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About Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
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Gamechanger: Do we really need a lumbar puncture for all febrile infants 0-28 days old?

PECARN febrile infant rule age 0-28 days

A new international pooled analysis challenges the age-old dogma that all febrile infants 0-28 days require a lumbar puncture (LP). Can the PECARN febrile infant prediction rule safely identify a low-risk subset for invasive bacterial illnesses (bacterial meningitis and bacteremia) [1]?

Bottom Line

For more than  four decades, the standard of care for febrile infants in the first month of life has been aggressive: full sepsis workup (including an LP), admission, and IV antibiotics. A new study in JAMA suggests this paradigm may be shifting [2, 3].

  • In an international pooled analysis of more than  1,500 febrile infants aged ≤28 days, the updated PECARN febrile infant prediction rule missed zero cases of bacterial meningitis.
  • Inclusion Criteria: Non-ill-appearing, full time (≥37 weeks) infants aged 0–28 days with fever (≥38.0°C), who underwent blood and urine testing including procalcitonin (PCT).
  • Exclusion Criteria: Critically ill appearance, prematurity, comorbidities, or antibiotic use in preceding days.
  • Implication: Cerebrospinal fluid analysis is unnecessary for a subset of non-ill-appearing febrile infants ≤28 days old.
  • What now? The current data provides a solid, practice-changing, evidence-based foundation for a shared decision-making conversation that wasn’t possible before.

Study

To answer this question, the authors performed 2 distinct analyses:

  1. Primary Analysis (The “External” Test): To test the rule’s validity in new, diverse populations, the primary analysis pooled data from 4 prospective international cohort studies (Canada, Spain, Europe, UK/Ireland).
    • Population: 1,537 non-ill-appearing, full-term (≥37 weeks) infants aged 0–28 days with fever (≥38C)
    • Why no US data? This was done to validate the PECARN rule externally, avoiding the bias of testing it on the same US population from which it was derived.
  1. Secondary Analysis (The “Maximize Power” Test): To generate the most precise safety estimates possible, the authors then pooled the 4 international cohorts PLUS the 2 original US-based PECARN cohorts.
    • Population: 2,531 infants total
    • Result: Even with the added US data, the rule missed zero cases of bacterial meningitis.

What is the updated PECARN febrile infant prediction?

An infant ≤28 days old is low risk if they meet all 3 criteria:

  1. Urinalysis: Negative
  2. Absolute neutrophil count (ANC): ≤4,000/mm3
  3. Serum procalcitonin: ≤0.5 ng/mL

The Findings

The prevalence of Invasive Bacterial Infections (IBI) in all studied patients was 4.5%.

  • 3.8% bacteremia
  • 0.7% meningitis

Performance of the PECARN Rule

Metric Primary Analysis of 4 International Cohorts (95% CI) Secondary Analysis of 4 International + 2 US PECARN Cohorts (95% CI)
Total Infants 1,537 2,531
Classified as “Low Risk” 632 (41.1%) 1,079 (42.6%)
Sensitivity 94.2%
(85.6–97.8%)		 94.8%
(88.1–97.8%)
Specificity 41.6%
(36.7–46.7%)		 43.3%
(38.7–48.0%)
Negative Predictive Value (NPV) 99.4%
(98.1–99.8%)		 99.6%
(98.7–99.9%)
Positive Predictive Value (PPV) 6.9% ( 4.8–9.9%) 6.1%
(4.5–8.2%)
Missed Meningitis Cases 0 (out of 11 cases) 0 (out of 22 cases)
Missed Bacteremia Cases 4 (5.8% of IBI cases) 5 (5.3% of IBI cases)

Number needed to tap calculation

One of the most compelling arguments for using this rule is the statistical trade-off required to find a single missed case. The authors provide estimated Negative Predictive Values (NPV) across a range of disease prevalences.

