5 Scheduling Software Options in the Emergency Department: An In-Depth Review

iStock_000011114453XSmallFrom the dawn of Emergency Medicine, the tradition of schedule creation has been an arduous task handed down from chief to chief. Only the most masochistic of individuals dared to rise to the challenges inherent in planning shift coverage around the concerts, reunions, and weddings of their closest peers. Luckily, as design and technology continue to advance, an increasing number of software options have become available to help assist the Scheduler in his or her duties. The software options have dramatic variations in price, interface, and capabilities. The inaugural ALIEM Chief Resident Incubator team hopes to shed some light on the various options, to help you pick the right tool for your program.

 

Google DocsMedRezAMiONShift AdminWhenToWork

Review by Dr. Zach Risler (Drexel)

Selling point

At Drexel, we use Google Docs to make our schedule. This works well for our program but may not work as well for others. Our schedule is based on a fixed 8-10 day rotating schedule (i.e. 6 days on, 2 days off or 6 days on, 4 days off); therefore it is easy to add individuals schedule to a predetermined template that is easily translated into a spreadsheet. This system works well if there is not a lot of variety in how many shifts you need to fill and the type of residents who fill them. However, each schedule is entered by hand with no automatization of the scheduling process. One particular advantage of using Google Docs, is that we have created a separate public folder with links to important documents, and articles, all accessible in one central location.

For the scheduler

To initially set up the spreadsheet takes some time. We have multiple ways to view the schedule, including one sheet for each rotation site, and another sheet broken down by residency class. This allows both the residents and faculty to quickly identify both an individual resident’s location that month as well as the resident schedule at each particular site. Once up and running it is easy to navigate and viewable from multiple platforms.

Customization

While Google Sheets is obviously not a scheduling program. There are some features that make it work well for this function. You can easily add additional sheets to each file to allow for multiple schedules in one place. The schedules can easily be color coded for ease of reading and organization. The file can also be shared with a link for viewing purposes or can be shared for editing purposes for all chiefs or administrators. The schedule is automatically set up to be viewed and edited easily across platforms; so editors can work on the schedule at home or on the go with a tablet or smartphone.

For the residents

Fairly easy to navigate, but can be bulky to look at so many schedules in one file. There is no easy way to separate individuals schedules out from the entire file. But you can search a spreadsheet by using control+F.  You also cannot export the schedule out to a 3rd party calendar program, like Apple Calendar.

Google Docs Annual Schedule This is an example of the R1 yearlong schedule. Each resident has a letter and rotate through the blocks. (i.e. Resident A starts in the CCU then moves to HUH (our main hospital) and so on.) On the left are the rotation sites and across the top are dates ranges for each block. Along the bottom is a sheet for each class and each hospital site.

Google Docs Schedule This is an example of the schedule at two of our community sites. The dates are on the left and the shifts and locations are across the top. Each resident rotates through the shifts (7a-7p, 12p-12a)

Software compatibility

Works well on all systems: Macs, PCs, phones, and tablets

Pros

  • Familiar software
  • Easy to view on multiple platforms (phone, computer, printed)
  • Easy to share with other departments through a link (do not need a separate login or password to another program)
  • Can give people access to view or edit – including residents, attendings, off service rotators or edit chiefs, PD, APDs, program coordinators
  • Allows residents to see everyone’s schedules to help make switches possible
  • Cost: Free

Cons

  • Less utility in a residency program that has a more random schedule
  • All swaps, trades, or requests need to be done individually by scheduling chief
  • No way to generate reports for each resident regarding number of shifts worked, holidays worked or type of shifts worked
  • No built in way to communicate possible trades
  • All schedules are hand entered – which can increase the risk for errors and uneven scheduling

Cost

  • Free

Conclusion

Google Docs is a free solution that is a viable option best suited for EM programs with a regular and repeating scheduling pattern. It is limited by its lack of any scheduling-specific features. The diversity and ubiquity of the Google ecosystem also makes this a great option for those who are using other Google tools.

Review by Dr. Sam Shaikh (Wayne State / Sinai-Grace)

www.MedRez.net

Selling point

Here at Sinai-Grace, we are using MedRez for the first time. In prior years, schedules were done in Excel, which former chief’s report required 40+ hours just to develop the baseline schedule. When exploring scheduling software options, I was drawn to MedRez for the advertised randomizer, as well as the price of $395/year. Our residents staff 3 teams in our ED with 3 different shifts (as well as some coverage at a 4th site, our rural/community site). Scheduling is also complicated by our grand rounds on Thursday morning, which essentially mandate individuals working Wednesday afternoon or night shift to attend grand rounds and remain unable to work clinically on Thursday.

For the scheduler

Initial setup with MedRez can be a bit cumbersome. Before you can do any scheduling for an individual block you will need to setup resident names, block dates, block names, annual rotation schedule, shifts, and tallies (which tag the shifts as ‘day’, ‘night’, etc)  Some of these parameters have to be created in a specific order, which you don’t find out until you run into an error message (or do a detailed pre-reading of the help documentation).

Once up and running, the interface still takes a little getting used to, but does work quite efficiently. There are tools for batch selection and deletion. For example, removing all PGY-II residents from afternoon shifts for the block can be easily accomplished. As you schedule shifts, the software will attempt to highlight individuals who could fill the shift, based on your programmed duty hours. Conversely, you can select an individual and it will highlight potential shifts in the block they could cover. Unfortunately, the programming of duty hours is not 100% EM-centric. For example, we aim to limit the number of night shifts in a row to 4 and to give at least one extra day after the post-nights day off. This was too complex to fit into the existing duty hours parameters in MedRez.

The ‘Random Generator’ was one of the most important features I was looking for in a program, but it does have some limitations. I dreamed of a program that would do all my work for me, while I basked in the glory of chiefdom. Unfortunately this is not the case. Despite the software being aware of who is in the ED for each block, the generator does not take this into account when programming coverage on the first and last days of the block. Also, as some of our coverage rules are unable to be programmed in, the generator ends up with some shift coverage that needs to be tweaked after the fact. We also try to designate one weekend off per block, which the random generator is so far unable to fill reliably. Subsequently, my workflow involved identifying who can cover afternoon and night shifts on the first/last days and entering those in manually before starting the random generator, followed by extensive reorganizing. That said, I do find the tool overall very helpful. I am provided a nice rough draft of generally who will be covering days/afternoons/nights during a certain week. The random generator has also been 100% so far in granting vacation requests (which users can input on their own).

