EM Collective Wisdom: Salim R. Rezaie

Author: Salim R. Rezaie, MD (@srrezaie, Creator and Founder of REBEL EM, www.rebelem.com; Greater San Antonio Emergency Physicians (GSEP), Emergency Medicine/Internal Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

1) Why still Emergency Medicine?

Every day is different, with new and unique challenges.  Emergency medicine is not only the best 20 minutes of every specialty, but it is truly the front line of medicine and patient care. We see all comers regardless of social status, age, complaint, or acuity.  Our doors are open 24-7-365, we provide a safety net to those who are uninsured and patients having a hard time accessing the health care system.  We get to see everything, we get to do almost everything, we get to save lives, make people better, relieve suffering, and comfort the silent majority of humanity that has nowhere else to turn.

2) Most impactful case. 

There are so many I could put in this spot, but one in particular was a healthy guy having chest pain.  He came to the ED with his wife and 15-year-old daughter.  He didn’t want to come; his wife made him.  He thought he was just having really bad indigestion and that the pain would go away.  His initial ECG was read as normal.  He ended up having a cardiac arrest within 5 – 10 minutes of his arrival.  I will never forget the look of sheer horror on his wife and daughter’s faces. The patient ended up going to the cath lab and found to have a 100% proximal LAD lesion.  He got two stents, and after a long ICU stay he ended up walking out of the hospital with no neurologic deficits.  Although the case ended well for him, there were some very important lessons I learned:

  1. ECGs are Hard: Just like anything else that is hard in life, continued deliberate practice is the key. It is not just going through the motions of signing off on ECGs, but getting feedback on what you could have done better that is the key piece that ensures mistakes are not made, patient care is improved, and our minds continue to grow.  ECGs take time and practice in regards to reading and interpretation.  Don’t just trust the computer reading of ECGs.  If you don’t feel comfortable reading ECGs, then become comfortable.  This is one of the most important things that we do on a daily basis at work.  Changes on ECGs can be subtle, but it is the curious mind that can find the signal amongst all the noise.
  2. POCUS: Use ultrasound liberally in chest pain patients. It is no longer ok to say, I don’t feel comfortable using ultrasound or I don’t know how. This is the future of emergency medicine and the future is now.  I can’t remember the last time my stethoscope changed a patient outcome, but I can sure recall the many times the use of ultrasound did.  Sign up for workshops, or even consider going back and doing a fellowship.  This saves patients’ lives.  You will be surprised the number of times this will change your decision making, disposition, or even expedite the care your patients are receiving.
  3. Follow-up: One aspect of emergency medicine that I have always found difficult to palate is the lack of follow up with our patients. We see, we resuscitate, we admit, end of story. Have you ever gone up into the hospital to check on your patients? You may be the most brilliant physician in the world, but patients don’t care about that.  What they are impressed by is your bedside manner, compassion, and the fact that you truly care about them.  It takes skill to build rapport and trust with patients who you are meeting for the first time.  The number one reason physicians get sued is due to the lack of communication with their patients.  Imagine their surprise when you pop in to check in on them.  This cannot be done in every patient, or you would never go home, but just making a bit more effort in your toughest cases, to follow up, helps you the provider both emotionally and mentally, but more importantly also shows the patient and their family how much you do truly care.

3) Most important career decision leading to satisfaction.

Speaking at the national and international level. Let me tell everyone a little secret… speaking was one of my biggest fears.  Getting up in front of a few hundred to few thousand colleagues was debilitating and mortifying to me.  I mean what does a simple kid born in San Antonio, TX have to offer the world? But being the stubborn person I am, I strived to improve my presentation skills, the way I conveyed information and get over my fear of public speaking. This has been a conscious effort on my part, with hundreds and thousands of hours of work, reading and practice. It turns out getting over my biggest fear was one of the best things I could have ever done.  It has led me to meet so many people from all over the globe, but more importantly the friendships and networks I have built have led me to the biggest satisfaction in my career.  Don’t get me wrong, I love working clinical shifts, but they can become mundane, lead to burnout, and ultimately jade a person if there is not something more than punching in and punching out everyday.  Reflection and engagement with so many amazing people, that I may not have otherwise met, is the foundation of my striving for self-improvement, and ultimately the satisfaction in what I do day in and day out.

