EMRA Antibiotic Guide

84 Pages·2016·22.68 MB·English

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Letter from
the Editor
Abby Cosgrove, MD
Editor-in-Chief, EM Resident
Washington University in St. Louis
St. Louis, MO
As emergency medicine
physicians, our daily lives
— hence our careers — are
composed of collections of
short stories.
I
s ee my mail carrier about once a from the very same hospital where she other stories about our own experiences.
week. She usually arrives around 11 had touched her son for the last time. I Some of these stories are funny, some are
am, sometimes later. If I am home, I contemplated why I had let all of those heartwarming, some are incredibly sad,
will wave from the kitchen, occasionally days pass without me ever even asking and some are otherwise inconceivable.
running out with something I forgot to her name. I thought about how reading a We cannot live through what we see and
mail in my post-shift daze. We smile and story, a snippet from her life, had changed feel on a daily basis without being able to
say, “Hi how are you?” and then go about my entire outlook and perspective. How share these stories with others. Especially
our business. I often wonder how much it humanized her, made me feel for her, in this era of occupational burnout,
she knows about me just by the nature made me feel connected to her. sharing our stories with each other is a
of the mail she delivers. A letter from As emergency medicine physicians, way in which we are able to re-connect
mom in New Jersey, an ACEPNow issue, our daily lives, hence our careers, are with the world, to be able to take a step
a college alumni magazine, Fixer Upper composed of collections of short stories. back, to process, to breathe.
reruns playing on the television. Oh, the We are drawn to these stories not only I encourage you to think about the
stories and secrets she must bring home because we are caregivers, but also power of storytelling, both the stories our
from her daily peek into the lives of the because we are human. We craft our patients tell us, and the stories we tell
citizens of the city. history of present illness by narrating each other. Whether within the context of
Several months ago, I saw her picture what our patients tell us, and we base our initiating palliative care (p. 12), embracing
pop up on the Humans of St. Louis treatment decisions on our interpretation new technology (p. 20), or yearning for
Facebook blog. It took me a few seconds of these narratives. an outlet on days when you simply feel
to figure out why her face was familiar. The problem in emergency medicine is you cannot go on (p. 34), storytelling is an
A patient, perhaps? No, it was my mail that we often do not have the time for, nor indispensable part of medicine and of the
carrier. Her name is Vera. I had never the access to, the entire story. And missing human experience.
even asked. The quote next to her picture out on the full story takes away from Vera has not returned to my home.
read, “I just live day-by-day. Minute- opportunities to heal and connect with She may have changed routes, or she may
by-minute. Hour-by-hour. My son was our patients. It detracts from our ability to have changed jobs altogether. I regret not
murdered last year. Shot in the head. create a sense of mutual understanding, of having said, or listened, more. My hope
24 years old.” The story revealed how community. While it is difficult to change for her is that if she ever ends up in the
her son, Christopher, had been an organ the time constraints within the ED, when emergency department, her provider will
donor to 5 recipients across the country. taking the extra few minutes to sit down listen intently to the story she has to tell.
Even more coincidental, Christopher’s last and listen, to hold our patients’ stories — She will mention she is a mail carrier. And
minutes on earth were spent in the very their words, their facial expressions, their for once, an emergency physician will be
same ED where I work. fears — within our hearts, we might be able able to ask somebody else, “What’s the
I wondered if she ever thought about to see their needs just a little more clearly. craziest thing you’ve ever seen?” She will
that as she tucked in my emergency And just as our patients tell us stories, tell a funny story. And they will have a
medicine journals alongside news updates we feel an inherent need to tell each good laugh together. ¬
October/November 2016 | EM Resident 3
TABLE OF CONTENTS
EDITORIAL STAFF Categories
EDITOR-IN-CHIEF
Abby Cosgrove, MD
Washington University in St. Louis
COVER STORY
SECTION EDITORS 8 CRITICAL CARE
CRITICAL CARE
REBOA: A
Maite Huis in ‘t Veld, MD
Michele Callahan, MD PRECIOUS LIFELINE
University of Maryland
The goal of REBOA is to occlude
ECG
blood flow to the major arterial
Zachary S. Wilson, MD
Icahn SOM at Mt. Sinai vessel that is actively bleeding,
and aortic insertion will target one
EMS
of three relevant anatomic zones.
