Modern Resident - The newsletter of AAEM/RSA
August/September 2012
Volume 4: Issue 2  |  FacebookTwitterLinkedIn


Your 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: Rachael Engle, DO
Managing Editor: Jody Bath, AAEM/RSA Staff

Special thanks to this issue's contributors:
Sarah Terez Malka, MD; Trent Reed, DO FACEP; Veronica Tucci, MD JD; Ann Marie Lee, MD FAAP; Justin Sempsrott, MD; Andrew Schmidt, DO; Meaghan Mercer, DO; David Orban, MD FACEP; Geoff Jara-Almonte, MD; Steven McGuire, DO; Lauren Myers; Matthew DuMouchel; Justin Rizer; and Mike Moore

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by September 24th for the October/November edition.

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


Join us for AAEM/RSA Advocacy Day on September 12, 2012!

Join us in Washington, D.C., to lobby members of Congress to support H.R. 6142, the Assuring Medicare Stability and Access for Seniors Act of 2012. We will also address other important issues including GME Funding, Medical Liability Reform and the creation of a Federal Narcotic Tracking Program.

Join us at 8:30am for an Introduction to Advocacy and Roundtable Discussion led by:
Mike Ybarra, MD
AAEM Government & National Affairs Committee Chair & YPS Secretary-Treasurer

No lobbying experience necessary. Join us in the Hall of States in room 283, and have your voice heard on Capitol Hill!

Click here for more information and to register for FREE! Please contact us with any questions.


Education Committee Update

Sarah Terez Malka, MD
Indiana University

The AAEM/RSA Education Committee has several exciting educational offerings in progress for this coming year! We're looking forward to a great turnout at the RSA/YPS track to be held at the 19th Annual AAEM Scientific Assembly in Las Vegas, February 9–13, 2013. We'll be adding more interactive sessions, including a CV workshop, and will have multiple lecture options available for those at different stages in their training and careers. For those with an academic interest, we're proud to be expanding the CORD Academic Assembly resident track (co-sponsored with EMRA) to a full day of participatory workshops.


Photo of the Month #1

Lauren Myers
Trent Reed, DO FACEP
Loyola University Chicago Stritch School of Medicine

Patient Vignette:
A 31-year-old female is brought in by EMS for left hand pain after a minor motor vehicle accident. The patient complains of pain and soreness after forceful abduction of her thumb against the steering wheel. There is swelling over the base of the thumb near the metacarpophalangeal (MCP) joint with tenderness to palpation on the ulnar side of the 1st MCP joint and a weakened pincer grasp. The joint was not stress tested.


Click to enlarge
Published with permission from: www.learningradiology.com

Question:
In addition to a fracture at the base of the proximal phalynx of the 1st digit, what is the diagnosis?

A. 1st MCP dislocation
B. Scaphoid fracture
C. Acute exacerbation of chronic arthritis
D. Ulnar collateral ligament injury

Answer:
D is correct. Ulnar collateral ligament (UCL) injury, also known as skier’s thumb, is an acute injury that can be easy to miss resulting in permanent disability of the pincer grasp if not treated and diagnosed early. Patients often present with pain, swelling and tenderness along the ulnar aspect of the 1st MCP and loss of pincer grasp power. X-ray should be obtained first prior to considering joint stress testing. If no fracture is noted, one can then apply a valgus force with the thumb in 30 degrees of flexion, which will reveal increased laxity of the joint. Plain X-rays are the initial diagnostic test and can sometimes reveal an avulsion fracture of the base of the proximal phalanx of the 1st digit as pictured, though this is not necessary to make the diagnosis of UCL injury. Treatment in the emergency department includes immobilization of the digit with a thumb spica splint and close follow up with a hand specialist for reassessment and possible surgical intervention.