4) What does future of EM look like?

Very bright.  It has been almost 40 years since emergency medicine was recognized as a specialty. To see all of the new directions we are going in is absolutely phenomenal. We started as the new kid on the block, trying to find our way and now we do hospice and palliative care, critical care, hyperbaric medicine, sports medicine, toxicology, ultrasound and so much more.  The open use of technology is one of the biggest things I see increasing in the future. We have already embraced and are on the forefront of online education with blogs and podcasts, but now we are also embracing technology clinically.  Ultrasound probes that plug into our mobile devices, telemedicine, transesophageal echocardiography, and the list just continues to grow.  We always have and still are pushing the envelope of patient care, and I can’t think of a more exciting time to be part of this specialty.

5) Greatest achievement / why giving back is important.

I don’t know that I have a single greatest achievement.  I think this has yet to come for me.  I am still relatively early in my career (only 8 years out from residency and haven’t even had to do my first recertification yet). In the end, not sure that I even care about man/woman made achievements, as these are just pieces of paper or plaques to hang up on a wall.  The ultimate achievement that I strive for, is to inspire those around me to be better.

Paying it forward is the greatest thing a person can do.  I would not have made it to the place that I am today if it were not for so many amazing mentors giving back to me.  Making everyone around you a better person is the way to grow leaders that are innovative, productive, and contribute to the collective intelligence. To do this we have to not only set an example, but be the example, by requiring the best version of ourselves as often as possible, continue to strive for excellence, and instill autonomy/accountability in others. I think Nelson Mandela said it best, “What counts in life is not the mere fact that we have lived.  It is what difference we have made to the lives of others that will determine the significance of the life we lead.” If that doesn’t motivate you to give back, then just think, the people we teach today will be the people caring for us in the future.

6) Favorite failure.

Is there such a thing?  Not sure anyone ever wants to fail, much less have a favorite failure.  I think the more important message for me is that failure, in and of itself isn’t terrible; the failure to learn and change is.  Without failure and setbacks, we can’t reach our highest potential, grow our internal strength/fulfillment, and most importantly improve our personal development.  Failure allows us to find new abilities we didn’t know that we could ever have, changes our self-concept, which gives us the confidence to face future failures.  One of my favorite quotes on failure is by Denis Waitley, “Failure should be our teacher, not our undertaker.  Failure is delay, not defeat.  It is a temporary detour, not a dead end.  Failure is something we can avoid only by saying nothing, doing nothing, and being nothing.”

7) One thing you would change about our field.

More interdisciplinary collaboration.  Sometimes emergency medicine feels like such a bubble.  As a dual trained physician in emergency medicine and internal medicine, I find more interdisciplinary collaboration helps not only patient care but the system in which we work in.  The current version of healthcare is not ideal, and I am not gonna sugar coat it, it’s broken.  So what are you gonna do about it?  You can bitch and complain, or you can try and help change the things you hate. Patient care doesn’t end when the patient is discharged or admitted… that is only the beginning.  It is only through interdisciplinary collaboration that we can help improve the care our patients are getting by improving the system in which they receive care.   Who knows, maybe even make some friends on the other side of emergency medicine.

8) Something that you love that has indirectly impacted your EM career.