MedRez Scheduling Interface Tallies can be customized, and goals for each individual can be set. In this case we see Dr. Montrelli needs at least one more swing shift and 3 more total shifts. Dr. Shalam need 2 more shifts to meet her goal of 17 shifts.

For the residents

MedRez has a completely different front-end for the users than the scheduler. This is a more modern interface, that scales for mobile, tablet, and web. It is highly touch-optimized and provides great features for users including export to .ics (for Google Cal/ Apple Calendar), vacation requests, and printing of a PDF with an individual’s block schedule. I have heard nothing but great feedback from my co-residents on these perks. One limitation to note is that individuals have equal access to everyone’s schedules. This could theoretically allow a maleficent individual to modify others vacation requests or identify perceived disparities in scheduling equality to whine about. Your program’s MedRez home page can have password protection, but subsequent to that there is no further security on each residents individual page.

MedRez User Homepage Each user has their own individual page for scheduling and requests.

Export to PDF Users can print a PDF of their schedule. Perfect to put on the fridge or email to mom.

Software compatibility

Both the scheduling and user interface work well, including on mobile interfaces and the old version of Internet Explorer running inside our EMR.

I have found 2 technical hiccups with MedRez. The first is with scrolling on computers with touch screens, like the Surface, using Google Chrome. When on the user interface, scrolling can only be accomplished through touch and not the mouse wheel. Other browsers respond to both scrolling and touch scroll. Per discussions with the programmer, this is a limitation of the website being optimized for touch devices. Secondly, exporting a calendar feed to Google Calendar defaults to GMT time zone. This is a limitation of GCal, and can be circumvented by using the export to .ics feature. That said, I have found the support to be excellent. The creator of the software provides quick and relevant responses to emails, even for users in the trial.

Pros

  • Random generator
  • Vacation requests
  • Easy to view on phone/tablet/computer as well as export to pdf
  • Identifies and highlight potentially resident/shift pairings & duty hour violations while scheduling
  • Tracks annual totals for each tally (days, nights, ultrasound, etc)
  • Single click to add/remove coverage
  • Tools for dynamic batch selection

Cons

  • Duty hour customization not optimized for EM scheduling.
  • No integrated mechanism for shift swaps
  • All resident schedules are open
  • Not free

Cost

  • $395/year

Conclusion

MedRez is a strong web-based scheduling platform. It has made life easier for our program – both for the schedule-maker and the residents. Utilizing the random generator as a starting point, creating a block schedule takes just a few hours rather than days. Vacation and day-off requests have near 100% fulfillment with the combination of the generator and hand-tweaking. The user interface has excellent touch-enabled functionality and robust capabilities. While the initial setup was a bit onerous and the random generator is not perfect, the benefits of MedRez are readily apparent.

Review by Dr. Mike Hansen (Christiana Care)

amion

www.amion.com

Selling point

Amion is an online website that caters to medical scheduling. It’s set up like a fancy online excel file. It offers different ‘pages,’ where you can schedule the yearly block schedule, call schedule and daily shift schedule. It’s accessible to everyone with the use of a program specific passcode. It’s created with the use of their supplemental program, called OnCall. Everything is updated in real time. It also allows access to the Amion mobile app, where you can view your program’s daily schedule.

For the scheduler

To start, you have to download Amion’s scheduling program on your computer, called ‘OnCall.’ This was primarily designed to be run on a PC, but they offer a download option that comes with WineBottler that will run on Mac’s. I use a Mac, and other than an occasional hiccup, it operates smoothly.

Amion can be edited to your program’s specific requirements. This general setup was passed down to me (see image below), but if you are just starting, this will take some time to set up, as you will start with a blank slate.

Amion Scheduler's View How my OnCall program appears. From here, I have to manually place in every resident.

Once this is set up, then you can manually schedule every individual resident (which also takes a lot of time). It does have a helpful sidebar that appears while you’re doing the daily shift schedule that shows the amount of shifts the resident has that block and their vacation requests. Unfortunately, everything still has to be entered in manually. This increases your risk for errors.  There is a built in autoscheduler, but it cannot handle all the individual preferences our program needs (for example, we have a night block that cannot be worked into the scheduler). It alerts you if you have overlapped someone’s schedule, but it does not allow you to program in ACGME duty hour violations or any way to alert you if you schedule someone for less than a certain number of hours between shifts. It does allow you to work on the schedule however far out you need, and can publish the schedule online to any date you want. It saves online to the server, but you also have the option to save to your hard drive in case a file gets corrupted or something changes.

It also has a block view, which allows you to publish the resident’s assigned blocks for the academic year. You can edit the dates of the blocks to however your program designates (4 week blocks v monthly, etc).  The nice feature of the block view is you can enter everyone’s vacation requests and weekends need off in at the start of the year. When you’re scheduling, an alert will pop up if you are attempting to schedule a resident when they’ve requested off.

The third option is to schedule call. You can then schedule residents for call each day and have that populate to the Amion website.

Amion has an online swapping feature. We do not have this activated, as all swaps have to be approved through the chiefs. There is also the option for people to do their vacation and other shift requests online that will upload to OnCall.

It does have a useful help page on the website that is full of videos and advice on how to set up everything and to use all the different functions it provides.

For the resident

It allows the resident to link the website to their personal calendar (iCal, Google calendar) with helpful embedded links. Also, Amion allows the resident to view the schedule 3 different ways.

The first view is the block shift schedule. Where you can view the entire ED schedule and also have the option to highlight anyone’s individual schedule.

Amion Schedule View An example of an old schedule. Different level residents are represented in different colors.

The second view is the calendar view. This is specific for one resident and shows your approved vacation, call, and shifts.

Amion Calendar View This is specific for one resident and shows your approved vacation, call and shifts.