Jeremy Lacocque, DO
Midwestern University
HEALTH POLICY
Elizabeth Davlantes, MD
Emory University
4 PRESIDENT’S MESSAGE 14 TOXICOLOGY
MEDICAL STUDENT
5 Tips for Gasping for Air
Thomas Eales
Des Moines University Residency Albuterol-Induced Lactic Acidosis
and Beyond
PEDIATRICS
Kaia Knutson, MD Gain insight from 16 ULTRASOUND
Kyra Reed, MD your outgoing The UtiliTEE
Indiana University EMRA President
of Ultrasound
ULTRASOUND in Cardiac
Andrew Oh, MD Arrest
New York University/Bellevue 5 STATE OF EMRA
Membership Report
EDITORIAL COMMITTEE Projects 18 SIMULATION
Timothy Snow, MD completed, Medical Acting 101
Vice Chair, Editorial Committee
new benefits
Icahn SOM, Mt Sinai New York
and 2017
Becoming America’s
Jennifer Beck-Esmay, MD plans
Next Top Medical
New York University/Bellevue
Performer
Karen Bowers, MD 6 MEDICAL STUDENT COUNCIL
Emory University
The AAMC Standardized
Marvinia Charles, MD Video Interview
Rutgers NJMS 20 INFORMATICS
A New
Lucia Derks, MD Approach Through Rose-Colored
University of Cincinnati to the Glasses
Zach Jarou, MD Residency
Denver Health Application?
Aryeh Lapin, MD
St. Luke’s-Roosevelt, New York 12 PALLIATIVE CARE
Palliative Care, Part 1 Perils and Pitfalls of Adopting
Bleeding-Edge Technology in the ED
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mmaaggaazziinnee ooff tthhee EEmmeerrggeennccyy MMeeddiicciinnee RReessiiddeennttss’’ 22 CRITICAL CARE
AAssssoocciiaattiioonn ((EEMMRRAA)).. TThhee ooppiinniioonnss hheerreeiinn aarree tthhoossee
The Future
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oorrggaanniizzaattiioonnss,, oorr ffeeddeerraall aaggeenncciieess.. EEMMRRAA eennccoouurraaggeess is Now
rreeaaddeerrss ttoo iinnffoorrmm tthheemmsseellvveess ffuullllyy aabboouutt aallll iissssuueess
Current Advances
pprreesseenntteedd.. EEMM RReessiiddeenntt rreesseerrvveess tthhee rriigghhtt ttoo eeddiitt aallll
mmaatteerriiaall aanndd ddooeess nnoott gguuaarraanntteeee ppuubblliiccaattiioonn.. in Rapid Stroke
The Importance of Early Diagnosis
©© CCooppyyrriigghhtt 22001166
Implementation in the ED
EEmmeerrggeennccyy MMeeddiicciinnee RReessiiddeennttss’’ AAssssoocciiaattiioonn
BOARD OF DIRECTORS
Ramnik “Ricky” Dhaliwal, MD, JD
President
24 CLINICAL CASE 32 RESIDENT EDITORIAL Hennepin County Medical Center
OMM in the Emergency Burning the Candle
Alicia Kurtz, MD
Department at Both Ends
President-Elect
Anyone UCSF Fresno
Can DO It!
During a stretch of shifts that had Matt Rudy, MD
left me sleep-deprived, I went to Immediate Past President
University Hospital
sew up a laceration. It was no big
deal – until I stuck myself.
Alison Smith, MD, MPH
ACEP Representative
35 EMPOWER University of Utah
Sharing Our
26 PEDIATRICS Nick Governatori, MD
Stories
Pediatric Emergency Academic Affairs Rep
Thomas Jefferson University
Medicine Michael J. Caudell, MD, FACEP,
FAWM, DiMM
Abby Cosgrove, MD
Secretary/Editor-in-Chief
Washington University
38 NEWS & NOTES
Award Recipients, Nida Degesys, MD
Sponsors, Speaker of the Council
EMRAfied and University of California San Francisco
New Resources
Evidence-Based Updates
Tiffany Jackson, MD
Vice-Speaker of the Council
28 TOXICOLOGY University of Alabama at Birmingham
43 VISUAL DIAGNOSIS
Drop Dead Gorgeous
Diagnose this Condition Jasmeet Dhaliwal, MD, MPH
The Danger of Weight Legislative Advisor
Loss Supplements Denver Health
Leonard Stallings, MD
RC-EM Rep
East Carolina University Brody SOM
Christian Dameff, MD, MS
A 62-year-old male presents
Informatics Coordinator
to the ED complaining of right
Maricopa Medical Center
knee pain.
