EMBound_InLine

A newsletter for medical students pursuing a career in emergency medicine

November 2021
EM Bound pencil sketch
Letter from the Editor:

Hello #EMBound Med students,

Fall is in full swing with the changes of seasons. We hope you are doing well and staying safe. Interview season is now starting for our MS4s. In this issue, we have highlighted some interview tips to help you be successful. For our MS1-3s, you are pushing forward your growth in medical knowledge and skills. We have included pearls to help you learn more about EM, and also rock your rotations. Never forget how talented you are! We look forward to welcoming you into our field as colleagues someday. In the interim, we are thankful to be with you on this journey
to becoming #EMBound.

--Sree Natesan, MD Editor-in-Chief
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CLERKSHIP LIFE &
RESIDENCY APPLICATION SEASON

Residency Interviews:

Creating Positive Vibes Virtually

David Gordon, MD
Undergraduate Education Director
Duke University

Another virtual interview season has arrived! While in-person interviewing has its benefits, I want to reassure you that virtual interviewing will still enable you to convey why you will be a great resident and meet people to gain a sense of whether the program is right for you.

Reflecting on last year's experience and building on earlier advice, I want to re-emphasize some pointers for success:
  • Mental Preparation: Be ready to talk about yourself from both a personal and professional standpoint. Be prepared to provide deeper insight into your commitment to emergency medicine, your specific interests in a program, as well as anything you thought was important enough to be put into your ERAS application. Hobbies can make for excellent talking points and help break up the monotony that creeps in during months of interviewing. And be prepared for the most intimidating and scary question of them all, “Do you have any questions for me?” This is the most common question interviewers ask, so have a question or two ready. Keep it genuine and personal. Avoid asking what can already be found on the website. Asking about ways you could pursue your personal interests or what the interviewer appreciates about their program are better questions than generic inquiries about the relationship with trauma or off-service rotations. On interview day, they are always great!
  • Emotional Restoration: Even with virtual interviewing, body language and energy levels still come through. You want to come into your interviews feeling rested, excited, and ready to talk. In the back of their minds, interviewers are asking themselves, “When it’s 2 AM and the ED is falling apart, is this the person I want to be working with?” Making the interview easy through engaging conversation and a good sense of humor is one way to help the answer be “yes.” Good eye contact and positive body language also go a long way. Staying rejuvenated during interview season won’t necessarily come easy, so be intentional about getting good sleep, exercise, and nutrition.
  • Technical Readiness: Bad lighting is not going to make or break your interview, but why not optimize your situation? Ring lights are widely available to get good lighting coming from behind your camera. Have the camera itself at or above your eyes, not coming from below. And be aware that your background can become part of the conversation. I had a good time last year learning about applicants just from asking about objects on walls, books on shelves, and plants on tables. It is all about learning more about who you are and what makes you unique.
Lights, camera, action! Get ready for the show. We all look forward to seeing you on screen soon and sharing a good conversation.

Additional Resources
EMBound Interview
EM Bound book

ROTATION TUNE-UP

Arm yourself with Clinical Tools

In this series, we will be looking into commonly available tips and tricks, guidelines, algorithms, and clinical decision-making scores relevant to your clerkship rotation. Our goal is to augment your presentations on shift and set you up for success. We hope that you find this new series helpful as you embark on your journey to emergency medicine.

See Wha-?!

How to utilize CIWA in Alcohol Withdrawal

Sree Natesan, MD
Assistant Program Director
Duke Emergency Medicine

Alcoholism is a disease the afflicts millions across the globe. In fact, alcohol abuse, alcoholism, and alcohol use disorder (AUD) kill over 3 million people each year and account for up to 6% of deaths globally. Within the United States, 95k people die each year from AUD. According to the NIH: From a 2019 survey:
  • 85.6% of people 18 or older have reported that they drank alcohol at some point in their lifetime
    • 69.5% of this group reported that they drank in the past year
    • 54.9% (59.1% of men and 51.0 % of women in this age group) reported that they drank in the past month
  • 39.7% of 12- to 20-year-olds reported that they have had at least 1 drink in their lives. with 18.5% reported drinking alcohol in the past month (17.2% of males and 19.9% of females).
Alcohol intoxication is commonly seen within the ED. We must be thoughtful in our evaluation of the patient to identify any traumatic injuries that may have occurred while they were under the influence. Furthermore, as they await sobriety, we must keep an eye on signs of withdrawal. Obtaining a thorough history of alcoholism, frequency and volume of alcohol consumed, prior withdrawal history, and prior hospitalizations/ICU admissions can help guide your management of these patients. Your physical exam is also crucial in helping you identify signs of withdrawals.

