Trick of the Trade: IV-Push Antibiotics in the ED

IV_arm5 copyLimited intravenous access is a common conundrum in the Emergency Department, with heavy implications for medication administration. Of particular concern, are the profoundly septic patients that necessitate multiple timely therapies, which require tying up a line – fluids, pressors, several antibiotics, etc. The shift away from less central line (i.e. triple lumen) placement for initial resuscitation, may serve to further exacerbate this issue.

The Problem

Since most of these septic patients will require more than one antimicrobial for empiric coverage, the exact timing of therapy and desired order of administration are details that may not be adequately communicated. How many times have you noticed after ordering vancomycin and cefepime, that vancomycin has been administered first, allowing several hours to go by without having received that broad-spectrum, gram-negative coverage with cefepime?

Despite these challenges, the Surviving Sepsis Campaign (SSC) guidelines currently recommend administration of appropriate empiric antibiotics within 1 hour after recognition of severe sepsis [1]. This is largely based upon a retrospective analysis of 2,731 patients with septic shock, which demonstrated that administration of effective antibiotics within the first hour of documented hypotension was independently associated with increased survival to hospital discharge [2]. Currently however, a lack of guidance exists regarding the best way to achieve this important aspect of the resuscitation bundle.


Trick of the Trade – IV Push Antibiotics

Administration of antibiotics via intravenous push (IVP) may be one approach to hasten antibiotic administration without tying up lines. Additionally, while communicating the desired order of administration is still important, when faced with limited IV access, nurses may be more inclined to initiate the IVP antibiotic first, due to shorter administration times. Further, IVP administration of antibiotics may be a more economically beneficial alternative as compared to more common methods [3]. Through cost avoidance of both pharmacy preparation and nursing administration time, as well as eliminating the need for minibags and IV tubing, one study estimated savings of $184,000 per year [4].

Listed below are various antibiotics that have been shown to be safe when given as an IVP to adults: [5][6][7][8]

Antibiotic Concentration*, Diluent Rate of Administration Osmolality (mOsm/L)**
Cefazolin 1 g/10 mL, SWFI 1-2 min 340
Cefuroxime 750 mg/10 mL, SWFI 1-2 min 447
Cefoxitin 1 g/10 mL, SWFI 2-4 min 525
Cefotaxime 1 g/10 mL, SWFI 1-2 min 440
Ceftriaxone 1 g/10 mL, SWFI 1-2 min 423
Ceftazidime 1 g/10 mL, SWFI 1-2 min 435
Cefepime 1 g/10 mL, SWFI 2-4 min <400
Meropenem 1 g/10 mL, SWFI 3-5 min <500
Aztreonam 1 g/10 mL, SWFI 2-4 min 487

SWFI, sterile water for injection;

* The concentrations stated above do not necessarily represent recommended doses; these should be used to determine the volume required for higher/lower doses (e.g. cefepime 2 g/20 mL SWFI)

** Substances with an osmolality less than 600 mOsm/L are generally acceptable for administration via a peripheral line [9]

Important Considerations

  • When implementing IVP antibiotics in your ED, standardize the process. This may require substantial changes in nursing practice, updating policies and procedures, departmental education, adjustments to electronic order sets, adjustments to product stocking and inventory, as well as implementing oversight for unforeseen adverse effects
  • It is important to note, that the use of sterile water for injection (SWFI) is to help minimize osmolality; reconstituting with NS or D5W may produce significant phlebitis, and increase the risk for extravasation injury. Read more information (extravasation injuries PDF) on this topic.
  • As with any IV preparation, remember to properly label your syringe. Refer to Dr. Bryan Hayes’ post on The Art of Syringe Labeling in the ED.
  • Beta-lactam antibiotics are often administered as prolonged infusions in order to take advantage of their pharmacokinetic/pharmacodynamic profiles (T > MIC). However, this is usually employed for subsequent maintenance doses, and is also not practical for initiation in the ED. Moreover, time to administration of the initial dose is a more important factor in septic patients.
  • The literature used to support the aforementioned IVP antibiotics did not include pediatric patients. Therefore, the safety and feasibility of implementing this practice within the pediatric population is uncertain.

