EMBound_InLine

A newsletter for medical students pursuing a career in emergency medicine

September 2021
EM Bound pencil sketch
Letter from the Editor:

Hello #EMBound Med students,

As we say goodbye to Summer and hello to Fall, we enter the season of change. Our Sub-Is are getting ready for ERAS opening, interview season starting, and the many transitions of the end of medical schools. For the rest of our medical students, you too are going through growing and learning new knowledge and responsibilities as you move through classes and rotations. Please know we are here to support you at any leg of your journey to becoming #EMBound.

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

Applying to Emergency Medicine: Do I have a good list?

David Gordon, MD
Undergraduate Education Director
Duke University

September marks the next phase of the residency application season, during which applicants may begin applying, and towards the end of the month, programs may begin reviewing. In this stage, the perennial questions of “How many programs?” and “Which programs should I apply to?” come full steam ahead. Like many things, the answers to these questions are individualized based on personal goals and one’s level of competitiveness. And like most things pertaining to application strategies, the best sources of information are local advisors who know their students best and are informed by the experience of previous students from their institution. There are, however, some general principles and resources that are good for all applicants to know.
  • Begin with you: Before asking where to apply, make sure you have taken a self-inventory on what matters to you. Residency will be the most formative and rewarding time in your medical training, but it is no walk in the park. Be honest with yourself about whether you need a specific geography or living environment to support your well-being. Ask yourself: Is it important for you to be near family for support, or are you out for adventure and want to try something different? Do you thrive in the big city or prefer quieter living? Do you learn best by doing, or do you need time to think and process? There is no right or wrong here. Knowing yourself upfront will help make sure you put yourself in a good position to find that right fit and help others in guiding you accurately.
  • Where should I apply? After completing your self-inventory, you can use directories to develop and refine your list. EMRA Match and the SAEM Directories both allow you to filter by geography, practice setting, and length of training. If you are an International Medical Graduate (IMG), EMRA Match, as well as the AAMC’s Residency ExplorerTM Tool, can provide you with information on the percentage of IMGs and visa sponsorship at a program. While making sure you identify programs that meet your personal needs, it is also good to be open to different possibilities and not limit yourself at this stage. Explore programs with different practice environments and lengths of training as this may either reaffirm your priorities or pleasantly surprise you with new possibilities.
  • How many programs should I apply to? The number of programs an applicant should apply to is a combination of an applicant’s competitiveness and that of the programs being considered. While Step 1 scores will be phasing out as a numeric screening mechanism in its move to pass/fail and holistic review is being increasingly advocated for in support of diversity initiatives, remaining cognizant of one’s Step 1 score for this application cycle doesn’t hurt. EMRA match has a Step 1 Cut Off filter to show - at least historically - what some programs have considered a desirable score. The AAMC’s Apply Smart provides data on a point of diminishing returns above which an applicant based on their Step 1 score and applicant type (e.g., U.S. MD vs. DO) gains a minimal advantage in applying to more programs. For example, for U.S MD applicants, the range is 24 to 33 programs, whereas, for DO applicants, it is 35 to 38. Limiting the predictive ability of this information is the importance of the SLOE, which is often the most important factor when programs review applicants. Do not expect to be told what your SLOE rankings are, but you should be able to gain a sense of your performance from the grade and feedback you received on your 4th year EM rotation.
  • Talk to people. Lots and lots of people. The common saying goes that all EM programs will give you great training, but there are programs that, because of geography and visibility, may be more difficult to match into because of applicant numbers and selectivity. In addition to your advisor, talk to other faculty and residents to get feedback on your list or at least some of the programs you are considering. Listen for comments like “I know lots of people who are happy there” or “that’s a great place for …” You also may potentially want to adjust if the response to every program you mention is “that’s a hard place to get into.” Just like you did for college and medical school, it is good to have some range of competitiveness as it is not just the number but also the spread that determines the adequacy of your list.
  • Special Circumstances. If you are worried that you have “red flags” in your application that will challenge your ability to match in EM, the Emergency Medicine Application Tool for Common Hangups (EMATCH) can help you identify those situations and direct you to advising resources. For applicants with special circumstances such as couples matching, international medical applicants, or re-applying, multiple advising guides have been created.
This is a time of both high excitement and nerves. Know thyself, seek multiple sources of advice, and apply smartly. Programs across the country look forward to reading about you and getting to meet you soon!