References:

  1. Anderson, Bruce, Patrice Eiff, and Jonathan Grayzel. "Ulnar Collateral Ligament Injury (gamekeeper's or Skier's Thumb)." UpToDate Inc. N.p., 12 Sept. 2011. Web. 16 July 2012. http://www.uptodate.com/
  2. Davenport M, Sotereanos DG. Chapter 265. Injuries to the Hand and Digits. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

Board Review Questions – Pediatric Gastroenterology
Matthew DuMouchel, USF College of Medicine
*Veronica Tucci, MD JD, Baylor College of Medicine
Ann Marie Lee, MD FAAP, USF College of Medicine

*Assistant Professor of EM at Baylor College of Medicine - Manuscript prepared while chief resident for research at USF College of Medicine

1) A mother brings her 6-week-old Caucasian male infant to the ED with a complaint of vomiting. The infant has had increasing episodes of non-bilious vomiting for the last several weeks. He feeds well but shortly after feeding, the patient's mother reports that he vomits the formula. On physical examination, the next step in the infant's evaluation is:

  1. Complete blood count
  2. Chest X-ray
  3. Abdominal ultrasound
  4. CT scan of the abdomen
  5. Urinalysis

Answer:
C is correct. The patient in this clinical scenario has pyloric stenosis, and an abdominal or pyloric ultrasound is the diagnostic test of choice with an accuracy of 95%. Pyloric stenosis is a hypertrophy of the pylorus that leads to a gastric outlet obstruction. This condition classically appears between two weeks and six months of age and is the most common cause of surgically correctable vomiting in newborn populations. Rosen’s notes 2–6 weeks for presentation, and Tintinalli notes six weeks to six months. Although uncommon, prolonged emesis can result in hypochloremic metabolic alkalosis, which may be elucidated on a basic or comprehensive metabolic panel or blood gas. Neither a complete blood count (choice A) nor urinalysis (choice E) will aid in the diagnosis of pyloric stenosis. Additionally, other radiographic studies including a chest X-ray (choice B) and CT scan of the abdomen (choice D) are not warranted at this stage.
Tintinalli 7th edition, pg 740.

2) A 2-year-old Hispanic male presents to the ED for abdominal pain. The child has a history of an upper respiratory infection two weeks ago. Today, he has had intermittent crampy abdominal pain with pain-free periods. He has also had one episode of bloody stool, and his mother states that the child is sleeping more than usual this afternoon. The child’s evaluation should include:

  1. Abdominal series, antiemetic and pain medication
  2. IV access, NS fluid bolus, NPO and abdominal ultrasound
  3. IV access, NS bolus, NPO and barium enema
  4. Consult surgery, IV access, NS bolus, NPO, abdominal ultrasound and air enema
  5. Oral antibiotics, pain medication and discharge home

Answer:
D is correct. This child has intussusception, which is the most common cause of intestinal obstruction in patients between the ages of three months and six years. The classic presenting triad involves abdominal pain, bloody stools and vomiting, but 75% of patients with intussusception will have only two of these three features. Currant jelly stools are often described, but this is a late finding. Lethargy may be the presenting sign in 10% of cases. Current theory suggests that a lead point develops causing one segment of intestine to telescope on another. Lead points may be caused by enlarged Peyer's patches following recent infections as in this patient’s case. Intussusception is diagnosed by ultrasound (choice D). Abdominal plain films (choice A) may be obtained as part of the diagnostic evaluation and may suggest a mass or defect in the right upper quadrant, target or meninscus signs, but these will not definitively diagnose intussusception. Children should be given nothing by mouth, and IV access and fluid boluses should be administered. The treatment of choice is reduction by air enema. Air enema is preferred to other modalities including barium (choice C) because there is better pressure control and less risk of extravasation of irritating or toxic agent such as barium in the event of perforation. Reduction by air or barium enema is estimated at 90%. Surgery consult is warranted in cases of unsuccessful reduction or perforation.
Rosen, pg 2176–2177. Tintinalli, pg 841–842.

3) A 10-day-old ill-appearing infant presents with abrupt onset of abdominal pain, abdominal distension, bilious emesis and irritability. She was born full-term, and the patient's mother had no complications during her pregnancy. On examination, she is tachycardic and has a capillary refill > 5 seconds. This child's work-up should include:
  1. CBC, CMP, UA, abdominal series, IV access, NS bolus, antiemetic and pain medication
  2. CBC, CMP, UA, IV access, NS fluid bolus, NPO and abdominal ultrasound
  3. Consult surgery, CBC, CMP, IV access, NS bolus, NPO, NG tube placement and abdominal X-rays, broad spectrum IV antibiotics
  4. Consult surgery, CBC, CMP, IV access, NS bolus, NPO, abdominal ultrasound and barium or air enema, broad spectrum IV antibiotics
  5. Oral antibiotics, pain medication and discharge home