Amion Daily View Allows you to view all residents that are scheduled for a specific day.you can break this view into sections by department/hospital/shift type

Pros

  • Easily accessible across all platforms and devices
  • Provides iCal and Google calendar links, which automatically updates
  • Updates in real time
  • Other programs can view as long as they have the program password
  • All residents can view all schedules, allowing them to set-up swaps
  • Does have option to look at total amount of shifts worked and compare. Can publish this online versus making it private. Does not allow you to look at morning vs evening. Can look at overnights.
  • Can be passed down from chief to chief throughout the years

Cons

  • Auto scheduler tough to use and hard to make work with all the different challenges of ED scheduling
  • All swaps and vacation requests have to be done by scheduler (though there are options for this to be done through Amion)
  • Takes a lot of time to set up schedule
  • Not free

Cost

  • $350/year

Conclusion

AMiON is a web-based user interface for the scheduling program ‘OnCall’. It provides accessibility with support for a broad variety of devices and features tools for integration into calendar applications. It also features shift-swap and vacation capabilities. The auto scheduler is not in use in our department because it is unable to account for some of our rules, but your mileage may vary. Overall, AMiON provides a solid web interface and continues to be successfully utilized by our program.

Review by Dr. Corinne Horan (Jefferson) & Dr. Devin T. Burrup (Wright State University)

shiftadmin

shiftadmin.com

Selling point

Shift Admin is a web-based scheduling program that auto-generates schedules based on specific criteria defined by the Administrative User. The program can support the scheduling needs of multiple users at a single hospital or multiple facilities, and allows for integration into one schedule or generation of separate schedules. Cost for scheduling is based on the average number of residents on your monthly schedule, with the cost coming to $5/month/resident. Flat rates can also be negotiated directly. Customized rules have associated “point-values” assigned to them (defined by the Administrative User) which result in “penalties” if that rule is broken when a schedule is auto-generated. After specific requests have been entered (i.e. vacation, day off requests, etc), the auto-generator analyzes hundreds of millions of schedules to produce one with the least amount of penalty points possible. The Administrative User can then analyze the data to determine if the penalties are acceptable. Once a schedule is generated using the auto schedule generation feature, it can be edited/tweaked as needed. If edits are required, a new schedule can be generated using the Administrative Users edits as a new starting point, thus reducing overall penalties and improving the overall schedule. The schedule can then be exported to excel or PDF for email distribution. Users can also log-in to their online account to see the schedule, offer trades, or sync to external calendar software (i.e. iCal, Outlook or Google calendar) for offline use.

For the scheduler

Shift Admin requires a lot of data input prior to actually being able to create a schedule. Users can be input through the use of a CSV template available for download on the Shift Admin site. Schedulers then need to create “Contracts” to assign to each of these users, which is likely to be the most time-consuming aspect of setup. Contracts are designed in order to tell the schedule generator what the rules are for any specific resident. Each of our PGY classes has a separate contract, and this is where you input duty hour restrictions, how many nights each resident should work, how many days off they should have per week, and how many scheduling requests they are allowed to make. The contracts are not a particularly intuitive part of the program, as each “rule” created in the contract is additionally assigned a specific weight, which tells the schedule generator which rules are more important to abide by (ie: duty hour violations are more important than having a weekend off).

Once users have their contracts assigned, you can create schedule periods for each block schedule. Users in the department that month can be assigned, and specific schedule requests that must be honored (for example, clinic days for off-service residents and which residents cannot work nights the last night of the block) can be input by the scheduler on this page. This has also proven to be a time-consuming process due to the high number of off-service rotators that often do not follow our block schedule for their rotation.

Shift Admin Requests Admin entered requests fall below the line, whereas user input requests fall above the line. Requests can be marked as “FIXED,” and can be made only for specific shifts off in addition to full days off.

From there, Shift Admin’s schedule generator goes through millions of iterations of potential schedules until it comes up with one that breaks as few of your contract rules as possible (denoted by the weight). The generator runs for 20 minutes but can be stopped at any time. Manual edits can be made very easily once the schedule is generated, and when you are happy you simply publish the schedule for all users to view.

Shift Admin Schedule View Logged in users see their schedule highlighted

The entire process when starting fresh with Shift Admin can be arduous. They do, however, offer very responsive and helpful tech support. When initially learning the system, we set up online meetings with the tech specialists, who were happy to teach us the system (including going through an entire contract with us and teaching us the best way to assign weights). Their support has certainly made the program more “user friendly,” especially for those of us that are not as tech savvy. At any time, if you are having an issue, Shift Admin will typically respond to an email within 5 minutes or will answer the phone immediately to help you troubleshoot.

Customization

While the customization process can be very time consuming and may require a lot of changes when creating the first schedule, Shift Admin itself can be customized to work for very complicated schedules. At both Jefferson (which has 39 residents staffing 4 different EDs with 120 off-service rotators to incorporate annually) and Wright State (which has 46 residents staffing 6 different EDs), Shift Admin has made a huge difference in terms of the ease of scheduling. Staffing for multiple sites and specific requests off for conference and morale days can be incorporated into a single block schedule using Shift Admin.

The true customization comes mainly from building the contracts. By changing the penalty weights in the contracts for different rules, you can tell the system what is most important for your residents’ schedule. Do you think it’s absolutely necessary that all residents have at least one weekend off every block? You can weigh that particular rule more heavily than others, and the generator will break that rule less often. However, that also means that the generator may need to break another, less heavily weighted rule in order to build a functional schedule. These contracts can additionally be customized for each site your residents staff, and changed on a block-by-block basis to ensure that residents on a particular rotation are scheduled appropriately.

Additionally, each user profile can be customized for shift preference (i.e. if a resident requests to work all night shifts, the maximum number of night shifts can be changed for an individual user without affecting the base contract and other users assigned to it). This feature can be changed on each schedule and changing this preference in one schedule period does not automatically change it for all remainder schedule periods.

Software compatibility

The mobile site allows users to view only their schedule or the group schedule as well as make offers for shift trades. From the mobile site as well as the full site, users can subscribe to their schedule via iCal or Google calendar. Users can opt to view the full site if desired, which works well on an iPhone. For those who prefer paper, a PDF can be printed directly from the site.

