I am Dr. Demian Szyld, Medical Director of NYSIM: How I Stay Healthy in EM

How I Stay Healthy logoDr. Demian Szyld (@demianszyld) first contributed to ALiEM when he was a resident at the University of Pennsylvania. He went on to complete the Fellowship in Simulation and Education at STRATUS, the Center for Medical Simulation at Brigham and Women’s Hospital, and a Masters degree at the Harvard Graduate School of Education. He works at NYU Langone Medical Center where he is the Medical Director of the New York Simulation Center for the Health Sciences (NYSIM) and directs the Fellowship in Simulation and Education. Once a week he is an attending physician at Bellevue Hospital in New York. Demian teaches simulation instructor courses locally and internationally, does research, and speaks intenationally about teamwork and debriefing. On top of that, he publishes a monthly podcast connecting the Spanish-speaking simulation community. And he still manages to keep well. Check out how he stays healthy in EM!

  • Name: Demian Szyld, MD, EdM5367127723_97d350e6ff_o
  • Location: New York City
  • Current job(s): Medical Director and Fellowship Director, NYSIM (www.NYSIMCenter.org), Assistant Professor, Emergency Medicine, NYU School of Medicine Faculty, Institute for Medical Simulation (www.harvardmedsim.org), Co-Host and Creator, Simulación de Sur a Norte Podcast (www.mundodesimulacion.com)
  • One word that describes how you stay healthy: realistic-moderation
  • Primary behavior/activity for destressing: Connect with family and friends via Skype or FaceTime

What are the top 3 ways you keep healthy?

  1. Eating. I start out with a small breakfast (fruit and toast or cereal) and a double skim cafe latte that I make at home. I pack a lunch the night before, to keep AM stress down and give me more time with my daughter. Lunch is usually a salad, which keeps me in control of what I put in my body. I like arugula, cucumber, cherry tomato, bell pepper, and avocado. I keep good salad dressing in the fridge at work. I rarely snack at work but I’ll have a fruit or toast in the afternoon at home between work and dinner. Dinner is where I eat meat in the following ratios: 3:2:1 for fish, poultry, and beef respectively.
  1. Drinking. I try to drink at least 1 alcoholic beverage per night and rarely more than 3. When I drink I make it something special. Liquid calories are too precious to not be discerning about it. When family and other priorities allow, it is nice to combine post-shift debriefing with colleagues at the bar.
  1. Sleeping. I make sure I get enough. I don’t require much, but I am unhappy when I don’t get enough of it. 6.5 hours is my minimum, but 7 and 8 are much better for me. When I get my sleep, I’m a lot more patient, helpful, happy, and productive. In order to maintain sleep hygiene, I avoid caffeine after 2pm and alcohol consumption 1-2 hours prior to sleep. Occasionally life calls for a shorter night… when that happens I triple my morning coffee, stay well hydrated, and make sure I get more sleep then next night.

What’s your ideal workout?

It is really hard to make time in our busy lives to add exercising to our schedules. Since the equation is [Calories In] – [Calories Out] = [Weight Gained]. I have focused on keeping my caloric intake in check. Moderate exercise during several days of the week is my reachable goal. One thing that has been working for me is to integrate exercise into my commute. I try to walk or bike a few times per week. One recent trick I have discovered is to bring my bike to work on the ferry in the morning, this keeps me from breaking a sweat in the morning and needing to change clothes. In the afternoon I change into my riding gear and ride hard for 20-30 minutes.

Do you track your fitness? How?

I track my steps on my Pebble, but I don’t stress over it. Going on walks with the family or just taking the baby out is a great way to add steps.

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

Preparation: I prepare for nights like I do for international travel. (Switching days to nights is a lot like jet lag). I’m fortunate in that these days I do more travel than night shifts. Nonetheless, here are some principles. Starting out without sleep debt really helps me rally. I avoid adding an extra meal just because I’m awake longer so if I’ve been up all day at my day job, then I have dinner before the night shift, but I won’t pack a meal. On the other hand, on a string of nights it’s reasonable to have lunch or dinner mid shift.

Recovery: Recovering involves not going to bed stressed or angry. I avoid sunlight as much as possible (hat, sunglasses, subway, shades down), try to relax at home, and have breakfast before bed, as I don’t want to wake up from hunger. I get up after 4-6 hours and keep my coffee to a single espresso macchiato. Post night I avoid driving or big mentally taxing situations, as I know I’m not as sharp. I never use sleep aid medications when transitioning although it is tempting sometimes. (For fighting jetlag I do find melatonin useful in both directions).