Answer:
C is correct. This child most likely has proximal obstruction secondary to malrotation and a midgut volvulus. Necrotizing enterocolitis (NEC) is also a consideration. NEC is more commonly seen with premature infants. Abdominal X-rays may help distinguish between these entities. The presence of pneumatosis intestinalis on abdominal X-ray is diagnostic for NEC. Malrotation is more commonly associated with air fluid levels or a paucity of gas consistent with obstruction. Choice A is incorrect because immediate surgical consultation is warranted for both conditions. Fluid resuscitation is also necessary for both conditions. Broad spectrum IV antibiotics should also be initiated for ill or toxic-appearing children. Other imaging modalities such as abdominal ultrasound (choices B &: D) and CT scans are not warranted. Oral antibiotics (choice E) are not appropriate in toxic patients with compensated or uncompensated shock.
Rosen, pg 2176-2177. Tintinalli, pg 842-843.


Drowning
Justin Sempsrott, MD
University of Nevada Las Vegas
Andrew Schmidt, DO
University of Florida, Jacksonville

Dr. Sempsrott and Dr. Schmidt are the co-founders of Lifeguards Without Boarders, a not-for-profit organization composed of lifeguards and health care professionals who are devoted to doing their part, through domestic and international training, program development, and research, to lessen the global burden of drowning.

Drowning: An Update
In 2002, drowning was uniformly defined as "The process of experiencing respiratory impairment from submersion or immersion in liquid," with three possible outcomes: no morbidity, morbidity or mortality. To avoid confusion and promote consistency in reporting, terms such as "near," "dry," "wet," or "secondary" should never be used when referring to drowning injury. As the uniform definition states, the drowning event begins when the victim's airway drops below the surface of a fluid. Beginning with voluntary breath holding and moving through a sequence of aspiration (typically less than 30ml), possible laryngospasm (7-10% of cases), reflex swallowing, and, finally, involuntary aspiration, the victim not only suffers from a lack of inspired oxygen, but also from direct injury to the alveolar environment, further hindering oxygen transport for survivors. The sequence of events and duration of struggle can differ greatly between individuals, but ultimately results in a common injury: cerebral anoxia. It is important to understand that hypoxia is the primary injury sustained, the severity of which determines the degree of morbidity suffered by the victim. From hypoxia stems any number of injury pathways leading to cerebral hypoxia, cardiac dysrrhythmia, respiratory failure, etc. Despite the historical focus on treating the drowning victim by draining the lungs of fluids by any means possible (smoke, heimlich maneuver, laying over an oxen, tobacco enemas), the proper treatment of the drowning victim has evolved to focus on reversing hypoxia. Pre-hospital treatment should include a rapid patient evaluation, immediate oxygenation, and ventilation by bag valve mask, mouth to mouth, supraglottic or endotracheal airway placement, and prompt transport to a nearby hospital. In the case of cardiac arrest after a drowning event, resuscitation should be carried out following ACLS/BLS guidelines and by administering traditional CPR.

Once in the emergency department, optimizing oxygen delivery by means of passive oxygen delivery or positive pressure ventilations (depending on patient condition) should take precedence. Airway secretions and foam, due to both aerated pulmonary fluid and gastric contents, should be suctioned as needed, but not at the expense of oxygenation, and may be improved by placing an NG or OG tube. Patients who present with normal lung sounds, adequate oxygenation without intervention, and who experience no decompensation in condition, or otherwise healthy individuals who initially have impaired oxygenation which improves with minimal intervention, may be safely discharged home after 4-6 hours of observation. Patients with persistently abnormal lung sounds, those whose oxygenation remains impaired with supplemental oxygenation, or those with significant comorbidities would benefit from inpatient observation. Initial emergency department work-up in these individuals may include electrolyte measurement, although abnormalities following a drowning event are rare in the non-critical patient, and possibly a chest X-ray if there is concern for large aspiration or early ARDS (Acute Respiratory Distress Syndrome). Those requiring intubation will likely display a disease pattern similar to ARDS (diffuse patchy infiltrates on chest X-ray, PaO2/FiO2 ratio <200), and would likely benefit from low-volume, lung protecting ventilator settings following the ARDNet treatment algorithm in the ICU. It is recommended that these patients remain on invasive ventilation for at least 24 hours after improvement of ventilation measures since late pulmonary edema may occur due to continued lung parenchymal damage. Currently, there is insufficient evidence to recommend empiric glucocorticoid or antimicrobial administration, and the use of either should be based on clinical course and not the inciting event. Treatments currently under investigation include extracorporeal membrane oxygenation, prone ventilatory positioning, nitric oxide administration, and therapeutic hypothermia.