Take-Home Points

  • Various beta-lactam antibiotics may be safely administered via IVP.
  • IVP administration may be one strategy to help facilitate timely administration of antibiotics, and to prevent tying up multiple lines.
  • To date, no published literature exists to support the potential benefits (i.e. improved time to administration; improved outcomes) of IVP antibiotics in the Emergency Department; future studies are warranted.


  1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for the Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med. 2013;41:580-637. PMID: 23361625.
  2. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96. PMID: 16625125.
  3. Ambrose PG, Bui KQ, Richerson MA, et al. Pharmacoeconomic analysis of intravenous push vs. slow infusion of beta-lactam antibiotics. Clin Drug Invest. 1999 May;17(5):407-410. PMID: 9161666.
  4. Garrelts JC, Smith DF, Ast D, et al. A comparison of the safety, timing and cost-effectiveness of administering antibiotics by intravenous bolus (push) versus intravenous piggyback (slow infusion) in surgical prophylaxis. Pharmacoeconomics. 1992 Feb;1(2):116-23. PMID: 10172048.
  5. Garrelts JC, Ast D, LaRocca J, et al. Postinfusion phlebitis after intravenous push versus intravenous piggyback administration of antimicrobial agents. Clin Pharm. 1988;7:760-5. PMID: 3233896.
  6. Nowobilski-Vasilios A, Markel Poole S. Development and preliminary outcomes of a program for administering antimicrobials by I.V. push in home care. Am J Health-Syst Pharm. 1999;56:76-9. PMID: 10048883.
  7. Garrelts JC, Wagner DJ. The pharmacokinetics, safety and tolerance of cefepime administered as an intravenous bolus or as a rapid infusion. Ann Pharmacother. 1999;33:1258-61. PMID: 10630824.
  8. Norrby SR, Newell PA, Faulkner KL, et al. Safety profile of meropenem: international clinical experience based on the first 3125 patients treated with meropenem. J Antimicrob Chemother. 1995 Jul; 36 Suppl A:207-23. PMID: 8543496.
  9. Intravenous Nurses Society. Position paper: midline and mid-clavicular catheters. J Intraven Nurs. 1997;20:175-178.
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Author information

Adam Spaulding, PharmD BCPS

Adam Spaulding, PharmD BCPS

Emergency Medicine Pharmacist,

Pharmacy Residency Program Director,

Waterbury Hospital Health Center,

Adjunct Assistant Professor - UCONN School of Pharmacy,

Contributor to Emergency Medicine PharmD Blog

The post Trick of the Trade: IV-Push Antibiotics in the ED appeared first on ALiEM.

ALiEM Bookclub: We Need to Talk About Kevin

we-need-to-talk-about-kevinWe Need to Talk About Kevin. Yes we do, I’m afraid. You may have been (like me, for many years) avoiding reading this novel by Lionel Shriver, ducking away from discussions and avoiding reviews, having got wind of the gist of the story through the mass media.

To summarise the book, We Need to Talk About Kevin by Lionel Shriver is written in the form of letters penned by Eva Khatchadourian to her estranged husband Franklin. These missives form a chronological examination of her life before and after the entrance of their son Kevin into their lives (or perhaps, more accurately, the invasion), and they follow the painful path through his childhood, dissecting the family relationships that shape his development along the way. There is no secret about the main event. Kevin, at the tender and cleverly calculated age of 15 years and 362 days, commits mass murder in his school gym.

I need to declare at the outset that I loved this book. It is masterfully written, in my opinion. Any book that can grab you by the throat, shake you until the tears fall and the nausea wells, and every so often cause you to drop the book in shock and surprise, despite knowing the inevitable premise, is a work of consummate skill.

So why are we discussing it in the ALiEM book club? What does this book have to do with critical care and emergency physicians? I would hazard a guess at saying ‘everything.’

