EM-Bound Medical Students: The EM Profession

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Jan 2024 EM Bound newsletter

For many patients with substance use disorders (SUD), the Emergency Department represents an initial point of contact for care. Sometimes, this comes as a result of complications from substance use such as overdose or withdrawal. Often, patients present with a primary goal of seeking help navigating the “detox” system. While exposure to these presentations will come as part of our everyday training in EM, the pathway exists for EM docs to receive additional training in Addiction Medicine through a fellowship program.

In the past decade, a lot of attention has surrounded the role of EM in the ongoing opiate epidemic. A spotlight on medication-assisted treatment (MAT) and buprenorphine prescribing has facilitated routes for EM docs obtaining a DEA X-waiver and in some states being able to prescribe medications without additional DEA requirements. Beyond this important example, training in Addiction Medicine can provide the skills needed to promote advocacy and research on a population level and learn the intricacies of providing counseling for individual patients.

Addiction Medicine is an ACGME-accredited subspecialty with a board certification process overseen by the American Board of Preventive Medicine. Over eighty 1-year fellowships are available across various disciplines, including Emergency Medicine, Family Medicine, and Psychiatry. Training in Addiction Medicine can provide the knowledge and skills necessary to facilitate ED-based programs that provide screening, brief intervention, referral to treatment, and overdose prevention education.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Nov 2023 EM Bound newsletter

I once had the opportunity to speak in front of our EM interest group during a story-sharing event. Having been a part of so many interesting patient encounters over the last several years, I struggled to settle on what story I would share. Unable to choose just one, I decided instead to speak about the concept of slowing down in EM, a concept you wouldn’t think fits the hustle and bustle of the ED. Truth is though, that many of the patients we see in the ED will benefit more from our time and connection than any medication or treatment we could offer.

One of the stories that came to mind was that of an older patient who passed away under my care in the ED during the early months of COVID. Visitation rules were at their strictest, and I had been communicating with family outside of the building, coordinating and understanding goals of care. Although I had several other patients on my mind as well, it hit me at some point that I needed to slow down and fully commit myself to this patient who would likely pass before the end of my shift, especially since I was functioning as the point of contact with family. I asked the family if there was anything I could say or do for their loved one in the ED and was asked to play a specific song that was known to be her favorite. Working with the patient’s nurse, we coordinated to focus on her comfort, we began to play the song in the room, and I expressed some messages of love that the family had asked me to convey. Before the nurse and I could leave the room, the song came to an end. Almost simultaneously, the patient took her last breath. Some might say it was coincidental. I like to think it was that the patient found calm and peace after hearing the words of her family and the song they played for her. Looking back at that night, I am glad that I took the extra minutes to connect with the patient and her family. Sure I was stressed by the growing list of tasks and new patients piling up, but it was important for me to slow down in that moment for them.

As a student, we encourage you to become the primary point of contact for your patients and their families. You may have the opportunity to spend more time at the bedside than other members of the team. As you enter the next few months, perhaps marked by the final rotations of medical school if you’re entering The Match, try and stay open to the times when it’ll mean a lot, for both you and your patients, to slow down and take in the moment.

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Oct 2023 EM Bound newsletter

Sports Medicine focuses on the prevention, diagnosis, and treatment of injuries in athletes, both on and off the field. Sports medicine physicians also work to understand the impact of acute and chronic illness on athletic performance. Recognized in 1992 by the American Board of Medical Specialties, training fellowships in sports medicine are available to graduates of family medicine, internal medicine, pediatrics, physical medicine and rehabilitation, and emergency medicine (EM) residency programs.

While orthopedic surgery may be necessary for many injuries experienced by athletes, Sports Medicine has been able to fill the gap in clinical care for those with performance-related injuries that are not operative, as well as non-musculoskeletal ailments such as concussions, heat illness. As a niche sub-specialty, the field of Sports Medicine continues to expand in terms of research and clinical care applications.

Career paths in Sports Medicine are varied, but often include a combination of emergency department (ED) shifts and work with athletic teams or programs. Some Sports Medicine physicians become designated team doctors while others work in directorship roles with governing organizations. Some work in academic settings and participate in research and scholarship, while others work in private practice and focus on clinical care. Some focus mostly on EM with occasional participation in mass sporting events, and others work mostly in sports medicine clinics while working periodically in an ED. The choice is up to you on how you choose to envision your career in this niche.

