EMRA*Cast

Dr. Jessie Werner hands over the mic over to our five new EMRA*Cast hosts. Take a listen and get to know them before they go live with their own episodes.

Overview: Imagine being one of a few dozen Emergency Medicine trained physicians responsible for the lives of millions in a vulnerable country. This is the practice and training environment faced on a daily basis by the noble Doctors who represent the first classes of Emergency Medicine Residents in Haiti. Take a moment to hear their stories and please continue to support Haiti’s first Emergency Medicine Residency program!

Host: Tiffany Proffitt DO, MABS Attending Honor Health

Guest Panel: 

Jacqueline Tin, MD, MPH, Vice Chair of the EMRA International Committee

Wesner Jacotin, MD, Emergency Medicine Resident at the University Hospital of Mirebalais, Haiti

Jose Moncricket, MD, Emergency Medicine Physician and former resident at the University Hospital of Mirebalais, Haiti

Suggested References:

The Hôspital Universitaire Mirebalais Residency will be the first EM training program in Haiti 

Reach out to the EMRA International Committee: [email protected] 

Key Points:

• You can make a difference supporting the next generations of Emergency Medicine trained physicians on a global scale!
• Think beyond your own boarders and boundaries, join the International Committee!

Host: Dr. Isaac Agboola, MD, MS  

Guest: Dr. Zach Jarou, MD, MBA  

Overview: On this episode, Dr. Agboola and Dr. Jarou venture into the oftentimes convoluted task of applying to Emergency Medicine residency. They discuss common pitfalls and misconceptions, giving evidence-based advice on how to increase success in applying whether it be to a community or educational setting. This episode is primarily geared towards medical students applying as well as advisors for these individuals. 

Key Resources:

• EMRA & Cord Advising Guide    https://www.emra.org/books/msadvisingguide/msag/ 

• EMRA Match Tool    https://webapps.emra.org/utils/spa/match#/search/map

• EMRA Student-Resident Mentorship Program (program helped to find mentors for medical students interested in EM residency) https://www.emra.org/students/advising-resources/student-resident-mentorship-program/ 

• Program Director Interview Series - Various PD’s give an inside look into what they are looking for in an applicant for their programs

https://www.emra.org/emresident/articles/categories/topics/medical-students/match/program-director-interviews

Key Points:

•  Plan your application based on your personal situation.

•  You are probably applying to more programs than you need to.

• When it comes to away rotations, rotate in an environment that is the best for you, given what you want to get out of residency. 

• The three-year vs. four-year program discussion should be less about the training time and more about how that particular program is structured, but most importantly about how it can help you to achieve your goals long term. 

• Statistically speaking the things that have been shown to be most important to applicants are: (1) Geography, (2) Practice Environment, (3) Step 1 cutoffs, and (4) Time (shift length/shift amount, three years vs. four years).

• Applicants that are IMG, DO, or other special circumstances should take careful consideration when applying.

• An average applicant (i.e., average board scores, SLOEs, research experiences) should be applying to approximately 30 programs.

• There is no perfect equation for success in the Match; it’s important that you meet with trusted advisors and find a plan that best suits you and your competitiveness. 

References:

• EMRA & Cord Advising Guide    https://www.emra.org/books/msadvisingguide/msag/ 

Transitions of care are one of the most dangerous activities in medicine. Numerous studies highlight the rates of medical errors which occur at the time of sign-outs. Formalized sign-out processes have been shown to significantly decrease breakdowns in communication and reduce adverse events. In this episode, Dr. Kaminsky sits down with residents from across the country to dissect and discuss different sign-out styles and share some insights regarding bias and areas for improvement.

Host:

• Alex Kaminsky, MD -- UCSF, Fresno

Guests:

• Rosemarie Diaz, MD – University of Michigan
• Mary McLean, MD – St. John's Riverside Hospital
• Nicholas Robbins, MD – John Peter Smith Hospital
  

Key Resources:

• Safer Sign Out Protocol: Available at ACEP.

• EMRA: Transitions of Care

• https://www.emra.org/students/advising-resources/transitions-of-care/#:~:text=Improving%20transitions%20of%20care%20%E2%80%93%20also,transfer%20of%20patient%20care%20information

Key Points:

• In a prospective multi-center study (>10,000 patients) communication error occurred at a rate pf 24.5 per 100 admissions. Preventable errors were found to be 4.7 per 100 admissions.

• Effective sign-out strategies have been shown to reduce overall medical errors by ~23% and preventable adverse events by ~30%.

Hand-Off Tools:

Remember CODE STATUS!

IPASS: 

Illness severity: Stable, “watcher,” unstable

Patient Summary: HPI, ED course/Ongoing assessment, Plan

Action List: “To-do”

Situation Awareness and Contingency Planning: “If this, then do that.” Give your colleagues an idea of what to do if an event occurs.