When we want to learn about the nuts and bolts of administering the science of critical care, we turn to texts and websites and our colleagues and teachers. But when we want to truly get inside the head of another, and learn about humanity from the inside out, we turn to novels. Books give us windows into the minds of people/characters/good and bad, and allow us to understand and foster empathy. So it is with Kevin. Lionel Shriver tackles an exhaustive list of themes of modern family life in middle America, all of them written with a shrewd intelligence and observation. They are all explored with an almost dispassionate curiosity by Shriver, and never feel like they are falling into polemic.

To list just a smattering of the themes examined:

  • The nature vs nurture debate. Is evil born or made? This is the overarching theme of the book. How much did Eva’s relationship with her son forge the path that he took? If I had one criticism of this book, it would be that the character of Kevin was perhaps unrelentingly evil and malevolent from the start. At times it almost felt like caricature, and detracted from the immersion and faith I had in the importance of the story. Some of the scenes from Kevin’s infant and childhood years seemed impossible to believe. We all have come into contact with antisocial personalities, and seen the spoils of their behaviour. It is difficult to envisage this in somebody so young.
  • Parenting in the modern age. Why do we choose to bear children? The reasons for doing so are often complex, and not always altruistic or venerable. Eva is an ambivalent mother from the start, and this informs much of her interpretation of her relationship with Kevin.
  • The banal and hackneyed wealth of the middle class. Interwoven throughout the book are comments on the choices made from within the luxury of a first world life. These choices bother Eva, and she is quick to speak out about them, peppering the book with her harsh commentary, but they are not enough for her to take any active stand.
  • The phenomena of mass school shootings. This book occurs around the time of Columbine, an event referenced several times, along with others of a similar ilk. There are no answers in here. Like any good novel, it just opens up a space in which you can ask questions of yourself and the world around you. But, particularly as a hopelessly befuddled Australian, where these events seem like they belong to another, crueler, doomed planet, I was left understanding the motivation for these unspeakable horrors no more than when I first picked up the book.

Even the pervasive desire for fifteen minutes of fame in today’s celebrity bedeviled world gets the treatment, with the incarcerated Kevin bemoaning other mass murderer’s substandard methods whilst they hog the limelight.

There are so very many other subplots and themes in this book, that I don’t feel I can do them justice, such as the influence of the American presidential race, the personality of the All-American ‘Gee-Whiz’ husband and his contribution to the unfolding of the story, the civil courts, the responsibilities of the school system, and many more. My recommendation? Go read the book. And be prepared for a surprise.

Discussion Questions

It is customary to conclude a review like this with some questions.  Some of these I have already alluded to. The answers, however, are unlikely to be found in the book. What this extraordinary novel does, is open up the door into further fundamental questions, that we should all be asking of ourselves, and of our society to which we contribute.

  1. What is evil? Is it born, or made?
  2. Why are school shootings, although nominally present in other countries, vastly more frequent in the U.S.? Are there behaviour patterns, individual characteristics, or societal issues, that specifically predispose to these events, and if so, how can they be identified and prevented?
  3. Is the love of a parent for a child unconditional?

We Need to Talk About Kevin was also released in movie format in 2012 staring Tilda Swinton and Ezra Miller. (Rotten Tomatoes Review)

* Disclaimer: We have no affiliations financial or otherwise with the authors, the books, Amazon, or Rotten Tomatoes


Author information

Michelle Johnston, MBBS FACEM

Michelle Johnston, MBBS FACEM

Specialist Emergency Physician

Royal Perth Hospital

Perth, Australia

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Vancomycin Loading Doses in Pediatric Patients: A Missed Opportunity?

Pediatric Syringe Pump

In January 2014, ALiEM featured a must-read post by Bryan Hayes regarding proper dosing of vancomycin in the emergency department, including a special note related to the recommendations regarding consideration of loading doses of vancomycin ranging from 25 to 30 mg/kg in adult patients who are critically ill with a high suspicion for MRSA infection.

