EM Bound Newsletter

**A newsletter for medical students pursuing a career in Emergency Medicine**

June 2020

We are thrilled that you are interested in the exciting field of Emergency Medicine (EM)! We are beyond excited to launch the inaugural issue of Academic Life in Emergency Medicine’s (ALiEM) EM Bound. This free monthly newsletter for EM-bound medical students serves as a resource and guide on their journey to the residency match and beyond.

TOP NEWS

“I haven’t done any clinical work since February. Am I going to be ready to be an intern?”

We understand how scary and frustrating the impact of the COVID-19 restrictions has on your medical education. Please know that the rest of the country, in fact, the world, is also trying to figure this out with you. A good start is to use Bridge to EM as a guide.

Bridge to EM is an 8-week curriculum made to equip you with the tools to help build your medical knowledge foundation so you can start your first day with confidence. All of these resources are free for students with an EMRA membership (the C3 podcasts are open access through June 2020) and have all been vetted to ensure up-to-date information. These resources are well-made, practical for real life, and high yield.

There will also be a lot of logistics questions that will come up–how do I move to the new city for my training? Will I be allowed to work? Am I going to be prepared to see my first patient? Know that you are not alone in this. Please join the conversation on social media regarding this topic. Some key conversations are happening at #MedStudentTwitter. Oh, and before you buy that BMW to celebrate your graduation, pause and read this article, “The BIG Financial Mistake I (almost) Made After Med-School Graduation.”

SPOTLIGHT

Graduation in times of COVID-19 Global Pandemic

For our MS4’s, it’s hard to believe that this month serves as the culmination of all the work and effort you have put into your journey to become a physician. Congratulations! Getting to this point has not been easy–those sleepless nights studying for biochemistry, getting to know your classmates as you immerse yourself in gross anatomy, those multitudes of tests and step exams you had to endure. Who knew that talking about food while dissecting a cadaver would not be weird at all. And remember organic chemistry in undergrad? Fast forward to this time two years ago, you were nervous and equally excited about finally doing your clinical rotations. Did you get your first choice rotation? Did you know you were going to pursue EM back then?

As you ponder these questions, what is clear is that the past 3 months have put your world off-kilter. What you thought was going to be a grand celebration of all of your hard work, the senioritis kicking in, and some of you even had international away rotations set up–all of this has now been converted into 2 words, “social distancing,” or “global pandemic,” or “COVID-19.” You had to celebrate The Match virtually and now you’re celebrating graduation with the fanfare behind a computer screen. Were you able to attend the AMA sponsored #30kNewDocs celebration?

While we can’t give you fireworks and confetti, we at ALiEM want to celebrate all of your work, achievements, trials, and tribulations! After all, there is something to say about graduating medical school and starting your EM residency in the midst of a full-blown pandemic. Whether you are excited, nervous, or afraid, we are grateful for your commitment to EM and welcome you as part of the frontline clinicians starting July 1st. We would like to extend our invitation to you at our ALiEM Level UP event on Monday, June 15 at 5 pm PST/8 pm EST as we celebrate the graduates of EM residencies across the country to give you a perspective of your future and how far you have come.

Congratulations again! We celebrate your success and look forward to working alongside you as comrades in EM!

COVID-19 UPDATES

Pediatric Emergency Medicine (PEM):
Multisystem Inflammatory Syndrome in Children (MIS-C)

Anita Thomas MD MPH, Rebekah Burns MD
Seattle Children’s Hospital/University of Washington

Here is a quick resource on MIS-C or PIMS (pediatric inflammatory multisystem syndrome) as related to COVID-19.

Fast Facts

Children were initially thought to be minimally affected by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causing Coronavirus Disease 2019 (COVID-19).
What is MIS-C/PIMS? A systemic pediatric vasculitis triggered by a hyperinflammatory response, similar to Kawasaki disease (KD) or toxic shock syndrome (TSS). It is thought to be triggered by SARS-Co-V-2 exposure.
Time to Illness: Incubation period is unknown, but most cases have had exposure within 4 weeks of presentation.
At Risk: Patients < 21 years old. Based on current data, it is relatively infrequent, but a “hot zone” in Italy reported a 30-fold increase in monthly presentations of Kawasaki-like illness. COVID-19 tends to more adversely affect children < 1-year-old and those with chronic conditions such as asthma, cardiac disease, or immunosuppression.
Treatment: Mostly supportive. If patients meet criteria for complete or partial KD they should receive standard therapies including IVIG, aspirin, and possibly glucocorticoids.

Comparing Kawasaki Disease to MIS-C COVID-19

Differential Diagnosis: Sepsis, Kawasaki Disease, toxic shock syndrome, streptococcal infection, macrophage activation syndrome, myocarditis (i.e., inflammatory processes).
Work-up: If worried about MIS-C, consider obtaining the following (results consistent with disease shown in parenthesis)*:

We know, it seems like the broadest possible workup, but remember, this disease process is novel, and we still don’t know a lot about it.
Pearl: BE CAUTIOUS with fluid boluses, but resuscitate appropriately. These patients can have cardiac involvement, including cardiogenic shock.

Additional Vetted Resources:

References:

AAP: Ask the Expert: What are the presenting signs and symptoms in children with confirmed COVID-19 disease?
CDC: Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19)
Royal College of Paediatrics and Child Health Guidance: Paediatric Multisystem Inflammatory Syndrome Temporally Associated with COVID-19
The Lancet: Hyperinflammatory shock in children during COVID-19 pandemic
The Lancet: An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study

COVID-19 PPE Pearls: See the May 2020 newsletter.

