Modern Resident - The newsletter of AAEM/RSA
April/May 2012
Volume 3: Issue 6  |  FacebookTwitter


Congratulations to the new 2012-2013 Leaders:

President
Leana S. Wen, MD MSc

Vice President
Stephanie Gardner, MD

Secretary-Treasurer
Taylor McCormick, MD

Immediate Past President
Teresa M. Ross, MD

At-Large Board Members
Rachael Engle, DO
Ali Farzad, MD
Megan Healy, MD
Sarah Terez Malka, MD
Meaghan Mercer, DO

Medical Student Council President
Mary Calderone

Publications Advisor - Ex-Officio Board Member
Joel Schofer, MD RDMS FAAEM

Modern Resident Contributors

Copy Editor: Taylor McCormick, MD
Managing Editor: Jody Bath, AAEM/RSA Staff

Special thanks to this issue's contributors:
McKaila Allcorn, DO; Brett Rosen, MD; Michael Hemak, MD; Manon Kwon, MD; Veronica Tucci, MD JD; Catherine Carrubba, MD FACEP; Casey Grover, MD; Teresa Ross, MD; Ali Farzad, MD; David Scordino, MD; Terez Malka, MD; Meaghan Mercer, DO; Aditya Ancha, MSIV; and Eric Schott, MS III.

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by June 15th for the June/July edition.

Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA.


Clinical Pearl – Osteochondritis Dissecans

McKaila Allcorn, DO
Kent Hospital

A 45 year-old male presents with atraumatic left ankle pain and swelling. He is otherwise healthy with the exception of chronic low back pain. He works a desk job and denies any history of overuse of the lower extremities. Due to the significant swelling (without warmth or redness) and inability to ambulate, plain films were obtained.

Click to enlarge

Osteochondritis dissecans most commonly affects the knees, but may also affect other joints including the elbow and ankle. The exact mechanism is unknown, but it is thought to result from ischemia to a localized area of subchondral bone, resulting in breakdown of the overlying articular cartilage (essentially avascular necrosis). In adolescents, it is more often associated with repetitive trauma and sports. The condition is somewhat rare, but suspicion should be high in patients presenting with atraumatic joint pain, especially when it involves effusions, crepitus, and "locking" of the joint without a specific incident. It is frequently missed and may require bone scan or CT if suspicion is high (which is important because patients who undergo early intervention have far superior outcomes). ED management includes immobilization, partial or non-weight bearing, pain control, and prompt follow-up with orthopedics.

References:

  1. Clanton TO, DeLee JC (July 1982). "Osteochondritis dissecans. History, pathophysiology and current treatment concepts." Clinical Orthopaedics and Related Research. 167 (167): 50–64.
  2. Campbell, Willis Cohoon, and S. Terry Canale. Campbell's Operative Orthopaedics. 11. 2. Philidelphia: Mosby Elsevier, 2008. 2378-2379, 2848-2855.

Henoch-Schönlein Purpura

Brett Rosen, MD
York Hospital Emergency Medicine Residency Program
AAEM Social Media Committee Chair

Henoch-Schönlein Purpura (HSP) is an IgA-mediated, small vessel vasculitis that predominantly affects children. IgA, C3, and immune complexes deposit in arterioles, capillaries, and venules. It is important to differentiate this from IgA nephropathy where renal biopsies show similar pathology; however, IgA nephropathy mainly affects the kidneys of young adults. HSP can affect any organ system though the skin, gastrointestinal, and urinary systems are most common. Approximately 75% of cases occur in children between the ages of 2 and 11. About half of patients have had a preceding upper respiratory infection. The cause of HSP is unknown though there is some evidence to suggest that it may be of an infectious or drug-related etiology, as anti-streptolysin O titers are elevated in around 50% of patients. Children generally present with the classic rash described as non-blanching palpable purpuric lesions, with or without petechiae, on the lower extremities and buttocks.