While no formal requirements exist for applying to a Sports Medicine fellowship, the American Medical Society for Sports Medicine has created a road map to training that residents can use to inform their elective rotations, scholarship participation, and career planning.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Aug 2023 EM Bound newsletter

Care coordination in the Emergency Department (ED) often requires more than just consideration of the medical aspects of the disease. We’ve talked before in this section about the growing field of Social Emergency Medicine, and the importance of social determinants of health in what we do for the acutely ill and injured patients we see. Addressing the psychosocial components of a patient’s care plan requires a multifaceted approach. Social Work (SW) and Case Management (CM) teams fill integral roles in providing patient-centered care. Not every ED, and not every shift, will have a social worker or case manager, but if you’re lucky enough to have them around, it’s good to know what they can help you with.

SW and CM often work hand-in-hand and their services can overlap. In general, social workers should be seen as counselors and patient advocates, while case managers provide care coordination for medical needs. Together, they work to avoid unnecessary admissions, ensure safe discharges, and bridge the gap between inpatient and outpatient care.

Some of the services they can assist with include:

  • Patient education and counseling after new diagnoses
  • Counseling on substance and alcohol use disorder
  • Connecting patients and families with services such as home health, wound care, etc
  • Coordinating needs assessment for appropriate care: skilled nursing facility, acute rehabilitation facility, outpatient physical therapy
  • Arranging transportation upon discharge
  • Providing crisis intervention and family counseling after sharing of bad news, traumatic injuries, patient deaths, etc
  • Screening for needs: food insecurity, homelessness, financial concerns
  • Assisting with legal concerns like intimate partner violence, child abuse, or elder abuse
  • Utilization concerns for patients with frequent presentations or difficulty accessing definitive primary or referral care

Common consults to SW and CM include:

  • Transportation back to a care facility or home. This can come in the way of coordinating taxi/ride-share, public transportation (bus ticket), arranging wheelchair/gurney van, or requesting ambulance transport.
  • New placement in skilled nursing, subacute, rehab, or long-term care facilities.
  • Speaking with psychiatric patients or substance use patients about community resources available to help aid in their recovery.
  • Counseling of patients after a new cancer diagnosis, loss of pregnancy, domestic violence, or abuse.
  • Help with identifying unknown patients, locating family, or obtaining collateral information.

Hospice/End-of-life Care/Goals-of-Care

As the acute care setting of the Emergency Department continues to adjust to meet the needs of patients with chronic illness, more and more we find ourselves having end-of-life care discussions with families. During these difficult clinical times, case managers can often look into what options might exist for in-home hospice services, preventing a lengthy and perhaps unnecessary hospital admission. Social workers can participate in the delivery of bad news and provide support for family members in the decision-making process of goals-of-care and end-of-life care.

As you spend more time in the ED, you may learn about requirements for SW and CM involvement in specific types of cases. For example, in California, there are legal requirements that homeless patients be provided with certain services prior to discharge, and often SW and CM facilitate meeting this mandate. Each ED may be different in providing the services above. Inquire about the role that SW and CM play in the ED and available resources for the patients you serve as you are rotating through.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in July 2023 EM Bound newsletter

This month marks a huge milestone for medical students, now interns, entering residency. Similarly, many pre-clinical students are finishing up courses, taking Step 1, and entering their first clerkships. This transition in medical education is something highlighted every year as a “changing of the guard” for the healthcare workforce. With this change often comes a whirlwind of emotions- excitement wrapped in nostalgia, anticipation encased in anxiousness, and eagerness marked with caution.

Now, we’ve all likely heard the joking statement that you should avoid getting sick in July. This jab plays on the idea that inefficiencies in the provision of medical care result from new trainees taking on new roles. Rather than accepting this negativity, I would encourage you instead to focus on the understood fact that in an academic medical center teaching and training is built into the practice of medicine, and patient safety is always at the core of supervision.

What do the studies actually show?

  • The data goes back and forth: Small studies have demonstrated changes in practice patterns during the July “transition month,” such as medication prescribing and hospital stays, but few have demonstrated clinically relevant impacts on patient outcomes.
  • Subgroups of patients may experience impacts in care: Large and multi-institutional studies show negligible effect on most outcomes for the general patient population, but trends towards negative outcomes do materialize when doing subgroup analysis.
    • Some groups of patients that have been shown to experience increases in morbidity and mortality are cardiac patients, such as those requiring percutaneous intervention, and specialized surgery patients, such as those receiving cerebrospinal fluid shunts. It can be somewhat easy to see why- these interventions are highly skilled and require much experience.
  • Academic centers perform better: When comparing teaching hospitals to non-teaching hospitals, patient outcomes across the board are better. While the “July Effect” may be real in some specific and peculiar cases, patients receive better care all-around at academic centers.