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

I eat meals rather than snack and I try to fit them in as early as possible. On morning shifts it’s after rounds, seeing everyone and handling the first wave of patients before the afternoon glut. On evening shifts between seeing everyone and the evening rush there’s usually a time when there isn’t as much movement. Prevention is the best form of treatment here too.

How do you ensure you are mentally in check?

Debrief with work colleagues, and debrief with your family too (maintaining HIPPA of course). You can’t stay in check by keeping it all in. Also, it’s unlikely that one will learn from experience alone, so processing, reflecting, and discussing experiences help us make sense and gain lessons for the future.

Another important aspect to staying mentally in check in my view has to do with who you work with. A department leader or medical director (or residency/ fellowship director for that matter) that you trust and respect and you believe has your best interest in mind is really critical. Similarly, when building teams or choosing workgroups, be sure to select individuals who will contribute and who you will enjoy spending time with, talking with and learning with each other. Life is too short and too precious to spend with people you don’t admire or get along with.

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

As a full time educator and part time ED doc, my challenge is to keep on prioritizing and protecting my clinical time. I’d say that at least once per year, I have to ask myself if I still enjoy clinical work and if it remains a priority. Taking care of patients and teaching at the bedside is a privilege and gives me great joy, so I constantly renew my commitment to the field and to patient care.

On a practical note, while on shift I make sure I take care of my team and myself: safety first, universal precautions, offer task assistance and mutual support. I suspect that we will be performing procedures and ultrasounds and documenting on computers for at least 30 more years, and that our work environments will probably remain suboptimal (crowded, poorly designed from an ergonomics point of view, and larger and larger spaces). So invest in yourself and slow down. Evaluate your posture and prepare ergonomically for procedures. You have a choice when wheeling around the ultrasound machine to roll up the cables to avoid tripping and push it gently with two hands, rather than pulling it behind you like a stubborn child. At the bedside, elevate the bed, lower the bedside so that you can remain standing. Not only will you last longer in EM, but you’ll also have fewer musculoskeletal aches and pains. It can be hard to know when one is not being safe or ergonomic, so let people on your team know when you’re seeing them work in these ways.

Best advice you have received for maintaining health?

Avoid chronic weight gain! In our 20’s and 30’s we may not think that gaining half a pound or a pound a year is significant… but over 30 years… those ounces add up and can become a risk factor! Also, don’t diet! Make lifestyle changes that work for you, your family, and your environment that will stick for the long haul.

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

Brian Lin
Matthew Fields
Ambrose Wong

Author information

Zafrina Poonja

Zafrina Poonja

ALiEM Assistant Editor,
How I Stay Health in EM series
Emergency Medicine Resident
University of Saskatchewan

The post I am Dr. Demian Szyld, Medical Director of NYSIM: How I Stay Healthy in EM appeared first on ALiEM.

MEdIC Series | The Case of the FOAM Promotion

AcademiaWelcome back to season 3 of the ALiEM MEdIC series! The MEdIC team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, and Teresa Chan) are very excited to kick off the ‘school year’ again with another online discussion within the ALiEM Medical Education in Cases series.

Join us now to discuss the case of the FOAM (Free Open Access Meducation) promotion wherein Chris, the assistant professor, finds himself reflecting about whether he should incorporate his online and FOAM works into his promotions package.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the FOAM promotion

by Anand Swaminathan (@EMSwami)

It was the end of another long overnight shift, and Chris was feeling good after successfully resuscitating a patient with septic shock patient and another with a gunshot wound to the chest. Sign-out was wrapping up. Looking up from his pile of completed charting, Chris noticed that his colleague and mentor Dr. John Siu was walking up towards him.

“Hey, Chris. I have a meeting in an hour, but want to grab a post-shift bite before you go home? John was one of the faculty members and had been a mentor to Chris throughout his first few years of being an attending. John was also on the university Promotion and Tenure (P&T) committee, and Chris has been thinking a lot about advancing his faculty career recently.

“Sure, why not.” Chris responds.

Walking over to the hospital café, the pair chatted and caught up about life, family, and their recent vacations. However, as they sat down, Chris stirred up the courage to chat about a dilemma that was weighing on his mind.

“So… John, I’ve been thinking a lot about getting my application together for promotion to Associate Professor. Can I pick your brain a bit?”