If we assume a 1.00% prevalence of bacterial meningitis (which is conservative; the study observed 0.7%), the NPV for bacterial meningitis is 99.95% [2].

This means that for every 10,000 PECARN low-risk infants, 9,995 do not have bacterial meningitis, and 5 might. We can translate this into a “Number Needed to Tap” (NNT) to find one missed case:

  • Risk of Missed Case = 1 – 0.9995 = 0.0005
  • NNT = 1 / 0.0005 = 2000

Bottom Line: You would hypothetically need to perform 2,000 lumbar punctures on low-risk infants to find ONE case of bacterial meningitis that the rule missed.

Important guardrails: Who is this rule for?

Before applying these findings, we need to understand the strict inclusion criteria. This study—and the PECARN rule itself—was only validated on a specific population.

The “Must-Have” Checklist:

  • ✅ Non-ill-Appearing: The infant cannot appear ill. The study defined this strictly, excluding infants with abnormal appearance, work of breathing, or circulation findings (often using the Pediatric Assessment Triangle or other illness indicators). If the baby looks sick, the rule does not apply.
  • ✅ Full-Term: Infants must be ≥37 weeks gestation. Preterm infants have different immunological risks and were excluded.
  • ✅ Age 0–28 Days: This specific analysis focused exclusively on the first 28 days of life.
  • ✅ Proven Fever: Documented temperature ≥38C

The SBI vs. IBI distinction

If you are already using the PECARN rule for older infants (29–60 days), you likely use it to rule out Serious Bacterial Infections (SBIs), which includes urinary tract infections (UTIs) [1].

This study is different – it focused purely on invasive bacterial infections (IBIs), which is defined as bacteremia and/or bacterial meningitis.

What did the PECARN rule miss?

The rule had perfect sensitivity for bacterial meningitis, but it did miss 5 cases of bacteremia out of more than 2,500 infants ≤28 days old despite a low-risk stratification. Let’s look at the 5 cases classified as “missed bacteremia:

  • 1 case: H. influenzae bacteremia
  • 1 case: E. coli bacteremia (without UTI)
  • 1 case: E. coli bacteremia (with E. coli UTI)
  • 2 cases: S. aureus bacteremia (One of these also had a concurrent E. coli UTI).

The authors note that S. aureus in blood cultures can be a contaminant rather than a true pathogen. If these S. aureus cases were indeed contaminants, the true sensitivity of the rule would be even higher than reported.

Notably, all 5 cases of missed bacteremia occurred in infants aged 8-21 days. There were 0 missed bacteremia cases in the 22-28 day age group.

How do we reconcile this with the most current 2021 AAP guidelines?

To understand why this study is a big deal, we have to look at what the American Academy of Pediatrics (AAP) guidelines currently tells us to do. The new data exposes a potential practice shift specifically for infants in the third week of life (8–21 days).

Age Group Current AAP Guidelines (2021) New PECARN Data (2025) Bottom Line for Practice
0–7 Days

Excluded

Standard of care is full sepsis workup (including LP), IV antibiotics, and admission.

Technically Included

Rule missed 0 cases of IBI in this age group, but sample size was smaller (~15% of cohort).

No Change

Due to perinatal risks and smaller sample sizes, the full sepsis workup remains a safe standard of care.
8–21 Days

• Action: Routine LP required

• Strategy: Full sepsis workup (including LP), IV antibiotics, and admission

• Reasoning: Previously considered insufficient data

Potential to Defer LP

• Meningitis: 0 missed cases

• Bacteremia: 5 missed cases (all occurred in the 8–21 day window).

• Nuance: High sensitivity for meningitis challenges the mandatory LP rule, but missed bacteremia warrants caution.

Proceed with Caution

While you might safely skip the LP (since 0 infants with bacterial meningitis were missed), the risk of missed bacteremia suggests these infants still require close monitoring. A reasonable approach for a well-appearing infant with normal inflammatory markers and urinalysis might be to skip the LP, give no antibiotics, but still hospitalize for observation.
22–28 Days

• Action: Risk stratify

• Strategy: Defer LP if inflammatory markers are normal.