What does this mean for me?

  • You’re not the only one in a new environment: If you are a core student or a sub-intern in the month of July, recognize that you’ll be working next to residents taking on new roles themselves with junior residents becoming senior supervisors.
  • Oversight is multi-layered: Program leadership and attendings are ready to support your clinical development while ensuring patient safety. Academic medical centers rely on the naturally existing levels of oversight: nursing staff, senior residents, attendings.

What can I do?

  • Recognize limitations and knowledge gaps: Accept any moments of “I’m not sure” or “ I don’t know” as opportunities to learn and grow.
  • Seek out clarification often: Ask for assistance or clarification of a task early. Don’t waste time and energy on small things. Save that for bigger tasks. Don’t know how to place a consult? Ask for help right away and take notes for the next time.
  • If something doesn’t seem right, bring it up: As a medical student, you get to spend a lot of time with patients, so if you notice that something doesn’t add up- with medications, with lab results, or with the patient’s clinical course- bring it up to your team. Whether it was something to be concerned about in the end or not, you’ll learn from that discussion.

Resources

Carina Deck, PharmD
Brian Dang, PharmD, BCCCP
Stanford Department of Emergency Medicine
Originally published in May 2023 EM Bound newsletter

There’s a pharmacist in the ED!?

Emergency Medicine (EM) Clinical Pharmacy is a growing field. In 2015, the American College of Emergency Physicians (ACEP) published a statement encouraging the involvement of pharmacists as part of the interdisciplinary team. It stated that all institutions should work toward a goal of 24/7 EM pharmacist coverage. EM pharmacists can help in numerous situations and serve as a valuable resource.

To become a clinical pharmacist, one must pursue an undergraduate degree, followed by a 4-year Doctor of Pharmacy (PharmD) degree, then residency and/or fellowship. The first year of residency is generally a broad overview of clinical pharmacy, and in 2020 had a match rate of ~63% of applicants. The second year of residency is specialized – such as emergency medicine, cardiology, or infectious disease, and in 2020 had a match rate of ~73%. In emergency medicine, pharmacists may go on to pursue a fellowship in toxicology or other certifications such as Advanced Trauma Life Support (ATLS), Advanced Hazmat Life Support (AHLS), Emergency Neurological Life Support (ENLS), and board certification.

So, what does an EM pharmacist do?

Resuscitation

  • Be it trauma, toxicology emergencies, stroke, myocardial infarction, or cardiac/respiratory arrest, EM pharmacists love being at the bedside and can facilitate improved patient care.
  • Rapid medication procurement, bedside medication compounding
    • ↓ time to analgesia in trauma, ↓ time to antibiotics in sepsis, ↓ time to thrombolysis in acute ischemic stroke → improved patient outcomes
  • Appropriate medication selection and dose → reduction in medication errors

Antimicrobial Stewardship

  • Encourage appropriate use of antibiotics to ↓ antimicrobial resistance
  • Involvement in callback culture programs to provide recommendations for antimicrobial selection when resistance or lack of coverage is evident

Medication Order Review

  • Expedite orders and provide prospective and/or retrospective review in urgent situations
  • ~ 1/3 of medication errors are intercepted during prospective order review
  • Urgently expedite medications to bedside and provide recommendations for medications

Medication Information

  • Pharmacists love to talk about medications and evidence! Have a question about medication administration? Antibiotic spectrum? Non-formulary equivalents? Evidence for new therapies? Ask your friendly EM Pharmacist!

Medication Reconciliation/Transitions of Care

  • Some sites have dedicated pharmacy technicians/pharmacists for completing medication reconciliations.
  • Assist in the selection of discharge medications that a patient’s insurance will cover → minimizes calls from outpatient pharmacies

Education

  • Patients/Caregivers
    • EM pharmacists provide patient education for high-risk discharge prescriptions like anticoagulants or intramuscular epinephrine.

Learners

  • EM rotations are popular for pharmacy students and residents – EM pharmacists are always teaching.
  • Many create “Pharmacy Education Boards,” quick infographics designed to educate anyone in the ED. Request a topic from your pharmacist!
  • ALiEM has a Pharm Series with great information curated for easy review and retention! Check out the example below.

em pharm pearls glucose d50 rise

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in March 2023 EM Bound newsletter

You’re about to complete The Match. It symbolically represents the end of your time in medical school (although remember, you still have to make it to graduation, so finish strong) and the beginning of your next journey- residency.