So when should the emergency physician be concerned? Be sure to elicit a complete review of systems, and perform a full head-to-toe examination to identify other affected organ systems. Colicky abdominal pain and vomiting, with or without bloody stools, can be a sign of intussusception, which in HSP it is more often ileoileal versus the more common ileocolic. Arthralgias are also fairly common with HSP, occurring mainly in the knees and ankles. Acute scrotal pain and edema should make you think about testicular torsion, which is difficult to distinguish from HSP-related epididymoorchitis.

Laboratory analysis should include a urinalysis for blood and protein, indicating kidney involvement. If drawing blood, obtaining a blood urea nitrogen (BUN) and creatinine will establish baseline kidney function. You may want to order laboratory studies to rule out other potential diagnoses on your differential based on the patient's presentation, but they are not required to diagnose HSP. A normal platelet count helps to rule out thrombocytopenic causes of petechiae, such as idiopathic thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and disseminated intravascular coagulation (DIC).

So now that you have established a diagnosis and have ruled out other dangerous diagnoses, what should disposition be for these children? Concern for intussusception or testicular torsion should prompt emergent imaging and consultation with your pediatric subspecialists or transfer to a facility where they are available. Ill-appearing children, or those with evidence of nephritis (hematuria, elevated creatinine, or hypertension), require consultation with your pediatric service and may require inpatient admission. Non-steroidal anti-inflammatory drugs (NSAIDs) are acceptable to use if there is no renal involvement. Advanced therapeutic regimens for severe HSP (steroids, IVIG, azathioprine, etc.) should be administered by an appropriate specialist outside of the ED setting. If the child appears otherwise well, as the vast majority will, discharge is safe with strict return precautions and close outpatient follow-up for weekly blood pressure checks and urine testing until told to stop by their pediatrician.

In conclusion, HSP is a relatively common disorder that you will encounter in your career. In about 95% of cases, the course is benign, and children do well with no long-term complications. Five percent of cases are complicated by long-term hypertension with less than 1% developing end-stage renal disease. The vast majority (greater than 75%) will have a single episode lasting 4-6 weeks without any later recurrence of symptoms. The emergency physician should be aware of the more serious complications of this disorder and arrange appropriate care and follow-up as indicated by the presenting clinical condition.

References:

  1. Bossart P, Dronen S. "Henöch-Schonlein Purpura in Emergency Medicine." Medscape Online, accessed 1 March 2012.
  2. Kraft DM, McKee D, Scott C. "Henöch-Schonlein Purpura: A Review."American Family Physician, 1998 Aug 1; 58(2):405-408.
  3. Stoudt, AK. Henöch–Schonlein Purpura in Greenberg's Text-Atlas of Emergency Medicine, 2005.

Critical Limb Ischemia from Burkitt's Lymphoma

Michael Hemak, MD
Manon Kwon, MD
Los Angeles County + University of Southern California Emergency Medicine

A 28-year old male with a history of HIV on HAART (CD4+ count 461) presented to the emergency department complaining of left axillary swelling with pain and erythema. The patient reported swelling roughly one week after being bitten on the left hand by a neighborhood cat. His symptoms worsened over the subsequent two months despite a 30-day course of Doxycycline followed by a 14-day course of Ciprofloxacin for presumed cat scratch disease. On examination, there was a large 15 x 10cm left axillary swelling, which was firm and moderately tender to palpation. It was non-fluctuant with no bleeding or discharge but some overlying skin blistering and ulceration. Distally, there was extensive pitting edema of the entire left upper extremity with a diminished radial pulse but a normal sensory and motor exam.

Click to enlarge

Chest CT demonstrated a 15 x 17 x 17cm enhancing mass with areas of overlying skin thickening and tissue edema and severe attenuation of the left subclavian artery, which coursed through the mass.

