EM/IM Combined Residency: What up with that?

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Authors: Kyla Rakoczy

MS-3, University of Miami Miller School of Medicine

Kasha Bornstein, MD, MPH
PGY-1, LSU New Orleans Internal Medicine/Emergency Medicine

Choosing a specialty is one of the most daunting tasks of medical school. Pursuing an emergency medicine residency affords a fast-paced, often unpredictable environment with a diversity of patients unique to the specialty, while the life of an internist involves rounding, longitudinal patient care, and long contemplative sessions pertaining to pathophysiology and diagnosis. A combined Emergency Medicine (EM)/Internal Medicine (IM) residency program may allow for the best of both worlds. There are currently eleven, and soon to be twelve, programs that offer a combined five-year program. Required exposures in EM include experience performing invasive procedures, critical care experience, pediatric exposure, and emergency preparedness, while the IM aspect requires completion of rotations through IM subspecialties including oncology, cardiology, and infectious disease, with clinic opportunities in neurology, rheumatology, and endocrinology, as well as an additional four months dedicated specifically to pediatrics.[1] Graduates of the combined degree may choose to work solely in either field, enter a subspecialty, pursue additional fellowship experience in critical care, or engage in research.[2] The most popular fellowship pursued by combined training candidates is critical care (CC), and there are five all-inclusive combined EM/IM/CC programs in the United States. This path involves seventy-two months split between emergency medicine and internal medicine with additional experience in the critical care setting.[3] Upon completion of this challenging six-year period, residents are eligible for triple-board certification. Many triple-certified physicians choose to divide their time between the emergency department (ED) and intensive care unit (ICU) for extra variability in their careers, staying sharp in both the high acuity and physiological management of the most ill and complex patients.

The Role of Ridesharing in Emergency Medicine

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Authors: Jennifer Rosenbaum, MD; Nicole V. Lucas, MD; and Kraftin E. Schreyer, MD CMQ FAAE

Originally published: Common Sense
January/February 2021

The advent and broad availability of ridesharing services, such as Lyft and Uber, are changing the way patients access medical services, and emergency departments (EDs) are taking notice. Health care providers are increasingly aware that patients’ social determinants greatly affect their clinical outcomes. One of these factors is access to transportation, and ridesharing might be part of the solution.

Chronic Pain and Addiction Patients Need Us Now More Than Ever

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Author: Shane A. Sobrio, MD
Originally published: Common Sense
March/April 2021

Flashback to 2019. Hong Kong protests were raging on, the U.S. Women’s National Team won the world cup, Donald Trump was being impeached, and the health care battle continued to revolve around the opioid epidemic. It wasn’t necessarily easy, but it was familiar. Practices were being implemented to help prevent reckless opioid prescribing and increase availability of naloxone which, to an extent, were working. Flash forward to 2020, the year of the COVID-19 pandemic. Millions of people worldwide now dead from a novel respiratory virus and opioids are a distant memory, no longer causing the problems they used to, right? Unfortunately, not right at all.

The Brink of Burnout

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Author: Ryan P. Gibney, MD

Originally published: Common Sense
March/April 2021

It definitely felt different this new year. The normal buzz around town, packed stores, twinkling lights, and family gatherings uncharacteristically muted as compared to years past. I noticed a profound change in the hospital starting in mid-November: the winter chill was ever present in the air, while families prepped for the upcoming holidays in uncertainty. It started as a trickle three or four critically ill patient’s per day—COVID and others—but quickly became evident that the levee holding back the flood of patients was about to break. Over the course of two weeks, I saw the volume expand from a few sick COVID patients to every other patient coming in at the brink of complete respiratory failure, clinging to each breath, struggling to speak any words. Time and time again, I would ask a single family member to say their goodbyes while I prepared airway equipment and counseled families and patients that I was concerned and this may be the last time they speak to their loved ones. Tears and fear filling the eyes of patients and their family, quivering lips hidden behind flimsy masks, screaming, and hand holding had become the pre-intubation ritual I was now performing countless times per day. It is incredibly difficult. 

Resident Journal Review: Massive Transfusion Protocols (MTPs) in Traumatic Hemorrhage

Authors: Taylor M. Douglas, MD; Taylor Conrad, MD MS; Wesley Chan, MD; and Christianna Sim, MD MPH
Editor: Kelly Maurelus, MD FAAEM and Kami Hu, MD FAAEM

Most, if not all, emergency medicine clinicians are familiar with massive transfusion protocols (MTP), which were developed to create a systematic method for the administration of large volume resuscitation for hemorrhagic shock. The evidence behind these protocols and how they were developed, however, are less well known. First seen in military trauma settings, MTPs have been translated to civilian patients with the supporting evidence to do so following behind their application.1 The American College of Surgeons’ (ACS) Trauma Quality Improvement Program (TQIP) Massive Transfusion in Trauma Guidelines leave a good amount of flexibility for hospitals regarding transfusion protocols, focusing more on systems-level aspects of designing and implementing MTPs.2,3 Here we examine some of the evidence behind the various components of MTPs, specifically calcium and factor VIIa, and the ratios in which the main products of red blood cells, plasma, and platelets should be administered.