• Reasoning: Biomarkers considered reliable risk stratification tools for meningitis.

Evidence to Defer LP

• Meningitis: 0 missed cases

• Bacteremia: 0 missed cases

Strong Validation

This study supports the AAP’s existing recommendation: Skip the LP if all the PECARN criteria (UA, ANC, PCT) are negative, but admit for observation.

Additional Considerations

  1. Procalcitonin is mandatory: This rule relies on serum procalcitonin. If your facility only uses CRP and WBC, you cannot use this reduction strategy safely.
  1. Consider herpes simplex virus (HSV) meningoencephalitis: This PECARN rule is to identify young febrile infants with bacterial infections and not HSV. You thus must still risk-stratify for HSV separately (seizures, vesicles, maternal history, etc) and perform a LP if HSV is suspected, independent of the PECARN prediction rule.

Summary

For the first time, we have high-quality, multi-national data suggesting that a routine LP may not be necessary for every febrile infant ≤28 days old. While guidelines have not officially changed, this study provides the evidence needed to support shared decision-making with caregivers.

We can now honestly tell parents: “Based on these blood and urine tests, the chance of your baby having bacterial meningitis is extremely low—likely less than 1 in 2,000. We can safely hold off on the spinal tap and antibiotics right now and admit for observation.”

That is a conversation we couldn’t have yesterday.

References

  1. Kuppermann N, Dayan PS, Levine DA, et al; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA Pediatr. 2019;173(4):342-351. doi:10.1001/jamapediatrics.2018.5501. PMID 30776077
  2. Burstein B, Waterfield T, Umana E, Xie J, Kuppermann N. Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger. JAMA. Published online December 8, 2025. doi: 10.1001/jama.2025.21454
  3. Searns JB, O’Leary ST. Moving the Field Forward to Safely Do Less With Febrile Neonates. JAMA. Published online December 8, 2025. doi: 10.1001/jama.2025.23133
  4. Pantell RH, Roberts KB, Adams WG, et al; Subcommittee on Febrile Infants. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021;148(2):e2021052228. PMID 34281996
By |2026-01-09T03:36:22-08:00Dec 24, 2025|Expert Peer Reviewed (Clinical), Infectious Disease, Pediatrics|
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When Research Meets Social Media Expertise: Lessons from the PECARN-ALiEM Partnership

PECARN - ALiEM partnership twitter X
From Pipe Dream to Proven Strategy: How a 4-year partnership between PECARN and ALiEM created a replicable framework for evidence-based research dissemination

Sometimes the best collaborations begin with simple questions. Following Dr. Nathan Kuppermann’s grand rounds presentation in 2018, I had the opportunity to discuss an idea with him as PECARN’s Steering Committee Chair: might there be untapped potential in using social media platforms like Twitter to amplify PECARN’s research impact? Five years later, that initial conversation has grown into a reality with a systematic approach and measurable outcomes.

Social media is not just about fads and marketing. In fact, it represents the foreseeable future for information dissemination, even in scientific research, because it meets learners and providers where they already are. Rather than hoping clinicians would stumble upon publications in traditional journals, we should actively bring the research to the platforms they frequently check.

Why Organizational Social Media Requires Strategic Planning

Organizational social media for research dissemination can’t just “do social media.” This endeavor requires fundamentally different approaches than personal academic accounts. While individual faculty might share insights casually or build personal brands, research organizations need systematic frameworks that ensure consistency, maintain academic rigor, and deliver measurable impact.

The critical distinction: institutional social media isn’t about intuition or viral content—it demands rigorous planning, dedicated resources, and iterative optimization based on analytics. Just as we wouldn’t launch a research study without proper methodology and oversight, we shouldn’t approach organizational research dissemination without strategic frameworks and quality control systems.