Acute limb ischemia is a potentially catastrophic and limb-threatening complication traditionally associated with the triad of pain at rest, skin ulcers, and gangrene. The evaluation begins with a history and physical exam tailored toward identifying any underlying vascular disease. Historical clues include hypertension, diabetes, kidney, or cardiac disease, and peripheral vascular disease. Physical exam requires careful attention to the affected limb's peripheral pulse, skin changes, and neuromuscular examination, and a complete survey for bruits or aneurysms. Acute limb ischemia is most commonly encountered in the lower extremities as a complication of peripheral vascular disease, arterioembolic phenomenon, or after vascular surgical procedures. However, malignancy must remain in the differential diagnosis. This is particularly true of those who lack traditional vascular risk factors and the immunocompromised. Infrequently, there have been case reports of arterial ischemia of the digits1-2 or the entire upper limb resulting from neoplasms.3 In addition to tumor emboli and paraneoplastic processes, this case suggests mechanical compression by tumor burden as another etiology. When resulting from neoplasm, the progression of ischemic disease may abate with chemotherapy directed at the underlying malignancy.

This patient underwent FNA biopsy, which revealed Burkitt's lymphoma. He was started on R-CODOX (Rituximab, Cyclophosphamide, Vincristine, Doxorubicine) with intrathecal Methotrexate and was discharged home several weeks later to continue chemotherapy treatment.

References:

  1. Halpern SM, Todd P, Kirby JD. (1994) Hodgkin's disease presenting with digital ischaemia. Clin Exp Dermatol 19(4):330–331.
  2. Smith P, Rice M, Ricci N, Toogood I, Roberton D. (1993) A case of Burkitt's lymphoma presenting with digital ischaemia. Acta Paediatr 82(2):217–219. Stoudt, AK. Henöch-Schonlein Purpura in Greenberg's Text–Atlas of Emergency Medicine, 2005.
  3. Daruwalla ZJ, Razak ARA, Duke D, Grogan L. (2010) Acute upper arm ischaemia: a rare presentation of non–Hodgkin's lymphoma. Ir J Med Sci 179:589–592.

Neurology Board Review Questions
Aditya Ancha, MSIV
Veronica Tucci, MD JD
Catherine Carrubba, MD FACEP
University of South Florida School of Medicine

Q1: A 58 year-old diabetic female presents with bilateral eye pain that began one week ago. She states the pain is located in and behind her eyes, is an 8/10 on the pain scale, does not radiate elsewhere, and is constant. She also complains of an associated posterior headache extending like a band around her head, bilaterally. The headache pain is also an 8/10, feels like a pounding sensation occurring simultaneously with her bilateral eye pain, and is constant. The patient reports nausea but denies fevers, chills, vomiting, eye discharge, eye redness, loss of vision, photophobia and phonophobia, or using any over-the-counter medications. Her family history is only significant for diabetes. On physical exam, her vital signs include: BP 110/75, P 90, R 19, T 99.8 degrees. Both pupils are equal, round, and reactive to light, her extra-ocular muscles are intact bilaterally, her visual acuity 20/30 in each eye, her visual fields are grossly intact to confrontation testing, and both sclera and conjunctiva are white and quiet. Tonometry testing revealed a pressure of +13mmHg in the left eye and +14mmHg in the right eye. Palpation of her posterior scalp elicited pain. What is the most likely diagnosis?

A. common migraine
B. classic migraine
C. acute angle glaucoma
D. tension headache
E. viral conjunctivitis

Answer: Choice D is correct. A tension-type headache is typically bilateral, band-like, pulsatile, and reproducible by palpation. Tension headaches are generally not worsened by exertion and not typically associated with nausea and vomiting. Extracranial muscle tension is very likely the etiology here. Migraines are most commonly unilateral, pulsating, worsened by physical activity, and are generally accompanied by nausea, vomiting, photophobia, and phonophobia, making choices A and B unlikely answer choices. Choice C is incorrect, since her eyes are not red, tearing, or fixed and mid-dilated, intraocular pressure readings in both eyes are below 20mmHg, and glaucoma rarely presents bilaterally. Choice E is incorrect because her conjunciva and sclera are not reddened or inflamed.