“Of course. Always happy to help. What have you done so far?”

“Well, I’ve been keeping my CV updated and I think it’s filling up nicely. My concern is that a lot of what I’ve worked on is non-traditional from the university’s perspective. I’ve been very active in resident- and medical student-education, and I’ve had the opportunity to publish a few peer-reviewed publications. I’m also on the hospital sepsis care committee, so that means I’m displaying some clinical involvement. Most of my non-clinical work, however, has been spent on a number of free open access medical education projects…”

“Is that the FOAM stuff?” asked John. “I’ve been noticing a lot of your stuff popping up everywhere! It seems you really enjoy it, no?”

Chris nodded. Chris had been relatively productive online and written a bunch of blog posts. He’d also participated in a couple of podcasts. More recently, he’d taken on an editorial role on a major FOAM website.

“Clearly, you’ve been busy with everything you’ve been doing but I’m not sure this is going to be enough for the P&T committee to move you up,” stated John, furrowing his brow. “It’s not that your work has not been fantastic and impactful, but our P&T committee… Well, they’re pretty old school in their perspective, and I think they’re going to want more of the standard publications and research. The truth is, I don’t know if anyone has gone up before the committee since these non-traditional forms of scholarship have been around so I don’t know how they’re going to respond.

Breakfast is served, and Chris mulled over what John was saying. Frankly, he was a bit discouraged, but as a rather disruptive and enthusiastic guy, Chris wasn’t afraid to fight an uphill battle. Chris reflected that perhaps promotion might not be daunting as John anticipated. John had no idea how his work would be received because it was quite different from the work that other people had previously done. Moreover, as there was no precedent at his institution, it did appear that he needed to think about how best to represent his work to the committee since there was no obvious pre-packaged way to present FOAM for the P&T committee.


Key Questions

  1. Given the lack of precedent with using FOAM for promotion in his institution, where should Chris go to get further advice on putting his application together?
  2. What metrics can Chris use to show his P&T committee the impact of the work he has done?
  3. Should Chris put the focus on his work in FOAM or direct attention in his promotion packet towards the traditional work (journal publications, clinical teaching, hospital committee participation) that he’s done?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts were:

  • Damian Roland (@Damian_Roland) – Pediatric Emergency Medicine staff physician at the University Hospitals of Leicester NHS Trust. He has a special research interest in quality and process improvement, Identification of serious illness in children and medical education evaluation. Have a look at his blog rolobotrambles.com and reflect on “what I learned this week” (#WILTW)!  Dr. Roland also encourages readers to check out changeday.nhs.uk and “pledge to do something better together”!
  • Daniel Cabrera (@cabreraERDR)- Consultant in Emergency Medicine at the Mayo Clinic in Rochester, MN, where he has been since 2005. A native of Chile, he obtained his medical degree from Pontificia Universidad Catolica de Chile where he was also part of an experimental training program in EM. He then completed an Emergency Medicine residency at Mayo Clinic. He holds the academic rank of Assistant Professor of Emergency Medicine. He is the editor- in-chief for the Mayo Clinic EM Blog and is the co-director of Mayo Hootsuite Healthcare in Social Media course. His academic interests include knowledge management, clinical decision-making, graduate education, orphan diseases, and Open Knowledge.
  • Bryan Judge – Attending emergency physician and Program Director of the Grand Rapids Michigan Emergency Medicine program. He is also the Chair of his local University P&T Committee.

On October 2, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of the Backroom Blunder.  After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on October 2, 2015.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Author information

Teresa Chan, MD

ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada
+ Teresa Chan

The post MEdIC Series | The Case of the FOAM Promotion appeared first on ALiEM.

AIR-Pro Series: Cardiovascular (2015)

ALiEM-AIR-Badge-PRO-only smBelow we have listed our selection of the 8 highest quality blog posts related to 3 advanced level questions on cardiovascular topics posed, curated, and approved for residency training by the AIR-Pro Series Board. The blogs relate to the following questions:

  1. Advanced concepts about Sgarbossa’s Criteria
  2. Troubleshooting pacemaker’s and automated implantable cardioverter defibrillators (AICD’s)
  3. Troubleshooting left ventricular assist devices (LVAD’s)

In this module, we have 5 AIR-Pro’s and 3 Honorable Mentions. To strive for comprehensiveness, we selected from a broad spectrum of blogs identified through FOAMSearch.net.