The Partnership Model: When Research Meets Social Media Expertise

Our approach began with recognizing a fundamental truth: most research organizations lack the specialized expertise needed for effective social media presence. Rather than building these capabilities from scratch, PECARN partnered with ALiEM, leveraging our existing social media infrastructure and experience. What started as an experimental collaboration became a four-year case study, which we recently published in JMIR Formative Research [1]. We share our processes, outcomes, and lessons learned to provide a replicable framework and roadmap for other research organizations considering similar initiatives on Twitter/X (or alternative social media platforms).

The Foundation: Building Sustainable Infrastructure

Organizational Inputs:

  • Research Organization (PECARN) – content expertise and credibility
  • Social Media Experts (ALiEM) – Twitter/X platform knowledge and audience understanding
  • Funding & Leadership Support – executive champions and resource allocation
  • Technical Infrastructure – analytics tools, scheduling platforms, communication systems

The 5-Person Dream Team:

  • Content Writers (2): Physician-researchers who understand both clinical context and platform constraints
  • Peer Reviewers (2): Quality control experts ensuring academic rigor
  • Account Monitors (2): Daily engagement specialists building community
  • Analytics Manager (1): Data scientist tracking performance and optimization
  • Graphic Designer (1): Visual content specialist (added after 2 years based on data)

We created 2-person teams for key roles to ensure sustainability and backup coverage. Faculty have competing priorities, and redundancy ensures consistent output despite scheduling challenges.

pecarn ALiEM twitter X partnership research dissemination architect

What the Numbers Taught Us

The key to our success wasn’t guesswork—it was rigorous analytics tracking and iterative evidence-based improvement. Over the 4 years (2020-23), 569 tweets were published, 99 PECARN journal publications were featured, and we grew an audience of over 2,000 followers.

Tweet-Level Analytics: The Strategy Elements That Actually Work

Through multiple linear regression analysis, we identified 3 characteristics with statistically significant impact on both impressions and engagement:

  1. Polls (β = 0.278): Our most impactful discovery was that interactive polls became our strongest engagement driver. we used polls to introduce clinical scenarios related to featured research, allowing audiences to test their knowledge before revealing study findings.
  2. Graphics (β = 0.195): Professional graphics significantly boosted engagement, leading us to add a dedicated graphic designer to the team after 2 years. This wasn’t cosmetic—it was a data-driven personnel decision.
  3. URL Links (β = 0.173): Links to full articles didn’t just drive traffic; they contributed to increased Altmetric Attention Scores, providing measurable academic impact beyond social media metrics.

Surprisingly, emojis showed a negative correlation with engagement in our academic audience. We hypothesize that these emojis may have not resonated with our academic and healthcare professions audience— a reminder that strategies must be tailored to the desired audience.

research dissemination architect pecarn ALiEM twitter X

Lessons Learned for Building Research Dissemination Architecture

1. Analytics Are Non-Negotiable

Don’t guess about what works. Track impressions, engagement, click-through rates, and downstream academic metrics. What gets measured gets optimized.

2. Quality Control Maintains Credibility

Our peer review process for each tweet provided academic rigor for accuracy and quality, treating social media content with the same methodological care we apply to research publications. This approach strengthened PECARN’s digital credibility and built trustworthiness with our professional audience who expect evidence-based content even in 280 characters.

3. Team Redundancy Ensures Sustainability

Faculty have complex schedules. Build systems that work despite individual availability challenges.

4. Visual Content Isn’t Optional

Professional graphics aren’t “nice to have”—they’re proven engagement drivers in the era of information overload. They are worth the investment.

New Academic Role: Research Dissemination Architect

What began as grassroots FOAM (Free Open Access Medical education) with individual bloggers and social media educators has evolved into something more substantial: the emergence of the “Research Dissemination Architect” as a legitimate, potentially funded position within academic institutions and research organizations.