Reading books for leisure.  As I have gotten into my early 40s (yes, I am getting old), I have really begun to enjoy the softer sides of medicine: leadership, performance, happiness, how our brains work, effective communication, and so much more.  These are not things I was taught in school or during my training, yet they are the most important parts of the job.  This has also emphasized the fact that it is not truly a work-life balance that needs to occur, but a moderation in everything we do that leads to ultimate happiness.  So, what are some of the things that can increase your happiness:

  1. Create value for the greater good and seek roles that match your passions.
  2. Make sure you give your mind downtime. It is important to give your mind time off in order to improve insights and recharge your energy.  Your brain is no different than any other muscle in your body, it needs rest.
  3. Enjoy the journey and not just the destination.
  4. Don’t spread yourself too thin. Pick a few priorities, whether it be in life or at work and make huge efforts in those areas.  The more tasks you make for yourself, the less time you have for family and yourself, which can lead to depression and burnout.
  5. Yearly reflection is important. This is where you set the big goals in your life and work (i.e. “This is what I want to achieve over the next year”).  This is so important because it can help make decisions of yes or no when asked to work on projects.
  6. Kill all the push notifications on your phone (reduce distractions). Kill these distractions and check them on your own time and not others.  The amount of mental resources we have available to be able to attend to the things we are currently doing is limited.  Distractions such as email and social media don’t let you enjoy the current moment that you are in.
  7. Know your strengths and continue to build on them, but also know your weaknesses and find people who can help you improve on them.
  8. Take care of your health. Food prep, practice good sleep hygiene, and exercise.  If you don’t make time for your own health, you will ultimately have to make time for the medical problems you will acquire.

 

3 people you’d like to see fill this out

1) Gillian Schmitz

2) Tarlan Hedayati

3) Rob Bryant

The post EM Collective Wisdom: Salim R. Rezaie appeared first on emDOCs.net - Emergency Medicine Education.

Remind me again about neonatal jaundice??

I have a new niece, Kaitlyn Marie, who is just crushing life so far, but my brother called me and asked all about neonatal jaundice, so here is some info to help you the next time you see this in the peds ED or someone you know calls you to ask.

Why are babies at risk for hyperbilirubinemia? They produce more (more RBCs with a shorter half life), they clear it less effectively (natural deficiency in UGT1a1 enzyme), and they have increased enterohepatic circulation of bilirubin. Babies who get dehydrated at at higher risk too.

Which neonates at risk for SEVERE hyperbilirubinemia?

How do you know if the level is safe?

You need to know hours of life and then you can calculate whether or not their level is safe

Use the Bhutani nomogram

or you can use an online calculator

http://bilitool.org/

What do you do if the level is high?

These babies get admitted and can either get phototherapy or exchange transfusion. These babies also need IV hydration.

Pediatric SVT

This case is written by Drs. Laura Simone and Olivia Ostrow. They are both Pediatric Emergency Physicians at Toronto’s Sick Kids Hospital.

Why it Matters

SVT is the most common pediatric dysrhythmia that we see in the ED after sinus tachycardia. But sometimes, in very young children and infants, it can be hard to distinguish the two! This case highlights some important features of the management of SVT, including:

  • The need for an ECG when they heart rate is very high
  • The role of vagal maneuvers as a first attempt at cardioversion
  • The dosing of adenosine and electricity for cardioversion of SVT

Clinical Vignette

A 12-month old male is brought into your ED today by his parents because he has been fussy, crying all night and not feeding well today. He had emesis x 1 (non-bilious, non-bloody). At triage, the RN had difficulty recording the heart rate but by auscultation it seemed “quite rapid” and he “feels a bit warm”.

Case Summary

The team has been called to the ED after a 12-month old is brought in with a rapid heart rate. The team will realize the patient is in a stable SVT rhythm, with no response to either vagal maneuvers or adenosine. The patient will then progress to having an unstable SVT. If the SVT is defibrillated (i.e. – shocked without synchronization), the patient will progress to VT arrest. If the SVT is cardioverted, the patient will clinically improve.

Download the case here: Pediatric SVT

Initial ECG for the case found here:

SVT

(ECG source: http://hqmeded-ecg.blogspot.ca/2013/01/heart-rate-of-230-beats-per-minute.html)

Post-Cardioversion ECG for the case found here:

normal-sinus-rhythm (1)

(ECG source: http://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)

VT ECG for the case found here:

VT

(ECG source: https://lifeinthefastlane.com/ecg-library/ventricular-tachycardia/)