Critical Care Update - "LVADology"
Meaghan Mercer, DO
University of Nevada Las Vegas

"We need a doctor in critical bed 5," being paged overhead is the first thing I hear walking into my shift. As I pull back the curtain, I immediately realize I am out of my league; protruding from the patient's abdomen are tubes connected to a battery, a very ill patient, and a nurse staring at me wide eyed stating "I feel no pulse." With the prevalence of heart failure increasing due to life prolonging treatment, more patients are being placed on a Left Ventricular Assist Device (LVAD) both as a bridge to transplantation and as destination therapy for those who are poor transplant candidates. With the growing LVAD population, it is important as EM physicians to understand our role in care for those with these devices.

The Nuts and Bolts
There are four main devices that are currently on the market. The first generation or "pulsatile" devices are designed to mimic the heart's physiology as pump enhancers (these devices also have external hand pumps). Second generation or "continuous flow" devices can both assist patients with a low ejection fraction, or, the patient may be completely dependent on the device; this is one of the most widely implanted devices (*this patient will be pulseless). Third generation devices are similar to second generation devices, just improved upon to decrease clot formation risk, and fourth generation devices (in clinical trials) are a pneumatically driven total artificial hearts.1

The Crashing LVAD Patient
When you get an LVAD patient in your ER, how does your management change? ABCs — Airway, Breathing, Check for other causes (listen to chest to hear if the device is working). *In second generation devices, you have to alter your assessment of typical vital signs. As mentioned previously, many of these patients are pulseless, and you need to use a Doppler to identify if the patient is perfusing. If the patient has no pulse, check if the device is running; if it is not, trouble shoot, check the battery life and connection wires. If the device is working and the patient is still pulseless, you have to discern your hospitals' protocol. The device manufacturers do not recommend doing chest compressions on patients with a LVAD, but if the patient is pulseless then it may be necessary until you can get a consult from the LVAD coordinator.2

Other acute complications — thromboembolism occurs in 10-25% of patients and the REMATCH study3 showed that 24% of patients with LVAD experienced significant neurologic event.4 Postoperative hemorrhage and infections are also significant complications for these patients. This is a very short overview, and I highly encourage you to educate yourself on the in-depth treatment if you have LVAD patients at your facility.

References:

  1. http://www.thoratec.com/downloads/LVAD-FactSheet.pdf
  2. http://www.mylvad.com/assets/ems_docs/00003528-2012-field-guide.pdf
  3. Long JW, Kfoury AG, Slaughter MS, Silver M, Milano C, Rogers J, Delgado R, Frazier OH. Long-term destination therapy with the HeartMate XVE left ventricular assist device: improved outcomes since the REMATCH study. Congest Heart Fail. 2005 May-Jun;11(3):133-8. http://www.ncbi.nlm.nih.gov/pubmed/15947534
  4. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W; REMATCH study group. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345(20):1435-1443.

Call for VP Council Representatives

Vice President's Council Recruitment - September 7-21, 2012!

The AAEM/RSA Vice President's Council has been created by AAEM/RSA to increase our outreach to EM residency programs to better serve our members. We are recruiting a resident AAEM/RSA member from each EM residency program that does not already have a volunteer to serve as their representative to the Council. This is a great way for you to get involved. Watch for more information!


