EMBound_InLine
NOVEMBER 2022

A newsletter for medical students pursuing a career in emergency medicine

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Letter from the Editor:

Hello #EMBound Med students,

Happy November! This is a great time for us to pause and say we are thankful for our medical students and the bright future we are reminded of when we look at you. Whether you are a first-year med student learning about EM, or a fourth-year #EMBound med student hoping to rock your interviews-- know you have the talent, passion, and skills to make your dreams come true. We, at AliEM, are here to help you on your journey to becoming #EMBound.

In this newsletter, we have excellent guidance for our MS4s regarding communication during the interview season. We will also be sharing a quick approach to abdominal pain, a discussion on medical toxicology, and finally pausing to talk about emotional self-care. Also check out EM Over Easy, a fantastic podcast with great conversation on #MoreThanMedicine!

Wishing you a very happy holiday season.
--Sree Natesan, MD Editor-in-Chief
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CLERKSHIP LIFE &
RESIDENCY APPLICATION SEASON

What Haven’t You Called Me?

Communication Guidelines for Interview Requests


David Gordon, MD
Associate Program Director
Duke University

November has strolled in and you still haven’t heard from your favorite program. Or maybe you are worried you have fewer interviews than you are comfortable with. Is it okay to reach out to programs at this point to let them know you are still out there and genuinely interested? This is the first year Emergency Medicine has participated in program signaling, but as in prior application cycles, my personal opinion is that the arrival of November marks an appropriate time for applicants to begin individually emailing programs of high interest. That being said, there are a few ground rules and suggestions to keep this form of communication effective for everyone:
  1. Limited Number: This is not round two of ERAS where applicants should blast 20 plus programs and see what sticks. If everyone did that, it would only make for a bunch of disgruntled program directors and render this form of communication useless. So begin with a limited number of programs to reach out to - with around two being an approximate guide. You should only be reaching out to programs you have yet to hear back from.
  2. Limited Size: This is also not the time to resend another personal statement. A lengthy email can create a negative first impression visually from the time it’s opened. Try to keep the main text of your email to one paragraph. Your goal here is simple: 1) reaffirm your interest in the program, 2) briefly explain the reasons for your genuine interest, and 3) express appreciation for being considered for an interview.
  3. Be Specific: It can be helpful to reinforce any professional or personal reasons why the program is of particular interest. Professional reasons could include an EM subspecialty (e.g., ultrasound, toxicology) or an area of research that is strongly supported by a program. One can also make reference to desirable aspects of a curriculum or institutional strength, but try to avoid the use of generic statements that are cut-and-paste in nature. Personal reasons for wanting to be in an area - such as being near family - can be impactful and should be shared. If you are couples matching and your partner received an interview at the institution, mentioning this information can also add credibility to your expression of sincere interest.
These emails will not guarantee an interview, but they should at least help ensure your application has been carefully considered. As always, if you have any concerns over your interview numbers or overall situation, be sure to engage with your advisor for tailored guidance. Best of luck and happy interviewing!

Resources:
EM over Easy
Medicine is much more than what the classroom and rotations provide. Truly practicing good medicine involves critical conversations, understanding social dynamics, and knowing how to have a few good laughs too! To be a part #MoreThanMedicine conversation, listen to the EM Over Easy Podcast with EM docs and hosts Andy Little, Tanner Gronowski, Drew Kalnow, and John Casey.

For this short stack session, invited guests, Dr. Kevin Tomecsek and Drew Jones discuss some deep short stack questions with John Casey and Andy Little.

The Questions:
  • Would you donate an organ to someone in this room?
  • What is your irrational fear?
  • Is it better to be right or to do right?

Find us at www.emovereasy.com, @emovereasy on Twitter, and on your favorite podcast player!

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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.

Approach to Abdominal Pain

Sree Natesan, MD
Associate Program Director
Duke University

Abdominal pain is one of the most common chief complaints you’ll encounter in the emergency department. The emergent differential diagnosis is broad and can feel daunting as you are trying to figure out what is the true diagnosis for your patient. Developing a systematic approach to evaluating abdominal pain can provide patients with thorough, efficient, and accurate care.

Here are some key considerations:
  • Don't underestimate the power of your history & physical exam: A thorough history to localize the abdominal pain and associated symptoms can help to create a differential diagnosis. Using this, you can then focus your abdominal exam to help hone in on your working diagnosis. In fact: research has demonstrated that a careful history and physical exam alone can lead to the correct diagnosis in up to 3/4 of the cases!
  • The lost art of the physical exam: The cough test, inspiration test, and peritonitis test can help to determine if a patient has a concerning abdominal examination.
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  • Imaging: For unstable patients, consider bedside ultrasound (to rule out free fluid) and/or an upright plain radiograph (to rule out free air) to determine the cause of the abdominal pain.
  • Pain management: Never withhold pain medication in a patient presenting with abdominal pain.
Resources:
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SPOTLIGHT

Medical Toxicology


Eddie Charles Michael Garcia, MD
Clinical Assistant Professor, Emergency Medicine
Stanford University School of Medicine

What is medical toxicology?
Toxicology is a subspecialty for the management of poisonings, overdoses, drug interactions, envenomations, and occupational exposures.

But, what is medical toxicology really?
Toxicology is the nerdy side of emergency medicine. Toxicologists love rare cases, trivia, and, possibly, even basic science! If you give a toxicologist a chance to talk, they will. Toxicology rounds produce thoughtful discussions about both critically ill and seemingly routine patients, all while in the acute setting of the emergency department.