Recommended pediatric dosing of vancomycin

In pediatric patients with serious and/or invasive infection, the recommended dosing regimen of vancomycin is [1]:

15 mg/kg/dose administered every 6 hours

Challenges associated with aggressive empiric dosing of vancomycin in pediatrics

Although a number pharmacokinetic models have established that such a dosing scheme may achieve a desired area under the curve/minimum inhibitory concentration (AUC:MIC) ratio of at least 400 mcg • hr/mL [2][3], several studies in pediatric patients have demonstrated that even this aggressive regimen does not lead to desired associated serum concentrations of 15 to 20 mcg/mL for serious infections when measured at steady state [4][5].

Is more aggressive empiric dosing necessary?

Results of the recently published Pediatric Assessment of Vancomycin Empiric Dosing (PAVED) study suggest that empiric dosing of vancomycin in pediatric patients may need to be more aggressive based on age and desired therapeutic concentration [6]:

Desired Therapeutic Concentration Age
1 to 6 years >6 years
10 to 15 mcg/mL 70 mg/kg/day divided q6h 60 mg/kg/day divided q8h
15 to 20 mcg/mL 90 mg/kg/day divided q6h 70 mg/kg/day divided q6h


Pharmacokinetic considerations in pediatrics

Pharmacokinetic parameters to be considered in pediatric patients related to vancomycin include the following:

  • Volume of distribution (Vd): Neonates and young infants tend to possess higher apparent volumes of distribution. As a result, these patients may exhibit lower plasma concentrations following the administration of hydrophilic medications such as vancomycin [7].
  • Clearance: Age-dependent variations in clearance of occur in the early stages of life, with peak clearance generally occurring between 2 and 6 years of age before decreasing and ultimately reaching the adult plateau by puberty [8]

Is a loading dose of vancomycin the answer in pediatrics?

Given the physiological and pharmacokinetic challenges of vancomycin in pediatric patients, can these be overcome with a loading dose of vancomycin in pediatric patients? That is, does a loading dose of 25-30 mg/kg of vancomycin hold any benefit in critically ill pediatric patients in achieving therapeutic concentrations without posing a serious risk for toxicity?

Clinical studies

Surprisingly, the evidence for loading doses of vancomycin is relatively scarce in the pediatric population.

  • STUDY 1: In a prospective, double-blind study conducted by Demirjian and colleagues [9], 59 patients between the ages of 2 and 18 years of age were randomized to receive either a loading dose of vancomycin of 30 mg/kg or a standard dose of 20 mg/kg, both followed by a standard dose of 20 mg/kg administered every 8 hours.
    • At 8 hours post-infusion of the first dose, 11% of patients in the loading dose group (2/19) attained a serum concentration of 15 to 20 mcg/mL compared to none of the 27 patients in conventional dosing group (p = 0.17).
    • Yet, pharmacokinetic analyses demonstrated no measurable differences in achievement of AUC:MIC, as both groups reached levels greater than 400 mcg • hr/mL (p = 0.79).
    • In terms of adverse effects:
      • Red man syndrome occurred in 48% and 24% of patients in the loading dose and conventional dosing groups, respectively (p = 0.06).
      • In addition, serum creatinine doubled from baseline values within 7 days of initiation of vancomycin in 4 patients in the loading dose group (13%) versus 1 patient in the conventional dosing group (3%) (p = 0.14).
    • Conclusion: A loading dose did not necessarily lead to rapid achievement of therapeutic concentrations, and systemic exposure to vancomycin was sufficient, based on observed AUC:MIC, in both treatment arms.
  • STUDY 2: Bartlett and colleagues evaluated the effects of vancomycin loading doses based on subsequent trough concentrations in a single center retrospective study [10].
    • 54 pediatric patients who were at least 3 months in age were included in the analysis.
    • 11 patients who received a loading dose of vancomycin had higher initial median steady state concentrations relative to those who received conventional dosing of vancomycin (10.5 mcg/mL versus 9.8 mcg/mL).
    • Loading doses of vancomycin ranged from 18 to 27 mg/kg, and none of these patients experienced nephrotoxicity.
    • Conclusion: Loading doses of vancomycin are associated with higher initial trough concentrations, and that more aggressive dosing strategies for vancomycin may be of benefit in pediatric patients.