Neuromuscular Disorders Board Review Questions
Justin Rizer, USF College of Medicine
*Veronica Tucci, MD JD, Baylor College of Medicine
David Orban, MD FACEP, USF College of Medicine

*Assistant Professor of EM at Baylor College of Medicine - Manuscript prepared while chief resident for research at USF College of Medicine

1) A 22-year-old male presents to the ED complaining of weakness in both of his legs and a tingling sensation in his toes for the past few days. Past medical history is significant for Type 1 Diabetes, which the patient states is well-controlled on an insulin pump. Otherwise, the patient has been healthy except for a mild cold that resolved spontaneously approximately three weeks prior. He adamantly denies any recent travel, trauma or changes in his diet. On physical exam, the patient is resting comfortably, cranial nerves are intact, upper extremity deep tendon reflexes are 2+ bilaterally, patellar reflex is 1+ bilaterally, and Achilles reflex is absent. Babinski sign is negative. The patient has 3/5 dorsiflexion and 4/5 knee extension bilaterally. No ulcers or obvious trauma are present on the lower extremities. The most likely diagnosis is:

  1. Diabetic polyneuropathy
  2. Deep peroneal nerve entrapment
  3. Guillain-Barre Syndrome
  4. Lumbar plexopathy
  5. Amytrophic Lateral Sclerosis

Answer:
C is correct. Progressive ascending bilateral weakness following a recent URI is a classic description for Guillain-Barre Syndrome (GBS). GBS is an autoimmune demyelination disorder of peripheral nerves associated with decreased sensation and reduced or absent DTR's, but not UMN signs such as positive Babinski's. Lack of foot ulcers and presence of insulin pump for DM Type 1 make diabetic polyneuropathy less likely. Deep peroneal nerve entrapment is usually unilateral and associated with trauma. Lumbar plexopathy is associated with specific dermatomal distribution of sensory loss and is usually unilateral. This patient has sensory impairment whereas ALS patients retain sensation.

Reference:

  1. Andrus P, Jagoda A. Chapter 166. Acute Peripheral Neurologic Lesions. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6366162. Accessed June 2, 2012.

2) A 19-year-old female arrives to the ED via ambulance accompanied by her mother who explains that the patient has been having worsening leg weakness over the past week to the point that she is unable to walk, but is now having difficulty breathing as well. Upon further questioning, the mother tells you that the patient has no medical history or allergies, but vaguely remembers her having a cold a couple weeks ago. Vitals are: Temp 98.7, HR: 90, RR: 22, BP:130/78, O2 sat 82. She is on room air, having difficulty speaking in complete sentences, using accessory muscles, and is unable to ambulate. You suspect Guillain-Barre Syndrome (GBS) with impending respiratory failure. Which of the following are indications for intubation in this patient:

  1. PaO2 of 82mmHg
  2. Vital capacity 18ml/kg
  3. Inability to ambulate
  4. Bulbar dysfunction
  5. Respiratory rate of 22

Answer:
D is correct. This patient has a classic history for GBS and is in obvious respiratory distress. The indications for intubation in GBS patients experiencing respiratory failure are: Vital capacity <15mL/kg, PaO2 <70mmHg on RA, aspiration or bulbar dysfunction (difficulty breathing, swallowing or speech). The patient is having difficulty with speech; bulbar dysfunction. Inability to ambulate is an indication for ICU admission, not intubation. Elevated respiratory rate is not criteria for intubation in this population.

References:

  1. Andrus P, Jagoda A. Chapter 166. Acute Peripheral Neurologic Lesions. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6366162. Accessed June 2, 2012.
  2. Lawn ND, Table 166-3. Fletcher DD, Henderson RD, et al: Anticipating mechanical ventilation in Guillain-Barré syndrome. Arch Neurol 58: 893, 2001.

3) A 27-year-old male presents to the ED with constant tingling in his feet and worsening weakness that started in his feet, but now he notices it in his legs. He denies any similar symptoms in his upper extremities. He has no past medical history other than some "flu-like" symptoms a couple weeks ago, and he is not taking any medications. Patient is afebrile with normal deep tendon reflexes but has decreased strength bilaterally with dorsiflexion, plantar flexion and knee extension. Lumbar puncture is performed and reveals opening pressure: 70mm H2O, glucose: 50mg/dL, protein: 60mg/dl, RBC’s: 0/mm3, WBC's: 5/mm3 with predominately monocytes. The next best step in management is:

  1. Start broad spectrum antibiotics and admit patient
  2. Start IVIG and admit patient
  3. Start corticosteroids and admit patient
  4. Refer to outpatient neurology for nerve biopsy

Answer:
B is correct. A young adult with recent viral illness with mild sensory deficits and ascending muscle weakness is concerning for Guillain-Barre Syndrome (GBS). The diagnosis is confirmed by LP which reveals elevated protein with normal glucose, pressure and cells. The patient appears stable now, but should be admitted for continued monitoring of respiratory status and administration of therapy. While most cases are self-limited, IVIG or plasmapheresis may aid recovery. Neither antibiotics nor steroids are of benefit in the resolution of GBS. Nerve biopsy is unnecessary for diagnosis, and delay in treatment may result in respiratory compromise.