Shift Admin Shift Trade User shift trade interface

Pros

  • Generator that analyzes millions of schedule iterations
  • Exceptional tech support
  • Customizable
  • Easy-to-read schedule
  • Resident driven requests and shift trades
  • Compatible

Cons

  • Time consuming set up
  • Not free

Cost

  • $5/month/resident

Conclusion

Shift Admin is an online schedule management system that makes scheduling quick and effective. The auto-generator uses a complex algorithm to analyze hundreds of millions of schedules, resulting in a schedule that best meets predefined criteria. The interface is intuitive and easy to use. Both users and admin can input specific requests. Although it takes a significant amount of time to set-up, the support staff is knowledgeable, friendly, and helpful. Despite it being more expensive than it’s scheduling competitors, I feel it has tremendous benefits and is worth the cost. Shift Admin will ultimately decrease the amount of time required to create schedules. After all, nothing is more valuable during residency, than our time.

Reviewed by Dr. Alex Harding (Hackensack University Medical Center)

wtw

http://www.WhenToWork.com

Selling point

With a website founded in 2000 and developed by math PhD’s, WhenToWork (WTW) boasts that they have been providing scheduling solutions for 28 years total. At our institution, it has been the preferred scheduling software for attendings and scribes for years. When our residency was founded, it became our scheduling tool as well (possibly due to ease of just increasing payments to an already approved company). It provides a relatively bare-bones scheduling interface with lots of functionality and customizability. Their main “claim to fame” feature is the “autofill” system, developed by the aforementioned PhD’s.

For the scheduler

Starting with WTW is easy – for each employee, a name and email address is supplied. There are options to add phone numbers, fax numbers, addresses, and other extensive identifying information as needed. There is then a single button to press that sends login information to anyone who has not yet accessed the site. Once this is complete, with or without the employee logging in, they are available for scheduling. Individual hour restrictions and shifts per week can be set to help avoid duty hour conflicts. The website loads quickly, and provides several different graph and text views of the schedule. There is an Android app that is relatively straightforward and, while it has less functionality than the full site, is useful for schedule checking on the go.

As for the actual schedule itself, hours and location of shifts are made clear, color coding helps differentiate between shifts, and shift hour templates can be programmed in for quick entry into the schedule. The shift by shift input can be cumbersome, but there are deeper features that allow streamlining of the process. There is an available trade board that, while unintuitive, allows users to control their trades rather than needing implementation by the admin. The site also accepts schedule requests, and these can be applied prior to inputting the schedule so nobody is scheduled during time they do not want to work.

WhenToWork Settings for adding a shift

While I have not personally used the autofill function yet, the summaries seem promising. Employees can enter time off, as well as shift preferences, which can then be used to autofill the schedule based on admin-set parameters. I suspect that with the variability of the schedule in EM, it may take more work to correctly utilize this functionality – a project that will take some time to flesh out. This seems more easily implemented in jobs with more uniform shift types (versus the constantly changing resident landscape)

For the residents

WhenToWork’s best feature for residents is the ease of viewing the schedule. Each schedule entry is color-coded and labeled with the area and time. Both the app and the website allow users to view “WHO’S ON NOW” and “WHO’S ON LATER” links, along with individualized schedules for themselves and others (viewable in daily, weekly, and monthly increments). Schedule requests are easy to put in, and allow users to select days and give reasons for their selection. These are automatically forwarded to the scheduler. There is a messaging system that sends a message straight to the admins through the website.

The only hefty downside I have found from a user perspective is the difficulty of shift swaps. This process typically involves 4-5 steps to approve and implement a shift swap, which has required an explanation multiple times. Also, there is no app available for iOS products (though the mobile website suffices for most applications).

Overall, shift swaps aside, WhenToWork has received no complaints from our residents, who seem to find it easy to navigate, easy to view schedules, and great for schedule requests and communication.

WhenToWork Schedule Schedule view for WTW

Pros

  • Very easy to access – employees can be entered with minimum information and automatically sent login instructions
  • Communication – messages can be posted permanently to a message board on the schedule itself, messages can be sent directly to employees and admin, and there is even an option to send an urgent text alert to all employees
  • Ease of use – the minimalist nature of the website makes it easy to load, the android app allows portability, and the ability to export shifts to iCal, google calendar, and other third party systems is very useful. The website and app both have the option to display “Who’s On Now/Who’s On Later” which can help greatly in planning events and ensuring residents who are scheduled are in attendance
  • Customizability – shift templates, weekly and monthly templates can be created to make the scheduling process easier, and various colors help easily differentiate shift times/types.
  • Hours management – each employee can be customized with max hours per week, required time off per week, and other parameters. The system will then automatically detect and flag duty hour violations.

Cons

  • Submitting trade requests is unwieldy and has a steep learning curve – employees must put their shift on the tradeboard, the other employee suggests a trade, each must confirm the trade, then it is sent to admin for approval. This could likely be streamlined.
  • No support for an iOS app at the time of this writing – iPhone users must go through the website.
  • Changing shifts from one area to another requires deleting the shift and recreating it to properly display the correct shift location
  • By default, any changes to the schedule automatically sends an email to the affected user, which can be annoying when many changes are being made without deselecting this option manually each time
  • Entering shifts can feel cumbersome to a new user who hasn’t yet mastered the intricacies of the system
  • Cost: Not free

Cost

  • Cost: Variable based on duration and number of employees – for our 36-resident program, it costs $330/year.
  • The cost for WTW is available on monthly, 3 month, 6 month, or yearly terms. Longer contract lengths offer significant savings. This pricing scheme is readily available on the website, and is dependent on the number of employees to be supported on the site. As our residency has 36 residents, we fall into the category that, on a yearly basis, pays $330 per year.

Conclusion

WhenToWork is not the most aesthetically appealing scheduling option, and it has a steep learning curve, but there are many benefits and options available that can make it a great scheduling tool for any residency. The ability to easily communicate, quickly access the schedule, export the schedule, and shift hour violation checks make it very useful for a chief resident scheduler. While there are several downsides, they are easily addressable and, overall, once the scheduler and residents become familiar with the interface, it is a very solid scheduling option.

Editor: Dr. Adaira Chou

 * Disclaimer: We have no affiliations (financial or otherwise) with the software scheduling platforms.

Author information

Sam Shaikh, DO

Sam Shaikh, DO

Editor, 60-Second Soapbox series
Emergency Medicine Chief Resident
Sinai-Grace Hospital/ Detroit Medical Center
2014-15 ALiEM-CORD Social Media and Digital Scholarship Fellow

The post 5 Scheduling Software Options in the Emergency Department: An In-Depth Review appeared first on ALiEM.