You’ll hear time and time again that you should “read up on your patients” and “find something to learn from every case you see.” At the same time, you’ll feel like “there’s not enough time” between shifts and “so much information out there” to know where is best to start. Don’t worry- ultimately you will find a system that works for you.

This month, I want to shine our spotlight on the amazing effort led by EM resident Dr. Nicholas Dulin from Einstein Medical Center. Dr. Dulin and some awesome faculty raters have updated a new collection of ALiEM’s 52 Articles in 52 Weeks to provide interns with a roadmap of key literature from recent years.

Along with the ALiEM Bridge to EM curriculum, this ALiEM resource represents curated and focused material to start diving into as you prepare for EM residency.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Feb 2023 EM Bound newsletter

On January 2, 2023 Damar Hamlin, a defensive safety with the Buffalo Bills, suffered a cardiac arrest after completing what appeared to be a routine tackle. Cardiopulmonary resuscitation (CPR) was initiated on field, defibrillation performed with an automated external defibrillator, and a return of spontaneous circulation was achieved. Nine days later, he was discharged from the hospital in remarkable condition and on the road to recovery.

Recently, I was the responding physician to a cardiac arrest that occurred in the waiting room of our Emergency Department. After identifying ventricular fibrillation and recognizing an absence of pulses, CPR was initiated, defibrillation delivered, advanced cardiac life support (ACLS) informed medications administered, and the patient regained a sinus rhythm. I visited with her today and marveled at the stories she had to share, demonstrating the absence of marked neurological injury.

I believe both examples highlight the impact that high-performance, quality CPR has on the outcome of patients with witnessed cardiac arrest.

Although you may not have completed ACLS training, you have likely witnessed or at the least encountered some instruction on performing CPR. There are many clinical and non-clinical skills that you will develop through your training, the rate and depth of compressions along with the closed-loop communication required, that will prepare you to be part of resuscitation teams.

High-performance CPR is an educational movement to emphasize the importance of timely chest compressions and defibrillation.

It would be unrealistic for me to summarize ACLS in a single post. Clinically, there are also nuances in knowing when and when not to use this guideline/algorithm. Still, there are some concrete things that can be reviewed.

Priority in ACLS

  • Quality chest compressions are paramount to supporting perfusion.
  • Although we traditionally follow an “A-B-C” approach, and the airway is still important, the initiation of compressions in a timely manner is key.

Primary Question in ACLS: Shockable or non-shockable rhythm?

  • Once the need for CPR is identified, the next question becomes, “Is the cardiac rhythm one that would respond to electrical defibrillation?”
  • The early detection of Ventricular Tachycardia and Ventricular Fibrillation will allow for early defibrillation, conversion to sinus rhythm, and return of spontaneous circulation and perfusion.

The Goal: Minimize disruption in chest compressions

  • Every time that chest compressions are interrupted, end-organ perfusion diminishes and it takes time to regain the perfusion pressure accumulated.
  • The goal should be to minimize interruptions to quality chest compressions.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Jan 2023 EM Bound newsletter

So you might think… “I’m just a medical student, why do I have to worry about changes to billing codes?” Well, the thing is you will have to deal with it in the future, and the notes you help write now do contribute to billing decisions.

Since the 1990s, billing for patient encounters has been directly linked to the complexity of care that is substantiated by the documentation in the medical note. A billing code, derived from the Current Procedural Terminology (CPT) developed by the American Medical Association (AMA), is assigned to the encounter and used for reimbursement calculations. This is true for all medical encounters, Emergency Medicine or other specialties, outpatient or inpatient. CPT codes 99281-99285 have represented, respectively, encounters that were considered Level 1 with minimal risk and not complex medical-decision making (MDM) to Level 5 which are high-risk cases requiring highly complex medical decision-making.

The biggest change in the 2023 iteration of CPT code determination is that complexity of visits will be determined by documented MDM. The code numbering, fortunately, will remain the same.