References:

  1. Denny, CJ, et al. "Chapter 159. Headache and Facial Pain" (Chapter). Tintinalli JE, et al.: Tintinalli's Emergency Medicine: A Comprehensive Guide, 7e.
  2. Walker, RA, et al. "Chapter 236. Eye Emergencies" (Chapter). Tintinalli JE, et al.: Tintinalli's Emergency Medicine: A Comprehensive Guide, 7e.

Q2: A 58 year-old female presents with a sudden headache complaining of excruciating pain that began several days ago while tending to her garden. The patient denies any recent traumatic fall, a past history of migraines, or any recent stress that may be affecting her. The physician orders a headache cocktail which helps mitigate most, if not all, of the patient's pain. The physician then orders a head CT scan, which proves to be negative, and performs a lumbar puncture after obtaining consent from the patient, which also turns out to be negative for any pathology. Twenty-four hours later, the patient complains of her headache symptoms returning. She states her headache is distinctly different from her previous one the day before. The headache is located in her occipital area, is an 8/10 on the pain scale, has a throbbing sensation – different from how her last headache felt – and the pain is exacerbated by sneezing and defecating. What is the physician's next step in management?

A. consult neurosurgery
B. order a MRI
C. consult anesthesiology to insert a blood patch
D. reorder a headache cocktail
E. place in the supine position, maintain hydration, and administer analgesics and antiemetics

Answer: Choice E is correct. Initially, the physician was concerned with a possible subarachnoid hemorrhage. However, the patient's new headache following the lumbar puncture is most likely a post-lumbar puncture headache. Post-lumbar puncture headaches occur 24 to 48 hours after the procedure and are generally located in the frontal or occipital area. They are usually pressure-like, throbbing, and variable in intensity. Associated symptoms may include nausea, vomiting, vertigo, and tinnitus. Risk factors for post-lumbar puncture headaches include using a needle size larger than a 22 gauge, using a cutting needle such as a Quinckie, multiple puncture attempts, and failure to replace the stylet when withdrawing the needle. Some physicians will administer 500mg IV of caffeine sodium benzoate, however the efficacy of this treatment is considered controversial. If the patient's headache remains after 24 hours, an epidural blood patch (choice C) of 20 to 30mL of the patient's own blood may be administered by an anesthesiologist. A negative head CT scan with a negative CSF analysis already rules out a possible intracranial hemorrhage, so choice A is incorrect. Choice B may be a possible option but is not related to the lumbar-puncture headache at hand. Choice D ignores the underlying etiology of the headache.

Reference:

  1. Ladde, JG. "Chapter 169. Central Nervous System Procedures and Devices." Tintinalli, JE, et al.: Tintinalli's Emergency Medicine: A Comprehensive Guide, 7e.

Q3: A 40 year-old female patient presents with respiratory distress, double vision, and generalized weakness in her upper extremities and facial muscles. She tells you she has a diagnosis of myasthenia gravis and she ran out of her medications several weeks ago. You notice that she is alert and oriented with no changes in mental status. While you prepare for rapid sequence intubation in case her condition deteriorates, you go ahead and proceed with the Tensilon test. After you slowly push 2mg of edrophonium chloride IV, she begins to experience twitching, tearing, and sweating, while her breathing difficulty remains the same. What is the next step you take in managing this patient?

A. administer up to 10mg of edrophonium chloride IV
B. proceed with intubation
C. stop edrophonium chloride IV administration
D. administer neostigmine IM or SC in 0.5-2.0mg doses
E. administer neostigmine PO 15mg TAB

Answer: Choice C is correct. Careful attention must be paid to the development of cholinergic symptoms during the administration of an anticholinergic agent. An edrophonium test is considered to have a positive result if the resolution of muscle weakness occurs within a few minutes – the onset of edrophonium chloride is 30 seconds, while its duration is 5 to 10 minutes. A slow IV push of 1-2mg of edrophonium chloride should be given first, and the patient should be observed for any adverse reactions. If muscle fasciculations, respiratory depression, or cholinergic symptoms develop, edrophonium chloride administration should be immediately halted (C). If no evidence of cholinergic symptoms exist, then up to 10mg of edrophonium chloride may be administered and the patient may be observed for improved symptoms. Choice B is based on clinical grounds, and the patient here is not in severe respiratory distress or exhibiting signs of altered mentation. Choice D and E are related to continued management of the patient and should only be considered with a positive Tensilon test.