Trick of the Trade: Ear foreign body removal with modified suction setup

popcorn-kernelsA 5 year old boy comes in who has stuck a small unpopped popcorn kernel into each ear. My resident and I discuss  different methods to try to get it out including an ear curette, tissue glue, suction, and calling the ear-nose-throat (ENT) specialist. The ear curette won’t work to get around and the kernels are smooth and hard to grasp and might cause trauma with swelling or bleeding. We quickly excluded irrigation because the kernel might swell more. Another method considered was a drop of tissue adhesive onto a q-tip stick to adhere onto the foreign body (FB) for extraction. We were a little leary of this however for fear of gluing the FB to the ear canal and suffering the wrath of ENT.

My resident prepared a 12 Fr Frazier suction catheter, which is good for ear FB’s like insects. The Frazier suction worked well enough to remove one of the kernels from one ear with a little coaxing. The other ear FB did not yield to the Frazier, presumably because the rigid end and smaller diameter does not provide a tight seal on these rounded FBs.

Frazier suction catheter ear FB

 

Trick of the Trade: Modified a 14 Fr suction catheter

After the failed rigid Frazier suction catheter attempts with the second kernel, we used a soft tipped, short suction tubing whose diameter nearly matched the foreign body. The theory was that it might provide a better suction seal. So, the standard 14 Fr suction catheter was cut short and it worked like a charm.

Suction Catheter Ear FB

 

Modified suction ear FB

 

We liked this best because the soft catheter is less likely to cause trauma, if the patient inadvertently moves, and the better suction force that it provided. We guess that it would work equally well in the case of a nasal FB. Ultimately, we feel that suctioning works best with objects having a smooth rounded or flat surface.

Twitter peer review

After posting this trick on Twitter, we received feedback via tweets that a mini-suction made from a cut butterfly needle can work for small beads. We are not sure that would work for larger FB’s like the popcorn kernel but it looks like there are a range of catheter diameters that one can try to find the best fit!

Regarding our concern of tissue adhesive on a q-tip inadvertently gluing the FB onto the ear canal, we learned that one might use an otoscope’s speculum to protect the ear canal from the glue.

Other ear foreign body removal tricks

We’ve also described using a pediatric video laryngoscope trick to provide excellent lighting, exposure, retraction, and magnification to visualize ear FB’s for removal but that would not have helped in this case with a larger ear FB.

Reference

Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007; 76(8): 1185-9. PMID: 17990843

 

Author information

Yen Chow, MD CCFP

Yen Chow, MD CCFP

Emergency Physician, Thunder Bay Regional Health Sciences Centre;
Regional Medical Director, Ornge;
Assistant Professor, Emergency Medicine Section, Northern Ontario School of Medicine

The post Trick of the Trade: Ear foreign body removal with modified suction setup appeared first on ALiEM.

I am Dr. Azita Hamedani, Founding EM Department Chair at University of Wisconsin: How I Work Smarter

How I Work Smarter Logo Today we have the privilege of hearing from Dr. Azita G. Hamedani MD, MPH, MBA, founding chair of the Department of Emergency Medicine at the University of Wisconsin School of Medicine and Public Health (UWSMPH). Under her leadership, the department has grown exponentially, growing from 6 to 36 residents, from 14 to 45 faculty while experiencing a 100% increase in patient volume. For showing exemplary skills in leadership, clinical quality, operations and healthcare finance she has been awarded – amongst other awards – both ACEP’s Outstanding ED Medical Director of the Year Award and the Association of Women in Academic Emergency Medicine Early Career Award. But beyond numbers and awards Dr. Hamedani is known for fostering the academic spirit at UWSMPH, elevating the department renowned to a national level. Below, she shares her tips on efficiency and getting things done.

  • Name: Azita G. Hamedaniazita hamedani
  • Location: Madison, Wisconsin
  • Current job: Chair, Department of Emergency Medicine at University of Wisconsin School of Medicine and Public Health
  • One word that best describes how you work: Non-stop
  • Current mobile device: Samsung – Galaxy S6
  • Current computer: Dell – Latitude E7540

What’s your office workspace setup like?

Anywhere that I can hook up my computer to Wi-Fi and have space for my external mouse – hotels, airports, kitchen table, library, pool.

Hamedani Work Station SmlDr. Hamedani’s on-the-go hotel work station

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

  • For the office, keep your own calendar. Only you can decide who gets bumped for whom, how much time to put in for travel, whether you can skip out on a meeting early to get to the next, and how to stack them so you aren’t coming in for only a single low-yield meeting.
  • For the home, try to touch non-work related paper (e.g. mail and kid’s school stuff) only once – pay it, RSVP, log it, set up reminder, etc. – do whatever you need to do with it and be done with it.

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

  • Blind cc yourself for any ‘work’ you send out via email, so it stays as a tickler in your inbox for if/when you receive a response or the work product back – best way to delegate while maintaing accountability.
  • Color code with at least 5 colors (as long as easy to do) so that you can quickly jump back to what needs your attention.

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

Set up your EMR system so that it alerts you anytime a lab comes back on your patient – EPIC has this functionality. Wish it would do the same for Rads…

ED charting: Macros or no macros?

Macros for Review of Systems and Physical Exam, but NOT Medical Decision Making.

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

There is no such thing as well-balanced, only constant juggling. Know your priorities, juggle only with those balls that are most important to you (the rest are just distractions), know when a ball needs your attention and attend to it before it hits the ground. All the balls are important, but not all the balls need the same amount of attention all the time. And when a particular ball does need attention, whether personal or professional, it is okay to put the others on hold.

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

I keep a detailed to do list, by day, by week, by month, by quarter, by year(s) – I keep it as an electronic word document, periodically update, and then print out again. Always good to keep track of what needs to get done in the short, intermediate, & long term. Also, easy place to jot down ‘what should get done’ – but just not now!

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

  1. Dr. Jen Wiler
  2. Dr. Arjun Venkatesh

Author information

Benjamin Azan, MD

Benjamin Azan, MD

Emergency Medicine Resident
Icahn School of Medicine at Mount Sinai
Founder/Editor of foambase.org

The post I am Dr. Azita Hamedani, Founding EM Department Chair at University of Wisconsin: How I Work Smarter appeared first on ALiEM.