Here’s a simplified rundown of the changes (slated to start January 1, 2023):

  • Since 1992, an ED visit was assigned a “level” and CPT code using guidelines that required certain thresholds be met in each of the history, physical exam, and medical-decision making components. Starting in 2023, the level/CPT code will be assigned by the complexity of the MDM documented in the note.
  • The complexity of MDM will be determined based on:
    • Number and complexity of problems addressed
    • Amount and/or complexity of data to be reviewed and analyzed
    • Risk of complications and/or morbidity or mortality of patient management

Things to note (pun intended-haha):

  1. While the number of history and physical exam components (for example, how many systems are addressed in the review of symptoms or how many systems are examined) that are documented will no longer be a requirement, there will still need to be a medically appropriate history and physical noted.
  2. Reviewing each diagnostic result, reviewing prior results in comparison, explaining why something was not ordered (for example when using diagnostic tools like PERC or PECARN, and reviewing prior notes can all contribute to the complexity of MDM.
  3. Time spent is NOT a determining factor for complexity.
  4. Social risk, i.e. homelessness and food insecurity can contribute to complexity under the “risk of complications” consideration.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Dec 2022 EM Bound newsletter

Across the country, Emergency Departments are experiencing more than just the seasonal surge in patient presentations. Many institutions are feeling the burn from high levels of hospital crowding and the resulting ED boarding. While admitted patients, and those awaiting transfer to another facility, boarding in the ED is not a new issue, the continued strain on healthcare systems is made more challenging with early and prolonged URI seasons.

What exactly is meant by ED boarding?

  • ACEP defines the “boarded patient” as “a patient who remains in the emergency department after the patient has been admitted or placed into observation status at the facility, but has not been transferred to an inpatient or observation unit.”
  • ED boarding is the result of many variables, including the increased surge in patient presentations, but can most directly be attributed to the lack of available beds on the inpatient floors. This in turn may have to do with physical space constraints. However, as experienced during COVID, as a result of staffing issues on both the nursing and physician sides.

What issues arise during high levels of ED Boarding?

  • ED boarding has been shown to contribute to poor patient outcomes. Wait times increase, ambulance traffic may be diverted, and delays in diagnosis and treatment can result. Boarding places a strain on the ED by utilizing resources that would otherwise be available to those with acute issues and undifferentiated complaints.
  • For ED physicians and nurses, this manifests in seeing a higher number of patients, encountering unhappy or even angry patients, and facing challenges in the delivery of high-quality care.

What can be done?

Many task forces and independent analyses have been conducted to identify tangible actions that can be implemented by hospital systems in response to hospital overcrowding and ED boarding. Models for crisis staffing to allow for the recruitment of additional staff, purposeful use of space such as PACUs as holding areas, and prioritization of early morning discharges from the hospital are just a few. Still, many of these solutions are temporizing and do not address the greater systems-level issues. Much attention has also been directed toward advocacy at the legislative and community education levels as well.

Ultimately, it’s important to think about ED boarding as more than just an “ED” problem. Hospital overcrowding is something that impacts providers at all levels of the healthcare system. The goal remains the same: providing the best care for our patients.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine

Edgardo Ordoñez, MD MPH
Baylor College of Medicine
Emergency Medicine

Originally published in Oct 2022 EM Bound newsletter

Hispanic Heritage Month

September 15th – October 15th marks Hispanic/Latinx Heritage Month. This “month” is meant to recognize the contributions and achievements of Hispanic and Latinx Americans to the US. September 15th was chosen as the beginning of the observance because of the many Latin American countries that celebrated their independence on this date. In the spirit of social justice, health equity, and inclusivity, this month’s Spotlight focuses on our Hispanic and Latinx patients and their experiences.

What’s the difference between Hispanic and Latinx?

This could be its own discussion. It’s important to understand that these terms describe ethnicity and culture– not race. Hispanic means people who speak Spanish or are descendants from Spanish-speaking countries. Latino/a describes those that are from Latin American countries. Some prefer the word Latino/a over Hispanic due to the ties of the term Hispanic to colonialism. The term Latinx derives from a push toward inclusion. Spanish languages use gendered adjectives and nouns. Using the gendered terms of the Spanish language is entirely acceptable, but using the non-gendered terms such as Latinx allows those who value and seek inclusive environments to know they are in safe spaces that will respect their identity.

Latinx culture and language

People of Latinx ethnicity are not monolithic. While Spanish is the most common language spoken in Latin American countries, a wide variety of other languages are present, including several Indigenous and Latin-derived languages like Creole and Portuguese. Language Justice is a key practice used in social justice movements in order to create shared power, practice inclusion, and dismantle traditional systems of oppression that have traditionally disenfranchised non-English speakers. This framework is essential to consider, given how people have been reprimanded, discriminated against, and discouraged from using their native languages. Understanding these concepts can help us change the narratives intended to be well-meaning but not equity-focused. For example, the use of the term limited English proficiency (LEP). This term, used widely in academic and clinical practice, centers privilege and power of dominant groups. In patient care, research, and work in our communities, we must make every effort to provide a culturally safe environment for everyone, including language. The terms “limited” and “proficiency” can be stigmatizing because it suggests a deficit. Instead, a more equity-focused alternative is saying that individuals have a language preference or a preferred language.