The 4 stages of ETOH withdrawal occur at varying timing post last drink, but generally are as follows:
  • At 6-12 Hours: Anxiety, anorexia, diaphoresis, gastrointestinal upset, hypertension, nausea, palpitations, tachycardia, tremors
  • At 12-24 Hours: Hallucinations: typically auditory, visual, or tactile in nature
  • At 24-48 Hours: Withdrawal seizures (generalized tonic-clonic seizures)
  • At 3-5 Days: Delirium Tremens (profound confusion, autonomic hyperactivity, and cardiovascular collapse)
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a symptom-triggered therapy that is widely cited and utilized. This is used to help guide patient monitoring through frequent nursing assessment and management, including the use of benzodiazepines which are the mainstay treatment. In addition, in chronic alcoholic patients, thiamine and multivitamins should be given and any electrolyte abnormalities should be corrected (particularly hypomagnesemia). Finally, alcoholism should be considered a chronic disease. Check your biases at the door and approach these patients with compassion and empathy. Offer resources through your case manager or social worker to help your patient on the path to recovery. You could be the difference in life and death for these patients by your ability to discuss with them alcohol cessation.

Resources
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COVID-19 UPDATES

COVID-19 has slowed its spread across the United States with numbers falling across the nation. Vaccines will soon be available for pediatrics aged 5-11 years old. Additionally, booster shots are recommended and readily available at your local clinics and pharmacies.

As the holidays draw near, please encourage your patients and families to ensure they are vaccinated in order to make this season safe, especially in lieu of the high travel that occurs. You can help play a role in fighting misinformation and sharing valuable resources to help our community.

Here are some key points:
  • Vaccines are effective in protecting people from severe disease that could lead to hospitalization and/or death.
  • The vaccine has been endorsed by our national medical groups as safe (particularly in pregnant patients who, if they contract COVID-19, may be at increased risk for preterm birth (delivering the baby earlier than 37 weeks) and increased risk for other poor pregnancy outcomes.
Here are the CDC Booster recommendations:
Stay safe! Here are some quick resources to share with your family and community regarding the Delta Variant and link to ARCHIVED newsletters with further COVID-19 information:
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SPOTLIGHT

Health Advocacy:

Care Beyond the Emergency Department

Moises Gallegos MD MPH
Clerkship Director
Stanford Emergency Medicine

Over previous issues, this section of our newsletter has highlighted many of the various areas of focus that emergency medicine (EM) physicians choose to become leaders in. With debates over the trajectory of healthcare in the United States continuing to unfold, the need for physician representation in legislative decisions is paramount. As versatile clinicians, EM physicians are often tapped to serve on advisory panels, consensus committees, and even serve in public office to inform the policies that define our delivery of health services. The field of Health Advocacy has provided EM physicians an opportunity to influence policy and improve not just the delivery of medicine, but the care of our patients.

On October 18, 2021, the President’s Commission on White House Fellows announced the appointment of new fellows for 2021-2022, a class that includes three emergency medicine physicians. These physicians leaders are an example of how EM can lead the way in service and advocacy.