Zachary Jarou, MD
Mel Herbert, MD
30 CARDIOLOGY 44 RESEARCH Membership Development Coordinator
STEMI or no SYToEuMr TIi?me, Rapid Research Review Denver Health
Your Legacy
A challenging diagnosis An Initiative of the EMRA Seth Kelly, MBA, MSIV
Research Committee
Medical Student Council Chair
TAMHSC College of Medicine
31 CONSULT CORNER
45 ECG CHALLENGE
Ortho Ashley Guthrie, DO
Member-at-Large
“Consult Corner”
St. Joseph’s Regional Medical Center
is designed
to help you
communicate
effectively when
Be sure to check EMResident.org
seeking input
for exclusive online content!
from other
specialists. 46 BOARD REVIEW Want to improve your CV?
Questions
Write for EM Resident!
Submit online at emresident.org.
PRESIDENT’S MESSAGE
5
TIPS
for Residency
Ramnik “Ricky” Dhaliwal, MD, JD
EMRA President
Hennepin County Medical Center
and Beyond Minneapolis, MN
@drdhali
A
s I write this final article in EM Resident as your finish residency and move on to your job, an
President, I am four months out from finishing my understanding of your strengths and weaknesses
EM/IM Residency at Hennepin County Medical will go a long way in solidifying your practice.
Center where I am now on faculty. My journey began two You can continue to improve in areas where you
years ago in Chicago when you chose me as president- need work and hone your strengths further.
elect and culminated over this past year, when I have been 4
Figure Out What Type of Job You Want
honored to serve you as president and will soon be passing
the reigns. During times of transition I have been lucky During residency, take time to reflect on what
to have great mentors who helped guide me and gave me type of practice you want. Start by assessing
advice (some good, some bad, and some unsolicited). I the practice you have at your residency. What
would like to impart some things I have learned over my five do you like or don’t like? What do you wish your
years of residency and during my first few months post- hospital did better? Take the time to reach out to
residency. your friends who have graduated and ask them
1 about where they work. Find out what things they
Get Involved to Better the Specialty
like and dislike and how it might differ from the
This sounds big, and it is, but it can be done at any level. practice at your residency. If you are able, take the
Getting involved could be at your residency to improve time to moonlight. This experience gives you the
some aspect of the residency or serving on a residency opportunity to see what other types of emergency
committee. You could get involved at the hospital level medicine practices look like and how they might fit
on a committee or working group. This could entail a your needs. Use this to assess the various groups
legislative issue you are passionate about, which you discuss you may be interested in, because if it doesn’t fit
with your city, state, or federal legislature. It could be you your needs, you will not be happy.
getting involved with EMRA, ACEP, SAEM, AMA, or other 5
Do Things That Make You Happy
organized group.
2 Residency is hard and so is life after residency.
Try to Learn Something New Every Day
It is imperative to continue doing the things
Every day should be a learning day, during residency and that make you happy, stay grounded, and
beyond. The amount of information we are required to have a good outlet. This may be athletics,
know can be overwhelming and it changes quickly. In an painting, hiking, reading, or spending
academic center it may easier to stay on top of everything time with your family and friends. EM is
new, but in the community, this may be challenging. Take a high-stress specialty with a higher level
any opportunity you can to learn something new, whether of burnout than many other specialties.
that be a new presentation of an illness you already know or Without a healthy means of release, the
something newly described in the literature. This knowledge stress can build up and become a danger. The
will keep you fresh and connected and help you provide the point is, the habits you develop now will stay with
best care for your patients. you as you continue your career, so create a good
3 starting point. No matter how good your job is you
Work to Your Limits and Know Your Limits
will not be happy there if you’re not happy outside
Pushing yourself in residency is imperative, as this is the the hospital.
time where you have the chance to safely test yourself. Thanks for the opportunity to be a part of such an
Take the opportunity to get out of your normal comfort amazing organization and to represent you over this
zone – you may surprise yourself! Testing your limits past year. I hope to continue to work to improve our
helps you grasp what you do and don’t know. When you specialty in whatever way I can. ¬
6 EMRA | emra.org • emresident.org
STATE OF EMRA
72120851
MEDICAL STUDENT COUNCIL
The AAMC
Standardized
Video
Interview
Thomas Eales, MSIV
EMRA MSC Editor
Des Moines University
Des Moines, IA
@tommyeales
Seth Kelly, MBA, MS-IV
EMRA MSC Chair
Texas A&M University
Temple, TX
@Seth_Kelly
A New Approach to the Residency Application?