Application to clinical practice

Clinical outcomes such as eradication of confirmed infection, length of stay, and mortality remain to be observed in this patient population. With the limited and inconsistent data associated with loading doses of vancomycin in pediatric patients, it is somewhat challenging to validate or contest its use as a standard practice in this population.

Take home point

Until we have more investigations to validate the results of the PAVED study related to more aggressive dosing of vancomycin, pediatric patients should still be prescribed a vancomycin dose of 15 mg/kg/dose every 6 hours. Loading doses of vancomycin of 25-30 mg/kg may be considered on a case-by-case basis in critically ill pediatric patients.


  1. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18-55. PMID: 21208910
  2. Frymoyer A, Guglielmo BJ, Wilson SD, et al. Impact of a hospitalwide increase in empiric pediatric vancomycin dosing on initial trough concentrations. Pharmacotherapy 2011; 31:871-876. PMID: 21923588
  3. Le J, Bradley JS, Murray W, et al. Improved vancomycin dosing in children using area under the curve exposure. Pediatr Infect Dis J 2013; 32:e155-1563. PMID: 23340565
  4. Eiland LS, English TM, Eiland EH 3rd. Assessment of vancomycin dosing and subsequent serum concentrations in pediatric patients. Ann Pharmacother 2011; 45:582-589. PMID: 21521865
  5. Frymoyer A, Hersh AL, Benet LZ, et al. Current recommended dosing of vancomycin for children with invasive methicillin-resistant Staphylococcus aureus infections is inadequate. Pediatr Infect Dis J 2009; 28:398-402. PMID: 19295465
  6. Rainkie D, Ensom MH, Carr R. Pediatric Assessment of Vancomycin Empiric Dosing (PAVED): a Retrospective Review. Paediatr Drugs 2015 March 27 [Epub ahead of print]. PMID: 25813682
  7. Kearns GL, Abdel-Rahman SM, Alander SW, et al. Developmental pharmacology: Drug disposition, action, and therapy in infants and children. N Engl J Med 2003; 349:1157-1167. PMID: 13679531
  8. Neuman G, Nulman I, Adeli K, et al. Implications of serum creatinine measurements on GFR estimation and vancomycin dosing in children. J Clin Pharmacol 2014; 54:785-791. PMID: 24596064
  9. Demirjian A, Finkelstein Y, Nava-Ocampo A, et al. A randomized controlled trial of a vancomycin loading dose in children. Pediatr Infect Dis J 2013; 32:1217-1223. PMID: 23817340
  10. Bartlett A, Brown-Alm D, Landon E, et al. Vancomycin loading dose in pediatric patients receiving intermittent vancomycin dosing. Abstract 162. Presented at ID Week; October 2-6, 2013; San Francisco, CA.
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Author information

Nadia Awad, PharmD, BCPS

Pediatric Pharmacist

Robert Wood Johnson University Hospital

Staff Blogger at Emergency Medicine PharmD

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I am Dr. Ben Smith, Director of Emergency Ultrasound at University of Tennessee, Chattanooga: How I Work Smarter

How I Work Smarter Logo If anyone in this series deserves the title of true “life hacker”, it’s Dr. Ben Smith (@UltrasoundJelly). A nuclear engineer turned emergency physician, you’ll see it is apparent he takes an engineer’s approach to productivity. In the clinical/education world, he is the Director of Emergency Ultrasound and the Associate Residency Director at University of Tennessee, Chattanooga. He’s a contributing member of FOAM via several websites, including and Although we may not all have the braun the manage our own server infrastructure to host FOAM sites (which Dr. Smith does), he breaks down some simple tips you can use to automate your life and get started on the path to life hacking.