AIR-Pro Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have two subsets of recommended resources. The AIR-Pro stamp of approval will only be given to posts scoring above a strict scoring cut-off of ≥28 points (out of 35 total), based on our AIR-Pro scoring instrument, which is slightly different from our original AIR Series scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR-Pro Board members as worthwhile, accurate, unbiased, appropriately referenced, and have a score of 26-27. All posts will still be part of the quiz needed to obtain III credit. To decrease the repetitive nature of posts relating to these advanced concepts, we did not always include every post found that met the score of ≥28 points.

After reading, please take the quiz. Feel free to ask questions in the blog comment section below. The AIR Board faculty will answer them within 48 hours of posting. Be sure to include your email or contact information where requested in the Disqus blog comment area, so that you will be notified when we reply.

Cardiovascular Module 2015: Recommended III credit hours

2.5 hours (20 minutes per article)

AIR-Pro Cardiovascular Reading

Article TitleAuthorDateLinkTitle
Making Sense of Sgarbossa’s Criteria – Chest Pain and Left Bundle Branch Block – Part 2Tom BouthilletApril 27, 2015ECG Medical Training, Sgarbossa Part 2AIR-Pro
Making Sense of Sgarbossa’s Criteria – Chest Pain and Left Bundle Branch Block – Part 3Tom BouthilletApril 27, 2015ECG Medical Training, Sgarbossa Part 3AIR-Pro
Sgarbossa CriteriaMike Cadogan & Chris NicksonJuly 1, 2012Life in the Fast Lane: SgarbossaHonorable Mention
Is there value in testing troponin levels after ICD discharge?Chris Targett & Tim HarrisFeb 26, 2014Best BetsAIR-Pro
Temporary Pacemaker TroubleshootingChris NicksonAugust 18, 2014Life in the Fast Lane: PacemakersHonorable Mention
MagnetChris NicksonMay 7, 2014Life in the Fast Lane: MagnetsHonorable Mention
Left Ventricular Assist DeviceSalim RezaieMay 29, 2014REBEL-EM: LVADAIR-Pro
LVAD Patients: What you need to knowSumintra WoodJuly 24, 2015EMDocs: LVADAIR-Pro

Optional Background Reading

The following table contains links to basic/background knowledge that may be helpful to review prior to reading these more advanced-level blog posts. These are not part of the III quiz.

Article TitleAuthorDateLink
Making Sense of Sgarbossa’s Criteria – Chest Pain and Left Bundle Branch Block – Part 1Tom BouthilletApril 23, 2015ECG Medical Training, Sgarbossa Part 1
Pacemaker Rhythms – Normal PatternsJohn Larkin & Ed BurnsJanuary 12, 2012Life in the Fast Lane: Normal Pacemakers


Take the quiz below, or click HERE to take you to the quiz site.
Be sure to enter your name and program, if you desire III credit.

 Background Information About the AIR-Pro Series

The ALiEM Approved Instructional Resources (AIR) Series is an effort to reward our residents for the reading and learning they are already doing online. We have created an Individual Interactive Instruction (III) opportunity utilizing Free Open Access Meducation (FOAM) resources for U.S. Emergency Medicine residents. For each module, the AIR-Pro Board curates and scores a list of blogs and podcasts specifically answering questions tailored to the senior resident. A quiz is available to complete after each module to obtain residency conference credit. Once completed, your name and institution will be logged into our private Google Drive database, which participating residency program directors can access to provide proof of completion.

Do you belong to a residency program that is not currently participating? No problem! Any one can read the AIR-Pro series curated post and complete the quiz for educational value!

If a residency program is interested in participating, please contact us!

Author information

Fareen Zaver, MD

Fareen Zaver, MD

Chief Resident
Department of Emergency Medicine
George Washington University

The post AIR-Pro Series: Cardiovascular (2015) appeared first on ALiEM.

New Advanced “AIR Professional” Series: AIR-Pro

ALiEM-AIR-Badge-PRO-only smWe are excited to introduce an offshoot of the AIR series (Approved Instructional Resources) called the AIR Professional series! The AIR-Pro series was conceived to answer more advanced level concepts, while continuing to follow the AIR series model of providing a credible method to identify quality blogs and podcasts. Similar to the AIR Series, we hope to provide U.S. Emergency Medicine residents an additional resource for Individualized Interactive Instruction (III) conference credit.