Reference:

  1. Sloan, EP, et al. "Chapter 167. Chronic Neurologic Disorders." Tintinalli, JE, et al: Tintinalli's Emergency Medicine: A Comprehensive Guide, 7e.

Electrolytes
Casey Grover, MD
Stanford/Kaiser Emergency Medicine

What do our patients with chest pain, altered mental status, belly pain, diabetes, alcohol withdrawal, seizures, and trauma have in common? They all have "basic labs" sent as part of our diagnostic evaluation. A basic metabolic panel (BMP or Chem-7) is often sent reflexively based on chief complaint or comorbidity without specific intention, or simply to get a "head start" in EDs with significant wait times.

But who really needs a BMP? Which patients are likely to have a clinically significant electrolyte abnormality and benefit from us finding it?

In a study of 1,093 patients that made an emergency department (ED) visit that included a basic metabolic panel, approximately 50% of patients had an electrolyte value that was out of the normal range. However, only about 15% of these 1,093 patients had what the researchers called a "clinically significant electrolyte abnormality (CSEA)" – defined as an abnormality that affected diagnosis, led to further diagnostic testing, or affected therapy. In reviewing their data, the researchers found that 98.8% of CSEAs were in patients with one or more of the following 10 characteristics: poor oral intake, vomiting, chronic hypertension, diuretic use, recent seizure, muscle weakness, age over 65, alcoholism, abnormal mental status, and recent history of electrolyte abnormality.1 When the authors went back and studied the question again to validate their original findings, they found that the presence of these characteristics were 95% sensitive for picking up a CSEA in the 982 patients in their validation study group.2

So what?!

While we often order blood tests without knowing exactly what we are looking for, a BMP is most likely to give us a clinically significant result in patients with one or more of the characteristics above. Lowe et al. have provided supporting evidence to reduce unnecessary testing in the ED. Clearly, you should not hold back from ordering electrolytes when you think they are indicated (such as in diabetics with an elevated finger stick glucose to look for acidosis), but realize that these ten characteristics are most predictive of patients who are likely to have an electrolyte abnormality.

References:

  1. Lowe RA, et al. Rational ordering of serum electrolytes: Development of clinical criteria. Ann Emerg Med. 1987; 16: 260-269.
  2. Lowe RA. Rational ordering of electrolytes in the Emergency Department. Ann Emerg Med. 1991; 20: 16-21.

AAEM/RSA Immediate Past President's Message
Teresa Ross, MD

AAEM/RSA continues to add our support to the critical issue of national drug shortages - an issue increasingly affecting ER docs and our patients. Most recently, we were on Capitol Hill, April 16, at a drug shortage symposium that joined the Department of Health and Human Services, the Food and Drug Administration, and multiple associations representing EMS, emergency nurses, emergency physicians, and pediatricians, and even Pfizer drug corporation. Only by communicating with our legislators can we ensure that our interests and the interests of our patients are clearly represented. Stay tuned on Facebook for more updates!

Link to Full Article from Common Sense


The Advancing Role of Technology in Emergency Medicine Education and Training: Interview with Amal Mattu, MD FAAEM
Ali Farzad, MD
AAEM/RSA Publications Committee Chair

I had the pleasure of interviewing one of the greatest educators of our time, Dr. Amal Mattu, vice-chair of the University of Maryland Department of Emergency Medicine. Dr. Mattu is a seasoned clinician with a true passion for EM and is known internationally as one of the premier speakers in our field. He is a well-respected expert in emergency cardiology and electrocardiography and a dedicated teacher who strives to make a difference by delivering quality education about high-risk topics.