  • Name: Ben C. Smith, MD, FACEPBen Smith Pic Square
  • Location: University of Tennessee, Chattanooga
  • Current job: Director of Emergency Ultrasound, Associate Residency Director
  • One word that best describes how you work: Efficiently-thorough
  • Current mobile device: Samsung Galaxy S4
  • Current computer: 13” Macbook Air i7, the perfect size/weight/battery life. Only thing it lacks is major computing power, if I need that I remote access my desktop or server.

Disclosure: I mention specific services and products here, but I receive no endorsements or remuneration from these vendors.

What’s your office workspace setup like?

Ben Smith Office

i7 Hackintosh Mac Pro

  • 27” Dell Ultrasharp IPS Monitor
    • I’m a big fan of one large, high pixel density monitor for lots of screen real estate.
  • 256 GB SSD for OS X Yosemite and currently active files, 3TB HDD for storage
  • Audio-Technica 2020 microphone: Ditch the tinny laptop mic to sound professional.
  • Novation Nocturn Desktop Controller
  • Keynote/Prezi
  • Photoshop / Lightroom
    • Master Photoshop to produce quality original #FOAMed content.
  • Google Everything / Hangouts
  • if I need to quickly trend some data or generate a graph.
  • Remote access via Screen Sharing

Ben Smith Desk

Ben Smith ServerDell PowerEdge Server

  • Dual hard drives in a RAID 1 array for data security
  • Ubuntu Server Linux / Apache / MySQL / PHP
  • Hosts 4 WordPress websites
  • Backup databases and WP folders on and off site daily (Crashplan)
  • Static content on the zippy Amazon Cloudfront content delivery network (CDN) so my sites are fast anywhere in the world
  • Remote Access via SSH
  • 1 Gb/s fiber optic internet connection, hosted from my office. I am the network admin, server maintainer, and webmaster for the sites above. This saves money.

What’s your best time-saving tip in the office or home?

What’s your best time-saving tip regarding email management?

  • Reply to all important emails within 24 hours.
  • Liberal use of “unsubscribe” links at the bottom of spam.
  • For spam that doesn’t include an unsubscribe link, create a filter to delete or move them to spam folder.
  • Keep a second email address active that you can use to register for various second-third tier online services. I have this email forwarded to my main account and automatically filtered into a separate folder for infrequent viewing.

What’s your best time-saving tip in the ED?

  • Utilize bedside ultrasound early to narrow your differential diagnosis and direct appropriate stabilizing interventions in critical patients.
  • Try to never be the personal cause of ED bottleneck, keep the rack empty, and put the orders in early.
  • When the ED gets really busy, I’m a big fan of thin slicing some orders quickly, then going back later to get a more thorough history once I’m no longer the bottleneck.

ED charting: Macros or no macros?

  • Yes, I do cautiously use macros. The time saved on repetitive documentation outweighs the risk. Main risk is over-documenting, just be certain you know your macros like the back of your hand. For instance, I know my normal physical exam – and I am sure to cover each of these bullet points at the bedside before I click the macro.

What’s the best advice you’ve ever received about work, life, or being efficient?

Is there anything else you’d like to add that might be interesting to readers?