Additional Resources
EM Bound book

ROTATION TUNE-UP

Arm yourself with Clinical Tools

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

Acute Pancreatitis: Sick or Not Sick

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

Pancreatitis is not an uncommon disease that we see in the emergency department. Often, the diagnostic workup includes determining if the pancreatitis is due to biliary disease as this is the most common cause. Other causes of pancreatitis include alcohol use, high triglycerides, trauma, other causes of obstruction, and even scorpion bite! Serum lipase 3x the upper limit of normal, serves as the cutoff for the diagnosis. But how do you decide who’s sick or not sick?

Some clinical guidelines are available, including Ranson’s criteria, the Harmless Acute Pancreatitis Score (HAPS), and the Bedside Index of Severity in Acute Pancreatitis (BISAP) Score. One of the limitations of Ranson’s criteria is that it requires 48-hour lab tests, including an ABG. This is not helpful in the ED. The HAP Score has three criteria: peritonitis, creatinine, and hematocrit. Given the subjective nature of the first criteria, this scoring guideline is less reliable. However, a score of 0 according to this guideline suggests “no pancreatic necrosis, need for dialysis, artificial ventilation or fatal outcome.”

The BISAP Score offers another risk stratification for patients with acute pancreatitis.
  • B is for BUN >25 mg/dl
  • I is for having impaired mental status (or how I remember as intoxication)
  • S is for having >2 SIRS Criteria
  • A is for age >60
  • P for the presence of pleural effusion
The scoring system is simple: Patients with a BISAP SCORE of 0 had <1% risk of mortality>

So next time you see a patient with pancreatitis, be sure to mention the BISAP score and help it guide you regarding the level of care needed for the patient.

5 Steps to Ace Your EM Rotation

Ellsworth (EJ) Wright, MD, MBS
Chief Resident
St. Joseph Regional Medical Center (Patterson, NJ)

Transitioning from the MS3 core rotation mentality to thinking like an MS4 in the Emergency Department (ED) is not easy. Fear not! You’ve already made the first step in the right direction by reading this newsletter. So here it is, the five key steps to succeed on your audition rotation in the ED.
  • Step 1: Prepare for the rotation. Just like anything in medicine, preparation is everything. You need to build a foundation that you can use when you get onto shift. Anand Swaminathan and I recently recorded a podcast on Rebel EM entitled, Crush Your Rotation. Have a listen! Then, find a resource to build a foundation in EM. I chose the ALiEM “Bridge to EM: Senior Medical Student Curriculum,” which gives you a schedule and what resources to use to cover the fundamentals of EM.
  • Step 2: Know your environment. On your first day, familiarize yourself with where everything is. It can really make a difference when you go to a resuscitation and you realize the ultrasound machine is missing, and you go ahead and bring it to the room. Next, introduce yourself to all the staff. The ED works as a team and each member is integral in providing care to our patients. We want you to be part of that team. When we know who you are, you are that much more likely to stand out as opposed to “that medical student” who has no name.
  • Step 3: See patients and own this role. Get busy: be assertive in seeing patients, and take ownership of your patients. This includes following up on labs and radiology tests, calling consults, and re-evaluating them to make sure our interventions are working. Get to the bedside as much as you can. Learn how to do procedures, learn how to put patients on the monitor, and offer to transport patients as needed (and only if you know how to get them to their destination). A student who takes the initiative to do these little things really stands out, but also, please understand your local environment. In California, you will be considered aggressive if you start pushing your patients to the CT scanner without telling anyone. Knowing the learning environment and cultural norms can help you fit in while still standing out. When in doubt, ask.
  • Step 4: The presentation. Start with EMRA’s “Patient Presentations in Emergency Medicine.” This is a great video that covers the basics of presenting in the ED. Next, read “The 3-Minute Emergency Medicine Medical Student Presentation,” by Davenport et al. This will build on the video and provide you with a framework for approaching the patient presentation. Always concentrate on what brought your patients to the ED TODAY! Present this information concisely followed by sharing your medical knowledge through your differential diagnosis and plan. Tell us why you think something is more likely, vs. least likely, while not leaving out Worst Case Scenario/Life-Threatening diagnosis. The SPIT mnemonic offers a great framework for discussing differential diagnoses: Serious, Probable (commit to one!), Interesting, and Treatment (of your probable diagnosis). This will help us better understand your clinical reasoning.
  • Step 5: Be yourself and relax. You’re in a new environment, you’re stressed with the thought of Matching, and the pressure is palpable. Breathe--it’s going to be OK. Try to incorporate into the team without stepping on toes. Sometimes less is more. Read the room and learn when to ask questions and when to simply observe.
So there you have it. Five pieces of advice to succeed on your EM audition rotation. Remember that the programs are also excited to get to know you and teach you. These rotations fly by, and before you know it, you’ll be sitting on the other side trying to help students succeed in their rotations.
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COVID-19 UPDATES