I am Dr. Kathryn Dong, Director of ARCH and Inner City Health and Wellness: How I Stay Healthy in EM

How I Stay Healthy logoDr. Kathryn Dong (@kathryndong) is no stranger when it comes to keeping well! Currently, she is the Director of the Inner City Health and Wellness Program and the Addiction Recovery Community Health (ARCH) Team. She also keeps busy with her 3 boys, who keep her active and on her toes! Dr. Dong’s inspiring work with inner city populations, has given her a welcoming perspective on the value of community. Here, she shares her thoughts on how to maintain mental wellness and keep mentally in check. Take a look at how she stays healthy in emergency medicine!

  • Name: Kathryn Dong2015-08-18_1
  • Location: Edmonton, Alberta
  • Current job(s): Mother of three boys ages 2, 6, and 8 years; Director of the Inner City Health and Wellness Program and the Addiction Recovery Community Health (ARCH) Team at the Royal Alexandra Hospital; Emergency Physician at the Royal Alexandra Hospital; Associate Clinical Professor, Department of Emergency Medicine, University of Alberta
  • One word that describes how you stay healthy: Perspective
  • Primary behavior/activity for destressing: Playing with my three boys!

What are the top 3 ways you keep healthy?

  1. Clear priorities. Having a clear idea of what is important to me (and not being driven by what is important to others, or what seems urgent in the moment) helps me to stay focused on the big picture. This ensures that I am only working on the things that are critical to my long-term goals and helps to keep my workload manageable.
  1. Living in the moment. Working in the emergency department is a constant reminder that life is short. I try to fully embrace each moment and give it my full attention. For me that means making sure my kids are well looked after when I am at work, so I can completely focus on providing the best care for my patients. It also means that I need to be able to leave work behind when I am home with my kids, so that they have my undivided attention.
  1. Being part of a community. Working in the inner city has taught me the power of community. I have met people who carry everything they own in a backpack, including a first aid kit they made out of left over supplies, just in case someone gets hurt. I have trained people to save the lives of their friends who have just overdosed when everyone is too scared to call 911. Being part of a group of people who do anything and everything to help each other out encourages me to worker harder and do my part.

What’s your ideal workout?

I have to say working full time and raising three kids does not leave much time for formal workouts! I hope that skiing, rock climbing, and hiking with three boys in tow (and/or being carried on my back) counts as exercise!

Do you track your fitness? How?

No.

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

I haven’t done full overnights (in the hospital) since our second son was born. I do all the night time care of our kids at home and my husband works all the night shifts. I do work a lot of early morning shifts, though, and getting enough sleep is key! Sleeping around shifts has to be made a top priority.

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

EAT! I don’t ever take enough of a break to eat a full meal, but I do eat throughout my shift. I bring bite-sized snacks that are easy to eat on the fly, like when I am stopping to check on a bunch of lab work. I also try to eat when I am listening to a student or resident present a case.

How do you ensure you are mentally in check?

This is an important one. Take care of your basic needs (eat, sleep, staying healthy). Take care of your family – your marriage, your kids, extended family, and friends. If these things are rock solid, you will be able to handle anything that life throws at you without losing your cool.

What are the biggest challenges you face in maintaining a longstanding career in EM? How do you address these challenges? Best advice you have received for maintaining health?

Maybe, for some people, emergency medicine is meant to be only part of a career path. I love emergency medicine, but for me what’s even cooler than doing an ED thoracotomy is preventing that person from getting stabbed in the first place. I run the Addiction Recovery and Community Health (ARCH) Team at our inner city hospital. This team helps our highest risk patients stabilize their substance use and also improve their social determinants of health. By working ‘upstream’ of the ED, I have the tremendous privilege of helping some of our regular ED users turn their lives around and take a different path.

Best advice you have received for maintaining health?

Health first, family second, work third (as told to me by Dr. Mike Bullard when I was a fifth year resident) – words to live by!

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

Corinne Hohl
Sarah Gray

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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Ultrasound For The Win! Case – 76M with Right-Sided Vision Loss #US4TW

Ultrasound-For-The-Win

Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where bedside ultrasound changed the management or aided in the diagnosis. In this case, a 76-year-old man presents with sudden-onset right-sided vision loss.

Case Presentation

A 76-year-old man with history of hypertension presents to the emergency department (ED) with a complaint of 5 hours of sudden-onset right-sided vision loss. He notes seeing flashes of light in the periphery of his field of vision followed by several “floaters”. He denies any trauma, headache, or pain. On physical examination, he appears well and is in no acute distress. Neurologic examination is grossly unremarkable. Pupils are 3 mm, round, and reactive to light bilaterally. Visual acuity is 20/20 OS, and 20/100 OD. Intraocular pressures are measured at 8 mm Hg bilaterally.

Vitals

BP 131/62 mmHg
P 78 bpm
RR 20 respirations/min
O2 99% room air
T 37.4 C

Differential Diagnosis

  • Migraine
  • Optic Neuropathy
  • Posterior Vitreous Detachment
  • Retinal Artery/Vein Occlusion
  • Retinal Detachment
  • Stroke/TIA
  • Uveitis

POINT-OF-CARE ULTRASOUND was performed which showed the following:

Figure 1 Retinal detachment of the affected eye

Figure 2 A retinal detachment is visualized (blue arrow). Also note the anterior chamber (AC) and vitreous chamber (VC)

Ultrasound Image Quality Assurance (QA)

The eye, being a superficial fluid-filled structure, is an optimal organ for diagnostic ultrasonography. Point-of-care ocular ultrasound is fairly straightforward; images are obtained using a high-frequency linear transducer with the “ocular” setting on the ultrasound machine, if available.

A generous amount of gel should be used over a closed eyelid, with or without a tegaderm. Both the affected and unaffected eye should be examined for comparison, with normal landmarks and anatomy noted (Fig. 3).

Figure 3 Normal Ultrasound Anatomy of the Eye: From anterior (top of image) to posterior (bottom of image): Cornea (C), Anterior Chamber (AC), Lens (L), Vitreous Chamber (VC), Retina (blue arrow), Optic Nerve (ON).

