and how it can improve your practice.
Host: Jessie Werner, MD
Guest: Brian Levine, MD
Overview: In this episode, Dr. Jessie Werner discusses the EMRA Antibiotic Guide with Editor-In-Chief, Dr. Brian Levine. Struggle with choosing the right med to treat that pneumonia? That complicated UTI? Find out how this tool can help you select the right antibiotic for just about any infection you encounter in the ED.
Key Resources:
- https://emra.org/about-emra/publications/bookstore/
Key Points:
-
Choosing the right antibiotic is hard! Rely on this guide to provide the most up-to-date recommendations for pretty much any infection you may encounter
-
Some new features to the guide:
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Updated antibiograms for local resistance patterns
-
Utility of ED tests (urine legionella, CSF, etc)
-
Penicillin-allergy algorithm
Dr. Tiffany Proffitt talks with Dr. Richard Bounds about the challenges of starting a residency program.
Podcast Host
Tiffany Proffitt DO, MABS PGY-3 Lakeland Health
Podcast Guest
Dr. Richard Bounds, Emergency Medicine Physician, Program Director for the new Emergency Medicine program at the University of Vermont, Associate Professor Department of Surgery, former Associate Program Director Christiana Care Health System Emergency Medicine Residency, and Co-Director Christiana Care Medical Education Fellowship, @rich_bounds
Short Description of Episode:Recorded at ACEP 2018 on the Expo floor. A discussion with Dr. Bound on the unique challenges of starting a residency program as well as advice to all the future program directors of the world regarding pitfalls to avoid and opportunities and resources to embrace. Are there questions you want that I didn’t ask? Find Dr. Bounds during his CORD session on dominating the ACGME site visit!
Content of Show Notes:
Dr. Bounds Top 3 for starting an Emergency Medicine residency:
1) Preparation
2) Foster Relationships – KEY TO GET THINGS DONE AND BE AN EFFECTIVE LEADER
3) Anticipate next steps – prepare for possible pitfalls! (see #1)!
Citations for Any Relevant Articles (AMA format please):
@UVM_EM
www.med.uvm.edu/emergencymedicine/education/residency
Leading change. John P. Kotter, 1996, Harvard Business School Press, Boston, MA
In this episode Dr. Miguel Reyes interviews Dr. Salim Rezaie about how best to approach and use FOAMed (Free Open Access Medical Education) as a resident.
Overview: Have you ever felt overwhelmed with the amount of content out there that comes out on a nearly daily basis? Well if so than this is the podcast for you. Here we talk about how to sift through the FOAM sources and how to implement into your practice as a resident.
Really great stuff in this podcast.
Key Points * Don't FOAM it alone * Use peer reviewed FOAM sources * Use news aggregator apps to collect all your FOAM into one place * Read the textbooks and suppliement with FOAM
References / Resources * REBELEM Got FOAM * Feedly
Dr. Alex Kaminsky speaks with Dr. Aimee Moulin about opioid withdrawal and the use of buprenorphine in the emergency department.
Overview: Opioid use disorder and opioid withdrawal are commonplace within emergency medicine. Traditionally, treatment strategies for withdrawal have emphasized symptom management and is generally accepted to be ineffective. Utilizing Buprenorphine in the ED has been demonstrated to be both safe and effective. Dr. Moulin joins the program to delve into the specifics, myths, barriers and other limitations to implementing Buprenorphine.
Key Resources: * COWS Score for Opiate Withdrawal – Quantifies the Severity of Opiate Withdrawal * ED Bridge -- Emergency Buprenorphine Treatment: * ED Treatment Algorithm * TOOLKIT – PROJECT SHOUT: NOTE THIS IS AN INPATIENT PATHWAY
Key Points * Opioid deaths are on the rise. In 2016 CDC estimates >42,000 opioid related deaths in the USA, an 300% increase since 2001. Now surpassed deaths by motor vehicle accidents. * Unlike alcohol dependence, opioid withdrawal can be managed safely as an outpatient. * Buprenorphine is a PARTIAL opioid agonist with a higher affinity for μ-opioid receptors than heroin, fentanyl and other opioids. This means it will selectively bind to μ-receptors and “kick off” the substance of abuse. * There is a ceiling effect with buprenorphine. The amount of euphoria is significantly diminished when used in routes other than oral. Receptor saturation with this plateau effect can lead to precipitated withdrawal. We see this in the ED every time we administer naloxone. * Buprenorphine’s effective ceiling is found at approximately 16mg. Higher doses increase duration of action, not effect of action. * Patients who present with a moderate to severe COWs score have been shown to benefit from ED buprenorphine with continued remission/treatment at 30 days. * You can DISPENSE Buprenorphine for up to 72 hours in the ED without a special “X-waiver” on your DEA License. * Major Barriers to Dispensing/Prescribing Buprenorphine surround “warm hand-off’s” and access to outpatient treatment/referral centers. * Interested residents should identify outpatient treatment facilities in their areas to begin the process of Buprenorphine administration in YOUR emergency departments!
References / Resources * D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. 2015;313(16):1636–1644. doi:10.1001/jama.2015.3474 * Duber, H, Barata I, et al. Identification, Management, and Transition of Care for Patients with Opioid Use Disorder in the Emergency Department. Annals of Emergency Medicine. 2018;72(4):420-431.
Host Alexander Kaminsky, MD University of California San Francisco – Fresno
PGY2
@Alex_KamskyEM
EMRA Cast Episodes
Guest **Dr. Aimee Moulin, MD** Associate Professor of Emergency Medicine at the University of California, Davis
Past president of CalACEP
Hospital Affiliation: University of California, Davis
@AimeeMoulin1
In this episode Dr. Deena Khamees, a PGY-2 at Baylor, interviews Dr. Christopher Doty, the current president elect of CORD and former program director at the University of Kentucky, regarding their programs’ experience with a resident suicide and how he has become an advocate for promoting physician resiliency in Emergency Medicine
Dr. Nick Governatori, an Assistant Residency Director at Thomas Jefferson University Hospital and former Director of Education on the EMRA Board talks about Advanced Practice Providers (APP) with Lynn Scherer, currently the Associate Director of APP Services and EMPA Residency Program Director with the Albert Einstein Medical Center and the Past President of SEMPA, and Dr. Matt Rudy, former EMRA President, and current Assistant Professor at Augusta University's Medical College of Georgia.
Dr. Kevin Klauer talks about the Art of Medicine, Health Care Delivery and Risk Management.