This represents a fundamental shift in how we think about knowledge translation careers. We’re no longer talking about faculty “doing social media on the side”—we’re talking about dedicated professional positions with specific expertise, measurable outcomes, and institutional recognition. Our recent publication in JMIR Formative Research documents our journey in this evolution. The ALiEM-PECARN partnership wasn’t just about Twitter success; it was about demonstrating that research dissemination can be a systematic, professional discipline worthy of institutional investment and academic recognition.

Conclusion

The PECARN-ALiEM partnership demonstrates that academic rigor and social media success aren’t mutually exclusive—they’re synergistic when approached systematically. Through this collaboration, we’ve contributed to establishing systematic approaches to research dissemination as a pathway toward accelerated knowledge translation.

Research Dissemination Architects represent an emerging career pathway that bridges traditional academic expertise with digital communication skills. As medical education continues evolving toward digital-first approaches, faculty who develop competency in evidence-based social media are positioning themselves at the forefront of this evolution. The framework we’ve developed offers one approach to professional research dissemination. As more organizations experiment with similar roles, we’ll undoubtedly see diverse models emerge, each contributing to our collective understanding of effective academic digital scholarship.

We hope our experience can inform others exploring this space. Whether you adapt our specific approach or develop entirely different methods, the opportunity to advance how research reaches its intended audiences has never been greater.

Reference

  1. Hooley GC, Magana JN, Woods JM, et al. Research Dissemination Strategies in Pediatric Emergency Care Using a Professional Twitter (X) Account: A Mixed Methods Developmental Study of a Logic Model Framework. JMIR Form Res. 2025;9:e59481. Published 2025 Jun 24. doi:10.2196/59481. PMID 40554778
By |2025-07-05T13:21:28-07:00Jul 5, 2025|Academic, Beyond the Abstract, Medical Education, Research, Social Media & Tech|
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EM Match Advice 48: Transitioning from ERAS to ResidencyCAS – Platform Features and Essential Resources

ResidencyCAS - transitioning out of ERAS application

In this episode of EM Match Advice, Dr. Sara Krzyzaniak (Stanford University EM Program Director) speaks with Dr. Liza Smith (Clerkship Director/Associate Program Director at UMass Baystate and past Chair of the CORD Application Process Improvement Committee, and Dr. Tim Fallon (Associate Program Director at Maine Medical Center and the committee’s current Chair), about the historic transition from ERAS to ResidencyCAS for EM residency applications. This marks the first year that EM is using ResidencyCAS as an application service, moving away from the ERAS platform used in previous years. The discussion focuses on essential resources and new platform features that applicants need to understand for successful applications.

Podcast: Transitioning from ERAS to ResidencyCAS

 

Critical Updates for the 2025-2026 Application Cycle

  • Do NOT apply to EM programs through ERAS for 2025-2026 – All EM applications go through ResidencyCAS.
  • ALL EM combined programs also use ResidencyCAS: EM-IM, EM-Peds, EM-Anesthesia, EM-FM, etc. are all on ResidencyCAS, not ERAS
    • Exception: If applying to separate specialties (e.g., both EM and IM as separate applications), you’ll need both ResidencyCAS for EM and ERAS for other specialties

Major Application Changes

  • Geographic preferences redesigned: The traditional regional geographic preference ranking has been eliminated. The new approach focuses on listing specific city-state locations where you’d feel supported (such as a hometown), rather than broad regional preferences
  • Hobbies section returns: The hobbies section is being reintroduced to ResidencyCAS applications
  • Non-work experience section added: Applicants can now include experiences outside of traditional work or medical activities

Key Dates for 2025-2026 EM ResidencyCAS Applications

  • June 4, 2025: ResidencyCAS application opens for data entry and initial application work
  • August 25, 2025: First date to officially request transcripts (USMLE/COMLEX) and Dean’s letters (MSPE) from schools
  • September 24, 2025: Application submission deadline
  • October 1, 2025: Programs can begin reviewing applications

Caution: These dates are specific to ResidencyCAS for Emergency Medicine applications. Always verify dates directly with official sources as they may be subject to change.