Scheduling of Modules

Approximately every 2 months, the AIR-Pro Board will release a list of high-quality blog posts and podcasts specifically selected in various advanced topic areas. As with the AIR Series, we will have an accompanying multiple choice quiz for AIR-Pro and Honorable mention posts, and track who completes it. If approved by their program director, EM residents who complete the quiz can receive III credit, similar to the AIR Series [read more about the AIR Series].

Why create an AIR-Pro Series in addition to the AIR Series?

We created this series because the AIR-Series has clearly filled a niche for III credit at over 65 U.S. EM residency programs. Many programs however struggle to give credit to the upper level resident completing the same material as the junior resident. We seek to use our expertise to determine upper level concepts and assist residency programs to promote asynchronous learning, online education, as well as reward residents who already effectively utilize blogs and podcasts in their lifelong learning plans.

To do this, we searched educational blogs and podcasts in a slightly different manner than the AIR Series.

 AIR SeriesAIR-Pro Series
Date of blog post or podcast publicationWithin 12 months of search dateAnytime
Included list of blogs and podcasts for searchOnly the top 50 websites per the Social Media IndexA much broader list of blogs and podcasts maintained at FOAMSearch.net
Included topicsAll topics within a large subject area, as listed on the CORD Tests schedule (e.g. pulmonary, gastrointestinal, ...) A limited number of very focused, advanced-level clinical queries within the featured subject area

AIR vs AIR-Pro Series


How do we select the articles?

For each major subject category, 5 EM Chief Residents propose 3-5 advanced clinical questions. Using FOAMsearch.net, an exhaustive comprehensive search is performed, finding all posts answering the clinical questions. These relevant posts are scored by 8 reviewers, among the AIR-Pro Board, using a revised version of the AIR Series scoring instrument. Depending on the redundancy of the highest scoring posts, 2-3 of these are selected to address each preselected question. To decrease any obvious bias, members of the AIR-Pro Board recuse themselves from evaluating posts they wrote or were directly involved in writing.

The AIR-Pro scoring instrument looks at five measurement outcomes, each using a Likert 7-point scale:

  1. Recency
  2. Content Accuracy
  3. Educational Utility for the Senior Resident
  4. Evidence Based Medicine
  5. Referenced

AIR-Pro: How is the scoring different from AIR?

There are 2 areas where the AIR-Pro scoring instrument differs from the previous AIR Series instrument.

  1. We replaced the Best Evidence in Emergency Medicine (BEEM) domain with Recency. Based on our experience with the AIR Series, we observed that many high-quality, advanced-level blogs and podcasts were older than 12 months. This 12 month cut-off was created partly to avoid impractically long lists of blog posts and podcasts to review each month. Because the AIR-Pro Series asks very focused questions, we removed this timeframe cutoff. Instead, more recently published posts were slightly favored with higher awarded points.
  2. The Educational Utility domain specifically targeted senior residents and not just residents in general in order to identify more advanced level educational content.

More background information about III

Read more at the AIR Series informational page.

I am an EM resident desiring III credit for AIR-Pro content

Please speak with your program director about this possibility. If you are told that the AIR-Pro series is approved for credit at your institution, complete the end-of-module quiz below and your participation will be recorded for your program director. Of course, you are always welcome to take the quiz for your own learning purposes.

I am an EM residency program interested in implementing the AIR-Pro series for III credit

If you already have administrative access to the Google Drive document with all resident participants in the AIR Series, you will automatically have access to the AIR Pro Administrative Spreadsheet as well. If you do not, please contact us for log-in access.

Members of AIR-Pro Board

  • Robert Cooney MD, Associate Program Director, Geisinger Emergency Medicine Residency Program
  • Michael Hansen DO, Chief Resident, Christiana Care
  • Nadim Lalani CEd, MD, FRCPC, Clinical Assistant Professor, Royal University Hospital
  • Evan Leibner MD, Ph.D, Chief Resident, Stony Brook University
  • Michelle Lin MD, ALiEM Editor-in-Chief, UCSF Associate Professor and Academy Endowed Chair for EM Education
  • Andy Little DO, Chief Resident, Doctors Hospital
  • Lynn Roppolo, MD,  Associate Program Director and Associate Professor, University of Texas Southwestern Department of EM
  • Salim Rezaie MD, Creator & Founder REBEL EM, Clinical Assistant Professor EM/IM, University of Texas Health Science Center at San Antonio
  • Jeff Riddell MD, Education Fellow, University of Washington
  • Maggie Sheehy MD, MSC, Chief Resident, University of Illinois Chicago
  • Fareen Zaver MD, Chief Resident, George Washington University
  • Samuel Zidovetzki MD, Chief Resident, University of Wisconsin