Reference:

  1. Andrus P, Jagoda A. Chapter 166. Acute Peripheral Neurologic Lesions. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6366162. Accessed June 2, 2012.

Health Care Reform Policy Update
Geoff Jara-Almonte, MD
Hennepin County Medical Center

Mandated expansion of Medicaid coverage was a mainstay of the Affordable Care Act until it was ruled unconstitutional by the Supreme Court in July. Data on the health benefit of Medicaid expansion is sparse and has been limited primarily to cross sectional and observational studies. In late July, a study published in NEJM provided important empirical data the effect of expanding state programs.

Investigators looked at three states — New York, Rhode Island and Arizona — all of which voluntarily expanded their Medicaid rolls in the past 10 years. All causes mortality was the primary endpoint, with self-reported health, barriers to care and insurance status as secondary endpoints. Investigators compared endpoints in the five years after the state expanded its Medicaid program to the five years preceding expansion.

They found that in the aggregate data combined from all three states, there was a statistically significant decrease in all causes mortality in the years after expansion compared to the years before expansion.

Investigators also used neighboring states as a control population and compared all causes mortality between the expansion states and control states for the five years post-expansion. Again, they found a statistically significant decrease in all cause mortality in those states that expanded Medicaid compared to those that did not.

While informative, this data is not definitive. When broken down on a state-by-state basis, only New York demonstrated a statistically significant difference in mortality after expansion, though non-significant trends were seen in other states.

There are also problems with the generalizability of the data to a nationwide Medicaid expansion. This study looked at states that expanded eligibility, but did not necessarily require enrollment. In each case there was relatively low take-up — meaning only a small fraction of those who were eligible joined the program. Those who chose to enroll likely had lower baseline health, and therefore, greater benefit from gaining insurance; these effects would not be observed in a broader expansion with near-universal take-up.

There is also potential for a selection bias — states that expanded their Medicaid rolls may have had higher-functioning programs to begin with. Expansion of Medicaid in states with less functional infrastructure, fewer financial resources, and are less political may not result in the same mortality benefit seen in this study population.

Nevertheless, this is an extremely important study in that it provides some of the highest quality evidence available on the mortality benefit of expanded Medicaid coverage.


Medical Student Experiences in Medical Communications
Mike Moore
Pacific Northwest University of Health Sciences

I recently completed the first rotation of my 4th year of medical school working on the staff of The Lancet. Founded in 1832 and based in London, it is one of the world’s oldest general medical journals. It is also one of the highest ranked medical journals in scope and impact.

Being able to work in a demanding medical communications environment like The Lancet is a project that I had been working on for about a year prior to my actual clinical rotation there working with the editors and staff. Medical communications is something that we all agree, as clinicians, is an important skill, whether we are trying to communicate medical information with fellow health care professionals or communicating information to the public. However, actually learning the mechanics of becoming a more effective communicator can be a difficult task.

I did not have much guidance as I started out on my path that put me in an office in London two days after finishing my last shelf exam of my MS3 year. My goal is to pass along some information on how to put together a good experience that will assist a student in assembling a quality educational experience.

First, I think it is important to consider the goals for a student rotation in medical communications. The skills you will need are ones that will serve you well in general or specialty medicine. For example, you will need a command of:

  • Clinical and basic medical sciences
  • Health politics and policy
  • Mechanics of science research, study/research characteristics and the fundamentals of informed consent/peer review

These are core concepts that are covered to a varying extent in many medical school programs, but there are excellent educational programs sponsored through the Council of Sciences Editors (http://www.councilscienceeditors.org) as well as programs through some educational institutions that are helpful as well. Use student membership in professional organizations to connect you with mentors that can help you develop your skills. Defining what you want to learn and achieve from working in medical communication will directly translate into writing goals and objectives to turn your practical experience into a valuable elective rotation.