What race are Latinx people?

As we all know, race is a social construct. This has become more embedded as a much-needed learning objective in medical education to help us shift from race-based medicine to race-conscious medicine. Using race as a proxy for biology and genetics in medicine has led to false beliefs about biological differences between racial groups. Like race, ethnicity is also a social construct, and we must be cautious when considering the needs of specific ethnic populations. Many people understand the concept of ethnicity but are less aware of the interrelationship of race and ethnicity. In considering Latinx communities, remember that they can be Black, White, Asian, and Indigenous. Some Black Latinx individuals may identify as Afro-Latino or Afro-Caribbean, as the African diaspora is seen throughout North, Central, and South America, along with the Caribbean. Has there ever been a situation where you walked into a phenotypically Black patient’s room and then been surprised when you realized they only speak Spanish? Or have you walked into a patient who “looks” Latinx (whatever that means), and are surprised that they don’t speak Spanish, but instead speak an Indigenous language? This is our unconscious mind (and bias) at play.

National Latino/a Physician Day

Despite Hispanic/Latinx individuals making up 19% of the US population, only 6% of physicians are themselves Hispanic/Latinx. October 1, 2022, was celebrated by many in healthcare as the inaugural National Latino/a Physician Day.

Edgardo Ordoñez, MD MPH
Baylor College of Medicine
Emergency Medicine
Originally published in Aug 2022 EM Bound newsletter

On the spectrum of dispositions from the Emergency Department, it is often easy to recognize early in the course of a patient’s presentation who will need to come in and be admitted, and who is likely to be discharged to outpatient care after some workup is done. Interesting cases such as an open tib-fib fracture from a motor vehicle collision, an ischemic stroke, and sepsis due to pneumonia all get admitted. The patients with otitis media, a corneal abrasion, and an uncomplicated abscess are discharged.

However, you may see cases on shift whose disposition can be less clear. You may find yourself thinking “if I could get this one test before they leave it would be best,” or “if only we had more time…”

Case 1

A 55-year-old male with a past Medical History significant for Diabetes Mellitus, Hypertension, and Hyperlipidemia presents to the Emergency Department with chest pain. He has a reassuring exam, his Chest X-Ray, ECG, and high sensitivity troponin are normal. He has a HEART score of 5. After completion of his evaluation, the patient is symptom-free. He does not have a primary care doctor in the area and does not have a cardiologist.

Case 2

A 23-year-old female with a Past Medical History of asthma and allergies presents with shortness of breath and wheezing. She has been using her rescue inhaler 5-6 times a day for the last two days. She has visible respiratory discomfort with some accessory muscle use and diffuse expiratory wheezing. She receives three rounds of nebulized treatments and steroids, and after re-evaluation, her symptoms have improved but she still has tachypnea and wheezing.

The two patients above were placed in the ED Observation Unit (EDOU), which is distinct from being admitted. Observation Medicine has become a growing field within Emergency Medicine, bringing together many aspects of quality improvement from a systems and patient care perspective.

What is an EDOU?

  • A dedicated area within, and under, the direction of the ED, where patients are managed to determine the need for inpatient admission. Most EDOU’s utilize protocols to provide efficient, evidence-based care.
  • There are typically two different pathways for EDOU patients: Therapeutic or Diagnostic protocols.
    • Therapeutic Observation
      • Diagnosis is relatively known and the decision point is whether intensive therapy will allow timely disposition.
      • High probability of treatment success within 24 hours (75-80%) utilizing the resources that are available.
      • Some examples are Asthma, CHF, Renal colic, Pyelonephritis.
    • Diagnostic Observation
      • Diagnosis for the patient is unknown with some degree of clinical uncertainty.
      • Patients will require further monitoring or diagnostic testing and workup.
      • The risk of disease progression is equally or more important as the existence of disease.
      • Some examples are Chest pain, Syncope, and TIA.

Considerations in Patient Selection for an EDOU

    • Generally, 5-8% of the total daily ED volume
    • Must be a patient-centered problem and not a system problem
    • Goal length of stay (LOS) in the EDOU would be ~ 15 hours but definitely < 24 hours
      • Remember that the patient had an ED length of stay (LOS) as well
      • 80/20 rule
        • ~ 80% of patients should be discharged
        • ~ 20% of patients should need to be admitted
    • All EDOU’s should have inclusion and exclusion criteria that provide guidelines on who can or cannot be placed in the EDOU (e.g., specific vital signs, lab abnormalities, comorbid conditions, etc.)
      • Allows for patient safety, efficient use, and helps triage appropriate patients.