The numbers don't lie: As of today, September 1st, 39 million total cases of COVID-19 have been reported in the US, with over 638k who have lost their lives as this deadly virus continues its sweep across our nation and world. As medical students, you can help us fight misinformation and share the benefits of vaccinations.

Here are some key points from the CDC:
  • Multiple variants of the virus that causes COVID-19 are circulating globally, including within the United States. Currently, four variants are classified as a variant of concern (VOC).
  • Currently, only about 52% of the U.S. population is vaccinated.
  • COVID-19 vaccines remain the most powerful tool we have against COVID-19, making it critical that all people get vaccinated as soon as they are eligible. Vaccines are effective in protecting you, especially against severe disease that could lead to hospitalization and/or death.
  • Recommend fully vaccinated people to wear a mask in public indoor settings in areas of substantial or high transmission.
  • On August 23, 2021, the U.S. Food and Drug Administration (FDA) granted full approval of the Comirnaty/Pfizer-BioNTech COVID-19 vaccine for the prevention of COVID-19 disease in people ages 16 years and older.
  • To find a vaccine provider near you, visit vaccines.gov or your state or local public health department.
Please stay safe! Here are some quick resources to share with your family and community regarding the Delta Variant and link to ARCHIVED newsletters with further COVID-19 information:

Resources:
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SPOTLIGHT

End-of-life Care in EM: Hospice and Palliative Medicine


Moises Gallegos MD MPH
Clerkship Director
Stanford Emergency Medicine

As Emergency Medicine providers, resuscitation of the critically ill patient is at the core of what we do. Our training prepares us to respond to abnormal vital signs and decompensating clinical states. Sometimes, however, the truly difficult aspect of our roles in medicine is recognizing when less may be more, and when, for the patient in front of us, addressing goals of care means more than resuscitation. End-of-life care in the Emergency Department requires special considerations, and we should recognize the role that emergency care teams play in palliative and hospice decisions.

Since 2006, Hospice and Palliative Medicine (HPM) has been recognized as a subspecialty and is available to EM physicians in a 1-year fellowship. Still, even if additional training in HPM is not in your future, there are great colleagues available to consult for care decisions. Many academic centers have multi-disciplinary teams with HPM physicians, case managers, and social workers to help navigate end-of-life care decisions.

How does Hospice and Palliative Medicine fit into Emergency Medicine?
Palliative care principles aim to improve the quality of life for patients and their families during critical illness by aiming to prevent and reduce suffering through a holistic approach. This includes providing resources, mental and physical support, and focuses on symptom improvement. This is accomplished by aligning care plans with the patient’s personal goals. It is also important to understand family goals and values. . As we see patients at terminal stages of acute or chronic illness, emergency medicine should embrace many of these core principles to improve the quality of care we provide.

What is the difference between Hospice and Palliative Care?
Palliative care and hospice both aim to provide comfort. However, palliative care does not require a terminal diagnosis. This service can be utilized for any serious illness, at any age, alongside any ongoing treatment. Hospice, in contrast, is started when the patient is considered to have a life expectancy of less than 6 months.

