New EMRA Leaders

Congratulations new EMRA Board Leaders!

Alicia Kurtz, MD, President
Chief Resident, UCSF Fresno, Fresno, CA
president@emra.org  /  @aliciakurtz_md

Describe your leadership style in 20 words or less.
Oooo — this is a tough one! But probably would be a derivative of the Golden Rule: Be the kind of leader you want to follow. To me this boils down to being willing to do the work (not just assign it to others), being OK with being wrong and owning it, letting yourself dream big and be vulnerable, taking feedback well and growing from it, always working to improve and move forward, keeping the focus on what’s best for the group, and maintaining a relentless positivity.

Best advice you’ve ever heard?
This is a tie:
1. “You never know where the road will go. My advice? Take the road.” — Julie Veinbergs, MD (the OB/GYN who delivered me!)
2. “When all eyes are on you… wink.” — Mike’s Hard Lime bottle cap

If your fellow residents picked a motto for you, what would it be?
Well, I can tell you that one of my attendings wrote on a shift eval of mine, “I wish Alicia would take a Valium before working with me.” Haha! So it would probably be something about having energy, and overabundance of enthusiasm, and frankly being a little crazy…

Respecting HIPAA, tell us about your most memorable patient encounter.
So many to choose from! One that stands out is definitely this young male who had some really intricate tattoo sleeves on his arms that were all cut up from broken glass. I spent the better part of an hour doing a careful job suturing his lacs to make sure the tattoo was going to line up well and his scars would fit into the art. When he realized what I was doing, he turned to his girlfriend and said, “Babe! Are you seeing this?! This b*&@! is a G!” Later on his way out of the ED he was showing his stitches to all the hallway patients and just kept saying, “She’s such a G!” He may have been a little intoxicated… but it still makes me smile to remember how stoked he was!

Favorite life-balancing hack?
I am a list maker! I live by my schedule and lists, which are organized by “urgent” (stuff that’s due now), “important” (maybe not due right now but should get done ASAP because they matter), and “general to-do” (can happen whenever, or not, and that would be OK). All of this is color-coded, obvy. The color-coding is key. (Plus makes it way more fun to look at!)

What goes on pizza?
OK seriously, I could never answer this question! Pizza is literally my very favorite food and I could never choose just one set of toppings! Depends on the mood. And how hungry you are. And whether you’re going to eat dessert after.

Most-used app on your phone?
Text messaging and email. Efficiency!

Favorite board game?
I’m a fan of just about any that result in tons of laughter. Contenders would include Catch Phrase, Quelf, and Cards Against Humanity.

Zach Jarou, MD, President-Elect
president-elect@emra.org  /  @zachjarou

What’s your primary goal in your new role with EMRA?
To support our new President Alicia Kurtz in executing her vision and preparing myself to be the voice of our organization when I assume the presidency next year.

Describe your leadership style in 20 words or less.
I lead by example. I like feedback, evidence, and being purposeful instead of rote.

If your fellow residents picked a motto for you, what would it be? Do something or get out of the way.

Favorite life-balancing hack?
Multitasking to the nth degree, and then finding a local beerfest.

Best advice you’ve ever heard?
As someone who normally likes to get things done as quickly as possible, a saying that I will be trying to keep in mind throughout my term is “If you want to go fast, go alone. If you want to go far, go together.”

What goes on pizza?
Banana peppers and feta OR sausage, grilled onions, and green pepper.

Wine, beer, coffee, water or something else?
Coffee in the morning, beer in the evening. I’m really into sours and West Coast-style IPAs. I also like Cabernets… and have sometimes even been known to drink water.

Most-used app on your phone?
Twitter! Be sure to follow: @zachjarou; @DenverEMed; @emresidents

Favorite board game?
Old school: Monopoly or Clue. New school: Settlers of Catan

Scott Pasichow, MD, MPH, Vice-Speaker of the Council
vicespeaker@emra.org  /  @SPMD16

What’s your primary goal in your new role with EMRA?
Increased representative involvement in the Representative Council with webcasting of meetings and online voting.