Why utilize an EDOU?

The EDOU can be a great asset to the hospital system and patients. When compared to observation or inpatient stays on the floors, dedicated and protocol-driven ED observation units have shorter LOS, decreased overall costs, and improved patient satisfaction while improving ED throughput and reducing EMS diversion.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in May 2022 EM Bound newsletter

Emergency Medicine physicians wear many hats. We’re diagnosticians, proceduralists, and resuscitationists. Okay, that last one is a made-up term, but it’s true! Emergency Medicine physicians are experts in the medical resuscitation of acutely ill or traumatically injured patients. In the ED, we often provide care for very complex patients in the most critical period of their disease state. This intersection with critical care medicine has led to a very natural extension of EM physicians into the critical care arena. Since 2011, critical care medicine training has been recognized as an ACGME-approved subspecialty for EM residency graduates.

Currently, EM physicians interested in fellowships for critical care training can follow several routes to fit their interests. Here are some of the fellowship options:

  • Anesthesia Critical Care Medicine: Provide trainees with the knowledge and skills necessary to work in multidisciplinary critical care units (medical, surgical, trauma, neuro, etc).
  • Internal Medicine Critical Care Medicine: Tend to focus more on medically ill patients, with less clinical time in surgical units.
  • Surgical Critical Care Medicine: Focus on the management of critical illness in the pre-procedure and post-operative periods as well as traumatic injuries.
  • Neurocritical Care Medicine: Focus on the unique considerations necessary in providing care for patients with neurological illnesses or injuries.

Board certification through the pathways of anesthesia, medicine, and surgery will provide the training necessary to work as an intensivist in a variety of clinical care units. Aside from academic centers, many hospitals do not consist of a dedicated Neurocritical intensive care unit, but physicians trained in this subspeciality provide care through multidisciplinary teams in a mixed unit setting.

Critical care fellowships can provide physicians the opportunity to receive training in advanced topics such as Extracorporeal Membrane Oxygenation, the use of REBOA devices, and surgical airways, among others. Some Emergency Departments have begun to create ED-ICUs in which critical care patients are managed by EM-Critical Care physicians for an initial period of time until a decision can be made for continued need of ICU level care or the patient can be safely downgraded to a step-down or floor level of care. If you feel a thrill in managing critically ill patients, a critical care fellowship may be what you are looking for! Check out the resources below to learn more.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in April 2022 EM Bound newsletter

For many people, Medicine is a means to explore other professional interests as well. Emergency Medicine, some might argue more so than other specialties, is a skill set that is “mobile” and can be applied in a variety of leadership settings. Global Health or International Health is a cornerstone of Emergency Medicine and draws many residents to elective rotations and additional fellowship training.

What is it?

Global/International EM is more than mission-trips, humanitarian aid, and disaster response. Core to the mission of Global/International EM is sustainability through capacity building, collaborations with communities, and development of emergency response systems.

Why is it important? Who does it benefit?

  • Many countries still do not have EM as a medical specialty. The U.S. was the first country to recognize a dedicated field for emergency triage and management of the acutely ill or injured, undifferentiated patient. Most other parts of the world work with a structured healthcare system adopted the Franco-German model where subspecialists triaged to their respective inpatient units.
  • Through the years, and as a result of various international natural and humanitarian disasters, EM emerged as a medical specialty that engages with direct provision of care. A few examples are through organizations such as Medecins Sans Frontieres (Doctors Without Borders), and the development of emergency management systems, such as through the World Association for Disaster and Emergency Medicine (WADEM).
  • Through collaboration with other EM subspecialties, such as Ultrasound, Education, and Pediatrics, Global/International EM providers share knowledge and best practices with local healthcare providers to empower the care they provide to the communities they serve.

How can I get involved?

  • There are roughly 50 Global/International EM fellowships. Each program may define a specific focus for fellows and applicants may be attracted by the existing connections with other countries that are already in place.
  • Often fellows will explore advanced education in either Tropical Medicine and Hygiene or a Masters of Public Health in Epidemiology.
  • Given the added complexity of scholarship work across borders, it is important for those interested in Global/International EM to seek mentorship early and begin to form strong networks with the communities that they are interested in working with.