What is a toxicology rotation like?
Just as an ultrasound rotation allows a learner to use 45 minutes to perform an ultrasound, a toxicology rotation slows the rapid pace of the emergency department to think through syndromes more in-depth. There are three main models for rotations, depending on what the institution has to offer. Very often, aspects from each of these models will be combined for an elective with a full toxicology experience.
  • The state’s poison center: This might be the most common toxicology elective available. You will spend your time consulting remotely for any calls that come into the poison center. Rounds will be similar to “workroom rounding,” where cases are discussed, but a patient is not physically seen.
  • A toxicology consult service: This is an experience similar to any inpatient consult service. Yes, you heard me right. Inpatient teams are consulting an emergency medicine specialty!
  • An emergency department-based service: You may meet in the emergency department with the team to wait for poisoned patients or to discuss toxicology-related subjects. When the weather is nice, you might sit outside on the grass and discuss mushrooms. Maybe you even go home early!
Who might be part of the toxicology team?
Like most medical teams, you will find attendings, fellows, residents, and medical students. There may be pharmacists, pharmacy residents, and pharmacy students as well. Although toxicology is primarily an emergency medicine subspecialty, you may have attendings and fellows previously trained in pediatrics, internal medicine, or occupational medicine.

What are the benefits of a toxicology rotation?
  • Poisoned patients represent some of the sickest of the sick patients in the emergency department. Many inpatient consults come from the Intensive Care Unit because of the higher level of care these patients require.
  • Toxicology will broaden your differential building dramatically. Never again will you have a differential diagnosis without at least one toxicology diagnosis on it!
  • Even if you decide not to go into emergency medicine, toxicology is relevant to all medical fields.
  • It never hurts to get test questions right. Toxicology is always a big part of emergency medicine exams, so learning to identify toxidromes can help you clinically and on your test!
Tips for a toxicology rotation:
  • You will likely be provided a small toxicology handbook of common poisons and antidotes. Read it! Most chapters can be read in just 3 minutes, so it is an easy way to prepare for rounds.
  • You may find yourself suddenly lost during rounds. Don’t be afraid to ask questions. I guarantee you that the resident sitting next to you also needs a refresher on Michaelis-Menton's kinetics.
  • Embrace the diversity of the team. Partner with a pharmacy student to approach difficult cases with greater cumulative knowledge.
Resources:
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WELLNESS CORNER

#StopTheStigmaEM, Emotional Self-Care,

and Finding Your Community in EM

Al’ai Alvarez, MD

Director of Well-Being
Stanford Emergency Medicine

Last month, national organizations in emergency medicine collaborated to launch the October #StopTheStigmaEM Month campaign to normalize the need to take care of our mental health as physicians and healers. We’ve learned a lot from doing this work–the stigma for seeking mental health, the discrepant access to mental health care, and the variable help-seeking behaviors of physicians.

Another important aspect of this campaign was highlighting the power of community. To put this in #EMBound perspective, many of you are going through interviews now, hoping to secure that residency spot. The process is intense, and because of the many known and unknown factors that influence your competitiveness as a candidate, it is very common for applicants to feel isolated.

And we know that several other contributing factors impact this sense of isolation. Experiencing an adverse event is an example. Yet, we often associate adverse events with challenging clinical cases--a patient dies, a bad outcome, or a medical error. The reality is that every day, we deal with challenges at work and within our home life, including managing our insecurities, doubts, and experiences of guilt and shame. The #StopTheStigmaEM campaign was helpful for me in highlighting that we don’t need to have a disorder to seek mental health support. Just like getting an annual check-up and preventative work with your primary care and your dentist, mental health care can have similar benefits. Practicing emotional self-care is just as important as preparing for that next interview or studying for that next exam. Additionally, there are many ways to acknowledge the challenges we encounter, and having a sense of community is a necessary resource.

We want to emphasize this. You don’t have to go through this journey alone. Reach out to mentors, colleagues, and friends. Celebrate the wins. Support each other. Be kind to yourself. This is just the beginning of a wonderful career in emergency medicine. #YouAreNotAlone.
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EXPAND YOUR
SOCIAL MEDIA HORIZONS

Check out our past issues to get acquainted with our materials, and we welcome those just joining us.

ERAS is finally submitted! Interview season is here, just as pumpkin spice lattés are in the air. While the next several months are filled with a rollercoaster of emotions, please know that you're not alone. Check out the content of these profiles in #SoMe.
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EM MATCH ADVICE PODCAST

The EM Match Advice series of podcasts are for senior EM medical students, co-hosted by Dr. Michael Gisondi and Dr. Michelle Lin. In this May 2022 episode, they take a deep-dive into the table below and discuss the surprising developments from the 2022 EM Residency Match that has NEVER happened before. The episode features an all-star residency director panel featuring Dr. Abra Fant (Northwestern University), Dr. Sara Krzyzaniak (Stanford University), and Dr. Bonnie Kaplan (Denver Health).
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ALiEM HIGHLIGHT REEL

The 2 most popular blog posts relevant for medical students in October 2022 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: 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 & #SoMe Editor: Al’ai Alvarez, MD (Stanford University)
EM Over Easy Editor: Andy Little, MD (AdventHealth)
Chief Advisor: Michelle Lin, MD (University of California, San Francisco)
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