Throughout the years, he has developed quite a loyal following because of the entertaining way he is able to present important clinical topics. He is the host of EMCast, a 90-minute monthly podcast in which he discusses recent literature, interesting cases, and current "hot" topics. He has kindly let me ask him a few questions about how technology has affected his teaching and delivery of educational materials, and even provides AAEM/RSA members with a sample of his new "EKG of the Week" video podcast. Dr. Mattu has created an incredible collection of must-watch videos that teach important EKG interpretation skills and present must-know information that will help you save lives!

Link to Full Interview


Echelons of Care
2nd Lt. Eric Schott, MS III
Uniformed Services University of the Health Sciences

The following series will be broken into two parts outlining the path of a soldier from battlefield injury to definitive care in the U.S.  Part one outlines the path of care while still in the combat zone.  Part two will summarize care following evacuation and will be included in the next issue of Modern Resident.

The path to definitive medical care and treatment of a warrior from the forward deployed environment, or 'outside the wire,' is composed of a system of levels, or ‘echelons,’ of care that progress from basic first aid to definitive care such as outpatient clinics and a wide variety of sub-specialty services. 

The first echelon of care is the most basic, focused on that care that the soldier can provide for themselves or one another (tourniquets, chemical/biological antidotes, etc.).  This also includes care from certified medical personnel traveling with the soldier’s war fighting unit. Once stabilized, given the circumstances such as enemy fire, weather conditions, and urgency of care, they then move to the Battalion Aid Station.  There, a physician or PA provides triage and basic care which results in either a return to duty or evacuation to the next echelon, if needed.  This level provides no surgical or patient holding capability.

If needed, patients are then sent to the second echelon of care consisting of a fully mobile surgical team designed to provide life and limb saving care to those unable to survive transport to the next level of care.  While the specific capabilities vary amongst the specific teams, the overall ability to provide emergency surgical care in the field is similar.  For example, the Air Force Mobile Field Surgical Team (MFST) is composed of a 5-person team (general surgeon, orthopedist, anesthetist, emergency medicine physician, and OR nurse/tech) and can provide 10 life/limb saving procedures in 24-48 hours from five backpacks (350lb total gear).  This team augments other non-surgical medical units. 

The third echelon of care is the highest level present in the combat zone; an example is the Craig Joint Theater Hospital located at Bagram Airfield, Afghanistan.  These facilities contain a wide variety of surgical, non-surgical, and support services ranging from ICUs, ORs, psychiatric care, blood bank, X-ray, CT, and physical therapy resources.  Additional teams and equipment can be added as needs and availability arise.  Naval hospital ships also fall under this level, providing a large host of physician and support staff and holding patients for days as needed for longer term care.  While this level provides an extensive array of capabilities, it is still in the combat zone and does not constitute a definitive care center.  Noteworthy, from the most recent conflicts in the Middle East, 98% of patients making it to an echelon III facility will survive – a testament to the outstanding care and support present at these facilities.

Once stabilized, patients are transported outside of the combat zone where more extensive resources are available.

To be continued in the next issue of Modern Resident.

References:

  1. Silva, K. (2010). Medical Care in Theater. 3rd Annual Trauma Spectrum Conference (pp. 10-11). Bethesda, MD: Defense Centers of Excellence.
  2. US Joint Chiefs of Staff. (1995). Joint Publication 4-02: Doctrine for Health Services Support in Joint Operations. Washington, DC: US Department of Defense.
  3. US Dept of the Army. (2004). Emergency War Surgery. Washington, DC: Borden Institute, Walter Reed Army Medical Center.