Synthesis by Receiver: Person taking the sign out does a “readback” of what they heard. Restate key actions. Also, the time to ask questions.

SBAR

Situation: Clearly and briefly define the situation

Background: Provide clear, relevant background information that relates to the situation. 

Assessment: A statement of your professional conclusion. 

Recommendation: What do you need from this individual? What to do and contingencies.

SHOUT

S: Sick or not Sick

H: History and Hospital Course 

O: Objective Data 

U: Upcoming plan, disposition

T: To do

 (note: This is by no means a comprehensive list)

References:

1. Brady P, Gorham J, Kosti A, et al "SHOUT" to improve the quality of care delivered to patients with acute kidney injury at Great Western Hospital. BMJ Open Quality 2015;4:u207938.w3198. doi: 10.1136/bmjquality.u207938.w3198
2. “SBAR a Powerful Tool to Help Improve Communication.” The Joint Commission, www.jointcommission.org/resources/news-and-multimedia/blogs/at-home-with-the-joint-commission/2013/11/sbar--a-powerful-tool-to-help-improve-communication/?_ga=2.175033826.1924301882.1600033523-2075193987.1600033523. 
3. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-12.
4. Heilman JA, Flanigan M, Nelson A, Johnson T, Yarris LM. Adapting the I-PASS Handoff Program for Emergency Department Inter-Shift Handoffs. West J Emerg Med. 2016;17(6):756-61.
5. Cheung DS, Kelly JJ, Beach C, Berkeley RP, Bitterman RA, Broida RI, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171-80.

Overview: On this EMRA*Cast, Dr. Agboola sits down and talks to Dr. Dajer about his experience working as a physician during 9/11.  Additionally, he gives his personal approach to disaster planning.

Key Resources:

• EMRA Pre-Hospital and Disaster Committee https://www.emra.org/be-involved/committees/prehospital-and-disaster-medicine-committee/

Key Points:

• Collaboration between EMS and ED staff is critical 
• Adapt to your own circumstances 
• In a disaster do not go into a disaster mode mentality
• Establish clear and central leadership
• You can always make more clinical spaces in a disaster situation

EMRA*Caster Dr. Alex Kaminsky sits down with Dr. Adam Rosh of Rosh Review to cover timelines, mindset, and strategies into successful preparation for both written boards and in-service examinations. Additionally, Adam imparts his wisdom as a passionate educator and former program director.

Overview: In this episode of EMRA*Cast, Dr. Jessie Werner and Dr. Jessica Whittle discuss high flow nasal cannula. Unsure of the difference among nasal cannula, a venti mask or a non-rebreather? Sick asthmatics? Pedi patients? Pneumonia? Learn when to use this modality to improve patient comfort and help stave off intubation.

Key Points:

• Regular nasal cannula goes up to 15L/min but patients are really only getting about 6L/min because of outside air mixing in
• The progression of FiO2 goes nasal cannula🡪venti🡪non-rebreather 
• High flow nasal cannula goes up to about 40L/min of flow and is humidified so it’s more comfortable for patients
• Evidence points to a mortality benefit using high flow nasal cannula in pneumonia patients

References:  

• Jentzer, Jacob, Cameron Dezfulian, and Lillian Emlet. "High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure: the FLORALI study." F1000Research 5.41 (2016): 41.
• Frat, Jean-Pierre, et al. "Preoxygenation with non-invasive ventilation versus high-flow nasal cannula oxygen therapy for intubation of patients with acute hypoxaemic respiratory failure in ICU: the prospective randomised controlled FLORALI-2 study protocol." BMJ open 7.12 (2017): e018611.
• Milési, Christophe, et al. "High flow on the rise—pediatric perspectives on the FLORALI trial." Journal of thoracic disease 7.8 (2015): E230.

Host: Tiffany Proffitt DO, MABS PGY-4 Lakeland Health

Guest Panel: 

Michael Gisondi, MD, FACEP – Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University School of Medicine, Former Program Director at Northwestern. 

Tarlan Hedayati, MD, FACEP – Chair of Education, Assistant Professor and Associate Program Director in the Department of Emergency Medicine at Cook County Hospital in Chicago

Andy Little, DO: Core Faculty, Research Director, Medical Education Fellowship Director at Doctors Hospital Emergency Medicine Residency, Co-founder and Host of EM Over Easy Podcast

Overview: 

In this episode, Tiffany talks with a panel of expert interviewers on how to conduct an interview. The panel provides tips and tricks to the resident interviewer when it comes time for interviewing medical student candidates for a spot in their programs. They discuss everything from putting interviewees at ease, to canned speeches to present to the unengaged interviewee, and some unexpected questions to set yourself apart as an interviewer. Our panel also reminds the resident interviewers of the honor it is to be a part of the interview process. Your program chose you as an interviewer because it values your opinion; don’t waste the opportunity.