Author information

Fareen Zaver, MD

Fareen Zaver, MD

Chief Resident
Department of Emergency Medicine
George Washington University

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EM Match Advice Series: The Non-LCME Applicant

EM Match iconYesterday the Electronic Residency Application Service (ERAS) opened its digital doors to medical students applying to ACGME residency programs. So we thought it was a perfect time to host another EM Match Advice Series installment. This time, we focus on the challenges that the non-LCME applicant encounters throughout the ACGME application process. These applicants include:

  1. Students from osteopathic medical schools
  2. Students from non-U.S. medical schools
  3. Applicants who have been in the military service and are returning for residency training
  4. Residents who want to transfer in from another specialty training program.

The Panelists: The Non-LCME Applicant

  • Michael Gisondi, MD (Northwestern PD, host)
  • Merle Carter, MD (Albert Einstein prior PD and soon-to-be Designated Institutional Official)
  • Doug Finefrock, DO (Hackensack PD and Vice Chair)
  • Damon Kuehl, MD (Virginia Tech Carilion PD)
  • Michelle Lin, MD (University of California San Francisco, ALiEM host)


  • 00:00 Introductions
  • 02:18  Defining the “Non-LCME Applicant”
  • 05:50  Dr. Carter provides advice for DO medical students
  • 27:30  Dr. Finefrock provides advice for international medical graduates
  • 43:30  Dr. Kuehl discusses military servicemen and servicewomen interested EM residency training
  • 53:00  Dr. Kuehl discusses non-EM residents interested in transferring into an EM residency training program
  • 59:51  The panelists try to stump Dr. Gisondi with cool information that he doesn’t already know about their programs.



Smith-Coggins R, Marco CA, Baren JM, et al. American Board of Emergency Medicine report on residency training information (2014-2015). Ann Emerg Med. 2015; 65(5): 584-94. PMID: 25910762


Screen Shot 2015-06-15 at 10.30.19 AM

Author information

Michael Gisondi, MD

Michael Gisondi, MD

Associate Professor, Residency Program and Medical Education Fellowship Director, Department of Emergency Medicine, Northwestern University

The post EM Match Advice Series: The Non-LCME Applicant appeared first on ALiEM.

Hip Fractures in Older Adults: An Important Source of Morbidity

hip fxHip fractures are an important cause of morbidity and mortality in older adults. The average age for hip fractures in the U.S. is 80 years, and a staggering 20% of women and 10% of men [1] will experience a hip fracture in their lifetime if they live to older age. This makes it a costly injury, racking up close to $15 billion per year in the U.S. alone [2]. Some hip fractures are obvious as soon as the patient rolls through the ambulance bay. Others can be subtle and require more than just a plain X-ray. This post will discuss risk factors for hip fractures, and how to diagnose and manage patients with hip fractures in the ED.

Epidemiology and Risk Factors

In young patients, hip fractures are usually associated with high speed impacts. By contrast, the primary cause of hip fractures in older adults is a simple fall from standing position. 1-year mortality following a hip fracture is high, around 16%, which is twice as high as age-matched controls who did not have a fracture [3][4]. The mortality risk is highest in the first 3 months after a fracture, in which there is a 5-8 fold higher risk of death [1]. Only half of patients who survive will return to pre-injury levels of function and be independently mobile, and 20% will need long-term care and will not be able to return home [5].

Many factors collide to put older adults at higher risk for hip fractures. Some of the risk factors are modifiable, while others are fixed:

Non Modifiable Risk Factors [6]:

  • Female gender – 80% of all hip fractures are in women [5]
  • Advanced age – almost all hip fractures are in people over age 65 years, but the average age is 80 years, making it almost an exclusive injury of the very old [5]
  • Prior hip fracture
  • Family history of hip fracture
  • Low socioeconomic status

Potentially Modifiable Risk Factors:

  • Osteoporosis
  • Frequent falls
  • Poor activity level and conditioning
  • Vitamin D deficiency
  • Certain medications, such as levothyroxine, which decreases bone density, and medications that reduce calcium levels, such as loop diuretics and proton pump inhibitors (PPI), and medications that increase the risk of falls due to sedation or postural hypotension.