Advocacy 101: Washington State Healthcare Law – Overturned But Not Dead
David Scordino, MD
Johns Hopkins Emergency Medicine

Last fall, Washington State Governor Chris Gregoire (D) signed into law legislation designed to limit Medicaid spending by re-directing lower acuity emergency department (ED) visits to primary care. These measures included denying payment for ambulance transport for non-emergent conditions, requiring timely follow up, notifying of patients of “inappropriate use” of ED care, and non-payment for any ED visit deemed non-emergent after the third visit. The impetus was that 13% of Medicaid recipients accounted for 43% of all ED visits and only 3% of the Medicaid recipients would be affected by this change. 1

Multiple professional groups, including the Washington Chapter of the American College of Emergency Physicians (WA-ACEP), attempted to define “non-emergent conditions” with the state.1 The list, as proposed, was altered following these sessions, and the final list of approximately 700 ICD-9 codes included “chest pain, sudden loss of vision, asthma, miscarriage with hemorrhage, kidney stones, and gallbladder problems.” 1

WA-ACEP and others filed a lawsuit claiming that the legislation was illegal and the state did not follow proper rule-making procedure. In November, Washington State Superior Court ruled that the state must halt implementation of the new Medicaid benefits plan until proper rule making procedures are obeyed. However, the judge did not rule on the legality of the law.2 Therefore, the law does not continue on as planned, leaving it in shock but not dead.

Legislation like that in Washington State poses a serious threat to emergency physicians, hospitals, and clinicians across the country. The fourth non-emergent visit is billed to the patient, and if it is not paid, then the hospital is stuck with the bill. Therefore, we are mandated to medically assess and screen the patient under EMTALA but may not be reimbursed. In addition, these billing statements are based on retrospective data. Chest pain, not found to be an MI, can be billed as “atypical chest pain” in the ICD-9 code and, thus, not an emergency. Did the physician know this prior to an evaluation and subsequent testing? No, but you could end up getting paid like you did know. Subsequently, the patient also had to know that this wasn’t an emergency before seeing a doctor.

Emergency medicine constitutes approximately 2% of medical spending in this country.3  There is little disagreement that changes need to be made, but we are not the golden cow from which serious savings result.  We cannot allow ourselves to become the low fruit on the tree.

References:

  1. Ault, A. Washington ACEP Aims to Overturn Medicaid limits. ACEP News. November 2011.
  2. Ruling Halts Washington State's Medicaid Emergency Room Visit Limit. November 18, 2011.
  3. "National Health Expenditure Projections 2008-2018," Department of Health and Human Services Office of the Actuary, Centers for Medicare & Medicaid Services, 2010.

Education Committee Update
Terez Malka, MD
AAEM/RSA Education Committee Chair

  1. Planning is underway for the resident track at next year's AAEM scientific assembly in Las Vegas. Expecting a great turnout, we are reformatting the track into several small group sessions to allow for more interaction and participation.
  2. Based on the success of this year's CORD SA resident track (co-coordinated with EMRA), we are expanding next year's session to a full day! This will be in the form of workshops and simulation scenarios and will emphasize resident teaching and professional development.
  3. In collaboration with the AAEM Education Committee, we're surveying members to determine their interest in developing an intensive education and leadership fellowship for residents and junior faculty pursuing academics.

We have an exciting and busy year coming up and lots of opportunities for committee members!


Medical Student Council Update
Meaghan Mercer, DO
AAEM/RSA Medical Student Council Immediate Past President

This year we have begun the second edition of Rules of the Road for Medical Students, held two regional medical student symposia, put on a great student track at the Scientific Assembly, coordinated residency and EMIG visits by AAEM board members, and many other projects are in the works!

As my medical student career comes to an end, I am often asked why I choose to support AAEM/RSA. My answer continues to evolve, and my passion for this association continues to grow. AAEM/RSA's dedication to education amazes me, and each AAEM/RSA meeting is filled with ideas on how to improve the quality of our educational materials and ways to increase member benefits. Underneath all of the benefits, there is a group of individuals fighting for the quality of emergency medicine training, advocating on Capitol Hill, and standing up for both the individual and specialty as a whole. Each member of AAEM/RSA adds strength to our fight for every individual's unencumbered access to quality emergency care by a specialist in emergency medicine.

Know that you can make a difference as a medical student, and thank you for your continued support!