WELCOME to the ALiEM Faculty Incubator 2018-2019 Class

We had an AMAZING kick-off this week at the Council of Emergency Medicine Residency Directors (CORD) Academic Assembly, welcoming our NEW 2018-19 ALiEM Faculty Incubator Class of Educator-Scholars! We received applications from across the country and internationally from budding scholars with a broad range of background and experiences. We narrowed it down to the top 32 applicants, who we know are rising leaders in education scholarship.

ALiEM Faculty Incubator Class of 2018-19

Photo Faculty Member and Affiliation
 

Layla Abubshait, MD

Assistant Professor
University of Sharjah
United Arab Emirates

Education Director
Emergency Medicine
Al-Qassimi Hospital

 

Jason An, MD

Associate Program Director
University of California Riverside Emergency Medicine Residency

Program Director (Transitional Year Residency)
Riverside Community Hospital

Manu Ayaan, MD

Assistant Professor
Emergency Medicine
Academy Of Medical Sciences
Pariyaram Medical College, India.

 

Michael Barrie, MD

Assistant Professor, Clerkship Director
Emergency Medicine
The Ohio State University College of Medicine

 

Shawn Dowling, MD, FRCPC

Medical Director
Physician Learning Program
The University of Calgary

Clinical Content Lead
Calgary Zone Emergency Department

 

Elizabeth Dubey, MD

Assistant Residency Program Director
Emergency Medicine Residency
Detroit Receiving Hospital

Assistant Professor
Emergency Medicine
Wayne State University School of Medicine

 

Christopher Fowler, DO

Assistant Professor
Department of Emergency Medicine
University of Arkansas for Medical Sciences

Clerkship Director
Emergency Medicine

Lisa Hoffman, DO

Associate Program Director
Emergency Medicine Residency
Geisinger Medical Center

 

Dallas Holladay, DO

Instructor
Department of Emergency Medicine
Rush University

 

Christian Jones, MD, MS, FACS

Assistant Professor
Department of Surgery
Johns Hopkins University School of Medicine

 

Annahieta Kalantari, DO, FACEP, FAAEM, FACOEP

Associate Program Director
Emergency Medicine Residency
Hershey Medical Center

Clinical Assistant Professor
Department of Emergency Medicine
Penn State Health

 

Nilantha Lenora, MD

Attending Physician
Adventist HealthCare, Shady Grove Medical Center
Rockville, Maryland

Senior Advisor
Sri Lanka Emergency Medicine registrar training program
Post Graduate Institute of Medicine
University of Colombo, Sri Lanka

Simiao Li-Sauerwine, MD, MS

PGY-4 at Northwestern University Emergency Medicine Residency

Upcoming:
Assistant Program Director
Department of Emergency Medicine
The Ohio State University

 

Christopher Lloyd, DO, FACEP

Assistant Residency Director
Doctors Hospital – Ohio Health Emergency Medicine Residency

Director
Medical Education Specialty Track for PGY-3 and PGY-4 residents

 

Lexie Mannix, MD

Simulation Fellow at Rush University/Cook County Hospital

Upcoming:
Assistant Residency Director, Assistant Clerkship Director
University of Florida – Jacksonville

Laurie Mazurik, MD, FRCPC, MBA, MSc, DM

Critical Care Transport and Emergency Physician
Sunnybrook Health Science
Faculty of Medicine
University of Toronto, Canada

 

Shannon McNamara, MD

Assistant Professor
Department of Emergency Medicine
Mount Sinai St. Luke’s West

Emergency Medicine Simulation Director
NYU Langone Health

 

Shawn Mondoux, MD, MSc, FRCPC

Assistant Professor
Division of Emergency Medicine, Department of Medicine
McMaster University

Institute for Health Policy, Management, and Evaluation
University of Toronto

Elissa Moore, DO

Assistant Professor and Clerkship Director for Medical Toxicology
Department of Emergency Medicine, Division of Toxicology
University of Southern California, Los Angeles

 

Melissa Parsons, MD

Assistant Professor, Assistant Program Director
Department of Emergency Medicine, Emergency Medicine Residency
University of Florida – Jacksonville

  Nicole Rocca, MD, FRCPC

Assistant Professor
Department of Emergency Medicine
Queen’s University Locum Physician
Department of Critical Care Medicine
 

