New EMRA Leaders

Congratulations new EMRA Board Leaders!

Alicia Kurtz, MD, President
Chief Resident, UCSF Fresno, Fresno, CA
[email protected]  / [email protected]_md

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

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

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

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

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

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

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

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

Zach Jarou, MD, President-Elect
[email protected]  /  @zachjarou

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

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

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

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

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

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

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

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

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

Scott Pasichow, MD, MPH, Vice-Speaker of the Council
[email protected]  /  @SPMD16

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

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

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

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

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

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

What goes on pizza?
Pepperoni and mushrooms

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

Most-used app on your phone?
Downcast

Favorite board game?
Risk

Nida F. Degesys, MD, ACEP Representative
[email protected]

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

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

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

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

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

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

What goes on pizza?
Lots of meat

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

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

Favorite board game?
Boggle

Shehni Nadeem, MD, Membership Development Coordinator
[email protected]  /  @ShehniNadeem

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

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

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

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

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

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

What goes on pizza?
Jalapenos!

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

Most-used app on your phone?
Google Calendar

Favorite board game?
Monopoly

Rachel Solnick, MD, Legislative Advisor
[email protected]  /  @RachelSolnickMD

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

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

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

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

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

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

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

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Congratulations Award Recipients!

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

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

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

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

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

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

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

FOAMer of the Year
Sean Dyer
, MD

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

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ACEP16: A Sure Bet for Progress

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

Resolutions & Elections

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

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

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

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

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

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

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

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

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

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

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

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Board Review Questions: November 2016

Provided by PEER VIII. PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. These questions are from the latest edition of PEER VIIITo learn more about PEER VIII, or to order it, go to www.acep.org/bookstore.

  1.  In pediatric patients, which of the following anatomic locations of lymphadenopathy is most likely to be associated with a serious underlying pathology?
    A.     Axillary
    B.     Inguinal
    C.     Jugulodigastric
    D.     Supraclavicular
  2. Which of the following agents is most appropriate to treat convulsions associated with a tricyclic antidepressant poisoning?
    A.     Flumazenil
    B.     Lorazepam
    C.     Physostigmine
    D.     Sodium bicarbonate
  3. Which of the following agents is contraindicated in the management of hypertension from acute cocaine intoxication?
    A.     Benzodiazepines
    B.     Metoprolol
    C.     Nitroglycerin
    D.     Phentolamine
  4. Which of the following statements regarding escharotomy is correct?
    A.     Escharotomy typically involves significant blood loss when properly performed
    B.     Muscle compartments in extremities with circumferential burns should be decompressed as soon as compartment pressures exceed 10 mm Hg
    C.     No anesthesia is needed for local pain control with full-thickness burns
    D.     Peripheral pulses are reliably absent when escharotomy of an extremity is needed
  5. A 22-year-old man presents with spasms in his neck and tongue. When his head is turned to the right, his tongue is noted to be deviated to the right. He is able to voluntarily move his tongue and neck to midline, but the contortions recur. He appears anxious. Which of the following medications is most likely to cause this side effect?
    A.     Clozapine
    B.     Ephedrine
    C.     Sumatriptan
    D.     Tramadol

Answers

  1. The answer is D, Supraclavicular.
    (Marx, 886-887; Tintinalli, 724, 787-788, 932-933, 1588-1589)

Supraclavicular lymph nodes drain the lymphatics from the mediastinum, including the lungs and the esophagus. On the left side, the supraclavicular nodes also drain the abdomen through the thoracic duct. The finding of a hardened, enlarged left supraclavicular lymph node with an abdominal malignancy was first described by Rudolf Virchow and Charles Emile Troisier and is thus referred to as both a Virchow node and a Troisier node. In both adults and children, the presence of an enlarged supraclavicular lymph node on either the left or the right side of the body is concerning for malignancy and should be aggressively evaluated, including making arrangements for urgent lymph node biopsy. Lymphadenopathy is frequently found in pediatric patients because they come in contact with a large variety of new antigens.

Lymphadenopathy is common in children younger than 12 years, with lymph nodes often felt in the axillary, inguinal, and cervical regions (including the jugulodigastric and parotid locations). The size of the lymph node that is considered to be normal varies by anatomic location. Inguinal lymph nodes can be as large as 1.5 cm in diameter, axillary lymph nodes 1 cm in diameter, and anterior cervical lymph nodes as large as 2 cm in diameter. Because lymphadenopathy is typically inflammatory, a patient with an enlarged lymph node with a focus of infection or inflammation can be reexamined in 1 to 2 weeks. In most anatomic locations, a lymph node larger than 3 cm is more likely to be associated with malignancy. However, an epitrochlear node (at the elbow) or a supraclavicular node larger than 0.5 cm is more likely to be associated with malignancy and should be promptly investigated.