Describe your leadership style in 20 words or less.
Diplomatic leader who wants to hear people’s ideas on how to accomplish a goal and build consensus.

If your fellow residents picked a motto for you, what would it be?
Don’t just do something, stand there!

Favorite life-balancing hack?
Sharing calendars between family members.

Respecting HIPAA, tell us about your most memorable patient encounter.
My first really sick patient in the PICU. She had just had a massive brain bleed, and her parents were trying to find ways of involving siblings in her care. Her sister made bracelets for the whole team to wear. I still have one on my office desk at home. The way the team worked together to care for her is emblematic of the teamwork that makes me love emergency medicine.

Best advice you’ve ever heard?
This too shall pass. It’s hard with all the stresses of life to remember that the little things are just that: little. Keep focus on the bigger goals and the details will work out.

What goes on pizza?
Pepperoni and mushrooms

Wine, beer, coffee, water or something else?
Good day? Haufenweise; Bad day? Scotch.

Most-used app on your phone?
Downcast

Favorite board game?
Risk

Nida F. Degesys, MD, ACEP Representative
aceprep@emra.org

What’s your primary goal in your new role with EMRA?
To represent our 15,000 members to the ACEP board on issues that are important to physicians-in-training.

Describe your leadership style in 20 words or less.
Direct, honest, assertive. (At UCSF we take a test, True Colors, describing our personalities in terms of colors, I am a “gold” — love lists, structure and organization — so I guess that impacts my leadership style.)

If your fellow residents picked a motto for you, what would it be?
Work hard, power through (with a smile — usually).

Favorite life-balancing hack?
Have a baby (no seriously, it teaches you what real sleep deprivation is and how to deal… after that everything seems easy).

Respecting HIPAA, tell us about your most memorable patient encounter.
Babies with burns — breaks my heart every time.

Best advice you’ve ever heard?
While you think you can do it all, you can’t, so pick things that are important to you and prioritize, outsource the rest

What goes on pizza?
Lots of meat

Wine, beer, coffee, water or something else?
Whiskey (preferably Scotch)

Most-used app on your phone?
What’s an app? Just kidding, Google Photos (I take like hundreds of pics/videos a day that require constant uploading to Google Photos)

Favorite board game?
Boggle

Shehni Nadeem, MD, Membership Development Coordinator
membershipcoord@emra.org  /  @ShehniNadeem

What’s your primary goal in your new role with EMRA?
To develop a leadership curriculum for medical students and residents to utilize across the nation with enhanced resources, early mentorship, opportunities for involvement, and guidance for career development.

Describe your leadership style in 20 words or less.
Innovative and integrative. In trying to create, I aim to take input and feedback from the whole team.

If your fellow residents picked a motto for you, what would it be?
“A person’s a person no matter how small.” —Dr. Seuss

Favorite life-balancing hack?
Schedule a date night once a week, whether it’s with yourself or someone else.

Respecting HIPAA, tell us about your most memorable patient encounter.
Early in intern year, I had a young homeless patient who presented with heat exhaustion. After treating her, I gave her a large sun hat from our donated clothing closet. Tears welled up in her eyes, as she thanked me for treating her with respect. I felt I had done little for her, but when I saw her again two weeks later, she beamed at me and declared, “Look Doc. No sunburn!”

Best advice you’ve ever heard?
To be yourself is to be enough.

What goes on pizza?
Jalapenos!

Wine, beer, coffee, water or something else?
Nothing beats a glass of water for me!

Most-used app on your phone?
Google Calendar

Favorite board game?
Monopoly

Rachel Solnick, MD, Legislative Advisor
legislativeadvisor@emra.org  /  @RachelSolnickMD

What’s your primary goal in your new role with EMRA?
I want to empower residents to see themselves as individual change agents, whether it be at the level of their residencies, hospitals, communities, state, or national. On every level there is room for positive change, and issues that are in dire need of someone who cares to come and shake things up. As doctors, and especially as emergency medicine doctors, we are excellent at quick diagnostics and being team leaders. We need to recognize we can apply these special skills beyond our direct patient care, and help improve the systems we operate in.