Rebecca Shaw, MBBS, FACEM

Medical Education Fellow
Department of Emergency Medicine
Gold Coast Hospital and Health Service
Queensland, Australia

 

Carly Silvester, MBBS

Medical Education Fellow
Department of Emergency Medicine
QEII Hospital
Brisbane, Australia

 

Randy Sorge, MD

PGY-4 at the Emergency Medicine Residency at Mount Sinai Hospital

Upcoming:
Assistant Clerkship Director
Louisiana State University Emergency Medicine Residency

 

Christine Stehman, MD

Assistant Professor
Department of Emergency Medicine
Indiana University School of Medicine

Brandon Stein, MD

Assistant Program Director
Department of Emergency Medicine
New York-Presbyterian/Queens

 

Megan Stobart-Gallagher, DO

Assistant Program Director
Emergency Medicine Residency Program
Einstein Medical Center

 

David Story, MD

Assistant Professor
Department of Emergency Medicine
Wake Forest Baptist Medical Center

Clerkship Director
Emergency Medicine Acting Internship

 

Gannon Sungar, DO

Assistant Professor
Department of Emergency Medicine
University of Colorado School of Medicine

Staff Physician
Denver Health Medical Center

 

Shreya Trivedi, MD

Medical Education Fellow
General Internal Medicine
New York University

MPHE Candidate
Maastricht University

 

Quinn Wicks, MD

PGY-3 at DMC Sinai-Grace Emergency Medicine Residency

Upcoming:
Medical Education Fellow
DMC Sinai-Grace Hospital

Amanda Young, MD

Assistant Professor
Department of Emergency Medicine
University of Arkansas

These 32 people were not the only ones with star potential. We are grateful for the numerous applicants, but are also sad to have to turn down some of our other applicants. We wish that we could have brought ALL of them on our team. We hope that they re-apply next year and/or connect with us down the road to let us know how you are doing. We are always happy to serve as a sounding board.

ALiEM Faculty Incubator kick-off event at CORD 2018: new connections, mentors, and friendships!

 

Author information

Sara M. Krzyzaniak, MD, FACEP

Sara M. Krzyzaniak, MD, FACEP

ALiEM Faculty Incubator
Chief Operating Officer
Assistant Program Director, Emergency Medicine Residency
University of Illinois College of Medicine at Peoria
OSF Healthcare Saint Francis Medical Center

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The Evil Twin – Orthopaedic Problems in Children Pt 2: Painful Presentations

Pretty much every individual symptom in children is likely to be something which is either normal or at very least will follow a benign course. Orthopaedic presentations are no exception.  If you've already read part 1 (orthopaedic problems in children) and came away with the impression that almost all children with bow legs, knock knees, in-toeing etc are essentially normal and that the problem is likely to self-resolve, you're not wrong.

This is one of the wonderful things about paediatrics.  Many concerning presentations are actually normal, allowing us to feel like we've done something great just by reassuring a parent that their child doesn't have anything wrong with them.  Also, many problems self resolve allowing us to take a light touch approach, avoiding unnecessary tests or treatment, always remembering to act in the best interests of the child.

These factors are also one of paediatrics greatest difficulties.  Everything is normal, except when it isn't and everything in children's health has an evil twin.

Let me give you some non-orthopaedic presentations as examples.
Paediatric orthopaedics is similarly riddled with presentations where the likelihood is that it is something that needs no intervention, while there always exists the possibility of a much more problematic pathology.  Like the evil twin (often used as a complicated anti-hero in literature and film) concept, the pathology that we have to be wary of usually shares many characteristics with the more benign explanation for the symptoms.  Since common things are common, the temptation is always to presume the more likely option. So how do we recognise the more dangerous orthopaedic problems, while avoiding over-investigation and over-referral?

First, it is important to know what is typical so that we can know what is atypical.  For example, irritable hip is usually seen from the age of one to six years old.  It can occur outside of that age range but is uncommon and so is diagnosed with an appropriate caution.

If a preschool child has a fall, the outcome is usually no injury or a fracture.  Sprains are uncommon in this age group because they are too flexible to easily strain a ligament to the point of injury.

Once we are familiar with what is both normal and common, it is important to know what the signs are of the common and expected, we need to know what should alert us to the more significant yet less common pathologies.  In other words, what are the red flags?