  • As our jobs and lives become more and more intertwined with technology, the benefit to being able to code is skyrocketing. Every professional should learn to code: start small and focus on one programming language early on. Coding concepts and basic constructs cross languages; it is only the syntax that changes.
  • To become productive, simplify. People are always surprised to find out I don’t have the newest laptop or phone. Don’t buy new tech just because it’s new. Ask yourself if you will really use your new gadget before diving in to a purchase. How you use your device is more important than what device you use.
  • I love OS X, it is far more stable than its Windows counterpart. One of my favorite things about OS X is simplified automation using command line bash scripts or, for the more GUI inclined, Applescript.
  • Using keyboard shortcuts helps me streamline my computer work, as they are always faster than mouse clicks (that’s why my favorite text editor is the command line only vi). Here are a few OS X shortcuts I use most frequently:
    • Command-C to copy, Command-V to paste
    • Command-Option-V to paste plain text into gmail (sans formatting)
    • Command-Shift-4 to select an area to save as a screenshot to your desktop
    • Command-Q to close an application
    • Option-control click on a misbehaving program in the Dock and select Force Quit to shut it down (will not save the file you’re working on)
    • Command-Spacebar to open up Spotlight to find a file quickly, Control-Command-Spacebar to do the same search using the Finder
    • Command-Z to undo… just about anything you just did. The most common time I use this one is when I mistype something or accidentally delete a paragraph or two. Want to re-do what you un-did (run-do anyone?): Command-Y.
    • Command-S to save your work. I am personally neurotic about this one, I hit it about once a minute when working on an important file.
  • Do you have a media file embedded in a Keynote or Powerpoint presentation that you’d like to use elsewhere, and you can’t remember where you stashed the original file? First, start by making a copy of your presentation. Then just change the copy’s extension to “.zip” and extract the folder. You’ll find all your files within. This works on modern versions of these applications on OS X and Windows alike.
  • I often find myself needing to do a quick screen recording to demonstrate something or record a lecture, podcast. While there are many paid options, I prefer to use the free one built into Quicktime.
  • I frequently find myself needing to fill-in and sign PDF forms emailed to me (hospital credentialing, anyone?). Instead of downloading the PDF, printing it, filling it out, scanning or faxing it… enter OS X Preview. Just open the file in Preview, then go to the Tools>Annotate>Text Menu to add text to a file. Tools>Annotate>Signature to sign your PDF. When done, hit Command-S to Save, then always “Print to PDF” to save the combined file. Email it back to the sender. You just saved some trees and obviated the need for fax machines.
  • Here are the blogs I read every day
    • Lifehacker – great tips from how to become a successful professional to the best way to cook bacon
    • Gizmodo – science, gadgets. What is more interesting?
    • PetaPixel – must read for fellow photogs

Who would you love for us to track down to answer these same questions?

  1. Mel Herbert (@MelHerbert)
  2. Mike Cadogan (@sandnsurf)
  3. Scott Wieters (@jscottwieters)

Author information

Benjamin Azan, MD

Benjamin Azan, MD

Emergency Medicine Resident

Icahn School of Medicine at Mount Sinai

Founder/Editor of

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I am Dr. Melody Ong, Emergency Medicine Resident: How I Stay Healthy in EM

How I Stay Healthy logoDr. Melody Ong is an emergency medicine resident finishing up her first year of residency. I had the pleasure of meeting her while on residency interviews last year and we hit it off! As we share similar interests, personalities, and opinions on wellness, I knew she would have something to contribute to say about staying healthy. Whether it be traveling to the World Cup to indulge in her favorite sport, or trekking through Patagonia in Southern Argentina, Dr. Ong strives to practice wellness even on her days off. Within her PGY-1 year, she has been able to consistently make time for all the things that help her stay healthy. Here’s how she does it!


  • Name: Melody OngMelody Ong - Photo CROPPED
  • Location: Winnipeg, Manitoba, Canada
  • Current job(s): PGY-1 Emergency Medicine
  • One word that describes how you stay healthy: Balance
  • Primary behavior/activity for destressing: Cranking up my Bose speakers to play a thumping mix from my favorite DJs and occasionally taking a mini dance break!

What are the top 3 ways you keep healthy?