Presentation and Diagnosis of Hip Fractures

The classic patient with a hip fracture is an older adult who has had a mechanical fall, and presents with pain in the groin area. The leg may be abducted, externally rotated, and shortened in cases of displaced fractures, or may have a normal appearance. They will have pain with any movement. You should avoid trying to range the hip if you are concerned there is a fracture, because it could worsen a displacement. During the physical exam, be sure to look for signs of other bony injuries to guide your diagnostic imaging. Feel for vertebral pain or femur pain, range their knees and check their wrists if they fell onto their hands. Also check their distal pulses. If there is a femur fracture and vascular injury, they may have diminished pulses and sensation in their feet. As with any fall, ask about headaches, loss of consciousness, and check for neck pain or external signs of head trauma. After a physical exam, the next step in diagnosis of the hip injury is plain films of the pelvis and hip.

In some cases the X-ray is negative but the patient still complains of hip or groin pain and has difficulty bearing weight. In these cases there may be an occult fracture. If they are not back to their baseline ambulatory status, then an MRI is warranted to look for occult fractures. A CT scan can also be used, but MRI is recommended if available.

Fractures are categorized as either extracapsular (inter- and sub-trochanteric), or intracapsular (those in the femoral head or neck). Intracapsular fractures tend to have more complications and do not heal as well [6]. Patients may require a hemarthroplasty for these fractures.

Management of Hip Fractures

For older patients with falls, we have several goals in the ED:

  1. Assess the extent of injuries: We have to ensure nothing else is missed such as a subdural, or a vertebral fracture.
  2. Consider the cause of the fall: It may have been mechanical, but the patient may have been less steady because of dehydration. Other times it may have been syncopal, necessitating a broader workup.
  3. Provide analgesia: Older adults may not be as vocal as younger patients about their need for pain medications. Typically they are not the patients you find complaining of a pain of 15 on a scale that only goes up to 10. Be sure to ask about their level of pain and treat it appropriately. Once you have obtained a neurologic exam of the extremity, you could consider a femoral nerve block (Sonosite YouTube tutorial video and a Ultrasound Podcasts tutorial) [7] or a fascia iliaca block [8], both of which can provide good analgesia. Otherwise, IV medications such as low-dose morphine with frequent reassessment and titration as needed is a good option. The nerve blocks can cut down on opiates required, which then exposes the patient to less risk of opiate-related side effects and respiratory depression.
  4. Consult orthopedics and admit the patient: Patients with hip fractures will typically be taken to the OR within 1-2 days. They will need hospital admission for pain control and care until their repair.

Take Home Points

  • Hip fractures are common in older adults and are a huge source of loss of function and mobility and have high rates of 1-year mortality.
  • Do not aggressively manipulate a patient’s hip if you suspect a fracture, as it could worsen a dislocation.
  • If the hip and pelvis X-rays are negative but the patient cannot bear weight or ambulate due to hip or groin pain, consider an MRI or a CT.
  • Treat the patient’s pain, and consider doing an ultrasound guided femoral nerve or fascia iliaca block.


  1. Landefeld CS. Goals of care for hip fracture: Promoting independence and reducing mortality. Arch Intern Med. 2011;171(20):1837-1838. PMID 22083570
  2. Dy CJ, McCollister KE, Lubarsky DA, Lane JM. An economic evaluation of a systems-based strategy to expedite surgical treatment of hip fractures. J Bone Joint Surg Am. 2011;93(14):1326-1334. PMID 21792499
  3. LeBlanc ES, Hillier TA, Pedula KL, et al. Hip fracture and increased short-term but not long-term mortality in healthy older women. Arch Intern Med. 2011;171(20):1831-1837. PMID 21949033
  4. Haentjens P, Magaziner J, Colon-Emeric CS, et al. Meta-analysis: Excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390. PMID 20231569 
  5. Parker M, Johansen A. Hip fracture. BMJ. 2006;333(7557):27-30 .PMID 16809710
  6. LeBlanc KE, Muncie HL,Jr, LeBlanc LL. Hip fracture: Diagnosis, treatment, and secondary prevention. Am Fam Physician. 2014;89(12):945-951. PMID 25162161
  7. Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. Am J Emerg Med. 2010;28(1):76-81. PMID 20006206
  8. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: A systematic review. CJEM. 2015:1-11. PMID 26330019

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Author information

Christina Shenvi, MD PhD

ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina

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