I
n the increasingly tech-savvy world extend interview invitations. Numerical usefulness of the SVI in the residency
of medical education, it comes as evaluation metrics such as USMLE and/ application process, specifically as it
no surprise that major changes are or COMLEX board scores and class relates to the generation of a new, more
occurring at every level of the training ranking have emerged as critical tools “holistic” score to be added into the ERAS
process. While this trend has resulted in residency programs can use to rapidly application.
the development of new and innovative narrow their focus to applicants who The study was designed such
learning platforms, one area of medical meet a certain demographic. that applicants each received 6
education that has remained relatively To explore a new method to random questions to assess 2 ACGME
unaffected over the years is perhaps one infuse an additional variable into competencies (professionalism and
of the most important: the residency the ERAS equation, the AAMC interpersonal/communication skills).
application process. announced a new Standardized Participants got 30 seconds to read the
With few exceptions, individuals Video Interview (SVI) research question, and then 3 minutes to answer
seeking graduate medical training in the study in May. All applicants to each question in a video recording. A
U.S. must participate in the American Accreditation Council for Graduate brief survey followed the session. The
Association of Medical Colleges (AAMC) Medical Education (ACGME)-accredited videos were then independently scored,
Electronic Residency Application Service Emergency Medicine (EM) residency with the intention of later correlating this
(ERAS). ERAS is a basic technology programs for the 2017 Match were invited score to application data and residency
platform that collects a standardized to participate in this study. performance metrics. Students who
set of information about applicants and Background chose to participate received a $50
distributes it en masse to residency Amazon gift code after completing the
The opt-in participant enrollment
programs. The result is a huge pool of interview and feedback process.
period for the AAMC’s SVI study spanned
data, made even larger by a trend of As outlined by the AAMC in the
June 27-Sept. 30, and the results analysis
increasing application numbers per informed consent document, the study
phase was projected to begin Oct. 1 and
applicant, through which program was strictly voluntary and blinded to avoid
conclude in December 2017. The goal
directors must comb when deciding to any impact on applications for the 2017
is to evaluate the validity, fairness, and
References available online.
8 EMRA | emra.org • emresident.org
Match. Neither participants nor program attempts at incorporating holistic Final Thoughts
directors (nor anyone affiliated with an components into the ERAS As the interview season approaches,
EM residency program) will receive any application is that the SVI study EM-bound applicants can rest assured
videos, scores, or other information at also aims to provide a numerical that no dramatic changes to ERAS will
any point during the process. score that can be used as an be made for this cycle. However, this
Holistic Evaluation objective data point to compare initiative should put medical students
The overall goal of incorporating applicants. on notice that the residency application
some assessment of process may be modified in the
interpersonal skill into the The study was designed such that near future.
residency application process How exactly will the
is nothing new. For example, applicants each received 6 random residency application process
membership in the Gold change and adapt to address
questions to assess 2 ACGME
Humanism Honor Society (an traditional difficulties in
organization that recognizes competencies (professionalism and applicant assessment identified
individuals who provide by educators? With the
humanistic care) is now a interpersonal/communication skills). integration of new technology,
standalone component of the the answer may trend toward
ERAS application. While the an increased personalization of
overall utility of this status the application; whether this
varies depending on the individual While it is difficult to assign a grade involves a video interview, however,
evaluating the applicant, the ultimate to a personal statement, there may be remains to be seen. For now, the best
goal of this modification to the ERAS some incentive for residency programs advice for students is to continue
application was to provide a relative to utilize the SVI score if the AAMC working hard, find mentors who
marker of desirable competencies in a is able to standardize the scoring can help them navigate the current
potential resident. process and demonstrate a correlation application process, and stay up to
The primary difference between with desirable resident performance date with any new changes as they
the SVI study and previous metrics. are announced. ¬
October/November 2016 | EM Resident 9
CRITICAL CARE
A Precious R
E
(Life)line
B
O
A
Danish Malik, MD
Critical Care Medicine Fellow
University of Pittsburgh
Medical Center
Pittsburgh, PA
@dmalik21
Megan Simon Thomas, MD
Emergency Medicine Resident
Mount Sinai/St. Luke’s-Roosevelt
Hospital Center
New York, NY