CLERKSHIP LIFE & RESIDENCY APPLICATION SEASON

How to Rock Your Sub-I

In accordance with national recommendations, it is expected this year that students applying to emergency medicine will only be rotating at their home institution with the exception of those who do not have access to a residency program in their school’s system. Doing well on your sub-I will remain key to obtaining a strong SLOE as well as showing your passion for Emergency Medicine. Here are some top tips for rocking it!

Show up ready to shine: Showing your passion for EM means being engaged and enthusiastic. Your eagerness and ability to help out your team can help you shine.
Show up on time: Be sure to be at least 5 minutes early so you end up at the right place at the right time. Showing up late can create a bad impression that may linger despite your best intentions to correct this. View yourself as what you are- an integral member of the team.
Make yourself indispensable: Helping the residents with tasks can elevate your status on the team. Whether it’s following up on labs/imaging, calling consults, updating the patient/family, or calling nursing homes/family for collateral information, think of innovative ways to help out with patient care. Your residents will love you for it!
Be prepared: Show up well-rested and ready to perform. Read ahead of time (check out our Bridge to EM Curriculum (https://www.aliem.com/bridge-to-em/) if you are looking for a place to start). Ensure your success by having your bag packed and ready for your first day (see all the essentials that you will need below).

Present like a pro: Clear and concise patient presentations are key to showcasing your medical knowledge and clinical reasoning skills. In each patient encounter, use the differential diagnosis as your guide for organization and content. Always know your patients’ vital signs and make it clear when you are concerned for the presence of a serious condition… or grab your supervisor right away if you think the patient requires immediate attention! By the end of the presentation, your listener should have a good feel for “what do you think is going on?” and “what do you want to do?” Before starting your sub-I, become familiar with the differential diagnosis for common complaints and the presentation style for emergency medicine.
- Top chief complaints:
  o Abdominal pain
  o Altered mental status
  o Back pain
  o Chest pain
  o Fever
  o Headache
  o Musculoskeletal injury, trauma, and wound care
  o Nausea and vomiting
  o Shortness of breath
  o Sore throat
Education Video: Patient Presentations in Emergency Medicine
Know your procedures: The best way to be allowed to do procedures is by knowing the process. When your team is doing a procedure, you can chime in on landmarks and the steps to demonstrate that you know the drill. This will help you earn their confidence and give you more opportunities to do procedures during your Sub-I.
- CDEM: Procedural Skills

Additional Resources:

Education Video: Effective Consultation in Emergency Medicine
CORE EM: Procedure Videos
SAEM: EM Clerkship Primer
EMRA: Crush your Clerkships

EXPAND YOUR SOCIAL MEDIA HORIZONS

It’s June! This means you’re about to either graduate or you’re about to apply for residency. Here are some hashtags that will help you with your journey. The first one is what residency programs use to highlight key concepts in their weekly didactics. This will give you some snippets of evidence-based medicine, as well as key concepts in EM. We wanted to put something COVID-related during the pandemic, so we thought something free-open-access-medical education is appropriate. Last, and certainly important, we at ALiEM believe in diversity and representation in medicine. Check out these hashtags to celebrate our diversity in medicine.

Three suggested Twitter accounts to follow today:

To help you get started with building your personal learning network, here are some Twitter hashtags to peruse:

You can engage with us at @ALiEMteam. We’d love to hear how you are doing!

IF I KNEW THEN WHAT I KNOW KNOW

A RESIDENT’S PERSPECTIVE

Graduation in the COVID-19 Era: Distanced but United
Nupur Nischal, DO (PGY-3)
Duke University Hospital Emergency Medicine
@nischalsays

We’ve done it quite a few times now, yet the idea of graduation still drums up emotional thoughts: caps flying in the air, family – exchanging hugs and happy tears, while our teachers and advisors gaze at us beaming with pride. “Of course, this is what was expected,” we think, downplaying the importance of the event. Yet physically walking across a stage receiving the many commendations for a successful future forces us to pause and reflect on the arduous path that led to this moment. It reminds us of our efforts, struggles, successes, and also of the failures that made us stronger. Though the stage might be missing this year, we are instead afforded a prolonged opportunity to be mindful of the strength we have accumulated during this important milestone.

The global pandemic has plunged us into a virtual world forcing us to find novel ways to connect. It is a practice that we have been gifted amongst this chaos and one I am certain will unite us long after we have moved on. COVID-19 reminds us our medical knowledge is not just scientific. In the face adversity, it’s creative and adaptable. It is an art that has revived our passion to never let anything compromise patient care. I have seen you, my colleagues, not only endure but grow- weary but unyielding. We have the opportunity to bring our novel ideas and fresh enthusiasm to institutions across the country, and rally to conquer this problem.

When asked how graduating during COVID-19 makes me feel, I can’t lie. It is a mixed bag of emotions. I am disappointed that my family won’t get to hear my name called as I am handed my diploma. I’m sad for all those missed hugs. I am enthusiastic about staying in touch with my community knowing we will continue to support each other. I’m uncomfortable about leaving at such a time, yet confident that we are equipped with the skills to solve problems never faced before. I am really afraid, yet even more excited we will be pushed further outside our comfort zones to accomplish great things. One distant day, when medical students read about the pandemic, I will be proud to say that we not only lived through it but graduated during it and contributed, necessary and essential in the eradication.

So, healthcare heroes — Yes, some of you may cringe at hearing that, but what you have achieved in these past years is nothing short of heroic; you have persevered through learning rigorous, overwhelming medical knowledge, have foregone parties with friends, have missed yet another family function, have cried in closets or bathroom showers, have laughed and rejoiced at successes, have seen death, and you have seen how beautiful life can be–You continuously are making life beautiful for so many people. Congratulations #Classof2020 on graduating! Remember the privilege of donning that long white coat and being called “Doctor” for the first time means you have the power and responsibility to change lives. Go forth! Go help your communities in the time when they need you most. Only a few can right now: You can and will!