Resources

Sarathi Kalra, MD MPH
Research Director
Assistant Professor
Department of Emergency Medicine
University of South Alabama
Originally published in March 2022 EM Bound newsletter

Regardless of specialty or subspecialty, research and scholarly work continue to be the epicenter of growth – both for the individual physician and for the world of medicine. While the specialty of Emergency Medicine has been in existence for nearly 40 years, there are not a lot of structured post-residency fellowship programs in research. This pattern can be noted in several other specialties/subspecialties including cardiology, neurology, or oncology.

Across the board, most research fellowship programs available provide a fundamental understanding of research methodology and allow trainees to get involved in ongoing departmental projects. While it may be easiest to get involved in existing departmental projects, such projects may not align with a trainee’s interests and overtime may bring frustration. The ability to contribute to evidence-based practice and directly impact patient care, and the variety of topics available through EM, however, remain a motivator to many clinician-scientists.

Why is research necessary?

Even if one is not interested in pursuing a long-term career in research, it is of utmost importance for a physician to be able to read a manuscript and be able to critique the validity of results and the evidence provided. We all have witnessed the spread of misinformation during the COVID-19 pandemic. Textbooks have become a dated method of learning new advances because it takes approximately five years from the time data is published to it being made available in a textbook. As physicians, we are lifelong learners, and after graduation from medical school and residency, manuscripts, abstracts, and conference lectures will continue to be the best way for evolving one’s practice.

Research takes time– be it translational or clinical. There are hoops to be jumped through with the Institutional Review Board, data collection, data analyses, meetings with principal investigator or research mentor, preparation of the manuscript, and submission to a journal (which sometimes may take months). The breadth and depth of EM require that we stay up to date as a specialty and active participation in research allows an individual to contribute to this.

How does an EM physician-to-be carve out their path in research?

Scholarly activity is a requirement for most residency programs, however, no strict guidelines exist from the ACGME. Each program will be different, but they will all look for applicants that have demonstrated an ability to think critically.

There are several ways to achieve research and scholarly activity– at the medical student level, trainees can seek mentorship from their faculty members for getting involved in ongoing departmental projects and get abstracts/manuscripts prepared for annual meetings.

At the resident level, trainees can pursue a research elective or opt for programs that offer combined Master’s In Public Health (MPH). Getting involved with EMRA, ACEP, SAEM, or leading academic journals as a resident-editor can also give a real-world experience before committing to a research path.

Eventually, one may consider a Research Fellowship, Masters of Science, Epidemiology, Public Health, Biostatistics, Medical Education, or even Ph.D. in these fields, to acquire skills necessary to spearhead research projects at their institution.

Resources

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in Jan 2022 EM Bound newsletter

The delivery of healthcare involves many intricate components. Although we don’t like to think of it as a “business,” the reality is that topics applicable to the business mentality can actually contribute to improved healthcare delivery and in turn patient outcomes. Administrative fellowships provide the EM physician with exposure and training in healthcare administration, quality assurance and improvement, patient safety, clinical operations, and healthcare systems research among other skills. The goal is to improve systems issues and ensure the quality of patient care.

Here are some of the most common Q&As:

What do I get out of doing an admin fellowship?

Although operations-related leadership roles in both academic and community emergency departments may not require a fellowship, the focused training provides an opportunity to participate in impactful projects with protected time. You not only dive in headfirst to ED operations, but in many fellowships, you will gain access to administration meetings across the hospital, healthcare, or even academic system. Often, the fellowship is accompanied by funding for a Masters in Business or other advanced degrees. This dedicated time to hone a craft can be beneficial for networking, finding a niche, and developing a career trajectory.

What kind of career comes from training in administration?

While the titles vary according to role and institution, some of the jobs that administrative fellows move on to fill include medical director of the ED or observation unit, patient safety and quality improvement officer, director of the physician group, health policy research, hospital committees, and other C-suite affiliated leadership positions. These doctors often work fewer clinical shifts in order to maintain a schedule that allows participation in regular meetings and leaves them available for any department issues that may need to be addressed.

What types of fellowships exist?

There are various types of administration fellowships, each with different focuses and with different structures. The majority of programs are 1-2 years long. Most are in an academic setting and with larger institution affiliation, some are offered as part of working for a community hospital system, and others are sponsored by contract management groups.

As a result of the different offerings for fellowship, each will have its own requirements for applying and interviewing. Check out the resources below to learn more about if an Administrative path is right for you.

Resources

Moises Gallegos, MD MPH

Moises Gallegos, MD MPH

Editor, ALiEM
Section Editor, ALiEM Medical Student Home Page
Clerkship Director
Clinical Assistant Professor of Emergency Medicine
Stanford University School of Medicine