Here’s an intro to their work:
  • Alister Martin MD MPP: Dr. Martin is a practicing EM physician at Massachusetts General Hospital and faculty with the Harvard Kennedy School of Behavioral Insights Group and Harvard Medical School’s Center for Social Justice and Health Equity. With a background in policy, Dr. Martin brings programming to the ED to help vulnerable populations. He is the founder of Vot-ER, a voter registration organization, and GOTVax, an initiative to deliver vaccines to vulnerable communities.
  • Garth Walker MD MPH: Dr. Walker is an Assistant Professor of Emergency Medicine at Northwestern University and is an academic public health expert working on eliminating structural barriers to healthcare that exist for marginalized communities. His scholarship addresses men’s health, the opiate epidemic, and gun violence. He is a featured correspondent for various media outlets promoting public health information.
  • Aakash Shah, MD: Dr. Shah is an emergency medicine physician with Hackensack Meridian Health and serves as Director of Addiction Medicine and Medical Director of Project HEAL, a hospital-based violence intervention program. He has been involved in various public health efforts to increase the availability of medications to treat opiate use disorders and connect uninsured patients with healthcare coverage. He has played an active role as an advisor to local, state, and federal policymakers.
While there is no one dedicated graduate fellowship or single route to becoming involved in advocacy work, EM is a specialty primed to jump into Health Advocacy. A multitude of cross-sectoral opportunities exists for EM physicians to get involved. This can be at the grassroots, local, state, or even federal level. A great place to start would be to look at the major organized medicine groups (ACEP, AAEM, SAEM, EMRA) and see what opportunities exist through their ongoing efforts. Furthermore, well-known service grants and fellowships outside of medicine provide an opportunity for collaboration to deliver health in all policies approach.

Resources
  1. Emergency Medicine Advocacy Handbook- Emergency Medicine Residents Association
  2. White House Appoints 2021-2022 Class of White House Fellows
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WELLNESS CORNER

To Be More Efficient, Sleep.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine

Happy November! Interview season is in full swing. It’s also the time of the year when it gets dark earlier, colder, and if projections are correct, flu and RSV will also compete with the COVID19 virus. Therefore, it is even more important also to take this moment to remind ourselves about self-care, specifically, about sleep.

Here are some important facts about sleep and how important it is:
  • Did you know that sleep deprivation in and of itself is an independent risk factor for burnout and medical errors? A study led by StanfordWellMD shows that sleep-related impairment has an odds ratio of 11.6 regarding interpersonal disengagement..!
  • Lack of sleep directly affects how we engage with others.
  • Improvement in sleep alone has been tied to ~38% reduction in medical errors among residents and fellows, even better than for faculty (~31%).
Last month, we talked about generous interpretation. I can’t imagine anyone having a generous interpretation when they are sleep-deprived. Equally important, this is within our control. I want to remind you that a few years ago, the World Medical Association revised the Declaration of Geneva (Hippocratic Oath) to include: I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard.”

As patient volumes increase, let’s take it upon ourselves to remind each other to take care of ourselves. Let us remind each other and ourselves to tend to our basic self-care needs: sleep, and while at work, food, and “bio-breaks.”

Emergency medicine is a fantastic field. It’s even better when we can enjoy the adrenaline rush, the impact we have on our patients, and the teamwork when we are well-rested and ready for the next day, the next patient, and that next surge of adrenaline.
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EXPAND YOUR
SOCIAL MEDIA HORIZONS

Interview season is here! It’s exciting and scary at the same time. Check out these faculty with special interests in helping learners like you weather the challenges of the interview season. From efficiency tips to normalizing the trepidation that comes with the interview season to just-the-facts tweetorial about #ERAS2022, these profiles will remind you that you’re not alone in this journey.
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EM MATCH ADVICE PODCAST

Welcome to the new academic year! The EM Match Advice series of podcasts are for senior EM medical students, co-hosted by Dr. Michael Gisondi and Dr. Michelle Lin. Check it out for some great tips to help you shine on your rotation.
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ALiEM HIGHLIGHT REEL

The 3 most popular blog posts relevant for medical students in October 2021 were the following:
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EM Study Resources

bridge to em
Reminder: Bridge to EM is designed to help you through this 8-week guide to provide structured preparation that is free for students. It contains vetted up-to-date information to help you shine on your ED rotation. If you are looking to brush up on knowledge, or get a glimpse of what this specialty entails, check out this awesome resource!
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EM BOUND TEAM

Editor-in-Chief, Rotation Tune-Up, and COVID-19 Updates: Sree Natesan, MD (Duke University)
Clerkship Section Editor: David Gordon MD (Duke University)
SpotLight Section Editor: Moises Gallegos, MD MPH (Stanford University)
Wellness Corner Section Editor: Al’ai Alvarez, MD (Stanford University)
Chief Advisor: Michelle Lin, MD (University of California, San Francisco)
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