There are some red flags that are fairly reliable and these are listed here.
However some of the red flags that are listed elsewhere are rather contextual, proving the evil twin problem.  For example, Arthritis Research UK lists nocturnal pains as a red flag symptom (1) while NHS choices lists nocturnal symptoms as a typical feature of growing pains (2).  That is  why red flags will only get you so far.  Sometimes certain presentations are a set piece.  Here are a few examples:

A 12 year old presents with bilateral knee pain, worse on the right.  The pain is worse after sports and is particularly bad on stairs.  He is limping.  Both knees have full range of movement and no effusion.  The tibial tuberosity is swollen and tender in both knees.

This is Osgood-Schlatters disease.  Simple.  This problem of adolescence is more a biomechanical problem than a true disease process.  There is little that can be done for this problem apart from symptomatic treatment and a careful management of the balance between being active and being in pain.  An orthopaedic surgeon can't fix this problem unfortunately.

A 7 year old presents with a limp and pain in the hip.  There is no history of injury.  They are not unwell or febrile.  Simple analgesia has helped but the limp is still obvious.  Examination is normal apart from a reduced internal and external rotation of one hip.

There are various possible explanations for this presentation, however index of suspicion for Perthe's disease has to be very high.  The mysterious onset of symptoms that is typical of Perthe's diease makes it a difficult diagnosis.  The early recognition of the disease is further hampered by the tendency that children have to reduce activity instead of increasing their complaining.  Orthopaedic surgeons don't have a magic treatment for Perthe's but will do everything they can to reduce the progression of this difficult disease.  X-ray or referral at presentation is recommended for a patient like this.

A 13 year old presents with what they think is a knee injury.  They have had some left knee discomfort which was made much worse by running yesterday.  Today, the pain is significant despite analgesia and they have a marked limp.  The most notable clinical finding is that movements of the left hip are restricted by pain.

This could be a muscular or ligamentous injury.  However it is also possible that this young person has a slipped upper femoral epiphysis.  The growth plate in adolescents is at risk of fracture and the subsequent movement can cause permanent damage if not treated as soon as possible.  These presentations are tricky as they come with a story that sounds more like a straightforward soft tissue injury.  The important thing is to have a high index of suspicion and a low threshold for X-ray or same day referral.

Edward Snelson
@sailordoctor
Specialising in conjoined Meducaction

Disclaimer: Once again, many thanks to the team of orthopaedic surgeons at the Sheffield Children's Hospital. This concludes the planned mini series of paediatric orthopaedic posts but if you have further questions or simply wish to tell us your favourite orthopaedic surgeon joke, please post in the comments box below.

References
  1. Foster E et al, Growing pains: a practical guide for primary care, www.arthritisresearchuk.org
  2. Growing pains (recurrent limb pain in children), NHS choices website

ECG of the Week – 23rd April 2018 – Interpretation

The following ECG is from a 41yr old male who was referred to telehealth from a rural center ~1500 km  (930 miles) from the nearest major hospital.



Click to enlarge

Rate:

  • 48 bpm

Rhythm:

  • Sinus arrhythmia
  • Sinus rhythm

Axis:

  • Normal

Intervals:

  • PR – Normal (~200ms)
  • QRS – Normal (80ms)
  • QT – 410ms (QTc Bazette 370ms)

Additional:

  • Early R wave transisition
  • Borderline voltage criteria LVH
    • V1 S + V5 R ~35mm
    • No non-voltage criteria present

Interpretation:

  • Sinus bradycardia with sinus arrhythmia

Considerations with sinus bradycardia

I get asked to review many ECG’s that show sinus bradycardia and there are a few considerations in these cases including:

  • Is the patient symptomatic ?
  • Is this ‘normal’ for the patient ?
  • What is / could be the cause ?

Regarding symptoms these may be the reason for an Emergency Department attendance or more insidious and can include:

  • Syncope
  • Dizziness
  • Light headedness
  • Dysponea
  • Decreased exercise tolerant
  • Lethargy
  • Palpitations
  • Chest pain

There are multiple potential causes of bradycardia including:

  • Physiological – athletes or during sleep
  • Increased vagal tone – nausea, vomiting, pain
  • Ischaemia
  • Drug effect / toxicity – inc, digoxin, beta-blockers, calcium channel blockers
  • Environmental – hypothermia
  • Endocrine – hypothyroid
  • Myocarditis
  • Sinus node dysfunction
  • Sleep apnoea

References / Further Reading

Life in the Fast Lane

Textbook

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.