References:

10 Tips to Become a Successful Interviewer: Do’s and Don’ts, ALiEM, Medical Education, Sep 15, 2016, Meg Pusateri, MD and Nicole Battaglioli, MD

https://www.aliem.com/2016/09/10-tips-become-successful-interviewer /

EM Match Advice: Interviewing Strategies, ALiEM, EM Match Advice, Aug 29, 2014, Dr. Michael Gisondi, MD

https://www.aliem.com/2014/08/em-match-advice-interviewing-strategies/

Collings J. Residency Interviews (PDF handout from Dr. Jamie Collings https://www.aliem.com/wp-content/uploads/Collings-Interview-Tips.pdf)

.

Questions:

• Who was your favorite teacher ever – from nursery school to now - and why?

• What’s the last book that you read? What is the book about, why did you pick that book, what do you like about the book?

• Ask about a flaw in the application.

• Ask about recent travel or a favorite trip.

• For four hours you will be placed on a monitored bed and you get to experience any illegal substance without risk of negative side effects or addiction, which would you try?

• Favorite movie.

• What is your biggest failure—can be non-medical. If your candidate struggles, then the interviewer shares one of her or his failures.

Key Points:

• To the senior residents - your program chose you as an interviewer because it values your opinion; don’t waste the opportunity. 
• When all else fails, play the tape.
• To the interviewees – we’re not out to get you, except maybe Dr. Little.

Does double defib work? Does it improve your chances of walking out of the hospital? What’s your CPC score? What is a CPC score? And how exactly do you conduct this procedure. In this episode, recorded live at ACEP 2019, Dr. Tiffany Proffitt discussed the ins and outs of double defibrillation with Dr. Mark Ramzy.

Host: Tiffany Proffitt DO, MABS Attending Physician, Honor Health, Scottsdale, AZ

Guest Panel: Mark Ramzy, DO, EMT-P, Critical Care Fellow at University of Pittsburgh, Chair of the EMRA Critical Care Committee.

Suggested References:

Dr. Ramzy’s very own presentation and sources on Double Defibrillation: https://docs.google.com/document/d/1VlkBhMOYT5oi93fPD8Q1B-JOMETkrY_vDl7r3zq2-JQ/

1. El Tawil C, et al. Double sequential defibrillation for refractory ventricular fibrillation. Am J Emerg Med. 2017; PMID: 28978402
2. Hajjar K et al. Dual defibrillation in patients with refractory ventricular fibrillation. Am J Emerg Med 2018. PMID: 29730094
3. S. Cheskes, et al. Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation 2020; PMID: 32084567
4. Ramzy M, "The DOSE VF Pilot RCT: Double Sequential External Defibrillation for Refractory Ventricular Fibrillation", REBEL EM blog, March 26, 2020. Available at: https://rebelem.com/the-dose-vf-pilot-rct-double-sequential-external-defibrillation-for-refractory-ventricular-fibrillation/.
5. Hamilton R, Ramzy M. Dual defibrillation is highly variable: an analysis of pulse interval delivered in dual defibrillation. Prehospital Emergency Care. 2019 PMID 31116612

Additional Readings:

1. EmCrit.org - Double Defibrillation
2. REBEL EM - Double Defibrillation

Key Points:

• Make sure the case is appropriate for the use of Double Defibrillation.
• Two defibrillators of the SAME brand.
• Pads, like your kids, do NOT TOUCH EACH OTHER!
• Completely anterior or anterior and posterior approach. 
• Hit the buttons at the same time.
• Try not to shock yourself or ruin your defibrillator.

Dr. Isaac Agboola along with a group interns from across the country approach how to navigate the challenging parts of residency outside of just the basic science.

On this episode, Isaac is joined by an illustrious cast of interns from all across the country to discuss the other side of residency outside of the science. This is the Resident Survival Guide, addressing the new and challenging aspects of transitioning from being a medical student to now being someone’s physician. “How to deal with uncertainty?”,“Resident wellness”, “Disposition indecision”, “How to deal with a difficulty attending”, “End of life discussions” etc.

• Residency is hard…. for everyone.
• Sometimes the best lessons come from people who aren’t your attendings.
• Every shift make a goal of something to improve on.
• Wellness is as wellness does. Do what makes you happy and keeps you balanced.
• Lean on your co-residents they can be your greatest support system.

References / Resources

• ALiEM
• EMRA
• LITFL - Life In The Fast Lane

Yale New Haven Medical Center
PGY1
EMRA Cast Episodes

Yale, PGY-1

Nebraska, PGY-1
@erinkarl_md
EMResident Articles

Emory, PGY-1
EMResident Articles