  1. The answer is B, Lorazepam.
    (Marx, 1964-1969; Nelson, 1056; Wolfson, 1498-1510)

Lorazepam or another benzodiazepine is the preferred initial agent to treat convulsions associated with tricyclic antidepressant (TCA) poisoning. Sodium bicarbonate is a reasonable choice to prevent worsened acidosis, but it is not effective for the treatment of the convulsions themselves. Various properties of TCAs that manifest in poisoning include sodium-channel blockade, antimuscarinic activity, peripheral alpha1 blockade, and GABA antagonism. The QRS prolongation from sodium-channel blockade is treated predominantly with intravenous administration of sodium bicarbonate, with the goal of preventing further prolongation and deterioration into dysrhythmias. The etiology of TCA-induced convulsions is probably multifactorial. Although status epilepticus can occur, even isolated convulsions represent significant toxicity after a TCA overdose and should be treated aggressively. Benzodiazepines, by causing GABA agonism, can stop convulsions and are considered first-line therapy. Rapid chemical paralysis to avoid worsening acidosis and subsequent exacerbation of sodium-channel blockade effect on the heart is prudent if benzodiazepines fail to work immediately. For convulsions refractory to benzodiazepines, propofol or barbiturates can be considered, although they are often challenging to administer in a hypotensive patient. Physostigmine, a reversible acetylcholinesterase inhibitor, can be used both diagnostically and therapeutically in various antimuscarinic poisonings. However, administration of physostigmine to patients with TCA poisoning (QRS-interval prolongation, convulsions) has resulted in asystole and is contraindicated. Flumazenil is also contraindicated for TCA poisoning. Although it does not cause seizures, it will temporarily reverse a coingested benzodiazepine, and, in the presence of a proconvulsant coingestant such as a TCA, this could lead to status epilepticus. The anticonvulsive properties of phenytoin are distinct from how TCAs induce convulsions. It has not been demonstrated to be of benefit in TCA-induced convulsions (or any other drug-induced convulsions), and it is not recommended.

  1. The answer is B, Metoprolol.
    (Nelson, 1096; Tintinalli, 441-448, 1234-1237)

Sedation with agents such as benzodiazepines is the primary initial management needed to control the agitation associated with cocaine and other sympathomimetic agent intoxications. Adequate sedation and hydration also effectively treat the associated hypertension and tachycardia. In the uncommon situation in which sedation does not effectively control the hypertension, direct-acting vasodilators such as nitroglycerin, nitroprusside, possibly nicardipine, and the alpha-antagonist phentolamine can all be used. The administration of beta-blockers such as metoprolol can lead to unopposed alpha agonism leading to vasospasm, worsened hypertension, and resultant complications. Although labetalol has some alpha1 antagonism in addition to beta antagonism, it has not been demonstrated to reverse potential coronary vasoconstriction. Some individuals have recently questioned the potential harm of beta-blocker administration in patients with MI and a history of cocaine use. However, hypertension from acute cocaine intoxication can certainly be exacerbated by beta-blocker administration, so it remains absolutely contraindicated.

  1. The answer is C, No anesthesia is needed for local pain control with full-thickness burns.
    (Marx, 765; Roberts, 712-714; Wolfson, 314)

Escharotomy is the incision into a full-thickness burn on either the torso or an extremity. Full-thickness burns are insensate to pain, so local anesthesia is not needed for incisions. Superficial blood vessels are typically coagulated as well, so bleeding is not usually a concern. Escharotomy typically extends only through the eschar into the subcutaneous fat and is therefore more superficial than a fasciotomy; this limits the associated bleeding as well. Compartment pressures greater than 30 mm Hg indicate a need for decompression, but patients can be symptomatic and have other indications for escharotomy before pressures rise this high. Pulselessness of the involved extremity is a less common finding, even if significant compromise of the tissues exists. Escharotomy is performed by making a longitudinal incision down to the fat through the eschar. Nerves and vessels should be avoided, but the most common mistake is not performing a deep enough incision. Cautery should be considered to reduce bleeding during the procedure.

  1. The answer is A, Clozapine.
    (Marx, 2043-2044; Wolfson, 1501-1503)

The patient in this question is having a dystonic reaction. Dystonic and akathetic reactions are most commonly associated with antiemetic and antipsychotic medications. Of the medications listed, clozapine, an antipsychotic medication, is known to cause both dystonic and akathetic reactions. Dystonic reactions involve muscular contortions, which can induce both physical and psychological discomfort. Any muscle group can be affected, but the more common locations include the neck (torticollis, retrocollis, anterocollis), eyelids (blepharospasm), and the lower jaw, mandible, and tongue (mandibular or lingual dystonia). Dystonic reactions are believed to be linked to alterations in neurotransmitter function (in particular dopamine and acetylcholine) in the basal ganglia. Akathisia is a condition that involves a component of restlessness as well as mental unrest and agitation. Both of these conditions can occur acutely after a single dose of a drug, as well as with chronic use. Treatment of either of these reactions involves use of an antimuscarinic agent such as diphenhydramine or benztropine mesylate. Intravenous administration is preferred because it is more reliable and allows rapid onset, but intramuscular and oral routes are acceptable. Typical resolution of symptoms occurs within about 2 minutes. For patients on chronic outpatient therapy, the agents should be discontinued. Sumatriptan and tramadol have all been implicated in the development of serotonin syndrome, a potentially life-threatening condition characterized by an excess of serotonin. It produces a hyperadrenergic state (fever, sweating, tremors, agitation) as well as myoclonus, hyperreflexia, and altered mental status. Ephedrine, which is currently banned in the United States, can cause sympathomimetic symptoms such as tachycardia, hypertension, and fever. The effects of ephedrine can be difficult to distinguish from serotonin syndrome.

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Rapid Research Review: Study Types

Case-Control (“What happened?”)

Compares a group with a disease to a group without disease.  This study can calculate an odds ratio.

Advantages: many exposures can be studied and is useful for rare disorders.

Disadvantages: confounding factors and the potential for recall/selection bias.

Cohort (“What will happen?”)

Compares a group with an exposure/risk factor to a group without exposure. This study can calculate a relative risk.

Advantages: ethically safe, timing and directionality of events can be established

Disadvantages: blinding is difficult; no randomization; controls may be difficult to identify

Cross-Sectional Study (“What is happening?”)

Collects data from a group of people to assess frequency of disease and related risk factors at a particular point in time. This study can help calculate disease prevalence.

Advantages: ethically safe

Disadvantages: potential recall or Neyman bias; association can be established but not causality

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