Featured Resources

1. ResidencyCAS Official Website

  • What it is: Official platform and information hub for ResidencyCAS applications
  • Access: ResidencyCAS.com

2. EMRA Advising Guide (Updated 2024)

  • Key chapters: Updated Chapter 4 and Chapter 7 focus specifically on ResidencyCAS applications
  • Access: Updated EMRA Advising Guide – ResidencyCAS Chapters

3. Applicant Sandbox

4. CORD Homepage Resources

  • Content: Information about the collaboration and resources being shared with programs
  • Access: CORD Homepage – ResidencyCAS Information

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

By |2026-06-16T16:19:02-07:00May 26, 2025|EM Match Advice, Medical Student|
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EM Match Advice 47: 2025 EM Match By The Numbers

EM Match Advice 2025 Match by the numbers

The Emergency Medicine (EM) Match process continues to evolve, with the specialty experiencing significant shifts in recent years. In this 47th installment of the EM Match Advice podcast series, Dr. Sara Krzyzaniak (Stanford EM PD) hosts the annual program director reflection on the Match with Dr. Abra Fant (Northwestern EM PD), who returns for her fourth consecutive year to share insights on the NRMP Match trends and data. 

Podcast Episode: EM Match by the Numbers

 

Tables: EM Match by the Numbers

EM Match Advice by the Numbers

 

EM Match by the Numbers by specialty

 

Key 2025 Match Statistics: A Clear Improvement

Significant Reduction in Unfilled Positions

The most notable trend in the 2025 EM match is the continued reduction in unfilled positions:

  • 65 (2%) unfilled positions in 2025, down from 135 (4%) unfilled positions in 2024
  • This continues the positive trend from the peak of 554 (18%) unfilled positions in 2023

Dr. Fant notes this represents a faster-than-expected recovery: “I think we all suspected we would recover as a specialty, but looking at other specialties that have gone through similar roller coasters, I think this recovery has been more rapid than potentially others anticipated.”

Program and Position Growth

The 2025 match showed stable program numbers with modest growth in positions:

  • 292 EM programs in 2025, unchanged from 2024
  • 3,068 total positions offered, up slightly from 3,026 in 2024
  • 3,753 total applicants to EM in 2025, up slightly from 3,574 in 2024

Applicant Demographics Remain Stable

The composition of the EM applicant pool remained relatively consistent year-over-year:

  • 1,514 US MD seniors (40% of applicants)
  • 1,231 DO seniors (33% of applicants)
  • The remaining 27% comprised IMGs and other applicant types

Fill Rates by Applicant Type

The distribution of positions filled by different applicant types remained stable:

  • 1,377 positions filled by US MD seniors (45% of filled positions)
  • 1,078 positions filled by DO seniors (35% of filled positions)
  • 446 positions filled by US IMGs (15% of filled positions)
  • The fill rate for EM positions was 98% overall

Factors Driving Success in the EM Match

Several key factors contribute to the improved Match results and program director priorities:

  1. Realistic interview and ranking practices
  2. Effective use of preference signals
  3. Better distribution of interviews 
  4. Geographic considerations
  5. Demonstrated interest in Emergency Medicine

Looking Ahead: Changes on the Horizon

Several significant changes are coming to EM education and the application process:

  • Proposed Resident Review Committee (RRC) program requirements: New RRC requirements were announced right around rank list certification day, which could significantly impact the upcoming match cycle.
  • Transition to ResidencyCAS system: The specialty is moving from ERAS to ResidencyCAS, representing substantial shift to an entirely new platform to manage applications, interviews, and communications.

Despite these upcoming changes, Dr. Fant remains optimistic: “Overall this is a really positive outlook for applicants to emergency medicine in the upcoming 2025-26 Match cycle.”