A retinal detachment (RD) is a separation of the two layers of the retina, which invariably causes blindness if left untreated [1]. On ultrasound, this appears as a bright hyperechoic wavy line within the vitreous chamber coming off the posterior aspect of the eye. Associated vitreous hemorrhage may also be visualized as hyperechoic strands within the vitreous chamber that move with eye movement, and has the appearance of clothes tumbling in a washing machine (The “Washing Machine Sign”).

It is especially important to optimize the gain, or brightness, with ocular studies. Generally, the gain is set slightly higher than usual to just the point of visualizing small echogenic material within the vitreous chamber. This avoids missing a potential subtle RD if the gain is set too low. With the ultrasound probe oriented transversely then longitudinally over the globe, the probe is fanned back and forth, spanning the entire globe. Finally, the patient should move their eye in all directions in order to fully evaluate the entire globe for pathology.

Common Pitfalls:

  1. Inadequate gain. Gain, or brightness, that is set too low can miss subtle structures including a detached retinal flap. Gain that is too high can increase acoustic enhancement artifacts posteriorly, also with the risk of missing a retinal detachment.
  2. It can be normal to see artifacts within the vitreous chamber, which may appear as bright echogenic material; movement of the eye should cause artifacts to “disappear”. (Figures 4, 5)

Figure 4 Pitfall: Normal ocular ultrasound with artifact in the vitreous chamber

Figure 5 Artifacts can sometimes be mistaken for retinal detachment or other pathology

Ultrasound Fanatic Side Note: Ophthalmologists were among the first physicians to use ultrasound in their clinical practice. Ultrasound of the orbit has been described in the ophthalmology literature to aid in the diagnosis of retinal detachment as early as 1957 by Oksala and Lehtinen [2]. Their use of A (Amplitude)-mode, visualized as a graph of spikes along an axis, differs from the more conventional B (Brightness)-mode, the series of 2D images that we currently use in the ED. For additional reading, please refer to History of Ophthalmic Ultrasound by Lizzi and Coleman [3].

Disposition and Case Conclusion

Given the concerning finding of a retinal detachment, ophthalmology was consulted and confirmed the diagnosis of retinal detachment. The patient underwent definitive treatment and his visual acuity has been spared.

Retinal detachment affects 1 in 300 people, and remains a time-critical and vision-threatening diagnosis that emergency physicians (EP) must consider in patients presenting with ocular complaints [4]. Patients presenting with RD typically complain of sudden-onset unilateral painless loss of vision or visual field deficits. They may describe “flashing lights”, “floaters”, or “spider webs” in their field of vision. If the macula is not detached, the goal is to undergo definitive treatment to spare the macula. Time to treatment is critical in these cases as the duration of macular detachment is inversely related to a patient’s ultimate visual acuity [5]. Patients will often have good outcomes if treated promptly. Thus, a high-level of suspicion and ophthalmologic consultation with close follow-up is warranted for definitive care.

The vast range of ocular pathologies that present to the ED remains challenging for the EP to diagnose without a dedicated fundoscopic examination. Unfortunately, a physical examination including non-dilated direct fundoscopy is often inadequate, and has been shown to miss 38% of retinal pathologies that required intervention [6]. The use of point-of-care ultrasound by the EP serves as a vital adjunct to clinical assessment in the time-critical diagnosis of intraocular diseases including retinal detachment. While seemingly an “advanced” ultrasound technique, the findings of RD are not subtle and can be easily identified, as was seen in this particular case. In fact, a prospective study by Shinar et al. found that EPs can accurately diagnose RD using bedside ultrasound with a sensitivity of 97% and specificity of 92% [7]. Additionally, Blaivas et al. showed that 60 out of 61 intraocular diseases were accurately diagnosed by the EP with bedside ultrasound when using an ophthalmologists’ evaluation as the gold standard [8].

The main indications for ocular ultrasound in the ED expand beyond looking for retinal detachment, and include assessing for vitreous hemorrhage, intraocular foreign bodies, lens dislocation, or to evaluate for signs of elevated intracranial pressure (Table 1). Note that the only absolute contraindication to ocular ultrasound is a suspected ruptured globe, in which case no pressure should be placed on the globe.

Table 1. Indications and Contraindications for Ocular Ultrasound in the Emergency Department

Indications for Ocular Ultrasound
Acute vision changes or loss of vision
Orbital trauma (when globe rupture is not suspected)
Atraumatic eye pain
Elevated intracranial pressure
Intraocular foreign body
Contraindications to Ocular Ultrasound
Suspected globe rupture

 

Take-Home Points on Retinal Detachment

  1. Retinal Detachment is a time-sensitive ophthalmologic emergency that invariably leads to blindness if left untreated. If there is suspicion of RD, ophthalmology consultation is warranted.
  1. While a dilated fundoscopic exam is typically required for diagnosis of RD, this is often not feasible or available in a busy ED or community setting.
  1. Emergency physicians can be highly accurate in the diagnosis of intraocular pathologies including RD with the aid of point-of-care ultrasound with 97% sensitivity and 92% specificity [8].

References

  1. Bhatia K, Sharma R. Eye emergencies. In: Adams JG. Emergency medicine. Philadelphia: Saunders Elsevier; 2008. 213–32. 
  2. OKSALA A, LEHTINEN A. Diagnostics of detachment of the retina by means of ultrasound. Acta Ophthalmol (Copenh). 1957; 35(5): 461-7. PMID: 13497646
  3. Lizzi FL, Coleman DJ. History of ophthalmic ultrasound. J Ultrasound Med. 2004; 23(10): 1255-66. PMID: 15448314
  4. Schott ML, Pierog JE, Williams SR. Pitfalls in the use of ocular ultrasound for evaluation of acute vision loss. J Emerg Med. 2013; 44(6): 1136-9. PMID: 23522956
  5. Marx et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th 2014. 
  6. Siegel BS, Thompson AK, Yolton DP, Reinke AR, Yolton RL. A comparison of diagnostic outcomes with and without pupillary dilatation. J Am Optom Assoc. 1990; 61(1): 25-34. PMID: 2319090
  7. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med. 2011; 40(1): 53-7. PMID: 19625159
  8. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002; 9(8): 791-9. PMID: 12153883

*Note: All identifying information and certain aspects of the case have been changed to maintain patient confidentiality and protected health information (PHI).

