A newsletter for medical students pursuing a career in emergency medicine

CLERKSHIP LIFE &
RESIDENCY APPLICATION SEASON

Reflections on Emergency Medicine

David Gordon, MD

• Intellectual: Emergency Medicine offers the excitement of the unexpected and unknown. Each shift is unique with a variety of patient presentations that span different medical specialties and diverse patient demographics. In the ED, emergency physicians are the first ones to lay eyes and hands on undifferentiated patients and have to think both critically and creatively about their diagnosis and treatment. In critical care situations, emergency physicians must quiet the mind to act methodically and decisively in life and death scenarios. EM offers great reward for those who enjoy being intellectually challenged as we must utilize the arsenal of medicine to figure out the best way to serve every patient that enters the ED.
• Relational: When it comes to interprofessional relationships, emergency medicine functions as a team sport. It is a specialty with a horizontal hierarchy reflected in close working relationships among attendings, residents, and students. Emergency physicians enjoy and depend on their collaboration with other health professionals including nursing, mid-level providers, paramedics, social workers, respiratory therapists, and more. With respect to patient care, emergency physicians are privileged with supporting patients and their families through moments of fear, hardship, and sometimes loss. The immediacy and significance of these moments bring great value and meaning to one’s career.
• Spiritual: Medicine is a profession rooted in service to humanity. No where is that mission more strongly manifested than in Emergency Medicine, and each year I see this increasingly recognized by and resonating with EM applicants. No matter the issue, the time of day, or one’s ability to pay, the doors of the ED are always open. There is a dignity and nobility in the role that ED’s play in the healthcare system which provides a big draw to EM and a reason one can feel good after every shift. The global pandemic recognized this during their #healthcareheros campaign. In that national shut-down, it was our field that showed up to do what we have done long before the pandemic, and will continue to do long after: to serve our community.

• EMRA and CORD Student Advising Guide

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

ROTATION TUNE-UP

Arm yourself with Clinical Tools

Headaches

Sree Natesan, MD

• History: A thorough history can help you elicit the etiology of the H/A. Here are a few considerations:
  • Onset: The onset of the H/A can really be the best place to start. Sudden onset, "thunderclap" can suggest a vascular etiology. A more gradual course may suggest an infectious or inflammatory etiology, whereas a progressive headache or neuro symptoms may suggest a malignancy etiology.
  • Character: While a lot of patients will say they are having the "worst headache of their life," not all of them are having a subarachnoid hemorrhage (SAH). Asking questions such as "what number was the pain when it started, what is the pain level now," or "did it come on gradually versus all of a sudden" can help you learn more. Another question is asking "when did you have a headache this bad" can gather the idea if this is the worst headache or not. A careful history is important.
  • Associated symptoms: Its key to do a good ROS. If the patient is having fever and neck stiffness, then meningitis would jump up on the DDx. If the patient is having an aura and photophobia, then migraine may be the culprit.
• Physical exam: Your exam is key to helping to elucidate the working DDx and guide your workup. Here are a few pearls to make sure you focus on when your patient presents with H/A:
  • Eye Exam: A fundoscopic exam looking for papilledema can help you figure out if your patient has increased intracranial pressure (ICP) in processes such as Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) or space occupying lesions like meningiomas, glioblastomas, metastatic disease).
  • Neuro Exam: You can localize the lesion (if one is present), based on your neurologic exam! It really is a map to the brain. Ensuring a thorough neuro exam means cranial nerves, strength, sensation, and reflexes. Cerebellar testing looking for nystagmus, abnormal finger-to-nose, heel-to-shin, or gait is important.
• Diagnostic/Therapeutics: The workup for H/A is really dependent on your thoughts on what the leading diagnosis is. For example, if you are worried about an infection, a lumbar puncture to analyze the fluid would be important. If your patient may have Pseuodotumor, an opening (and closing!) pressure from the spinal tap is key to the diagnosis. If you are worried about malignancy, imaging will be helpful (such as CT or MRI).

• ACEP Headache Guidelines

• ALiEM: Prochlorperazine, Metoclopramide, and Diphenhydramine for Acute Migraine Headache

• PEM Pearls: Migraine Treatment for Pediatric EM Patients

• EMDocs: Headache Management- Best Current Evidence

SPOTLIGHT

Anyone, Anything, Anytime… Anywhere:

Global Health in EM

• 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.

• Global Emergency Medicine Consortium
• EMRA Fellowship Guide: International EM

WELLNESS CORNER

Embrace the Discomfort of Change

EXPAND YOUR
SOCIAL MEDIA HORIZONS

EM MATCH ADVICE PODCAST

• EM Match Advice: Acing Your EM Rotation (30:38 min)

ALiEM HIGHLIGHT REEL

EM Study Resources

EM BOUND TEAM