  1. Eating and sleeping well. I make sure I eat at least three balanced full meals a day, while snacking throughout the day. Gone are the undergrad days where I could pull all-nighters. When I am not on call for an off-service rotation, I will try to get around 7 hours of sleep as I have found that that is the ideal amount for me. I ensure that my bed is for sleeping only, and I will try not to do work in bed (e.g. read a textbook or use my laptop).
  2. Staying physically active. I try to hit up the gym as regularly as possible. It feels great to sweat and continue on the adrenaline rush from a great shift (or to pound out the frustration from a not-so-good shift). Having been a competitive soccer player for most of my life, I  keep up with the sport by playing regularly on a co-ed team and in pick-up games with the guys.
  3. Music. Whether it is playing my piano, searching for new music on internet blogs, experimenting with music mixing software on my computer, or attending a music event live, music plays an integral part in keeping me mentally healthy. Simply put, I am a music fanatic and I always have music playing through some sort of device! The music I listen to typically includes heavy beats, drops, and strong chord progressions to pump me up before shifts and help me mentally after heavy academic days.

What’s your ideal workout?

My ideal work-out includes a mix of running and resistance-training. I am not currently training for any races so I typically run around 5 km or 25 minutes then work out a particular muscle group (e.g. legs, back, or chest).

10305510_10152050378361829_6968905851419840007_nNothing like a quick pick-up game of football in Brazil during the 2014 World cup.

Do you track your fitness? How?

I do not track my fitness and work-outs very formally. I can usually remember what I worked on last and try to make a note on my Google calendar of what muscle group I worked on that day. If I go for runs outside I use the MapMyRun app to log my route, time, and progress. However, it is a bit too cold where I am for that to do that for much of the year!

How do you prepare for a night shift? How do you recover from one?

As a junior resident with limited experience in Emergency Medicine, I am still trying to develop a proper routine for the night shift. We will typically have no more than 2 to 3 night shifts in a row. I always take a nap just before my first night shift. My sleeping routine for the day after depends on what I have planned. If I have something to attend to in the morning, I will stay up, try to get some work done, get my meeting or activity over with, and crash once I get home. If I have nothing planned for the morning I eat a rewarding breakfast and then force myself to sleep. That means sleeping in the dark with an eye mask and ear plugs (it can get quite noisy around my neighborhood during the day).

How do you avoid getting “hangry” (angry due to hunger) on shift?

I usually come prepared with extra snacks, both healthy and the occasional unhealthy one for a sugar boost. I like snacking on cereal, yogurt, and fruits. However, I have to admit, chocolate is my vice and I will allow myself to have a few bite-sized bars from time to time. My scrub pocket is unfortunately too small to stash snacks and I do not wear a white coat, so when there is a break in between seeing patients I run and grab a snack so I can briefly re-fuel.

How do you ensure you are mentally in check?

I can sense when I am out of balance and not in check because it affects my work performance. I will not be on my A-game and find myself getting frustrated and forgetting simple things. When this happens, I take action to get myself back to an equilibrium, so that things do not spiral downward any further. I am very blessed to have an incredibly supportive residency program with seniors and program directors who are always available to chat and help. As residents, I think there is a strong stigma associated with asking for help with many people seeing it as a sign of weakness or failure, or thinking that it will jeopardize future career opportunities. However, I try to remember that my program wants me to succeed and become the best Emergency Physicians out there, so they will provide support me when I need it.

What are the biggest challenges you face in maintaining a longstanding career in EM? How do you address these challenges?

Being able to maintain physical and mental wellness will be one of the biggest challenges I face, especially as I become more senior and eventually start working as an attending. What I am currently doing as a junior resident to stay healthy seems to be working, and I plan on keeping up with these activities so that it becomes second nature. This also helps develop resilience against the unpredictable curveballs that life throws at me.

Best advice you have received for maintaining health?

Remember to give time to yourself. There is only so much time in one day. Studying hours on end or diving straight into work right after coming home from a long day at the hospital is not very effective or productive. Setting aside dedicated time daily to allow for myself to mentally and physically re-charge, even if it is just half-an-hour, is key in helping me maintain health. This then translates in to better productivity and an overall happier self.

Who would you love for us to track down to answer these questions?

Ryan Tam
Chau Pham
Sean Fair

Author information

Zafrina Poonja

Zafrina Poonja

ALiEM Assistant Editor,

How I Stay Health in EM series

Emergency Medicine Resident

University of Saskatchewan

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