Author information

Jeffrey Shih, MD, RDMS

Jeffrey Shih, MD, RDMS

Assistant Editor, Ultrasound for the Win Series,

Academic Life in Emergency Medicine

The post Ultrasound For The Win! Case – 76M with Right-Sided Vision Loss #US4TW appeared first on ALiEM.

ALiEM Bookclub: The White Coat Investor

Book-Review-of-the-White-Coat-Investor

“What’s the good life? My definition is a life free from financial worries, a career where you make a real contribution to society, a few luxuries along the way, the ability to help others financially throughout your life, and a comfortable retirement at a time of your choosing.”

– Dr. James Dahle, author of The White Coat Investor

Despite all of the training we receive as medical students and residents – anatomy, physiology, pharmacology, pathology, BLS, ACLS, ATLS, medical ethics, research – residents and physicians are typically in the dark about the the world of personal finance and investing. Physicians are already, by virtue of relatively high return on our educational investment and excellent  job security, in a great position to grow wealth provided they are given the advice, understanding, and tools to effectively manage their personal finances and investments. Dr. James Dahle (@WCInvestor), a board-certified EM physician, wrote The White Coat Investor to provide the basic understanding about wealth management that physicians can use to turn our passion into what he calls “the good life.” While the book focuses on all physicians, regardless of specialty, his background in EM makes it especially applicable to EM residents and physicians (and even interested medical students).

Synopsis: How to Find the Good Life

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. – Atul Gawande

Dr. Dahle graduated from medical school in 2003. In just 10 years, with a stay-at-home wife and 3 children, he became a millionaire. He noted that many of his medical colleagues were uneducated about the ideal ways to manage their salaries, and thus his blog The White Coat Investor was born. Throughout the book, Dahle’s narrative is interspersed with advice on loan repayment, asset protection, and estate planning; making  a sometimes dry subject not only tolerable, but fun. Several anecdotes and specifically calculated examples give his advice a real foothold in the reader’s life.

In the first chapter, entitled, “The Big Squeeze,” Dahle explains that, in the face of rising tuition, lower reimbursement, and increasing regulations, financial literacy is more important than ever. Physicians spend a decade training during prime income-earning years. They often accumulate hundreds of thousands of dollars in debt, and they commonly have an indulgence reaction to an attending salary after years of delayed gratification. They are targeted by less-than-efficient financial professionals due to their profession. They are expected by society to live to a higher standard, and due to their basic benevolent nature tend to donate more to charities. Lastly, many physicians feel they don’t have the time to delve deeply into their finances. Dahle elucidates that when accounting for inflation, physicians are  making 28% less than they were 20 years ago and paying 4x as much for their education relative to inflation. Simply having a doctorate does not guarantee financial success.

In the following chapters, he creates a map for converting high income to high wealth with specific examples. Here are a few of the most salient points and recommendations:

Income and Wealth
Medical Students
Residents
Attendings
Retirement
Investing

Further knowledge

Despite relatively large salaries, physicians tend towards being UAWs (under accumulators of wealth). You can become a PAW (prodigious accumulator of wealth) by following the above guidelines and reading the later chapters on real estate investing, obtaining reliable financial advice, asset protection, estate planning, income taxes, and choosing a business structure. Dahle recommends that you read one book about finance each year and consider it CFE (continuing financial education). This will improve financial literacy and make obtaining your investing goals more enjoyable.

Clinical Application

Physicians typically enter the profession out of an innate desire to help others. Dahle suggests that one major obstacle to physician financial acumen is that money was never the initial motivating factor. It is for this reason that physicians are often embarrassed to speak about money and may even feel the need to apologize for having it. Fine details of wealth management are consequently left to others who may take advantage of such naivety. This, in combination with busy resident and attending work loads with little free time to read up on this complex topic, can cause the world of personal finance to feel overwhelming.

Dahle reframes the conversation concerning wealth in a powerful way. He points out that financial stability can open the door to your dream job. You can work on research, travel, volunteer in a free clinic, or just have the freedom to speak up when you feel that departmental changes are not in the best interest of patients. You can also take greater risks when it comes to venturing outside of emergency medicine to pursue passions of entrepreneurship or administration. And, when it is time to retire from the specialty, you can do so autonomously at the time of your choosing.

He states “money might not bring happiness, but having been both rich and poor, I definitely prefer rich.” He is able to live a life where there are no arguments over money and vacations are limited primarily by time, not finances. His children are able to participate in activities of their choosing, and he can engage in hobbies without guilt. His financial acumen allows him to support his loved ones as well as his favorite charitable causes.

Dahle provides a clear and common sense navigation of the world of finance that is digestible for the busy resident. He delivers compelling and feasible explanations for becoming a millionaire by forty. After reading this book, you will likely be inspired to learn more; links are provided at the end of each chapter to suggested deeper reading. Dahle offers more in-depth information on his very successful blog. This book ultimately reveals that improving your financial literacy can be enjoyable, and that optimizing personal finance and investment practices is less about the accumulation of dollars and more about ensuring the opportunity to accrue the experiences you desire for personal fulfillment – “The good life.”

DISCUSSION QUESTIONS

  1. What kind of retirement savings options are available to you at your institution? Are you actively using them?
  2. How does fellowship change financial prospects and what actions can one take to improve financial well-being during additional training?
  3. Practicing physicians, how did you live immediately following residency? Where did your loan repayment and retirement savings fall on your list of priorities following residency?
  4. What are the first steps one should take towards improving their financial situation?
  5. What is the most effective way to spend a sign on bonus/pay checks?

Google Hangout Discussion featuring the ALiEM Chief Resident Incubator

Google Hangout Discussion Participants

Author: Dr. James M. Dahle (@WCInvestor)

Featuring:

 * Disclaimer: We have no affiliations financial or otherwise with the authors, references or hyperlinks listed, the books, or Amazon.

 

Edited by Dr. Nikita Joshi and Dr. Matt Klein

Author information

Maggie Sheehy, MD, MSc

Maggie Sheehy, MD, MSc

Chief Resident PGY3

Department of Emergency Medicine
University of Illinois at Chicago

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