Second, using that mentorship network to identify practical opportunities for work at a journal is a critical next step. For me, blogging with an editor (http://www.thelancetstudent.com/users/mike) worked very well as a tool to help me hone my writing skills and make the contacts I needed for an in-person experience at the journal. Social media provides an opportunity to interact and network in ways that were difficult to do before, but can come with a unique set of problems. In addition, looking beyond a traditional in-person, on location experience to thinking about working with a remote experience where you can interact via email or other means (for example, phone or videoconferencing) and allow you to fit your experience into an otherwise inflexible schedule.

Finally, put your goals/objectives together with your practical experience to create an identifiable product that you can put on your CV. Many times this will be an article in a medical journal. However, it may also be an audiovisual production or a presentation at an educational meeting. One of the great privileges of being a student is taking the opportunity during the MS4 year to reach out and try new things. To me, the real benefit of spending time and effort on developing communications skills is that regardless of where you find yourself in medicine, the skills are in demand and will certainly serve you and your career well.


Attention Students: EMIG Select

Sign up 20 or more members of your medical school for AAEM/RSA student membership and get recognized in Modern Resident, Common Sense and Facebook! To view current EMIG Select programs, click here.

Contact us for more information and to sign up today!


DO in EM: Part 2
See Part 1 for my menu choices and statistics about DO's in the NRMP.
Steven McGuire, DO
Jacobi/Montefiore Medical Centers

One person’s good option is another person’s paralyzing choice. As a DO student, I could try to go into an AOA EM residency or an ACGME residency. That’s great, right? Sort of. Osteopathic students have the option of entering the AOA match, which works more or less the same way as the NRMP match, but it’s for DO students only and happens in February, not March. There are 45 AOA categorical 4-year EM residencies and 16 Combined EM programs (EM/IM, EM/peds, EM/FM) as of February 2012. There are none in Massachusetts, and only one in New England. Compare that to 153 ACGME EM programs and roughly 20 Combined Programs as of March 2012.

You can actually enter both matches though, right? Kind of. You can rank both AOA and ACGME programs. But since the AOA match is in February and the NRMP match is in March, that makes it all but impossible to practically rank both. The only ideal way it could work is that all of your top choice programs happen to be AOA and the rest were ACGME. Without weighing in on which programs are better and acknowledging that they are all competitive and produce well-trained EM physicians, I’ll just say that wasn’t how it turned out for me.

My top three choices happened to be ACGME programs, and my top AOA program was my 4th overall pick. I would have been very happy to match at any of them. But in this situation, if I entered the AOA match, it meant the very real possibility of not even getting the chance to match (or not) at my top three.

So in the end, being a DO student meant there were a few really good ways that I could foul up my life and bring my family crashing and burning with me. I could “go DO” and end up at programs that were good, but not geographically ideal or otherwise perfect “fits” for me. I could try to rank only my top DO choices, and if I did match, forgo the NRMP and my overall top three choices. If I didn’t match in the AOA match, then I could go through the NRMP and likely not match either. Or, I could go “all in,” NRMP only, and hope for my top three.

Did I mention they were my only three? Oh yeah. I only ranked three ACGME programs. [As an aside: if you ever wanted a good reason to take leadership positions in national EM organizations, I can basically guarantee you that these interviews were courtesy of networking I had done via national conferences.]

The universe had been good to me for the past four years. We made it all work while keeping our home in Boston while I was in Manhattan for the first two years, transferred to school in Maine, spent 3rd year in Rhode Island, and 4th year scattered all over New England.  So “all in” it was.

Ultimately, after a long conversation at the Olive Garden (where we handle all our major life decisions over unlimited soup, salad and breadsticks), my wife and I decided I would forgo the AOA match and take my chances in the NRMP match.

On Monday, March 12, 2012, I found out I didn’t ruin everything. On Friday, March 16, 2012, I discovered I’d be training in EM on the front lines. I look forward to meeting my intern colleagues at Jacobi and Montefiore Medical Centers as part of the Class of 2016.

My wife and I are going to Olive Garden this weekend to decide how much to sell our house in Boston for and where in NY we’ll be moving our family of four. I’ll save you some breadsticks.