“EM is one of the best specialties. It has been for many years and we have overcome plenty of roadblocks. We hope that you will join our ranks.”

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

By |2025-05-25T13:11:16-07:00Apr 24, 2025|EM Match Advice, Medical Student|
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EM Match Advice 46 | Program Directors Share Match Season Insights

EM Match Advice 46 podcast match season

As interview season wraps up, medical students across the country are preparing their rank lists for the upcoming Match. EM Match Advice podcast host, Dr. Sara Krzyzaniak (Stanford EM Program Director) recently sat down with Dr. Melissa Parsons (University of Florida College of Medicine – Jacksonville EM Program Director), to discuss the match process from both program and applicant perspectives.

Podcast: Match Season Insights

Podcast Sound Engineer: Dr. Kaitlin Bowers 

What’s Happening on the Program Side?

Programs are busy finalizing their rank lists through comprehensive meetings with their teams. Many programs, including UF Jacksonville, are intentionally completing their rank lists before hosting second looks in February. This approach ensures that second look attendance doesn’t influence ranking decisions.

Do Letters of Intent Matter?

The impact of post-interview communication varies by program. While some program directors may give slight consideration to genuine letters of intent, there’s a consensus that “ranking you highly” letters carry little weight. Dr. Parsons notes that programs can verify the authenticity of “#1” declarations on Match Day, making honesty crucial in these communications.

Creating Your Rank List: What Really Matters

Focus on these key factors:

  • Mentorship opportunities
  • Program reputation and graduate outcomes
  • Geographic location
  • Support systems and work-life balance
  • Clinical training environment
  • Fellowship and career opportunities
  • Your gut feeling about the program

What to avoid:

  • Overvaluing others’ opinions on programs
  • Putting too much stock in online forums/spreadsheets
  • Making decisions based on minor perks or small salary differences

Strategic Advice for Applicants

  1. Make Your List Early: Write down your rankings and display them somewhere visible. Live with the list for a few weeks before certification.
  2. Consider Location: Think beyond the hospital – where do you want to live for the next 3-4 years?
  3. Be Thorough: While top and bottom choices might be clear, pay special attention to middle-ranked programs. Given recent Match unpredictability, thorough consideration of all ranked programs is crucial.
  4. Attend Second Looks Strategically: Use these opportunities to gather information for your decision-making, understanding that programs should have their lists finalized beforehand.

Important Dates

  • February 3, 2025: Rank list entry opens
  • March 5, 2025: Rank list certification deadline
  • March 21, 2025: Match Day

Final Thoughts

Remember that the Match algorithm favors applicant preferences. Focus on creating a rank list that reflects your true preferences rather than trying to predict where programs might rank you. Trust your instincts and prioritize what matters most to you in your training journey.

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

 

 

 

By |2025-01-25T12:55:15-08:00Jan 29, 2025|EM Match Advice, Podcasts|
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EM Match Advice 44: Approaching your EM sub-internship clerkship – “Just gotta roll with it”

EM match advice approaching your sub-internship clerksihp

Dr. Sara Krzyzaniak (podcast host and Stanford University PD) and Dr. Michelle Lin (ALiEM Founder/UCSF) are joined by Dr. Jessica Bod (Yale University Clerkship Director and 2024 CDEM Clerkship Director of the Year award winner) in this episode to discuss how one might approach their emergency medicine sub-internship. Dr. Bod shares her her wealth of experience and wisdom to provide not only general advice but also answers more detailed questions like:

  • What are some things NOT to do on a rotation?
  • How do I judge my own competitiveness in the residency application process?
  • What if I have decided late in the process that emergency medicine is the career fit for me?
  • What should I expect AFTER the rotation?