Describe your leadership style in 20 words or less.
Create an environment that cultivates individual passions, and inspires contributions based on each person’s own drive to want to be part of something bigger.

If your fellow residents picked a motto for you, what would it be?
“Isn’t this awesome?!” I’m the happy-go-lucky one.

Best advice you’ve ever heard?
“Earn this.” It’s a quote from the movie “Saving Private Ryan.” While it is a clip that shows a soldier dying on the battlefield, it captures so much more. My medical school class was shown this clip on one of our last days of fourth year, with the message that what we do is a privilege and a duty. This inspires me to approach life with the perspective of trying to build something bigger and leave something better.

Wine, beer, coffee, water or something else?
All of them.

Most-used app on your phone?
Medically: WikEM (love FOAM); Personally: Spotify

Favorite board game?
Cranium for parties, Settlers of Catan.

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Congratulations Award Recipients!

ACEP16 Travel Scholarships:
Abena Obenewaa Akomeah
, MD; Jerome Rogich; Michelle Lynch

Clinical Excellence Award (presented by program director Salvatore Silvestri, MD, FACEP)
Orlando Regional Medical Center’s Tory Weatherford, MD; Christopher Ponder, MD;
Mandi Stone, MD; Amanda Tarkowski, MD; and Thomas Smith, MD

Joseph F. Waeckerle Alumni Award
Kevin Klauer
, DO, FACEP

Military Excellence Award (presented by Lt. Cmdr. Christine DeForest, DO)
Lt. Cmdr. Travis Deaton, MD: Steve Tantama, MD

EDDA Scholarships
Thiago Halmer
, MD, and B. Bruce Graham, MD

Leadership Excellence Award (presented by Christine Babcock, MD, FACEP)
Carrie Jurkiewicz, MD

Augustine D’Orta Award (presented by Alison Haddock, MD, FACEP)
Shehni Nadeem, MD

FOAMer of the Year
Sean Dyer
, MD

The CORD CPC Final Competition awards, presented by Amy Church, MD, FACEP,
went to Bryant Allen, MD; Chen He, MD; Guy Carmelli, MD; and Graham Brant-Zawadzki, MD, MA

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ACEP16: A Sure Bet for Progress

With EMRA events spanning more than a week in Las Vegas, progress surged on multiple fronts.

Resolutions & Elections

The Representative Council discussed, debated — and ultimately voted in favor of — four resolutions:

  1. Support high-fidelity simulation as a component of the ABEM oral certification exam.
  2. Support diversity and inclusion for emergency medicine physicians in training.
  3. Support awareness of and education about human trafficking.
  4. Support gun violence research from a public health perspective.

Additionally, the Rep Council elected five positions on the EMRA Board of Directors, including Zach Jarou, MD, as president-elect; Scott Pasichow, MD, MPH, as vice-speaker; Nida Degesys, MD, as ACEP representative; Shehni Nadeem, MD, as membership development coordinator; and Rachel Solnick, MD, as legislative advisor.

The five will join President Alicia Kurtz, MD, and Immediate Past President Ricky Dhaliwal, MD, JD, in shepherding the association for the coming year.

National updates include the ACEP leadership transition to Rebecca Parker, MD, as president; CORD partnering with ACEP on a Resilience Summit in February; and a reminder of ABEM’s new online certification application.

Enjoy a few scenes from Las Vegas. Meanwhile, be sure to join us at the ACEP Leadership & Advocacy Conference, March 12-15, in Washington, D.C.

After working hard at the EMRA Residency Program Fair,
the crew from UT Southwestern lets their true colors show at Studio EMRA.

EMRA’s Medical Student Forum and Luncheon allows students to interact
with program directors in lectures, small groups, and individually.

EMRA Program Representatives speak for the fellow residents
while voting on resolutions and board candidates.

With SIMWars, 20 in 6 Resident Lecture Competition, and the
brand-new EMRA MedWAR, residents have plenty of opportunity
to exercise their competitive natures.