What are some key components of end-of-life care?
  1. Clear communication: It is important for physicians to understand a patient’s values, concerns, and final decisions. Clear, open, and constant communication is essential.
  2. Ease suffering: A focus of hospice and palliative care is improved symptom management. This is variable for patients but may include pain and nausea management among others. Elevating a patient’s quality of life in the terminal stages of the disease will mean different things for different patients and their families. Inquire what can be done to make them or their loved one more comfortable.
  3. Create partnership: Aligning patient and family goals with care plans and creating a patient-centered approach will allow physicians to avoid additional harm and ensure emotional support.
What types of services are provided?
Palliative care and Hospice provide a myriad of services ranging from medication to specialty consultation, to home resources. Hospice provides home health services but also inpatient hospice for the final phase of the patients’ life. To read more on the resources provided, check out the American Hospice Foundation site.

A summary table can be seen below:
Palliative care vs Hospice
Ultimately, it’s about being thoughtful about the patient in front of you. End-of-life care in the ED is more than just confirming DNR status. It’s about framing your approach to care with patient and family values to ensure integrity and dignity are maintained as you care for them.

Resources
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WELLNESS CORNER

Setting Boundaries: Perspectives on Motivations

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

Many of our #Match2022 #EMBound readers are currently finally doing their sub-internship rotation in emergency medicine. This is in the context of the rising cases of the COVID-19 delta variant during this pandemic, and for many of you, your first away rotation. You’ve worked so hard to get to where you are now. You want to do so well, and you’ve come prepared--dressed to impress, have read several resources to help you answer the questions from your patients, residents, and attending. Things are going well, and you’re preparing for your shelf exam. You’re exhausted, and yet, you keep on telling yourself that if you just study for one more hour, if you can maybe cut one or two hours from your sleep, if you just say 30 more minutes on shift, maybe, just maybe, you’ll get a better grade.

Dr. Kristen Neff talks about two types of motivations. The first is the motivation of fear: fear of failure, fear of not doing well, fear of not being good enough. This motivation is not alien to physicians and those training to become one. After all, it’s what got us to where we are now. It’s the motivation that gives us our 2nd, 3rd, or 4th wind when we’re feeling depleted. And yet, in the long run, this is not sustainable.

The alternative to the motivation of fear is the motivation of care. It’s taking steps to take care of ourselves whenever we encounter challenging situations. By practicing self-awareness, we explore our own needs, which could be in the form of much-needed rest, a nice meal, or any of the other needs pointed out by Maslow.

Setting boundaries is not easy, especially given your role as a medical student. Yet, it can be done. Here are a few key ways to do so:
  • Focus on areas within your circle of influence. Do you really need to spend that extra hour to study, or will getting a good night’s rest allow you to be more present when you’re on shift? Yes, you will have to make sacrifices. This means sometimes saying no to watching the latest episode of Ted Lasso or having dinner with a friend in order for you to have more time to study. Just as important, you also will need to put the e-books down so you can spend time with your friends and even catch up on your favorite show.
  • Find a balance between work and rest. This is vital and takes deliberate practice. You’re not superhuman, no matter how you think you are. We all need rest, and we are not going to be successful if we’re always feeling tired. Taking a break allows us to look at a task with a fresh perspective, and allows us to be creative.
  • Have a growth mindset: Be kind to yourself. We all make mistakes. We all have areas where we struggle. This is part of our shared human experience. Being kind to yourself allows you to move past the ruminations of the shoulda/coulda/woulda, and instead focus on the next steps on how we can be better. By being kind to ourselves, we actually allow ourselves to see the path on how to get to where we want to be.
  • Plan for success. Studying daily can be a form of setting boundaries for yourself, just as giving yourself time to exercise or having a good time are examples of self-care. You deserve that. This also means you are not waiting until the very last minute to study. And don’t forget to ask for help.
With the motivation of care, you’ll find that you do not have to betray yourself in order to take care of others.
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EXPAND YOUR
SOCIAL MEDIA HORIZONS

September marks the beginning of fall and a new season for #EMBound students. You’re finishing your away rotations, and you’re also finalizing your ERAS application and meeting with your mentors. Check out the content of these profiles in #SoMe.
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EM MATCH ADVICE PODCAST

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

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

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

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