Podcast: Approaching your EM Sub-Internship Clerkship

 

Mentioned Links

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

 

 

 

By |2024-06-24T16:29:00-07:00Jun 25, 2024|EM Match Advice, Medical Student, Podcasts|
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From Collision to Clarity: PECARN cervical spine injury prediction rule for injured children

PECARN cervical spine injury prediction tool featured image (adapted from Midjourney)

For years, adult literature has provided clear guidelines for cervical spine imaging through the NEXUS and Canadian C-spine Rule (CCR) tools. These have been invaluable in helping clinicians decide when to image the neck in trauma patients. Similarly, the Pediatric Emergency Care Applied Research Network (PECARN) has developed robust tools for assessing blunt head trauma in children. However, until now, there has been a gap in guidance for clinicians managing pediatric patients at risk for cervical spine injuries.

Case Scenario: What would you do?

A 10-year-old boy presents to the emergency department (ED) after a high-speed motor vehicle collision. He complains of neck pain and is reluctant to move his head. The child’s mother is extremely worried, fearing the worst after witnessing the collision.

The Problem

Cervical spine injuries in children, while uncommon, can be devastating if not identified and treated promptly. Emergency physicians often face the challenge of deciding whether to proceed with imaging, given the potential risks associated with ionizing radiation from CT scans. The lack of clear guidelines specifically tailored for pediatric patients has historically led to either overuse of imaging, with its associated risks, or underuse, with the risk of missed injuries.

PECARN Cervical Spine Injury Prediction Rule

On June 4, 2024, Lancet published “PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.” This study proposes a new clinical prediction rule to guide imaging decisions for pediatric cervical spine injuries.

The study enrolled 22,430 children, aged 0–17 years, presenting with blunt trauma across 18 PECARN-affiliated ED in the US. About half were in the derivation and half in the validation cohort. The researchers derived and validated a clinical prediction rule using data from these children, which identified key risk factors for cervical spine injury, divided into high-risk and non-negligible (intermediate) risk factors.

High Risk (>12.1% risk of injury) -> Consider CT

  • Altered mental status (GCS 3-8 or AVPU = U)
  • Abnormal airway
  • Breathing
  • Circulation findings
  • Focal neurological deficits

Intermediate Risk (2.8% risk of injury) -> Consider X-Rays

  • Neck pain or midline neck tenderness
  • Mental status: GCS 9-14, AVPU = V or P, or other signs of altered mental status
  • Substantial head or torso injury

Definition on Cervical Spine Injury

  • Fractures or ligamentous injuries of the cervical spine
  • Cervical intraspinal hemorrhage
  • Cerebral artery injury
  • Cervical spinal cord injury, including
    • Changes in the cervical spinal cord on MRI
    • Cervical spinal cord injury without radiographic association
PECARN Cervical Spine Injury Prediction Tool

PECARN Cervical Spine Injury Prediction Tool (Download full sized PDF at PECARN site)

The prediction rule had strong test characteristics with 94.3% sensitivity and 99.9% negative predictive value, indicating that it can reliably identify children who do not need imaging, thus avoiding unnecessary radiation exposure. This evidence-based approach to pediatric trauma care would have reduced the number of CT scans by more than 50% without missing clinically relevant injuries.

Case Example Resolution

Using the PECARN cervical spine injury prediction rule, the attending physician evaluates the boy and finds that he does not exhibit any high-risk factors. However, because he reports neck pain and has midline neck tenderness on exam (intermediate risk), the rule recommends that the cervical spine can not be clinically cleared. It also suggests plain x-rays and not a CT scan. This differs from the adult population whereby CT scan imaging is often the first choice for diagnostic testing.

The x-rays reveal no evidence of cervical spine injury, and the boy is cleared with instructions for follow-up care. This approach not only alleviated the mother’s anxiety but also avoided unnecessary radiation exposure for the child.

Reference

Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024;8(7):482-490. doi:10.1016/S2352-4642(24)00104-4. PMID 38843852

By |2026-01-08T21:25:20-08:00Jun 10, 2024|Pediatrics, Radiology, Trauma|
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