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.

EM Away Rotations in a Pandemic

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Author: Lauren Lamparter – President, AAEM/RSA Medical Student Council

Originally published: Common Sense
March/April 2021

For the third-year medical student, the emergency medicine residency application process starts with applying to away rotations. This year, uncertainty remains around the possibility of aways, but hopefully, as COVID-19 vaccines are distributed more widely, travel and away rotations can become possible. One of the past AAEM/RSA Medical Student Council Presidents, Dr. Michael Wilk, wrote an article, “Seven Tips for Selecting Your EM Away Rotations.” His advice remains true whether you are able to rotate only at your home EM rotation, participate in one of the new virtual EM electives, or travel and participate in an away. So, here are his seven points, with my updated insight and an eighth point, for approaching the EM away rotations in a pandemic world.

Who Will Be Their Advocate? A Commentary on Facing Illness Alone.

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Author: Jennifer Gemmill, MD FAAEM
Originally published: Common Sense
January/February 2021

I am a terrible patient. I will refuse medicines prescribed to me. I will pick up my heavy 2-year-old just hours after delivering my newborn while the L&D nurses give me the evil eye. I will remove my own loop recorder in my bathroom at home instead of having it taken out by my unknowing cardiologist (it’s amazing how useful leftover lidocaine and eyebrow tweezers can be). If you are my physician for any reason, I will be a handful. However, I will also be my strongest advocate.

SBO: Seize Back Onus – Focus on POCUS.

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Authors: Ahmed Mamdouh Taha Mostafa, MD; Kevin C. Welch, DO; and Max Cooper, MD RDMS

Originally published: Common Sense
January/February 2021

Case
A 76-year-old female with a past medical history of hypertension, obstructive sleep apnea, diverticulitis, fibromyalgia, osteoarthritis, depression, and renal cell carcinoma status post remote nephrectomy who presented to our ED with four days of intermittent, diffuse, crampy abdominal pain associated with nausea and non-bloody, non-bilious emesis, hiccoughs, and inability to tolerate PO.

On examination, vital signs were temperature of 98.3º F, pulse of 108 bpm, respiratory rate of 15, blood pressure 146/91 and oxygen saturation of 97% on room air. Significant findings on examination were mild, diffuse tenderness over the abdomen on palpation, which was soft, positive for bowel sounds on auscultation. Bedside ultrasound performed showed keyboard sign - plicae circularis on the interior aspect of the jejunal wall, “to-and-fro” motion, and dilated bowel loops raising suspicion for small bowel obstruction (SBO), which was confirmed by CT.

How to Be a Great Senior Resident

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Author: Alexandria Gregory, MD – AAEM/RSA Editor, Common Sense

Originally published: Common Sense
January/February 2021

Four months after the beginning of second year, I still feel weird being called a “senior resident.” It feels like just yesterday I was the intern, lowest on the totem pole, learning to navigate the flow of patient care and the ED. I didn’t expect July 1st to feel any different than the days prior when I walked into my shift, but I was wrong. Suddenly, it felt as if my attendings trusted me more, and now there were more junior doctors seeking my advice regularly. I am lucky to be at an institution that encourages independence and leadership early on, so even at the beginning of PGY-2, we are working senior shifts and running critical care pod shifts, helping to supervise interns and medical students while in those roles. Even in just a few months, I have learned a lot about what makes for a great senior resident and the qualities I hope to emulate. A great senior resident:

Resident Journal Review: End-Tidal Carbon Dioxide Monitoring in Cardiopulmonary Resuscitation

Authors: Christianna Sim, MD MPH; Taylor Conrad, MD MS; Taylor M. Douglas, MD; Wesley Chan, MD

Editors: Kelly Maurelus, MD FAAEM and Kami Hu, MD FAAEM

Originally published: Common Sense
November/December 2020

Question: How can end-tidal carbon dioxide (ETCO2) monitoring guide our management of cardiac arrest?

In 2010, the American Heart Association (AHA) revised the Advanced Cardiac Life Support (ACLS) guidelines to include the recommendation of using capnography to monitor end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR),¹ and has continued this recommendation to date. Measured ETCO2 during cardiac arrest is a measure of the cardiac output generated by chest compressions but is affected by various other factors including endotracheal tube complications, ventilation, and medications administered. These issues notwithstanding, studies supporting ETCO2 as a surrogate marker of cardiac output outside of cardiac arrest^2,3 indicate that ETCO2 could be a non-invasive, more readily available means of providing feedback in real time during resuscitation efforts. Previous studies have shown that low (<10 mmHg) ETCO2 values during resuscitation are predictive of mortality^4,5,6 and that initial, average, and final ETCO2 are higher in successfully resuscitated patients^7,8 and there is an emerging possibility that ETCO2 could possibly even predict survival to discharge.^7,9 Here we review some of the more recent literature regarding the use of ETCO2 during CPR and evidence on how it can guide resuscitation efforts. 

Virtual Insanity: Adapting Curriculum to the Virtual Environment

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Author: Ryan Gibney, MD
AEM/RSA Editor
Originally published: Common Sense
November/December 2020

The sun peaks over the bay, as the crispness evaporates from the morning air to greet, what — in any other normal time — would be the start of a new school year. The traditional morning routine of packing lunch, gathering supplies, and a haphazard scurry to the front door to make it to class on time, has all but disappeared. The start of a new school year as a parent has brought a new face to education across the board. In my home, we have set up a dedicated learning space for both my daughter and I, complete with paper, pens, computers, reference books, and any other tool that may be needed. As I watch my daughter dive into the realm digital learning, I wonder how this generation is going to adapt. How are they going to apply their knowledge? Is this the new norm for education (please, God I hope not)? More importantly, how will the lack of social interaction shape her future? It has been shown that peer education with regards to emotional resiliency, empathy, and problem solving, are attained through social interactions. I believe that the same is true in medical education.