The second annual EMRA 20 in 6 Resident Lecture Competition
brought together 15 worthy speakers and 4 dynamic judges:
(from left) judges Mel Herbert, MD, FACEP, and Paul Jhun, MD, FAAEM,
winners William Fox, MD (2nd Place), Nikolai Schnittke, MD (1st Place),
and Caleb Sunde, MD (People’s Choice),
and judges Nikita Joshi, MD, and David Terca, MD (2015 winner).

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ST Elevation in aVL. Reciprocal ST depression in III. Is it MI?

I was reading this ECG in the queue, with no clinical info.

What do you think?


















My interpretation was LVH, no evidence of MI.   There was no previous ECG or echo for comparison.

My ECG diagnosis may surprise you, as I have long discussed "ST elevation in aVL with reciprocal ST depression in lead III" as due to high lateral MI.

This is different because:
1) There is saddleback morphology in aVL, and
2) There is also high voltage.

I have previously talked about ST elevation with saddleback morphology in lead V2 as rarely being due to anterior STEMI.  See this post (the only case I've seen in which it was STEMI): 

Anatomy of a Missed LAD Occlusion (classified as a NonSTEMI)


Voltage on this ECG does meet Estes criteria for LVH: 
1) At least one R- or S-wave greater than 20 mm (lead II) = 3 points.
2) ST-T abnormalities in the absence of digoxin = 3 points
Total = 6 points
5 points is definite
4 points is probable
This scoring system comes from this original article.

However, meeting LVH criteria is not critical, as they are not sensitive.  Many cases of LVH show themselves only by the typical repolarization abnormalities.  In this case, we see somewhat typical repolarization abnormalities in leads III and aVF.

Estes criteria are only 34% sensitive for LVH as diagnosed by echo.   

In this paper that used other criteria, the sensitivity for LVH by echo was less than 10%!
At least one of, with or without ST-T abnormalities:
1) R-wave 11 mm in aVL
2) R-wave at least 25 mm in left precordial leads
3) S-wave at least 25 mm in right precordial leads
4) Sum of precordial SV1 or SV2 plus RV5 or RV6 at least 35 mm
5) Sum of lead I plus lead II at least 25 mm.

In both studies, specificity of the criteria was nearly perfect.

Case Continued

This 30-something presented with headache and chest pain.  He had a history of hypertension, apparently completely untreated.  His chest pain had lasted 40 minutes and was now gone.

Blood pressure was 170/105.


Another ECG was recorded several hours later:
No significant change



The history of HTN, the elevated BP, the high voltage, and the saddelback make it very unlikely that this ST elevation is due to STEMI.

The patient ruled out for MI by negative delta troponins.

Here is a post on True Positive ST elevation in aVL vs. False Positive ST elevation in aVL
However, I do not discuss saddleback in aVL in this post.

Ambulatory Report – 11.30.16 – Joint Pain!

Thanks to LT & Jeff Kohlwes for presenting the case of a 40 yo M without significant PMH presenting with worsening knee pain and effusion, ultimately found to have pigmented villonodular synovitis.
  • Joint pain is common, and there are many approaches.  
    • I typically ask 3 questions to narrow my differential:
      • Monoarticular or Polyarticular?
      • Inflammatory or Non-Inflammatory?
      • Acute or Chronic?
    • Based on these three I can often narrow my differential significantly (below is a basic approach, this is by no means exhaustive)
  • So how do know if the joint pain is inflammatory or non-inflammatory?
    • Inflammatory
      • Warm, Red, Painful, Swollen, Effusion w/ WBCs
      • Morning stiffness for > 30min
      • Very hard to get out of bed, better after take a shower and move around in the morning
      • Better with activity
      • Better with NSAIDs
      • Waking up with pain at night
    • Non-Inflammatory
      • Painful, Stiff (Gelling Phenomenon = stiffness after non-activity), May have effusion w/ few WBCs
  • And what about that synovial fluid?
Evernote Link:

Filed under: Ambulatory, Morning Report Tagged: Ambulatory